- Albert Nobel stabilized Nitroglycerin for dynamite
- Some postulate that he died of Nitroglycerin toxicity
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Short Acting Nitroglycerin (Sublingual Nitroglycerin)
- Peak Levels: 1-2 minutes
- Duration: 30 to 60 minutes
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Long Acting Nitroglycerin (Isosorbide Dinitrate)
- Onset: 5 minutes for sublingual (30 minutes oral)
- Duration: 1 to 4 hours for sublingual (4-6 hours for oral, 8 hours for sustained release)
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Intravenous Nitroglycerin
- Onset in 2 minutes
- Duration 3 to 5 minutes
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Transdermal Nitroglycerin
- Peak levels: 30 to 60 minutes
- Duration: 12-14 hours per day (until patch removed)
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Nitroglycerin Paste (Ointment)
- Onset: 1 hour
- Duration: 2 to 12 hours
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Aortic Stenosis
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Pulmonary Hypertension
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Hypotension
- Avoid when systolic Blood Pressure <90 to 100 mmHg or more than 30 mmHg below baseline
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Hypotension due to nitrates is typically transient after single doses and responds to small fluid boluses
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Phosphodiesterase Inhibitor (e.g. Sildenafil, Tadalafil, Vardenafil)
- Guanylate Cyclase Simulator (Riociguat)
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Restrictive Cardiomyopathy (or Pericardial Tamponade, constrictive Pericarditis)
- Right sided Myocardial Infarction (subtype of inferior Myocardial Infarction)
- Caution in inferior STEMI with ST Elevation in V1 and ST depression in V2
- Hypertensive patients with MI, regardless of distribution, are unlikely to have adverse effects with Nitroglycerin
- Little evidence to support a broad avoidance of nitrates in inferior MI in normotensive or hypertensive patients
- Wilkinson-stokes (2023) Emerg Med J 40(2): 108-13 [PubMed]
- Relaxes vascular Smooth Muscle
- Venous Dilation (more than Nitroprusside)
- Inhibits venous return (Preload)
- Decreases intra-myocardial wall tension
- Decreases intraventricular work
- Reduces left ventricular filling pressure
- Decreases myocardial oxygen demand
- Reduces Myocardial Ischemia
- Cardiac Output
- Increased in Congestive Heart Failure
- Decreased or normal if no Heart Failure
- Arterial Dilation (less than Nitroprusside)
- Relieves Angina
- Dilates large coronary arteries
- Antagonizes vasospasm
- Increases coronary collateral Blood Flow
- Increases perfusion to ischemic Myocardium
- Decreases Systemic Vascular Resistance
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Esophageal Spasm also responds to nitrates
- Pain relief with Nitroglycerin is not always Angina
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Phosphodiesterase Inhibitors (e.g. Sildenafil, Tadalafil, Vardenafil)
- Profound hypotensive reaction
- Do not use with Nitroglycerin!
- Nitrates may be used >24 hours after Sildenafil or vardenafil or >48 hours after Tadalafil
- Guanylate Cyclase Simulator (Riociguat)
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Tissue Plasminogen Activator (Alteplase, tPA)
- IV Nitroglycerin may reduce plasma concentrations
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Heparin
- IV Nitroglycerin may reduce Anticoagulant response
- Pregnancy Category C
- Unknown safety in Lactation
- Orman and Mattu in Herbert (2017) EM:Rap 17(7): 6-7
- Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 70-1
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