By Adam Schneeweiss MD, Marija Weiss DSc (auth.)
Nitrates were for a few years the cornerstone of cardiovascular remedy for numerous symptoms. not just have nitrates stood the attempt of time for remedy of continual sturdy angina pectoris, however the symptoms for them have markedly ex panded. They now comprise all sorts of angina pectoris and myocardial ischemia, congestive center failure and hypertensive emergencies. The priceless results of nitrates in these kinds of stipulations consequence from their vasodilatory homes, however it remains to be uncertain even if the primary or peripheral results predominate within the thera peutic mechanism. lately nitrates were proven to satisfy crucial requirement for every and each drug - to lessen mortality. a wide scale research printed that isosorbide dinitrate, mixed with hydralazine, diminished long term mortality through 28% in sufferers with congestive center failure. This discovering will surely stimulate study on nitrates, and it would be anticipated that curiosity in those medications will markedly bring up. The basically used nitrates in medical perform are nitroglycerin and the com plex natural nitrates, as a rule isosorbide dinitrate. The natural mononitrates are actually less than medical research, and isosorbide-5-mononitrate (IS-5-MN) seems to be specially promising.
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The combination of both drugs dilated coronary stenoses more than either drug alone. Each drug dilated coronary stenoses by about 30% in approximately onehalf of the obstructions. The remaining one-half of stenoses did not respond to either drug. Both drugs given together produced a dilation of about 50% in more than half the stenoses. Responding and nonresponding lesions were found in the same patients. Nitroglycerin has the advantage of a more rapid onset of action than nifedipine. However, the anti anginal effect of nifedipine lasts longer than that of nitroglycerin.
Nevertheless, a crossover, doubleblind, randomized trial demonstrated that the anti-ischemic effects of nitrates were sustained in patients. It was concluded that long-term treatment with ISDN maintains its anti anginal activity even in the presence of diminution or complete abolition of the hemodynamic effects. The question of tolerance to nitrates in ischemic heart disease is put in perspective by the study of low dose intravenous nitroglycerin in acute myocardial infarction reported by Jugdutt et al [1l6a] (described in detail in chapter 9).
It should also be remembered that in some cases nifedipine has actually aggravated heart failure. At present there is one theoretical advantage for the use of beta-blockers in patients with postinfarction angina - the possibility of secondary prevention. Propranolol, timolol and metoprolol have been found effective for this indication. There are, however, three problems with this approach: 1. It is not known whether beta-blockers exert their protective effects for periods longer than those studied in the secondary prevention trials.