Coronary artery disease (CAD) affects a large number of the population every year. It is the leading cause of morbidity and mortality worldwide. According to the World Health Organization, over 7 million die of coronary artery disease (Ischemic heart disease) every year. CAD weakens the heart muscles and contributes to arrhythmia (the abnormal rhythm of the heart) and heart failure.
Let’s try to know about CAD first,
Coronary artery disease (CAD) is the most common type of heart disease which occurs due to the hardening and narrowing of the arteries which supply blood to the heart. As a result of CAD, the heart muscles cannot get the oxygen and blood it needs, which can lead to angina, myocardial infarction and then a heart attack. A completely blocked coronary artery causes a heart attack.
The CAD starts from shortness of breath with the chest pain of varying intensity. This kind of chest pain is called angina. The pain of angina can feel like a heart attack, but often it is a warning sign. Pain may extend into the arms, back of the neck, back, upper abdomen or jaw.
Angina occurs due to the narrowing of the blood vessels which supply blood to the heart. Thus heart muscles do not get enough blood and oxygen.
The risk factors for coronary artery disease include obesity, hypertension, diabetes, high cholesterol, amphetamine or cocaine abuse, smoking history, chronic kidney disease, autoimmune disorders and anemia.
The treatment of angina aims to reduce pain, prevent symptoms and decreases the risk of a heart attack.
General management of angina includes necessary lifestyle modifications like quitting smoking and alcohol, including regular exercise to control weight and a balanced diet (avoiding large meals). Medicines, along with lifestyle changes, can effectively be used in the management of angina pectoris, myocardial infarction and heart failure.
The various medicines prescribed in the management of angina are nitrates, calcium channel blockers, beta-blockers, anticoagulants, oral anti-platelet medications. Nitrate such as Nitroglycerin is the oldest and most ordinary prescribed anti-anginal agent. It is the first-line therapy in the management of angina. It reduces the intensity of angina attacks by relaxing the blood vessels. It is used in the management of various ischemic heart disease including angina, myocardial infarction and heart failure.
Let’s understand how Nitroglycerin is useful in the management of CAD.
Nitroglycerin belongs to the class of vasodilator. Nitroglycerin works by widening and relaxing of blood vessels and smooth muscle so that blood can flow more easily to the heart. This drug increases the amount of blood and oxygen that reaches your heart due to which the heart doesn’t work as hard that ultimately reduces chest pain. It belongs to a class of drugs called nitrates. They exert their effect by converting into nitric oxide (NO), which is a potent natural vasodilator. At low doses, it dilates veins as compared to arteries and hence reduces preload (volume of blood in the heart after filling). At higher doses, it dilates arteriolar smooth muscles, thereby decreasing after-load as well as peripheral resistance.
Uses of Nitroglycerin:
- It is used to prevent angina (chest pain) in people with coronary artery disease.
- For the treatment of acute myocardial infarction.
- It is also used as diuretics.
- Other uses of Nitroglycerin is in the treatment of hypertension and anal fissures.
How does it work?
Nitroglycerin forms free radical nitric oxide (NO) that activates guanylate cyclase, which results in increasing cyclic GMP (guanosine 3’5′ monophosphate).
- It leads to the dephosphorylation of myosin light chains which regulates the contraction of smooth muscles and result in vasodilatation. Hence it causes relaxation of vascular smooth muscles.
- It also reduces peripheral vascular resistance and arterial pressure and dilates the coronary arteries. The therapeutic doses of Nitroglycerin may reduce the systolic as well as diastolic blood pressure.
Dosage of Nitroglycerin:
Nitroglycerin is available as tablets, capsules, ointments, sprays, injectable and transdermal patches.
- Sublingual tablet: 0.3-0.6 mg sublingually (under the tongue) the dose may be repeated every 5 minutes until relief is obtained. If the chest pain persists after taking three tablets in 15 minutes, then prompt medical attention is recommended.
- Lingual Spray: 1 to 2 sprays (0.4 – 0.8 mg) on or under tongue 5 to 10 minutes before the activity that may precipitate an acute attack.
- Extended-release Capsule : 2.5 – 6 mg orally, 3-4 times in a day.
- Transdermal patch: 0.2 – 0.4 mg/hr patch applied topically once in a day for 12-14 hrs.
- There is no need for dose adjustment in patients with renal impairment.
Side effects of Nitroglycerin:
The side effects of Nitroglycerin include low blood pressure, weakness, dry mouth, blurred vision, vertigo, dizziness, nausea, vomiting, headache and flushing (warm or red condition of your skin).
- Never take Nitroglycerin without physician consultation.
- Nitroglycerin sublingual tablet should not be crushed chewed or swallowed. The tablet must be dissolved under the tongue at the first sign of an acute angina attack.
- It is contraindicated in patients who are using PDE-5 inhibitors like sildenafil citrate, tadalafil citrate because they potentiate the hypotensive effects of nitrates.
We hope now you are aware of the importance of Nitroglycerin in the management of coronary artery diseases.
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