Which instructions would the nurse provide to a patient who takes short-acting nitroglycerin

Nitroglycerin comes as a sublingual tablet to take under the tongue. The tablets is usually taken as needed, either 5 to 10 minutes before activities that may cause attacks of angina or at the first sign of an attack. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Take nitroglycerin exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor.

Nitroglycerin may not work as well after you have used it for some time or if you have taken many doses. Take the fewest tablets needed to relieve the pain of your attacks. If your angina attacks happen more often, last longer, or become more severe at any time during your treatment, call your doctor.

Talk to your doctor about how to use nitroglycerin tablets to treat angina attacks. Your doctor will probably tell you to sit down and take one dose of nitroglycerin when an attack begins. If your symptoms do not improve very much or if they worsen after you take this dose you may be told to call for emergency medical help right away. If your symptoms do not go away completely after you take the first dose, your doctor may tell you to take a second dose after 5 minutes have passed and a third dose 5 minutes after the second dose. Call for emergency medical help right away if your chest pain has not gone away completely 5 minutes after you take the third dose.

Do not chew, crush, or swallow nitroglycerin sublingual tablets. Instead, place the tablet under your tongue or between your cheek and gum and wait for it to dissolve. You may feel burning or tingling in your mouth as the tablet dissolves. This is normal but is not a sign that the tablet is working. Do not be concerned that the tablet is not working if you do not feel the burning or tingling.

1. Go AS, Mozaffarian D, Roger VL, et al.American Heart Association Statistics Committee and Stroke Statistics Subcommittee Heart disease and stroke statistics – 2013 update: a report from the American Heart Association. Circulation. 2013;127(1):e6–e245. [PMC free article] [PubMed] [Google Scholar]

2. Lerner DJ, Kannel WB. Patterns of coronary heart disease morbidity and mortality in the sexes: a 26-year follow-up of the Framingham population. Am Heart J. 1986;111(2):383–390. [PubMed] [Google Scholar]

3. Shaw LJ, Bairey Merz CN, Pepine CJ, et al.WISE Investigators Insights from the NHLBI-Sponsored Women’s Ischemia Syndrome Evaluation (WISE) Study: Part I: Gender differences in traditional and novel risk factors, symptom evaluation, and gender-optimized diagnostic strategies. J Am Coll Cardiol. 2006;47(3 Suppl):S4–S20. [PubMed] [Google Scholar]

4. Ferreira-Gonzalez I. The epidemiology of coronary heart disease. Rev Esp Cardiol. 2014;67(2):139–144. [PubMed] [Google Scholar]

5. Finegold JA, Asaria P, Francis DP. Mortality from ischaemic heart disease by country, region, and age: statistics from World Health Organisation and United Nations. Int J Cardiol. 2013;168(2):934–945. [PMC free article] [PubMed] [Google Scholar]

6. Montalescot G, Sechtem U, Achenbach S, et al.Task Force Members. ESC Committee for Practice Guidelines 2013 ESC guidelines on the management of stable coronary artery disease: The Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J. 2013;34(38):2949–3003. [PubMed] [Google Scholar]

7. Fihn SD, Gardin JM, Abrams J, et al.American College of Cardiology Foundation/American Heart Association Task Force 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2012;126(25):e354–e471. [PubMed] [Google Scholar]

8. Boden WE, Finn AV, Patel D, Peacock WF, Thadani U, Zimmerman FH. Nitrates as an integral part of optimal medical therapy and cardiac rehabilitation for stable angina: review of current concepts and therapeutics. Clin Cardiol. 2012;35(5):263–271. [PMC free article] [PubMed] [Google Scholar]

9. Murrell W. Nitroglycerine as a remedy for angina pectoris. Lancet. 1879;1:80–81. [Google Scholar]

10. Thadani U, Lipicky RJ. Short and long-acting oral nitrates for stable angina pectoris. Cardiovasc Drugs Ther. 1994;8(4):611–623. [PubMed] [Google Scholar]

11. Kimchi A, Lee G, Amsterdam E, Fujii K, Krieg P, Mason DT. Increased exercise tolerance after nitroglycerin oral spray: a new and effective therapeutic modality in angina pectoris. Circulation. 1983;67(1):124–127. [PubMed] [Google Scholar]

12. Kolenda K. Value of glyceryl trinitrate in exercise therapy. Prophylactic use in patients with coronary heart disease and stable angina pectoris. Fortschr Med. 1998;116:S65–S70. [Google Scholar]

13. Thadani U, Wittig T. A randomized, double-blind, placebo-controlled, crossover, dose-ranging multicenter study to determine the effect of sublingual nitroglycerin spray on exercise capacity in patients with chronic stable angina. Clin Med Insights Cardiol. 2012;6:87–95. [PMC free article] [PubMed] [Google Scholar]

14. Thadani U. Oral nitrates: more than symptomatic therapy in coronary artery disease? Cardiovasc Drugs Ther. 1997;11(Suppl 1):213–218. [PubMed] [Google Scholar]

15. Lüscher TF. Endogenous and exogenous nitrates and their role in myocardial ischaemia. Br J Clin Pharmacol. 1992;34(Suppl 1):29S–35S. [PMC free article] [PubMed] [Google Scholar]

16. Abrams J. The role of nitrates in coronary heart disease. Arch Intern Med. 1995;155(4):357–364. [PubMed] [Google Scholar]

17. Silber S. Nitrates: why and how should they be used today? Current status of the clinical usefulness of nitroglycerin, isosorbide dinitrate and isosorbide-5-mononitrate. Eur J Clin Pharmacol. 1990;38(Suppl 1):S35–S51. [PubMed] [Google Scholar]

18. Fallen EL, Nahmias C, Scheffel A, Coates G, Beanlands R, Garnett ES. Redistribution of myocardial blood flow with topical nitroglycerin in patients with coronary artery disease. Circulation. 1995;91(5):1381–1388. [PubMed] [Google Scholar]

19. Jugdutt BI, Becker LC, Hutchins GM, Bulkley BH, Reid PR, Kallman CH. Effect of intravenous nitroglycerin on collateral blood flow and infarct size in the conscious dog. Circulation. 1981;63(1):17–28. [PubMed] [Google Scholar]

20. Winbury MM, Howe BB, Weiss JR. Effect of nitroglycerin and dipyridamole on epicardial and endocardial oxygen tension – further evidence for redistribution of myocardial blood flow. J Pharmacol Exp Ther. 1971;176(1):184–199. [PubMed] [Google Scholar]

21. Fam WM, McGregor M. Effect of coronary vasodilator drugs on retrograde flow in areas of chronic myocardial ischemia. Circ Res. 1964;15:355–364. [PubMed] [Google Scholar]

22. Fam WM, McGregor M. Effect of nitroglycerin and dipyridamole on regional coronary resistance. Circ Res. 1968;22(5):649–659. [PubMed] [Google Scholar]

23. Horwitz LD, Gorlin R, Taylor WJ, Kemp HG. Effects of nitroglycerin on regional myocardial blood flow in coronary artery disease. J Clin Invest. 1971;50(8):1578–1584. [PMC free article] [PubMed] [Google Scholar]

24. Brown BG, Lee AB, Bolson EL, Dodge HT. Reflex constriction of significant coronary stenosis as a mechanism contributing to ischemic left ventricular dysfunction during isometric exercise. Circulation. 1984;70(1):18–24. [PubMed] [Google Scholar]

25. Fujita M, Yamanishi K, Inoko M, Miwa K. Preferential dilation of recipient coronary arteries of the collateral circulation by intracoronary administration of nitroglycerin. J Am Coll Cardiol. 1994;24(3):631–635. [PubMed] [Google Scholar]

26. Cohn PF, Maddox D, Holman BL, et al. Effect of sublingually administered nitroglycerin on regional myocardial blood flow in patients with coronary artery disease. Am J Cardiol. 1977;39(5):672–678. [PubMed] [Google Scholar]

27. Loscalzo J. Antiplatelet and antithrombotic effects of organic nitrates. Am J Cardiol. 1992;70(8):18B–22B. [PubMed] [Google Scholar]

28. Diodati J, Théroux P, Latour JG, Lacoste L, Lam JY, Waters D. Effects of nitroglycerin at therapeutic doses on platelet aggregation in unstable angina pectoris and acute myocardial infarction. Am J Cardiol. 1990;66(7):683–688. [PubMed] [Google Scholar]

29. Buschmann M, Wiegand A, Schnellbacher K, et al. Comparison of the effects of two different galenical preparations of glyceryl trinitrate on pulmonary artery pressure and on the finger pulse curve. Eur J Clin Pharmacol. 1993;44(5):451–456. [PubMed] [Google Scholar]

30. Kuvin JT, Patel AR, Sidhu MS, et al. Relation between high-density lipoprotein cholesterol and peripheral vasomotor function. Am J Cardiol. 2003;92(3):275–279. [PubMed] [Google Scholar]

31. Kuvin JT, Sidhu MS, Patel AR, Sliney KA, Pandian NG, Karas R. Pulse pressure and peripheral arterial vasoreactivity. J Hum Hypertens. 2005;19(6):501–502. [PubMed] [Google Scholar]

32. Tadamura E, Mamede M, Kubo S, et al. The effect of nitroglycerin on myocardial blood flow in various segments characterized by rest-redistribution thallium SPECT. J Nucl Med. 2003;44(5):745–751. [PubMed] [Google Scholar]

33. Sakakura K, Nakano M, Otsuka F, Ladich E, Kolodgie FD, Virmani R. Pathophysiology of atherosclerosis plaque progression. Heart Lung Circ. 2013;22(6):399–411. [PubMed] [Google Scholar]

34. Thadani U, Parker JO. Influence of glyceryl trinitrate during supine and upright exercise in patients with angina pectoris. Br Heart J. 1978;0(11):1229–1236. [PMC free article] [PubMed] [Google Scholar]

35. Zimmerman FH, Boden WE. Stable Angina: Optimizing Therapies Old and New. New York: Medscape Education; 2011. [Accessed April 15, 2014]. Available at http://www.medscape.org/viewarticle/741441_transcript. [Google Scholar]

36. Boden WE, O’Rourke RA, Teo KK, et al.COURAGE Trial Research Group Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med. 2007;356(15):1503–1516. [PubMed] [Google Scholar]

37. Boden WE, O’Rourke RA, Teo KK, et al.COURAGE trial coprincipal investigators and study coordinators Design and rationale of the Clinical Outcomes Utilizing Revascularization and Aggressive DruG Evaluation (COURAGE) trial Veterans Affairs Cooperative Studies Program no 424. Am Heart J. 2006;151(6):1173–1179. [PubMed] [Google Scholar]

38. Anderson JL, Adams CD, Antman EM, et al.Writing Group Members. ACCF/AHA Task Force Members 2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(18):e426–e579. [PubMed] [Google Scholar]

39. Johnson JM, Minson CT, Kellogg DL., Jr Cutaneous vasodilator and vasoconstrictor mechanisms in temperature regulation. Compr Physiol. 2014;4:33–89. [PubMed] [Google Scholar]

40. Wight LJ, VandenBurg MJ, Potter CE, Freeth CJ. A large scale comparative study in general practice with nitroglycerin spray and tablet formulations in elderly patients with angina pectoris. Eur J Clin Pharmacol. 1992;42(3):341–342. [PubMed] [Google Scholar]

41. Ducharme A, Dupuis J, McNicoll S, Harel F, Tardif JC. Comparison of nitroglycerin lingual spray and sublingual tablet on time of onset and duration of brachial artery vasodilation in normal subjects. Am J Cardiol. 1999;84(8):952–954. [PubMed] [Google Scholar]

42. Armstrong PW, Armstrong JA, Marks GS. Blood levels after sublingual nitroglycerin. Circulation. 1979;59(3):585–588. [PubMed] [Google Scholar]

43. Sato H, Koretsune Y, Taniguchi T, et al. Studies on the response of nitroglycerin oral spray compared with sublingual tablets for angina pectoris patients with dry mouth. A multicenter trial. Arzneimittelforschung. 1997;47(2):128–131. [PubMed] [Google Scholar]

44. Fox K, Garcia MA, Ardissino D, et al. Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology; ESC Committee for Practice Guidelines (CPG). Guidelines on the management of stable angina pectoris: executive summary: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J. 2006;27(11):1341–1381. [PubMed] [Google Scholar]

45. Vandenburg MJ, Wight LJ, Griffiths GK, Brandmann S. Sublingual nitroglycerin or spray in the treatment of angina. Br J Clin Pract. 1986;40(12):524–527. [PubMed] [Google Scholar]

46. Olesen J, Iversen HK, Thomsen LL. Nitric oxide supersensitivity: a possible molecular mechanism of migraine pain. Neuroreport. 1993;4(8):1027–1030. [PubMed] [Google Scholar]

47. Tfelt-Hansen PC, Tfelt-Hansen J. Nitroglycerin headache and nitroglycerin-induced primary headaches from 1846 and onwards: a historical overview and an update. Headache. 2009;49(3):445–456. [PubMed] [Google Scholar]

48. Münzel T, Daiber A, Mülsch A. Explaining the phenomenon of nitrate tolerance. Circ Res. 2005;97(7):618–628. [PubMed] [Google Scholar]

49. New Zealand Medicines and Medical Devices Safety Authority . Nitrolingual® Pumpspray Data Sheet (Glyceryl trinitrate 0.4 mg/metered dose) Wellington: New Zealand Medicines and Medical Devices Safety Authority; 2012. [Accessed July 15, 2014]. Available from: http://www.medsafe.govt.nz/profs/datasheet/n/nitrolingualpumpspray.pdf. [Google Scholar]

50. Hadjimiltiades S, Panidis IP, McAllister M, Ross J, Mintz GS. Dynamic changes in left ventricular outflow tract flow velocities after amyl nitrite inhalation in hypertrophic cardiomyopathy. Am Heart J. 1991;121:1143–1148. [PubMed] [Google Scholar]

51. Grose R, Nivatpumin T, Katz S, Yipintsoi T, Scheuer J. Mechanism of nitroglycerin effect in valvular aortic stenosis. Am J Cardiol. 1979;44(7):1371–1377. [PubMed] [Google Scholar]

52. Tebbe U, Neuhaus KL, Sauer G, Neumann P, Kreuzer H. Nitrates in aortic valve disease: acute and chronic effects. Z Kardiol. 1983;72(Suppl 3):152–155. [PubMed] [Google Scholar]

53. Basta LL, Raines D, Najjar S, Kioschos JM. Clinical, haemodynamic, and coronary angiographic correlates of angina pectoris in patients with severe aortic valve disease. Br Heart J. 1975;37(2):150–157. [PMC free article] [PubMed] [Google Scholar]

54. Maron DJ, Boden WE, Weintraub WS, Calfas KJ, O’Rourke RA. Is optimal medical therapy as used in the COURAGE Trial feasible for widespread use? Curr Treat Options Cardiovasc Med. 2011;13(1):16–25. [PubMed] [Google Scholar]

55. Weintraub WS, Boden WE, Zhang Z, et al.Department of Veterans Affairs Cooperative Studies Program No. 424 (COURAGE Trial) Investigators and Study Coordinators Cost-effectiveness of percutaneous coronary intervention in optimally treated stable coronary patients. Circ Cardiovasc Qual Outcomes. 2008;1(1):12–20. [PubMed] [Google Scholar]

56. Maron DJ. Using COURAGE to treat angina. Medscape J Med. 2008;10(12):286. [PMC free article] [PubMed] [Google Scholar]

57. Hambrecht R, Berra K, Calfas KJ. Cardiology patient page. Managing your angina symptoms with nitroglycerin: what about exercise? Circulation. 2013;127(22):e642–e645. [PubMed] [Google Scholar]

58. Aroney CN, Aylward P, Allen RM, et al.Acute Coronary Syndrome Guidelines Working Group . National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand, Guidelines for the Management of Acute Coronary Syndromes 2006. Sydney: The Cardiac Society of Australia and New Zealand; [Accessed January 9, 2014]. Available from: http://www.heartfoundation.org.au/SiteCollectionDocuments/mja-issue.pdf. [Google Scholar]

59. National Institute for Health and Care Excellence . NICE Clinical Guideline 126. Management of Stable Angina. London: National Institute for Health and Clinical Excellence; [Accessed January 9, 2014]. Available from: http://www.nice.org.uk/guidance/cg126/chapter/Key-priorities-for-implementation. [Google Scholar]

60. Canadian Cardiovascular Society . Consensus Conference on the Evaluation and Management of Chronic Ischemic Heart Disease. Ottawa: Canadian Cardiovascular Society; 1997. [Accessed January 9, 2014]. Available from: http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/IHD_CC_1997.pdf. [Google Scholar]

Page 2

Comparison of short- and long-acting nitrates