A cardiologist’s advice on how to use this “wonder drug”

19 Aug

by Carolyn Thomas  @HeartSisters

pillboxThe 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 in 2008, and particularly since being further diagnosed 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 pocket 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: (1)

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 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
  • Exertion
  • 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 (as directed in Dr. Lown’s instructions: sit down, lean forward, inhale deeply, and bear down as if for a bowel movement). 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 (as above). 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 angina 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 (he talks about nitro pills, but it’s equally true for nitro spray):

“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 (Tylenol) limit for adults at 4,000 milligrams per day. 

Before using a nitro spray for the first time, spray the pump into the air once or twice, away from yourself, others, or open flame. This is known as priming the pump. If you have not used this medication for six weeks or more, you’ll need to prime it again before use. Do not shake the container!

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.(2)

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.”

Taking nitro in anticipation of chest discomfort is also what I heard about recently from another heart patient living with debilitating bouts of angina. She also happens to be an elite tennis player who plays almost daily. She has learned firsthand the benefits of preventive nitro therapy.  For example, before and again halfway through each tennis game, she sits down next to the court, takes a shot of nitro spray, waits five minutes and then starts playing. By doing this, she’s able to keep up her daily tennis games.

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.(3)

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.

Bernard Lown(1) 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.
(2) 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.
(3) 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

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Q:  Do you tend to delay taking your nitro for angina?

 

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99 Responses to “A cardiologist’s advice on how to use this “wonder drug””

  1. Mike Ellis May 17, 2017 at 6:45 pm #

    Cat scan showed I had heart disease, does that mean I have a blockage?

    Like

    • Carolyn Thomas May 18, 2017 at 9:38 am #

      I’m not a physician so cannot address your specific case, Mike, but I can tell you that these scans may be more accurate in ruling out heart disease than in necessarily confirming it. They can be good at picking up very early coronary plaques, especially calcified plaque. Talk to your doctor to make sure you understand exactly what your test does or does not confirm and what your next steps should be.

      Like

  2. NADEEM May 14, 2017 at 8:16 am #

    Nice article. My headache subsided after taking paracetamol.
    Alhamdu Lillah.

    Like

  3. Debra March 22, 2017 at 12:56 pm #

    I have been in the hospital just 7 days ago. I go to the hospital when I have chest pain, I get scared because my parents died of heart and stroke. But 8 years ago I had a mild heart attack. Sometimes I feel like I am going crazy.

    Like

    • Carolyn Thomas March 22, 2017 at 2:58 pm #

      Hello Debra – I’m not a physician so cannot comment on your symptoms. Please see your doctor for help. You are not going crazy, but you’re probably feeling very worried about this chest pain. Good luck to you…

      Like

  4. Gale March 11, 2017 at 10:38 am #

    Hi there, just been diagnosed with angina and unsure of at what stage do I use my spray? my chest feels tight, then my left arm feels tight, so do I take it before my arm goes like that?

    Like

    • Carolyn Thomas March 11, 2017 at 11:29 am #

      Hello Gale – you should double-check with your physician of course, but generally speaking, Dr. Lown suggests patients can safely use nitro preventatively (in other words, don’t wait until you have unbearable chest pain before taking it). You may have to experiment a few times before you get the hang of when and how often this works for your angina.

      Like

  5. Rita January 28, 2017 at 6:59 am #

    I just started taking 30 mg of imdur for the first time today. Will it help with discomfort in my chest? And do I need to check b/p – I have high blood pressure but take meds for that?

    Like

    • Carolyn Thomas January 28, 2017 at 7:27 am #

      Hello Rita – I’m assuming your doctor has prescribed the Imdur for you. Yes it will usually help to manage the discomfort in your chest. Follow the instructions from your doctor on how to take it, and call your doctor if you experience any distressing side effects. Headaches are the most common in the beginning, but often ease up as your body adjusts. Most people experience lower blood pressure while taking this drug. You might want to monitor your BP for the first few weeks to see how your body reacts to the Imdur.

      Like

  6. Robert January 17, 2017 at 9:39 pm #

    Can nitro be used after open heart surgery? I had a triple bypass and experience angina. Being diabetic I’ve been working hard at keeping my blood sugar low, but what’s good for diabetes is not always good for the heart, which concerns me too.

    Liked by 1 person

    • Carolyn Thomas January 18, 2017 at 4:44 am #

      Hello Robert – I’m not a physician so cannot comment about your specific case, but I can tell you that generally nitro is often given to patients after bypass surgery if some of the coronary arteries could not be bypassed. We know that people living with diabetes are at higher risk for heart disease. Please talk to your endocrinologist about how your cardiac diagnosis affects your diabetes. Best of luck to you…

      Like

  7. Mary Kay Osborne December 16, 2016 at 12:51 pm #

    i had 2 stents placed and afterwards I would get angina a lot. I was diagnosed with small vessel disease and I was told nitro was my friend, but last spring I came across a website about raising the head of your bed 6 inches, so my husband raised the head of the bed 6 inches and I have had very few episodes of angina. Haven’t had to take nitro since. Needless to say, I am very happy!

    Liked by 1 person

    • Carolyn Thomas December 16, 2016 at 7:49 pm #

      Hello Mary Kay – I’m not a physician but I can tell you that there is some (limited) evidence that raising the head of the bed may have some effect on reducing some people’s angina symptoms. Certain types of angina occur while lying down (but not necessarily sleeping) because the fluids in the body are redistributed due to gravity, and the heart has to work harder. For example, a small, short-term 1982 study on 10 patients published in the British medical journal The Lancet (Mohl et al) found that hospital patients placed in a sleeping position called the “reverse Trendelenburg position” for one night (bed inclined at a 10 degree angle, so that the head is higher than the pelvis and the legs are lower than hip) did result in relief of angina pain. We also know that raising the head of the bed is sometimes recommended for other conditions, e.g. to reduce nighttime acid reflux pain (GERD) or frequent nighttime urination or some blood pressure issues at night. It sounds like this is also working for your small vessel disease symptoms.

      Like

  8. Liselotte Poss December 15, 2016 at 11:23 pm #

    Very helpful in regards to the proper usuage of nitro. Honestly never thought that I would have a heart problem, aneurysm. Go figure, being a smoker–thought the lungs would get it.

    I do have one question: why does the nitro burn when dissolving under the tongue?

    Thank you a lot for time and honesty about your use of nitro. Now I am not afraid of the drug or continuous usuage.

    Lisa

    Liked by 1 person

    • Carolyn Thomas December 16, 2016 at 11:58 am #

      Hello Liselotte (what a lovely name!) – I’m not a physician so can’t answer specifically about that sharp burning or tingling taste when you take nitro. I can tell you, however, that if you don’t feel that typical sharp burning or tingling, it apparently doesn’t mean it’s NOT working. The only exception is if you accidentally swallow a nitro pill (in which case you should take another dose as it must dissolve under the tongue to work effectively). And always keep your physician up to date on how often you need to be taking nitro. Best of luck to you…

      Like

  9. Robert Lee December 11, 2016 at 7:44 am #

    I cannot tell you how helpful this has been. I am 68 now, 3 yrs ago I was diagnosed with Congestive Heart Failure (CHF) and consequently had test to check the arteries, etc. My arteries are perfect, my cholesterol is where it belongs. I have been told I have cardiomyopathy (weak heart muscle) and irregular heart rhythm.

    For three years I have been afraid to take the nitro. I was told that If I have to take the nitro I better be on the way to the hospital. That is scary! So I have not used it. This morning at 4am I woke up and felt bad w/dull chest pain. by 6am still felt bad could not lay down. Drank water because I am on ‘furosemide’ to drain water from heart and lungs. Water helped a little. At 7:30am got up and started searching “nitro heart what it does”. Your web page was second on the list.

    At 8:00am took one nitro tab. Exact symptoms as described, light headed, rush of coolness, small headache. Must have needed it sooner than 8 because it took until 9:10am for me to level out and start feeling more normal. I have been trying real hard to balance the drugs carefully so as not to have many side effects. Also on carvedilol. I have a cardiologist who works with me to keep the doses at the lowest possible limits so as not to overload my system.

    Liked by 1 person

    • Carolyn Thomas December 11, 2016 at 8:12 am #

      Thanks so much for your comment here, Robert. Whoever warned you that taking even one dose of nitro in the first place meant a trip to the ER did you a disservice. Generally, as Dr. Bernard Lown advises, you can take at least two consecutive doses before you need to call 911, and in the majority of cases, either the first or second dose will do the trick. Talk to your cardiologist about taking nitro so that you are no longer scared to take this important and effective drug. Best of luck …

      Like

  10. CR December 8, 2016 at 11:15 am #

    This article was helpful. It helped relieve the fear and apprehension of using nitro spray on a regular basis. I am in pain, even at rest. However, afraid to use the spray to be more mobile. Fear of the unknown.

    Time to do some experimenting.

    Liked by 1 person

    • Carolyn Thomas December 8, 2016 at 11:13 pm #

      Good luck with your experiment, CR – just take it slow. If you’re in pain even at rest, you might also consider discussing the possibility of a prescription for a nitro patch rather than pills or spray.

      Like

  11. Amanda B October 8, 2016 at 10:00 pm #

    Thank you for sharing this information. My boyfriend’s dad had a heart attack about 6 years ago and more recently was diagnosed with angina. Over the past 5 months or so he’s been slowly experiencing more frequent and painful episodes. He’s seen his doctor and even had a couple stays in the hospital while he had tests done but his diagnosis was still angina.

    His symptoms have been keeping him from living his life, preventing him from doing anything he used to enjoy. So although he was prescribed nitroglycerin and has taken it before a few times for bad episodes, this is the first we have heard about the possibility of it being used for maintenance rather than an acute flare-up. We’re going to ask his doctor about this at his next appointment. So thank you again for providing a new avenue for us to look in to and hopefully maybe help him get his life back.

    Liked by 1 person

    • Carolyn Thomas October 9, 2016 at 5:04 am #

      Hello Amanda and thanks for your comment. I wonder if his doctor is aware that he isn’t using his nitro as needed? For example, is the nitro not working to address those bad episodes? If it is working, then taking it as needed at the start of an angina attack (not waiting until it’s so bad you have to go to hospital) could be the way to go. If the angina is what’s keeping him from doing what he loves doing in life, but he’s not taking his nitro that’s been prescribed for that angina, no wonder he’s suffering! The patient has to be willing to use the tools the doctor gives him. Best of luck…

      Like

  12. Catherine Santorelli October 7, 2016 at 8:39 pm #

    Very good article. I’ve always thought that if I took nitro too often it would lose its effectiveness. Now I see that’s not true. I was diagnosed with Prinzmetal Angina. It happens so often that I’ve been given isosorbide mononitrate to take daily. I have 3 stents but no blockages. Just the angina from spasms. It’s hard to live with because each time I think “Is this another heart attack?”. I’m 71 and live alone. I’m frightened of dying.

    Like

    • Carolyn Thomas October 8, 2016 at 5:21 am #

      Hello Catherine – I’m sorry you are going through this. I can sure remember that awful feeling (“Is this something? Is it nothing? Should I call 911?”) and it’s both exhausting and frightening. It is true that the body can build up a tolerance for long-acting nitro (specifically when wearing a nitro patch, for example, which is why patch wearers must give the body a break by taking the patch off overnight). Just double-check with your doctor about taking “breakthrough” doses of nitro as needed while you’re already on your Imdur (isosorbide mononitrate) – and if you do take breakthrough doses, make sure you’re sitting down as the effect can cause you to be light-headed. Many patients do take breakthrough doses even on a patch that are effective.

      Like

  13. CJ Osborne September 21, 2016 at 8:36 am #

    Thank you for posting this information. I’ve avoided taking my nitrostat for fear of headache, but you’ve covered how to help with that also. Understanding that it can be used without dependency or lessening its effectiveness is very reassuring. I better understand why my cardiologist recommends using it instead of enduring occasional angina.

    Liked by 1 person

    • Carolyn Thomas September 21, 2016 at 12:19 pm #

      Hello CJ – that’s just how I felt too before reading Dr. Lown’s very useful advice! I used to deliberately postpone taking nitro for angina, choosing to tough it out instead! Not any more! Remember: “Nitro is your friend”!

      Like

  14. Geraldine Matus September 10, 2016 at 4:54 am #

    Thanks for this helpful article. I’m beginning to better understand how to manage my heart health.

    Liked by 1 person

    • Carolyn Thomas September 10, 2016 at 6:04 am #

      Hi Geraldine – glad you found this helpful. Dr. Lown’s advice should be given to every patient taking nitro for angina!

      Like

  15. Mike August 6, 2016 at 7:13 pm #

    Wow! This is the best info I have ever read on how and why I should take my nitro tablets, even among medical websites I have read. I have been taking my tablets occasionally since my heart attack three years ago, early on, “waiting” as you point out, to see if the angina would go away on its own, or wondering if it was actually angina or perhaps just a nerve or chest muscle twinge.

    I learned to take it any time I first feel pain. Your article is very reassuring and is helpful to those who often have doubts whether we should be using it so much. Thanks for helping us.

    Liked by 1 person

    • Carolyn Thomas August 6, 2016 at 7:31 pm #

      Thanks so much for your perspective, Mike. I now take Dr. Lown’s further advice (taking a preemptive dose of nitro before I do something that I know from experience has previously caused angina). This works really well, too…

      Like

  16. Lukus July 1, 2016 at 8:28 pm #

    Awesome article. Thanks for the well laid out facts and tips.

    Liked by 1 person

  17. Trevor Cushman March 11, 2016 at 12:48 am #

    In the last 6 months I had a couple of stents put in and I was afraid what was going to happen next. They put me on Plavix and Lipitor; even though I didn’t have high blood pressure or high cholesterol numbers, they said once you get a stent it skews the numbers where what used to be good is no longer a good number and they also gave me Nitro.

    I’ve had the bottle for about 6 months and have been afraid to try it to this day. I don’t know why, I guess that’s part of being human. I was just scared. Well I was laying down tonight and the chest pain got worse so I decided to try it after reading the above article.

    I’d like to say thank you to the doctor who wrote that. I don’t know if you just saved me from discomfort or if you saved my life – thank you.
    Sincerely yours
    Trevor S Cushman

    Like

    • Carolyn Thomas March 11, 2016 at 4:57 pm #

      Hi Trevor – what a great example of how a simple medication like nitro does exactly what it’s supposed to do. Remember: “Nitro is your friend!”

      Like

  18. Christiana January 24, 2016 at 2:17 am #

    Is it common for nitro pills to give a nervous type feeling after you take it? I know the headaches are but I get a little anxiety and a nervous shaky wired feeling too.

    Liked by 1 person

    • Carolyn Thomas January 24, 2016 at 6:13 am #

      Hi Christiana – I haven’t head the term “anxiety” specifically, but it is common after a dose of nitro to experience dizziness or lightheadedness. I wonder if that’s what’s causing your reactions? The other thing to remember is that you’re taking nitro during a bout of chest pain, which may or may not mean an impending cardiac event – that’s enough in itself to make us anxious.

      Like

    • Adrienne Ottaviani March 11, 2016 at 5:05 pm #

      Does an EEG show angina?

      Like

      • Carolyn Thomas March 12, 2016 at 5:52 am #

        I’m guessing you mean EKG (study of electrical activity of the heart) not EEG (study of electrical activity of the brain) in which case the answer is “not necessarily”. About 40% of women, for example, experience no chest symptoms at all during a heart attack, and some people who have angina have normal EKGs.

        Like

  19. Les January 11, 2016 at 11:46 pm #

    How many times a day can you take nitroglycerin?

    Liked by 1 person

    • Carolyn Thomas January 12, 2016 at 5:58 am #

      Depends. I’m not a physician so can’t offer you specific advice for your situation, but my understanding is that if you’re taking nitro for an episode of chest pain, you should follow the 3-dose max as described above before seeking medical help. If, like me, you’re taking one dose a number of times throughout the day as needed, or if you’re finding that the oral spray/sub-lingual pill is no longer effectively managing symptoms, talk to your physician about extended-release capsules or a nitro patch instead.

      Like

  20. John Ferth December 13, 2015 at 12:32 am #

    Get the spray. Carry it with you all the time. Chest pain, too cold, big meal, before sex, sit down, spray under the tongue, relax a bit. There will be no headache after a while. $30.00 in Canada, you no longer need prescription, good for 3 years. It really works for me since a 1994 valve replacement and bypass. It is a miracle drug. And use it! Don’t be afraid.

    Liked by 1 person

    • Carolyn Thomas December 13, 2015 at 7:32 am #

      Hi John – like you, I carry my nitro with me 100% of the time, and like to use it pro-actively (like before a big hike) rather than wait for angina to become severe. I’m Canadian, and I still need my doctor’s prescription for nitro ($27 was the cost for my last refill) – yet non-Canadians can get it from mail-order pharmacies with no prescription?

      Like

  21. Frank McCambridge October 28, 2015 at 3:55 pm #

    I have used Nitro (as needed, for Angina) for fifteen years. Due to a move, I had to go to a different Cardiologist. She said that I should not use it and seemed to think that it was a very bad drug.

    Liked by 1 person

    • Carolyn Thomas October 28, 2015 at 5:27 pm #

      Hello Frank – if I were you, I’d be asking that cardiologist for the journal references behind her comment. I have never heard of telling heart patients with angina to stay away from nitro. Perhaps you are now on other meds that are contraindicated when taking nitro? A mystery….

      Like

  22. bveltrop72 July 27, 2015 at 4:32 pm #

    Oh Carolyn! Thank you for sharing this. I’ve always taught my cardiac patients this at discharge but not all nurses are created equal. hahaha

    By the way. Mom has found altitude changes affects her microvascular heart disease. I don’t know if you have also noticed this. BV

    Liked by 1 person

    • Carolyn Thomas July 27, 2015 at 5:07 pm #

      Thanks Beth – I sure wish all nurses (and docs) would do as you have done with nitro instructions, too! I had to accidentally stumble on Dr. Lown’s advice years after my own hospital discharge.

      Re MVD: I’ve been really surprised by factors that can significantly affect my symptoms (e.g. altitude, hot weather, cold (even in the frozen food aisle!), emotional stress – like being late for an appointment, etc etc.

      Liked by 1 person

  23. Jane June 17, 2015 at 11:20 am #

    I wonder about the effects of chronic preventive nitroglycerin use, and what the potential effects are. Say you’re taking the nitro before every physical exertion. How many times a day might that be? Are patients advised not to exceed certain amounts?

    Liked by 1 person

    • Carolyn Thomas June 17, 2015 at 8:34 pm #

      Hello Jane – I’m not a physician of course so cannot advise you on your specific case; you should ask your own cardiologist about this. Depending on the type of nitro you’re on (pills, spray, patch), there can be maximum daily dosage recommendations.

      But as Dr. Bernard Lown points out, preventive use of nitro is to be generally recommended for angina patients as opposed to waiting until after extreme angina pain has already struck. For example, I met a heart patient at Mayo who was an elite tennis player who played every day. She took nitro before each match, and then halfway through, she stopped, sat down on a bench, took another spray of nitro, waited five minutes and then was able to finish her game. She had been doing this every day for years, two sprays per day, and only for her tennis matches – as a preventive.

      We do know that there is such a thing as nitro tolerance that can develop in those wearing a long-acting nitro patch (it’s why they must take a 10-12 hour break from the drug to prevent that tolerance – short periods of nitrate absence from the body help to minimize this tolerance). Too much nitroglycerin can mean the drug stops working as well in controlling our symptoms. But it is possible to overdose on nitro – again, check with your cardiologist if you need more info.

      Like

  24. June Gordon March 28, 2015 at 3:49 am #

    Thanks, Carolyn, for the wealth of information. I am new to heart attacks and nitro, having just had a triple by-pass in December, 2014. Now that I have read so much about nitro, I will no longer be nervous about using it when necessary. I just had an angina attack and was afraid to use it with the nitro patch, and that question has still not been answered. My doctor told me to wait 24 hours after applying the nitro patch, and if the pain was still there I should head for the emergency room. I am going to take a chance on the nitro spray (in the correct position) the next time the pain starts up.

    As for the cost, seniors in Canada are fortunate as the nitro is covered by our health plan, other than the dispensing fee, which varies depending upon the pharmacy. Everyone should check out Walmart and Costco prices. You don’t need to be a Costco member to use the pharmacy. I am shocked at the prices some people in the U.S. are paying. There has to be a better way! Good luck to all.
    June

    Liked by 1 person

    • Carolyn Thomas March 28, 2015 at 5:33 am #

      Thanks for sharing your perspective here, June – there’s very little in the literature about taking nitro spray/pill while wearing a nitro patch. One resource suggests that sublingual (spray/pill) “may not work as well while you are taking nitroglycerin patch”. Double check with your cardiologist. Best of luck to you…

      Like

  25. Susan McCoy March 25, 2015 at 11:38 am #

    A very informative article, sounds like myself waiting to take nitro or not wanting to because of fear of a bad headache, but after reading this, it makes a lot of sense and rings so very true.

    So from now on, I will no longer wait sometimes hours I would wait to take my nitro and suffer. No more, but it’s important to have fresh nitro, get rid of your old out-dated nitro because it doesn’t work as well as we all should know.

    For now I keep it in three places: my purse, car, and bathroom. Thank you for the great information that makes a lot of sense.
    Sue McCoy

    Liked by 1 person

    • Carolyn Thomas March 25, 2015 at 12:40 pm #

      Thanks Sue – always a good idea to check the expiration date of your nitro (as it is with all meds). This may be particularly true for nitro pills/tablets – often recommended to replace every six months. Tablets are also especially sensitive to moisture, so should be stored in a dry location at room temperature (never in a high-humidity bathroom or kitchen – if you use a nitro spray, this isn’t an issue). While some studies have found that about 90% of most medications are likely safe and effective even 15 years past their original expiration date, the FDA now advises consumers NOT to use expired meds. Over time, the chemical composition of the drug may change, meaning that there’s no guarantee it will still be either effective or safe.

      Like you, I make sure I’m never far away from my nitro no matter where I go!

      Like

  26. Rich March 12, 2015 at 6:43 am #

    Question regarding Nitro patch.

    Roughly how long does it usually take for the nitro to be taken up by the body so as to begin having an effect? Are we talking 5 min. or 20 min etc?

    Like

    • Carolyn Thomas March 12, 2015 at 2:19 pm #

      Hello Rich – Nitro patches are used to prevent angina, but not to treat an attack of angina once it has begun. Generally (at a dosage of 0.4 mg per hour) it can take up to two hours to reach maximum concentration in the bloodstream, but most patients begin to notice first effects within an hour or so. (The typical “nitro headache” side effect may start an hour after patch application, for example). Patients are often prescribed a minimal dose patch at first that’s adjusted over time if angina symptoms persist. Ask your cardiologist for specifics. If you’re using a nitro spray (on or under your tongue) instead of a patch, it takes effect almost immediately to treat acute attacks of chest pain, within 3-5 minutes usually. Nitro tablets (also placed under the tongue or between cheek and gum) dissolve very quickly too.

      Like

  27. autocreate March 1, 2015 at 2:37 pm #

    Reblogged this and commented:
    To My Dear Brave Heart Sisters,
    We can’t have too much information about tackling heart disease. Read on.

    Like

  28. Tacey September 20, 2014 at 9:14 am #

    Thank you for this article. I keep coming back and rereading it over and over again and telling myself nitro is my friend. I am struggling.

    Like

  29. Jane January 24, 2014 at 10:03 am #

    Bronwyn – I have bad doctors as well. This isn’t the section in which to ask, but I wonder what this arrythmia has been doing for 4 years. I would think it is a benign condition? I know. More question marks.

    I was given nitroglycerin tablets for alleged angina. (It is alleged because the consult I had with another cardiologist told me I needed zero heart medications). I took it one time in the presence of nurses, so I would see what it was like. It took me two days to feel right again. May we all get the quality care we need.

    Like

  30. Quality Health Care, Please August 27, 2013 at 11:00 am #

    Nitroglycerin comes in several useful forms: the small pill you put under your tongue ($), a pressurized under the tongue spray ($$$), long acting pills ($$), long acting trans-dermal patches ($$$) and long acting topical paste ($).

    Quick acting nitro and nitro paste are both generic and low cost. But, I looked at the Walmart $4 prescription list and did not find either — so watch out for price gouging and shop around.

    Liked by 1 person

    • Carolyn Thomas August 27, 2013 at 11:11 am #

      Good advice, Dr. Beckett. Thanks for this. At GoodRx, I found nitro tabs for as little as $8.87 (in Seattle, with their free coupon – just enter the name of your city to find comparable coupon deals).

      Like

    • Leigh December 16, 2015 at 6:56 am #

      As of yesterday when I filled the first prescription of the nitro tablets for my husband, 4 little bottles cost $78 at my local Walmart. Considering how long it’s been around, I was shocked.

      Like

      • Macanandho In WI January 16, 2017 at 8:46 pm #

        Walgreens now have generic nitrostat. I then got doc to prescribe 4 bottles so I can keep in bedroom, coat pocket, key chain pill holder, basement where I do workouts, and my wife has one in purse. Cost me under 10.00 dollars for all with my insurance vs 25.00 for just one. Mine is fast acting type tabs that I prefer over spray because I potentially feel (probably more psychologically) secure for me personally it is more reliable delivery and not suseptable to malfunction if needed in emergency, though spray is easier/convenient .

        Like

  31. The Accidental Amazon August 24, 2013 at 7:31 am #

    Carolyn, this is great info! I’m going to pass this on to my nurse/PT colleagues.

    It’s also an amazing coincidence to see that this wisdom comes from Bernie Lown. Years ago, back in the early 1980s, I worked as the admin assistant for the national director of Physicians for Social Responsibility, the North American counterpart to Bernie’s group, IPPNW. It was a crazy time, when we were all trying to speak out on the medical consequences of nuclear weapons & help defuse the Cold War, while Reagan was planting nuclear weapons all over Europe.

    Bernie was on our Board of Directors & I got to meet him several times. He was a lovely man, and his patients are very lucky that he is still practicing with his usual thoughtfulness & compassion. Small world, isn’t it?

    xoxo,
    Kathi

    Liked by 1 person

    • Carolyn Thomas August 24, 2013 at 7:43 am #

      Thanks so much, Kathi. That is indeed a small world coincidence that you know “Bernie” Lown personally. It’s pretty impressive that, at age 92, he launched a (terrific!) new blog with his granddaughter, Melanie.

      Like

      • The Accidental Amazon August 25, 2013 at 3:29 am #

        And wouldn’t you know, his current post is about how the ‘big business’ of medicine can drive treatment decisions that are not based on clinical data. A subject both you & I have blogged about.

        I’m certainly bookmarking his blog!

        Liked by 1 person

  32. Kay Storey August 21, 2013 at 7:52 pm #

    I have quite low blood pressure so I am afraid to use it. I have a low dose but afraid I will pass out. So far my angina goes away with rest.

    Like

    • Carolyn Thomas August 21, 2013 at 8:12 pm #

      Hi Kay – what Dr. Lown tried with his heart patients was to have them take a trial dose while sitting in front of him so they could each assess its impact safely. I always try to lie down if possible for each dose to avoid feeling light-headed or faint (sometimes it’s not possible, so I sit – I never stand up until several minutes go by after the dose). If your angina is well-controlled by rest, that seems to be working for you. If rest doesn’t relieve it, nitro becomes your “just in case” therapy.

      Like

  33. Nitro Mama August 20, 2013 at 3:31 pm #

    This was very informative. I always carry my nitro with me. I use it about once a month. My headache is fleeting.

    Liked by 1 person

    • Carolyn Thomas August 20, 2013 at 9:46 pm #

      Nitro Mama, always best to carry your nitro with you just in case, right?

      Like

  34. jdegrand August 19, 2013 at 6:42 pm #

    Carolyn, once again you have given me such useful information. I have been using my nitro tabs for 2 years without gaining the full benefit. I have re-posted on Inspire and shared a click through link to your story. Thank you, I appreciate you so very much! Jana

    Liked by 1 person

  35. Kaylen Miller August 19, 2013 at 12:06 pm #

    I don’t always carry my nitro with me and have only had angina one time – right before I was admitted with a 99% blockage. Because I had no symptoms prior to such a severe blockage, I tend to think that nitro isn’t really going to be necessary before it’s too late for nitro.

    My nitro is in a little glass bottle and when I had it in a plastic keychain designed for pills, the nitro became just powder.

    The pharmacist said it must stay in the glass vial and I shouldn’t open it if not necessary… as one of the few females who rarely carries a purse, carrying the little glass vial of pills isn’t something I feel inclined to do – and especially since I have never had to use it.

    I really appreciate this article though, as I have had really negative feelings about taking a pill if the need arises. I also had no idea the proper way to take it – I assumed I should just sit down and try to relax.

    Thanks for this really helpful info!

    Liked by 1 person

    • Carolyn Thomas August 19, 2013 at 4:24 pm #

      Thanks Kaylen. You may never need to take your nitro, but it helps to be prepared and informed ahead of time JUST IN CASE. . .

      Like

    • Jane January 24, 2014 at 9:52 am #

      I wonder why nitro isn’t available in a blister pack.

      Liked by 1 person

  36. Mary August 19, 2013 at 9:00 am #

    Carolyn,

    Wonderful post! If I may, I will add a few more tips?

    1) Nitro can be used on an as-needed basis or on a prophylactic basis. My own cardiologist has suggested using it if I am about to do something more effortful, such as going for a walk or lightly exercising. I find that I do better when it’s cooler, so a lower temp may allow me to not need nitro, if I warm up slowly.

    2) Some don’t realize that spray and/or a tablet under the tongue is absorbed by keeping your mouth closed. Don’t spray and talk, as this dissipates the environment it needs to perform for you. Sit down or lie down and allow it to work. Don’t keep the demand high while your heart is recovering from an oxygen deficit. BTW, the heart receives the oxygen from BLOOD FLOW. Your vessels are temporarily boosted (dilation) and more flow is happening, bringing you more oxygen.

    3) Every time I used nitro for about a year, (more the tablet), I would inevitably cry. I really don’t know why except I felt like I was rescuing myself from near-death heart attack. The doctors are right, take it early before ischemia becomes established. It’s harder to rid yourself of it once it’s entrenched. If your ischemia is “refractory”, as in the tablet or spray works for a bit, then the pain comes back, you are in a chronic deficit due to your activities, emotions or temperature (or other reasons). This means your body wants you to lie down and let it recover.

    4) When I decided to switch to a low dose 12 hour nitro capsule (Nitro-Time), it gave me more capacity generally. I highly recommend this if you need to spray more often. After a few days of taking this, and yes, you can take it just during the day or on a 24 hour basis, the mild headache will subside. Better yet, take a Tylenol when you take the nitro and avoid it completely. Dry eyes are sometimes a side effect of the nitro, so you might need some moisturizing drops (not Visine).

    5) Remember that for about 20 minutes, the body can be working to compensate for the lack of oxygen and might have SILENT ISCHEMIA. This condition is not a good thing for your heart, as it’s oxygen deficient. That’s why you shouldn’t wait it out for a long time when you do use nitro. Silent Ischemia can have microscopic level damage, and just because you can’t feel it, doesn’t mean you should tough it out. As the cardiologist says, use the nitro sooner rather than later. It’s better for your body.

    Last of all, when they suggest using nitro DURING INTERCOURSE (!?!), I think most of us would have to laugh although it’s a serious suggestion. I don’t know too many people who would be in the mood or be determined enough to cheerily spray nitro for that pesky chest pain during sex. (“Hold on sweetheart” ..spray.. “Are you ok?” Said with mouth closed, muffled: “Oh, yea..where were we?”) For most, it would be a slight mood dampener.. But I guess the doctors have to have an answer to give us! Better yet, take the long acting version, or a bit of Xanax prior to the festivities…

    All the best!

    Mary

    Liked by 1 person

    • Carolyn Thomas August 19, 2013 at 2:44 pm #

      Lovely to hear from you, Mary and thank you for this comprehensive list of handy tips! So interesting about your experience crying when you used your nitro – I often feel like crying, but not from relief at dodging another heart attack. It’s more like: “NO! NO! NO! NO! NO! Today is NOT a good day for me to go back into hospital!”

      Like

    • Nan Linden October 28, 2014 at 10:13 pm #

      Actually I do know of a couple – they were having sex, and the husband just collapsed & died in front of his Wife. He was never known to have heart trouble. So it was quite a shock for the poor woman.

      Like

  37. Sandy August 19, 2013 at 7:33 am #

    I use the nitro pill under the tongue and yes you do get a headache but it doesn’t last long.

    The patch for me was a nightmare. I lived with a constant headache even with the lowest dose. The only thing I disagree with this article is that nitro is no longer “inexpensive”. It is now a level 3 on my insurance which makes it well over $100. in cost. When I first started taking it 20 years ago it was less than $5.00. Due to the cost I take it sparingly I will admit. My other heart medications are expensive and I get thrown in the “donut hole” by mid year and have to pay 100% of my drug cost which I cannot afford to do, therefore some of my medications are taken every other day or not at all.

    I am so scared what is going to happen when Obamacare kicks in. Sorry, I didn’t mean to get off the track. Bottom line is I really do need the nitro on a consistent basis but can’t afford to do so.

    Like

    • Carolyn Thomas August 19, 2013 at 8:11 am #

      Hi Sandy – glad your nitro pill seems to do the trick, and minus the headache. A couple years ago, we heard U.S. reports of the price of nitro jumping (up from $69 to $276 for example from one of my readers) amid recalls of some generics. Mine is called Mylan-Nitro 0.4 mg spray – $27 for a 6-month supply; this is a brand name drug available here in Canada. At GoodRx, I found nitro tabs for as little as $8.87 (in Seattle, with their free coupon – just enter the name of your city to find comparable coupon deals).

      Like

      • Sandy August 19, 2013 at 7:51 pm #

        You are very fortunate to be able to get it as such a low cost. Unfortunately mine is over $200 so I will be going without it. Here is what the insurance companies don’t seem to understand. When we are denied our medication due to cost, we are in the hospital more and in the long run it is costing them much more. They just don’t seem to get it.

        Like

        • Carolyn Thomas August 20, 2013 at 7:28 am #

          Tragic. This is why busloads of American patients take daytrips up to Canada, prescriptions in hand, to buy their meds here. Canadians are fortunate in many ways besides our nitro costs when it comes to health care.

          Like

          • Sandy August 20, 2013 at 7:33 am #

            Do you know if we can buy them thru the internet from Canada.

            Like

            • Carolyn Thomas August 20, 2013 at 7:47 am #

              Check the bottom of that “buy their meds here” link for more info. Meanwhile, just heard from another American heart patient who says her 30-pill vial of Nitrostat costs $16 from Wal-Mart.

              Like

            • chronicconcerns September 3, 2013 at 2:57 pm #

              I have a friend who buys nitro spray from a Canadian company for about $30 (last time she told me the price. I think that was for two bottles. It was an English brand and they flavor theirs like brandy instead of like peppermint like we have in the states.

              Like

    • Anna August 10, 2014 at 9:27 am #

      It cost pennies in other countries and doesn’t require a prescription. 40 capsules for 14 rubles= $0.387. Ask someone to buy who travels.

      Like

  38. Julia August 19, 2013 at 6:59 am #

    A great and timely article thank you! I have used all the excuses you listed.

    Now, I am more likely to use my nitro tabs as many questions have been answered.

    Liked by 1 person

  39. Bronwyn Elaine August 19, 2013 at 6:24 am #

    The nitro gives me a headache, within 11 minutes, that last for 24-36 hours. I don’t take it for that reason. When I get that excruciating chest pain (angina) I am halted in my tracks. Brought on by exertion or duress, I stop and suffer through approximately 6-7 minutes as the pain subsides. Then I go on without that debilitating nitro headache which always hangs on like I’ve been clubbed with a mallet, leaving me sensitive to light and sound and incapable of doing much more than crying in the dark for a full day.

    Would the spray be better? The patches bring in a dull, lasting headache within an hour. I don’t use nitro for the aforementioned reason; debilitating, long-lasting headache.

    Like

    • Carolyn Thomas August 19, 2013 at 6:45 am #

      Hello Bronwyn – yikes! That’s quite a reaction to your nitro! I’m assuming that your nitro patch was the lowest dose possible (0.2). Not sure if there’s any difference in side effects between spray, pills or patch – consult your doc for this; doctors should be made aware of cases like yours. If your community has a Regional Pain Clinic, ask your cardio for a referral there, too. My pain specialist told me that heart patients like me, suffering with intractable angina are, sadly, rarely referred to him.

      Many patients experience horrific headaches at the beginning of nitro therapy, but these typically diminish over time. Trouble is, if you’re suffering debilitating 36-hour migraine-like headaches, you’re unlikely to be willing to wait patiently for this kind of pain to subside while your body gradually adapts to nitro. Many times, taking a Tylenol 10-15 minutes before taking nitro can ward off headache (although that appears to be longer than the duration of your chest pain). Again, consult your cardiologist on this. Also read this article about TENS therapy for angina (my cardiologist prescribed this non-invasive, non-drug therapy for me a few years ago, and wearing my TENS unit morning to night has significantly reduced my need for nitro). Best of luck to you!
      C.

      Like

  40. Sharon August 19, 2013 at 5:00 am #

    Carolyn,
    You write the most thorough and informative posts! Each and every one is amazing. They have a way of making my life seem more “normal” as I learn to live with chronic angina. Thank you for all you do!

    Liked by 1 person

    • Carolyn Thomas August 19, 2013 at 6:16 am #

      Thanks so much for your kind words, Sharon. Thanks also for introducing me to your blog – I love it and just subscribed this morning!
      Take care,
      C.

      Like

      • Mirjami August 24, 2013 at 9:24 am #

        What a great recherche about the “wonder drug”, Carolyn. Thank you for that.

        I also read the “Coronary Artery Entrapment” of Dr. Lown. With my own almost 30 years experience with nitroglycerin I would undersign every word of Dr. Lown. I have used nitro tablets (5mg to bite) in all 8 circumstances and I still use.

        Like you I would not leave the house without my pills. It was so good to read about Dr. Lown and get confirmed my own ideas. I do not get any headache from 5 mg tablets. Nitro spray I do not like. They give it in the hospital and I get headache of it. Tablets have another advantage: You can take them secretly. It could be a bonbon. I do not make much fuss of taking nitro or not. Nowadays I could say I have taken nitro tablets more prophylactically than before.

        I 2003 I met a 50 year old woman. She was in rehab with me. She did not even know what nitro spray or tablets were. She had got a stent and had had a sudden cardiac arrest.

        Liked by 1 person

        • Carolyn Thomas August 24, 2013 at 12:20 pm #

          Thanks so much for your comment here, Mirjami, and for reminding us of one big advantage of nitro pills – you can take them without drawing any attention to what you’re doing! Can’t do that when you’re spraying nitro. . . P.S. That rehab story is incredible, isn’t it?

          Like

          • chronicconcerns September 3, 2013 at 3:02 pm #

            I think it rather looks like breath spray, myself. Also the spray has a 2 year shelf life and does not start degrading as soon as you open the bottle like the tablets. I got caught out with tabs that were too old at yoga one time. They were maybe 6 weeks post opening the bottle and somewhat weak at that point. I almost had them call EMS for me that time. I had to take 5 to get things calmed down.

            The spray has never let me down, and I am a frequent user.

            Liked by 1 person

            • Carolyn Thomas September 3, 2013 at 3:18 pm #

              Yes! Good idea – think of nitro as if it were breath spray. The spray can last 2-3 years before degrading (check the expiry date on the canister). Here’s a good tip to figure out how much is left in your spray canister: Place it in a bowl of water. The closer the canister floats to the surface of the water, the less medicine is left inside. Cool ay?

              Like

              • Bronwyn Elaine Streich September 4, 2013 at 7:34 am #

                Those of you who can use nitro are lucky. I have no relief from the pain (unless I just sit still and never get upset). Nitrostat gives me a whopping headache that lasts nearly a day. I have tried tablets and patches to no avail. Even the patch for a short period brings the horrible headache. I feel helpless against microvascular coronary disorder. Thank you for listening.

                Like

                • Carolyn Thomas September 4, 2013 at 7:40 am #

                  Bronwyn, has your cardiologist considered TENS therapy for angina? Non-invasive, non-drug.

                  Like

                  • Bronwyn Elaine Streich September 4, 2013 at 8:05 am #

                    Yes, we tried that after I read about it on this site. It did not work for me, seemed to exacerbate the issue. Now I’ve been told that I have had an arrythmia since 2009. I am scheduled to see an electrophysiologist. It’s like what came first? The chicken or the egg? I feel like the doctors I’ve seen either don’t care or don’t know how to treat me. Look at all the heart meds available! Is there a combination that could bring relief? Thank you,

                    Like

Trackbacks/Pingbacks

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  2. Purathrive Review - October 4, 2016

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