The heart drug called nitroglycerin was once described like this in the American Heart Association’s journal Circulation:
“Newer drugs quickly replace older remedies. This has not been the case with nitroglycerin, now in continuous medical use for more than a century.
“Although other applications for it have been found in cardiology, nitroglycerin is the mainstay for affording rapid, indeed almost immediate, pain relief for angina pectoris.
“At a time when the cost of pharmaceuticals is growing out of reach for many, nitroglycerin is still obtainable for pennies and remains one of the best buys in medicine.”
My little canister of nitro spray is indeed one of my closest companions. Since surviving a heart attack five years ago, and particularly since being further diagnosed since then with debilitating coronary microvascular disease, I would never even dream of setting foot out the door without my quick-acting nitro tucked into my little green wallet with me. Nitroglycerin (or nitroglycerine, glyceryl trinitrate, or GTN) comes in either short- or long-acting forms: spray, pills, skin ointment or transdermal patch, and as the AHA journal reminds us, it’s still one of the least expensive – and most immediately effective – of all my cardiac meds.
In cardiologist Dr. Bernard Lown‘s comprehensive article about nitroglycerin, he explains:*
“Angina pectoris is a discomfort behind the breastbone caused by a temporary inadequacy of blood flow to the heart muscle. It is not a heart attack. There is no heart damage. Many patients have had thousands of such episodes and live full and active lives reaching a ripe old age.
“Nitroglycerin is a true wonder drug. When it is taken properly – positive drug action is hastened by sitting, leaning forward, inhaling deeply, and bearing down as if for a bowel movement – it can help patients with angina achieve the goal of a pain-free life with little or no limitations.
“When you take nitroglycerin, your heart is able to do much more work without developing angina. It is common to see patients with angina return to full activity, largely because they have mastered the proper use of nitroglycerin.
“No matter how often you use it, it will consistently continue to work. It can help in the following circumstances:
- Brisk walking
- Cold, windy weather
- After a heavy meal
- Working under the pressure of a deadline
- Speaking in public
- During sexual intercourse
- During worry, tension or anger
“Nitroglycerin is truly a wonder drug. It dilates coronary arteries and decreases the workload of the heart, two factors responsible for the discomfort.
“Yet many anginal patients use the drug only sparingly, if at all. Early in my medical practice some 60 years ago, I was dismayed to learn that a majority of my angina patients did not take nitroglycerin despite my careful counseling. They failed to use it preventively – or even with chest discomfort.
“In many conversations, I learned that patients had to overcome a number of psychological hurdles about taking nitroglycerin. These included:
- an uncertainty about when exactly to take it
- a hope that an episode would rapidly abate spontaneously
- the fear of a throbbing headache (reported in over 2/3 of patients)
- anxiety that if nitro worked, it was proof of a cardiac problem
- an unwillingness to acknowledge having a heart condition that could cripple or kill
- an unreadiness to become dependent on or habituated to drugs”
As a heart patient with ongoing bouts of chest pain who’s had an up-close and personal relationship with my nitro spray, I understand each of these factors, including nitroglycerin’s dreaded Rule Of Three. Here’s how it works:
Sit or lie down to take your nitroglycerin. If you are driving, pull over and park the car. Taking nitroglycerin can lower your blood pressure, which could cause you to pass out if you are standing up. Take the first dose of nitro when you start having serious chest pain, and wait five minute to see if the symptoms start to decrease.
If not, take a second dose. Wait another five minutes.
If your pain persists, take a third dose – but you’d better be calling 911 at the same time.
This advice means that anytime a heart patient suffering alarming cardiac symptoms decides to take even that first dose, it’s with the knowledge (and fear) that today just might be the awful day you have to go back to hospital with a heart attack – or worse.
Dr. Lown was absolutely right! Over the past few years, in fact, I’ve spent countless hours foolishly suffering needlessly while trying to postpone that first nitro dose for just this reason: pure, unadulterated, frightened denial.
Yet as Dr. Lown advises, nitroglycerin is most helpful when taken at the first onset of chest discomfort - rather than after it has been present for several minutes.
Like many other heart patients I know, I’ve also had the experience of carefully weighing which kind of pain feels worse: my alarming chest pain, or nitro’s famous “nitro headache” side effect as it dilates the body’s blood vessels (including those in the head).
That’s why I liked Dr. Lown’s story of the advice he used to give his own patients living with angina after he guessed why they were so reluctant to take nitroglycerin:
“Listening carefully to dribs and drabs of stories from patients, I imagined the reality. It led to a drastic change in how I prescribed nitroglycerin. I started telling them:
“This small pill dissolves almost instantly. When it does, you have a tingling sensation under the tongue. You may experience a nice fullness and a very nice throbbing sensation in the head. These are due to a rush of blood confirming that your heart, like your head, is receiving more sorely needed oxygen.
“As a dividend you also get more oxygen delivered to your brain; most of us can profit from a little clearer thinking!”
After I read that story last year, I decided to follow Dr. Lown’s sneaky advice.
With the very next spray of required nitro, I began slowly breathing mindfully, waiting for that “nice fullness and a very nice throbbing sensation” in my head as I visualized the nitro dilating my reluctant blood vessels, imagining that lovely “rush of sorely needed oxygen” being delivered to my needy heart muscle - and my brain.
It’s still a headache, don’t get me wrong. But now it’s a “nice” ache for a very good cause. I’ve also found that it helps to take a Tylenol 10-15 minutes before taking nitro. Note: The Food and Drug Administration sets the maximum Acetaminophen limit for adults at 4,000 milligrams per day.
Dr. Lown still likes to quotes his teacher and mentor Dr. Sam Levine**, who maintained that the free use of nitroglycerin enables patients with angina to outlive their doctors.
And he also reminds us:
“Taken early, nitro protects the heart from possible injury. When chest discomfort is promptly relieved, there is no need to interrupt activities – except perhaps to slow their tempo. Better still is to take a pill in anticipation of discomfort. Under such circumstances of increased exertion, excitement, or anxiety, it may be worthwhile to take nitroglycerin preventively, thereby preventing angina’s very occurrence.”
According to Dr. Lown, nitroglycerin is not habit-forming, as it is neither a narcotic nor a pain-killer. Nitro can be taken a number of times throughout any given day as needed (as I’ve experienced on particularly bad days) or by wearing a longer-acting transdermal nitro patch.
While many heart patients know and love nitro as an effective vasodilator to treat severe chest pain symptoms or heart failure, nitroglycerin has also been used since the 1860s as an active ingredient in the manufacture of explosives, most notably dynamite, patented in 1867 by the famous scientist, Alfred Nobel.***
British physician Dr. William Murrell began treating his heart patients with small diluted doses of nitroglycerin in 1878 to replace the previous angina treatment called amyl nitrite (which worked well, but carried truly dreadful side effects). Angina relief with nitro was adopted into widespread use by physicians after Dr. Murrell published a study on it in the journal The Lancet in 1879.
Dr. Billy Goldberg is a New York emergency physician and the co-author (with Mark Leyner) of two fascinating books about health trivia. He explains that the medicinal dose of nitroglycerin in our heart medication is infinitesimal compared with the amount in a stick of dynamite. And it’s also highly diluted for safe handling.
Ironically, many years later, Alfred Nobel – the scientist who had first used nitro in the dynamite his company patented – was prescribed nitroglycerin for his own chronic angina pain. A few months before his death in 1896, Nobel wrote to a friend:
“Isn’t it the irony of fate that I have been prescribed nitroglycerin to be taken internally? They call it Trinitrin, so as not to scare the chemist and the public.”
IMPORTANT NOTE: This post should not be interpreted as medical advice. See your own physician for more information about chronic angina or nitroglycerin. Nitroglycerin is not recommended for certain patients – find out if you’re among this group.
.* Dr. Bernard Lown, author of The Lost Art of Healing: Practicing Compassion in Medicine, is the co-founder of the medical organization called International Physicians for the Prevention of Nuclear War, which was awarded the 1985 Nobel Peace Prize. He’s also known as a pioneer in research on sudden cardiac death. Dr. Lown developed the direct current defibrillator for resuscitating the arrested heart, as well as the cardioverter for correcting disordered heart rhythms. I’m a big fan of Dr. Lown’s work and his writing (see my previous articles about him here, here and here). But he’s first and foremost a cardiologist who’s been practicing medicine for over 60 years.
He and his granddaughter Melanie write the delightful blog called The Lown Conversation.
** Dr. Sam Levine is the same doctor who first observed that many patients suffering in mid-heart attack will hold a clenched right fist over the chest to describe their cardiac symptoms. This distinctively common reaction is now known by physicians as Levine’s Sign.
*** Marsh N. Marsh A. “A Short History Of Nitroglycerine And Nitric Oxide In Pharmacology And Physiology.” Clinical and Experimental Pharmacology and Physiology. Volume 27, Issue 4. p313–319, April 2000. DOI: 10.1046/j.1440-1681.2000.03240.x
Q: Do you tend to delay taking your nitro for angina?