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

~ Carolyn Thomas

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 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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Published by Carolyn Thomas

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

  1. 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?

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    1. 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.

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  2. 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?

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    1. 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.

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  3. 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.

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    1. 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…

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  5. 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!

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    1. 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.

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  6. 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

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    1. 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…

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  7. 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.

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    1. 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 …

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  8. 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.

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    1. 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.

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  9. 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.

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    1. 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…

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  10. 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.

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    1. 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.

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  12. 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.

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    1. 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”!

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  14. 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.

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    1. 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…

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  17. 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

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  18. 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.

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    1. 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.

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      1. 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.

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    1. 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.

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  20. 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.

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    1. 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?

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