by Carolyn Thomas ♥ @HeartSisters
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 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 taking 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 the late pioneer 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 or windy weather
- Hot weather
- Exertion
- After a heavy meal
- Stress
- 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”
How to take your nitro:
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. *See below for an updated version of this recommendation from Chicago cardiologist Dr. John P. Erwin.
Here’s how it works if you’re using a nitro spray or tablets:
1. 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.
2. If not, take a second dose (as above). Wait another five minutes.
3. 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 that today just might be the day you have to go back to hospital to seek medical attention.
NOTE: *Dr. John P. Erwin contacted me in May with this updated recommendation on the Rule of Three: “When I started practice, my teaching to patients was exactly the same as Dr. Lown ’s. We have subsequently updated our recommendations such that if the chest discomfort has not completely resolved five minutes after the first dosage, one should call 911 and then take the second nitro. In part, we changed our recommendations knowing that people held off too long for the first dose. . . Even if they take the other two doses 5 minutes apart, that’s 20-25 minutes of angina. I prefer to see the patient before profound heart muscle injury.”
Dr. Lown was right about taking nitro preventively – instead of waiting until the pain becomes unbearable. 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 we know that nitroglycerin is most helpful when taken at the first onset of chest discomfort – rather than after it has been present for several minutes.
For most patients living with regular angina symptoms, I have this advice based on Dr. Lown’s work:
“Nitro is your friend!”
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. Many patients find this side effect eases up over time. 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 liked to quote 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 tablets or spray 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 long-acting transdermal nitro patch.
If you’re using a nitro patch, by the way, you’ll likely be told to take a 10-12 hour “patch break” each day. This will help to reduce the risk of developing a tolerance to the drug (which could mean it won’t work as effectively to manage your angina symptoms). So you’ll be wearing a new patch each day, wearing it for 12-14 hours, discarding that patch and next morning starting again with a new patch. Read the product instructions carefully and always follow your physician’s specific guidance. And never, ever cut a patch in half.
UPDATE: In animal studies by Stanford University researchers, when nitroglycerin is given for hours as a continuous dose (16 hours+), nitro could eventually be harmful if it destroys an enzyme called ALDH2, which is responsible for converting nitro to nitric oxide (the compound that dilates blood vessels and increases blood flow to the heart muscle). Giving the enzyme activator called Alda-1 seemed to reverse the effects of the nitroglycerin. NOTE: This was an animal study, which essentially means it is bad news if you’re a mouse. No human studies have yet been published. And a patent has been filed by Stanford University for the therapeutic use of Alda-1 to target ALDH2 (which represents a potential financial conflict of interest that Stanford researchers are required to disclose).
While many heart patients now 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 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: This post should not be interpreted as medical advice. See your own physician for more information about chronic angina or nitroglycerin. Nitro is not recommended for certain patients – find out if you’re among this group.
♥
NOTE FROM CAROLYN: I wrote more about the important topics of addressing angina pain in my book, “A Woman’s Guide to Living with Heart Disease” (Johns Hopkins University). You can ask for it at your local library or favourite bookshop (please support your independent neighbourhood booksellers!) or order it online (paperback, hardcover or e-book) at Amazon – or order it directly from my publisher, Johns Hopkins University Press (use the code HTWN to save 30% off the list price).
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(1) The late Dr. Bernard Lown, author of The Lost Art of Healing: Practicing Compassion in Medicine, was 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 known first and foremost as a pioneer cardiologist who practiced 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.
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Q: Do you tend to delay taking your nitro despite angina pain?
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Heart Sisters 
I have spent the last hour trying to find information on use of nitrolingual pumpspray when you haven’t been prescribed it or diagnosed with angina. Just wondering if that’s dangerous / what would happen?
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Hello Rayleigh,
I can’t imagine why anybody would want to take nitro who hasn’t been prescribed nitro or diagnosed with angina. I’m not a physician, but I can tell you generally that you’d likely be experiencing headaches, flushing, rapid heartbeat and restlessness. Nitro is a vasodilator, meaning it helps to widen blood vessels – ALL blood vessels, including those that feed the brain, which is why the famous nitro headache is so common.
If you don’t need it, don’t take it.
Take care. . .
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Dear Heart Sisters readers: this comment has been deleted because I don’t like to expose my readers to gobbledygook. . .
You’re welcome. ♥
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I found this very informative. So thankful to have found this article.
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This article was very informative.
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I take nitroglycerin for chest pain, which I may have daily. My problem is the prescription is for 25 tabs that my pharmacy will only refill every 8 days, but I use them up before the 8 day refill period. Consequently, I may go days without any nitroglycerin because the pharmacy won’t refill the prescription. How can I get nitroglycerin when I need it?
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Hello David – I believe it depends on where you live. In some countries (e.g. in the UK as GTN) nitro is available over the counter without a prescription. I’ve heard from some of my American readers that they have ordered brand name nitro (e.g. Nitrostat) without prescription from Canadian mail order pharmacies.
It also may depend on whether your nitro tabs are taken only as needed in response to angina pain, or if your doctor’s prescription recommends taking tabs preventatively 3-4 times per day every day with or without angina symptoms. You didn’t mention if you are experiencing chest pain during those days when you have already run out of your nitro tabs.
I’m not a physician but I’m assuming generally that if you’re running out of your 25-tab supply within an 8-day period, you’re taking approximately three tabs per day, every day. I wonder if you have talked to your doctor about nitro trans-dermal patches (usually sold 30 per pack) – often prescribed for persistent angina that occurs every day. The nitro patch is usually applied in the morning and discarded 12 to 14 hours later (leaving a 10-12 hour overnight ‘holiday’ from the drug). Recent studies on nitro for angina pain have found that sustained routine use can reduce its effectiveness (which is why patch users must take a long break every day.
I recommend that you talk to your physician right away to help you address your questions. Good luck to you, take care. . .
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Eric, I am new to using Nitro as a preventative application. So, I’m lost here. Using 3 per day, you should be right on schedule, right?
Doing the math, 3 pills x 8 days= 24, which still should make it good to go. Perhaps, if you were to ask either your doctor to increase the strength which would mean more potent pills rather than more pills. Or ask your insurance company for their guidelines for coverage and ask them if they could change it to what you and your doctor feel is necessary. Are they generic? If so, since generic are usually cheaper ask your doc for two scrips, one for insurance, and one to fill online with GoodRx. If you are getting brand-name pills, then you may be allowed to get the generic with no problem. Insurance companies are more worried about having to pay for the cost more than the amount prescribed.
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I am taking once in a while nitro spray after having one stent in my aorta 5 – years ago.
I am just wondering if I am allowed to carry that spray bottle in my pocket while I am going walk or somewhere else?
Because I have been warned that nitro is explosive.
Thank you for explanation
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Hello Eric – that’s actually a common question from those people taking nitro!
It may reassure you to know that nitro has been safely used to treat heart patients with angina for over 130 years. As Dr. Billy Goldberg writes: “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.”
Yes, you can carry your nitro in your pocket. I would never leave home without my nitro spray (I typically carry it in my hand in a small cloth purse wherever I go. Some sources suggest that because the effectiveness of nitro may be affected by light, heat or moisture, you should not store it in the bathroom.
Take care. . .
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I am taking nitro spray once in while when needed. I had a blockage in my aorta 5 years ago and a stent was placed in the blood vessel.
Now..should I take a nitro spray prior to going outside to do some snow removal
(Shoveling)..or should I have it after shoveling?
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Hi Eric – I’m not a physician so cannot comment specifically on your situation, but I can say generally that Dr. Lown (cited in the article) recommended that his heart patients take their nitro “preventively.” In other words, don’t wait until you have serious symptoms to take it.
We know that snow-shoveling can be dangerous for some heart patients (depending on their overall health and fitness). It has two risk factors that could apply: cold weather and extreme exertion. It’s especially dangerous when people who are not used to heavy lifting or hard exertion decide to go out to shovel snow for a long period of time. Read this for more info on snow shoveling, including proper techniques to shovel snow more safely.
Generally, if you don’t already exercise regularly, you may not be strong enough to risk shoveling wet heavy snow.
It won’t hurt to try your nitro spray just before you head outside to shovel snow. Dress warmly and be careful while you’re outside working hard, however. At the very first sign of any chest tightness or pressure, stop shoveling and take another spray while you rest up indoors.
Good luck to you . . . 🙂
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I recently was diagnosed with congestive heart failure and prescribed coreg and lisnopril and Lasix. This was mid February 2022 and now things seem to be worse again, even worse than when diagnosed. Haven’t had an angiogram or ultrasound just x-ray in Emergency and blood work and still haven’t gone to see a cardio or any doctor (no insurance, no job) but have monthly visits from Amerimed.
I know I’m risking my life by these delays but I have to sort of delay bc of alzheimers mom of which I have no help. But I wanted to ask if nitro would help in situation of heart failure cause I don’t have chest pain as much as I have trouble breathing, even just brushing my hair or walking 15 yards I feel like I could pass out.
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Hello Brenda – I’m sorry that your symptoms seem to be getting worse. I’m not a physician so of course cannot comment specifically on your situation, but I can tell you generally that it sounds like the medications you’re taking are those that are commonly prescribed to people with your diagnosis, mostly to help your heart pump blood to the rest of your body, or to address symptoms (e.g. your Lasix helps to reduce fluid build-up). It may be that your medication dosages need adjusting; you could ask your local pharmacist for more information. Feeling light-headed or faint can also be a common side effect of some of these medications, especially when standing up from a sitting or lying down position so be extra careful doing that.
I’m not really familiar with Amerimed, except that it’s part of a mobile care service. Perhaps they come directly to your home – which would not interfere with your Mom’s care. It’s important that you explain your current symptoms to your Amerimed service provider so they can recommend something to address your shortness of breath.
Take care. . .
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Yes! Almost always. I try to talk myself into believing it’s anxiety, panic, indigestion, asthma….. anything other than my diagnosed angina.
This article was helpful. Thank you!
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Hi Colleen – it’s very common to be in denial about all kinds of symptoms. Sometimes these are just minor issues, but you never want to be in a serious situation where you have talked yourself out of believing that THIS TIME, it might be more serious!
The good thing about taking nitro for possible chronic angina symptoms is that if it DOES work to decrease your symptom, you can usually relax and go on resuming your life – but if the symptoms are due to something non-cardiac (like asthma, for example) your nitro is unlikely to work – thus helping you make a quick decision about seeking further help. So it can help you rule out or rule in potential causes for chest discomfort. There’s rarely any downside in trying nitro first.
Good luck to you!
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I have been reluctant to use the nitro for all the above reasons. Now after a change in my pacemaker, I can’t even walk across my house without having pains after reaching 120 bpm. So I was going to try more this weekend as the doctor suggested. But the pharmacy didn’t give me two bottles of 25 apiece. So I’m still using them sparingly to make it through the weekend.
So if they won’t change my pacemaker settings soon back to what it was, I will definitely get more nitro and use it sooner then after the pain is 1/2 way through. I hope this helps me.
I have also thought of using L-Arginine to see if it would help my situation? Thank you so much.
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Hello Daniel – not being able to walk across your house without pain is NOT “normal”. It sounds like you suspect your pacemaker settings might be the culprit? I’m not a physician so cannot guess what is causing these distressing symptoms, but I can tell you generally that if I were in your shoes, there are a couple of possible steps I might consider:
1. Explain your symptoms to your doctor (he/she may have suggestions to address this immediately)
2. If you were expecting more nitro tablets than you currently have, contact your pharmacy to see if an error may have resulted in you not having enough for the weekend
3. Re L-Arginine: my own cardiologist suggested this supplement for me after my heart attack 14 years ago, as it was very commonly recommended for angina symptoms. Since then, however, more recent studies have found some problems – especially if you’re also taking certain blood pressure or anti-platelet/anti-coagulant medications – or nitrate drugs like nitroglycerin (which can dangerously lower your blood pressure if combined with L-Arginine supplements).
The good news is that, according to this Mayo Clinic paper, our body usually makes all the L-arginine it needs; plus it’s also found in most protein-rich foods, including fish, red meat, poultry, soy, whole grains, beans and dairy products. Again, talk to your own doctor before trying this.
If it turns out that your doctor tells you that you have chronic angina, there are specific anti-anginal medications that can be prescribed, or different forms of nitro (like a patch, for example) but only your physician can advise you what’s best in your case.
Good luck to you. . .
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How many tablets of nitro can be taken in a day?
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Hello Dennis – I’m not a physician, but I can share with you this guide from Mayo Clinic (depending on if your nitro is the extended-release tablet (to prevent/treat an angina attack) or the sub-lingual (under the tongue) tablet to be taken during an angina attack:
– For oral dosage form (extended-release capsules): Adults – 2.5 to 6.5 milligrams (mg) 3 to 4 times a day. Follow your doctor’s instructions exactly. Your doctor may increase your dose as needed.
– For sublingual dosage form: Adults – 1 tablet placed under the tongue or between the cheek and gum at the first sign of an angina attack. One tablet may be taken every 5 minutes as needed, for up to 15 minutes. Do not take more than 3 tablets in 15 minutes. Or to prevent angina from exercise or stress, use 1 tablet 5 to 10 minutes before the activity.
When in doubt, always ask your own physician or your local pharmacist for advice. If tablets are not effective at managing your chest pain, ask about a nitro patch.
Good luck to you. . .
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Hi… I have five stents. I have a great cardiologist. I take carvedilol, 30 mg isosorbide, 40 mg furosemide, pantoprazole and 81 mg aspirin for three or four years and I think the carvedilol is giving me a side effect I don’t like.
I’m too tired, no libido, but other than that I feel great. I have the nitro in my pocket, I take it whenever I want. And I also take the isosorbide a couple of times a day. Additionally I take a B12 dissolvable tablet under my tongue every morning… I had lung cancer surgery a year ago… I’ve never taken any chemo or radiation and basically told the oncologist to stay away for me… My blood has no cancer markers and neither do my pet scans.
I’m very fortunate and I thank God for it and all the people that have prayed for me. In closing, reading Carolyn’s notes about nitro 4-5 years ago has really helped me.
You should know that I’m 85 and still working. All of you keep looking up and God bless you all.
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Hello Bob – you are a real survivor! I’m not a physician, so of course cannot comment specifically on your individual case, but I can say generally that you’re not alone. Heart patients often take a bunch of meds – including Carvedilol – one of the beta blocker family of medications; many of these drugs have tiredness and lower sex drive listed as known side effects.
You might be interested in reading this study on the very common experience of lower sex drive in men also taking drugs called “oral nitrates” for the chest pain of angina (e.g. isosorbide, nitro, etc. ) You didn’t mention having angina symptoms, but I’m guessing that’s why you might be taking your nitro “whenever you want”.
Researchers who authored this study wondered why even patients without angina symptoms are so often prescribed oral nitrates (which are used to treat angina). For example: “Nitrates do not prevent heart attacks and they don’t lengthen life”. They described the common problem like this: “Restoring sexual function to men who desire sexual activity is a quality-of-life issue that has been too long ignored. Oral nitrates can be stopped while continuing other heart disease treatments in stable men with stable heart disease.”
Again, I’m NOT a doctor, but it might be worth asking your doctor for a medication review. Often just a slight tweaking of the various meds we’re taking can mean a world of difference in reducing distressing side effects.
Take care, and stay safe out there. . .
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I hesitate because I am not certain the pain is angina.If I were sure I would immediately take nitro. I am grateful to have it because it has been a wonderful help in the past.
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Hi Nancy – sorry for the delay in responding to your comment (somehow this got lost in cyber-space!)
Some heart patients view their nitro dose as a type of diagnostic anginal test: if the dose works to reduce/stop the pain, it’s likely angina. (For example, nitro would not affect pain caused by a pulled muscle). If it doesn’t work, it may be a sign that the pain is due to non-cardiac causes.
From there, the next step would be figuring out precisely what’s causing that pain. But meanwhile, you’re already familiar with nitro and it sounds like it was a big help for you – so try it out to see if it still helps.
Good luck, take care. . .
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