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 Ralph – I’m not a physician, but I can say that most nitro drug insert packaging warns about the number of doses in terms of time (e.g. no more than three doses in one 15-minute period; if angina persists, call 911).

      Personally, on a ‘bad’ day of persistent chest pain, I have had 3-4 separate periods of angina (separated by hours) in which angina is relieved after just one dose of nitro). Please see your cardiologist for specific advice about your own experience just to make sure you’re on the right track.

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    1. Abel, I’m not a physician so I can’t comment about your own specific case, but I can tell you generally that nitro is what’s called a vasodilator drug, meaning that it helps to dilate (open up) the coronary arteries, as Dr. Lown explained in this article: “It dilates coronary arteries and decreases the workload of the heart, two factors responsible for the discomfort of angina” (chest pain caused by a narrowing of the artery). If taking nitro does not make the chest pain go away, it could mean a number of things (for example, that the chest pain is not heart-related after all, or that the nitro is not able to dilate the artery enough to reduce symptoms). In both cases, people should see a doctor if chest pain persists or gets worse.

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  3. Dear Carolyn, great advice / opinions / suggestions to us over here in ‘Good-ole-Blighty’ (UK).

    Diagnosed with Angina on Christmas Eve at 7:00PM as the practice closed for Christmas and given the advice after the 2nd spray and maybe in need of a 3rd, call 999! . . . great time of year don’t you think?

    Over the last month, I spent many hours staring at this ‘little red bottle’ in fear of a pain scale of 1 to 10 as to when to take the first ‘hit’!!

    Bumping into your “BEST HEART BLOG ON THE WEB!” even as a ‘man’ I found this to be so reassuring and can now see that “nitro is your friend” indeed. I am now using as a preventer more rather than a cure. Well done indeed 😉

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  4. I greatly benefit from using my nitroglycerin in this way since reading this article. Thank you.

    Unfortunately, 2 different pharmacist gave 2 different opinions on my using it so often. One said no problem, the other said no more than 3 a day.

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    1. Well, there you go, Heather. Perfect example of dueling professionals… Yours is the ultimate opinion that matters – do some homework, learn as much as you can, re-read Dr. Lown’s advice, and chat with your cardiologist to help you make the best decision for you.

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  6. Although this article is of some comfort, is the need to take nitroglycerin a warning sign that your arteries are clogging up and need more radical intervention such as stents or bypass?

    I have had one stent and one angioplasty at the same time in 2010 aged 54 at that time. I never go out without the spray. I have had the need to use it 3 or 4 times over the last 7 years. Each time I hesitate because its a realisation that my arteries are not in a good condition despite taking all the meds recommended. The nitro stops the pain which confirms my fear. I feel like the need to have it looked into but Dr’s state angiogram is not without its risks itself and not necessary in my case.

    Are there any other tests that could be done. I am not a believer in stress testing as I initially had such tests before my heart attack in 2010 and it revealed nothing. In fact some times when I feel pain now I get on the ex bike to see if it gets worse (stress test myself), curiosity will kill the cat eventually. Ironically the exercise seems to help the pain go away without the nitro.

    I am male 61 yrs old and relatively fit and active.

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    1. John, many of us tend to believe that for every symptom, there is an invasive clinical procedure that should/must be done (the sooner the better!!) and that every coronary artery blockage, no matter the size, needs to be opened up – despite the lack of scientific evidence to support these beliefs. It may even seem counter-intuitive to think that every twinge of chest pain shouldn’t be immediately “fixed”.

      But people like me who live with chronic angina need to know that an occasional episode of chest pain does not permanently damage the heart muscle, and having angina doesn’t actually mean a heart attack is imminent. I’m not a physician so cannot comment specifically on your case, but I can tell you that generally speaking, a person who has needed to use nitro to relieve chest pain only three or four times over a seven-year period is not likely suffering from chronic angina.

      The one thing you should seek immediate medical help for is any sudden or dramatic change in symptoms – otherwise, keep taking your meds, enjoy staying fit and active, and use that exercise bike. Daily physical exercise in fact (unless for some reason your doctor has warned you against it) is likely the best possible thing you can now do for your heart. Worrying is likely far more damaging to your coronary arteries than this occasional chest pain is. Best of luck to you….

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    1. Hi Liam – I’m not a physician, but I can tell you generally that if your nitro works to *completely* address your chest pain, you’re likely okay. (I’m assuming your doctor has already recommended nitro for your chest pain? If not, and this is new chest pain, and you have no nitro, seek a medical opinion!)

      You are correct: many of us living with chronic angina use nitro daily, or almost daily, or wear a nitro patch every day for persistent angina symptoms.

      The important thing to remember is the Rule of Three that I mentioned in this blog post: if your chest pain persists after taking the first dose of nitro, you can take a second dose five minutes later, and then a third dose five minutes later if that second one doesn’t work, but you’d better be calling 911 with that third dose.

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  8. I take 30 mg isosorbide in the early morning along with plavix. This keeps angina away until about 8:00-8:30 PM. THEN, the angina becomes intense. I take a small nitro tablet and try and relax. The pain subsides. If I get up, walk to the kitchen or get in bed and try to get into a comfortable position, that exertion brings back the pain. I hate the feeling.

    Doctors (plural) have been dragging their butts regarding what I thought 7 months ago was Peripheral Artery Disease (PAD). They ignored me and kept trying to give me $10 worth of blood pressure meds to “cure” me. As it turns out I now have PAD, a severe walking disability, heading for a CO2 vascular interventional radiology cat scan next Tuesday. Do I not trust current medical practice? It’s a cattle call with one doctor shuffling you off to another one. If I can get where I can walk again, I’ll never set foot in another doctor’s office. Thank God for the isosorbide and nitro tabs.

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    1. Hello Bob – I’m not a physician so cannot comment on your specific case, but I can tell you generally that many of my readers report angina symptoms worsening in the evening, made more pronounced by lying down, especially on the left side. Some less common cardiac conditions that can also cause increased chest pain when lying down include pericarditis (an inflammation of the sac surrounding your heart). Your current daytime meds strategy seems to be working okay; Dr. Lown would likely suggest you try preventive nitro as the clock approaches 8pm – in other words, do NOT wait until after the pain is intense.

      So much of medicine is simply trying to rule out what the problem is NOT….

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  10. I don’t have traditional angina, but rather an usual shortness of breath when I overexert.

    This started after an aborted PCI. I underwent an angiogram and explicitly asked that I not be stented unless it was a medical emergency. I was asymptomatic at the time. In fact, on a stress test I scored off the chart – 13 METS at age 75. But, they pushed me too hard (over 140ppm) and stenosis was detected. Hence the angiogram.

    The cardiologist attempted to stent me 5 times but couldn’t succeed because of the shape of my arteries. He claimed I had 90% blockage in one artery, 60% in another. A second opinion I got said it was closer to 80% and 50%. Since that time I have had various usual symptoms, several outbreaks of the flu, shortness of breath etc..

    After reading Dr. Lown’s articles I decided to take .4mg of Nitrostat prophylactically. e.g. before my 1 hour morning walk. I also keep my pulse rate below 120. I have no symptoms by following this regime. I went on a 2 week hiking vacation in Switzerland last month. I did 8-10 miles a day and took 3 Nitrostat tablets each day, about 2-3 hours apart. Felt great!!!

    Thank you Dr. Lown.

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  11. I think your article is terrific. I just took my first pill. 5 trips to the emergency room while they do the same tests and I keep getting worse. I told them two years ago the blood pressure medicine was frying my kidneys and I was having trouble walking. Now one doctor says it’s the stent may be plugged, the kidney doctor says my gfr (kidney filtration rate) is 23 (disastrous). The vascular surgeon won’t check for PAD because he can’t use iodine for the necessary. The endocrinologist says I may have a blockage. My primary physician says, “I don’t know.” You think I trust these guessers?

    I asked for the nitroglycerin today for terrible angina. One pill, I feel good for a change. Let me walk up and down the hallway a few times.. minute please..legs a little weak. No chest pain… general feeling of tiredness, can feel a little buzz in my head but no headache. All good so far. Breathing not impaired. A whole lot less anxiety. I should have been taking this 4 years ago I guess.
    Best to you all

    Bob

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    1. Bob, as I like to say: “nitro is your friend”. I’m glad that your first dosage gave you some relief at last! I love Dr. Bernard Lown’s advice mentioned in this article, but I’m also concerned that you’re getting all of these conflicting messages from your doctors. No wonder your legs feel a bit weak – it sounds like you may be what they call “de-conditioned” if you haven’t been feeling well enough to walk and get exercise lately. Best of luck to you…

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      1. Carolyn, what does deconditioned mean? My cadre of doctors act like they could care less if I live or die. I’m not sure I can make it to next Tuesday’s CAT scan. I can’t walk from here to the corner. Hydorochlorthiazide and lisinopril, after one week of use four years ago, lowered my kidney function from 60 gfr to 25. Absolute disaster they disavow in their end.

        My heart problems you know about. NOW, none of these doctors can say definitively, “Yes, it’s your heart, or it could be PAD, or your kidneys are one step away from dialysis, or you might have a pulmonary problem. Oh Yeah, we also might have to do vascular surgery on your legs.”

        Add the stress of being on medical leave from work, dealing with California state disability, my new health insurer, my short term disability insurance company at work, what a trying time. Sorry for sounding like A crybaby, but at 80 years old it pisses me off.

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        1. Hi again, Bob – just to clarify: you’re 80 and you’re on medical leave from work? I’m only asking because most 80 year olds I know are happily retired…

          You sound like you’ve had a relatively healthy life until all of this stuff started happening (was that about four years ago?) As I’d mentioned before, I’m concerned that you seem to be getting different advice/opinions from different doctors. Specialists, it’s true, can often work in a silo, focused on their uniquely separate organ, unless you go to a place like Mayo Clinic where care of the “whole patient” involves a team approach who all determine together what the optimal course of treatment might be.

          Also, in my experience, doctors rarely say a diagnosis “definitively” in the absence of diagnostic test results that clearly point to that diagnosis. Also in my experience, I know how truly dangerous it is to have a doctor “definitively” misdiagnose my heart attack as acid reflux and send me home from the ER with instructions to see my GP for a prescription for antacid drugs…

          Being “de-conditioned” is what happens when people like you report that you can no longer “walk from here to the corner”. Something is happening that is keeping you from moving your body as you’ve been used to moving it all your life.

          PS I do NOT think you are being a crybaby, by the way. Hang in there and good luck on Tuesday at your scan appointment – I’m really hoping this will help to determine the cause of your symptoms and the next treatment step!

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          1. Thank you Carolyn, it’s very kind of you to respond. Yes I’m still working because you can put my judgment about women right up there with Custer and Nixon.!! LOL

            Anyway, Merry Christmas and Happy New Year to you and yours!!

            As a footnote and afterthought, I took the isosorbide and plavix as usual this morning early, then around 2:30-3:00 I took the metropolol and losartan and tonite I feel fine and have had no chest pain all day so far. Once again it’s vascular I believe. They are checking the blood work tomorrow prior to Tuesday’s test.
            Thank you once again 💘😘
            Bob

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  12. I am new to the use of nitro. I was wondering if there was a limit to how many tablets you can use in a day? I know about the 3 in 15 mins for severe pain but was wondering if it’s ok to do 4 tablets a day if chest discomfort returns. Example, light chest pain at 8am so I take one. All is well. But what if mild chest pains return 2-3 more times in that day. Is it ok to take another tablet in those incidents? I did not see a daily maximum in the medical directions. Thanks for your input.

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    1. That’s a very good question, Gregg! I’m not a physician so can’t comment specifically on your case, but I can say that you are describing my nitro regimen exactly! It’s quite common, for example, for me to have a number of (mild-moderate) episodes of angina throughout what I’d call a ‘bad day’ – each requiring at least one dose of nitro (I happen to use spray, but taking nitro tablets is the same). Most of the time, one dose of nitro is enough to do the trick, at least for a while. Also, I’ve learned not to wait until angina pain is severe (it’s much easier to get on top of the chest pain while it’s still mild-moderate). If you find yourself having worsening cardiac symptoms every day, day after day, you could also ask your physician about switching to a nitro patch or extended release tablets (both of which require a ‘nitro-free’ break each day). They’re not appropriate for everybody, but might be an option someday. Best of luck to you…

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    2. I take up to 4-5 per day if needed, which isn’t very often. Dr. Lown gives an example of a patient who took 5 a day for 30 years and never got an angina attack.

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  13. Thank you for this information but I have been told that it’s not angina or heart related if you get a nitro headache – that it must be heartburn or stress. I have had several tests done and continue to have all the heart symptoms, unbeareable to live with. I have the patches but horrible headaches; my symptoms are random, not daily. Any suggestions would help this is going on 4 years now. Thank you

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    1. Hello Tammy – I’m not a physician, but I can tell you that whoever told you that a nitro headache is proof that your chest pain is not heart-related was quite wrong. It would be almost impossible, in fact, to find any credible information anywhere about the use of nitro for chest pain that does NOT list headache as a common side effect. Patches can also affect headaches, for the same reasons that nitro pills or spray would: they are all vasodilators, meaning they they open up the blood vessels, including those in the head and the brain, and this is what can lead to a headache.

      My understanding is that nitro patches are recommended for heart patients who have significant chest pain every day, several times a day – however, it sounds like yours are random, not daily, so I’m wondering why you have been prescribed a patch for random episodes. Please see your physician to discuss a medication review – something is causing your symptoms and you need to find out what that is. Best of luck to you…

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      1. I think she should ask her doctor for 30 mg of extended release isosorbide. Four years of no relief is a joke. Get the isosorbide and another doctor.

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  14. I’ve been told by my urologist that my very low testosterone levels more than likely caused my heart attack. So, I have been on testosterone therapy for almost 4 years now.He even gave me samples of Stendhal, Cialis and one other one. My cardiologist
    said I can use those as well however, if I have angina or chest pains I cannot take my nitro tabs. He told me he has patients that this has worked for and he told about a patient that had massive heart attack right “afterward.” He said it was up to me…

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  15. As a CAD patient, who has carried nitro for 30 years, I can relate to the reluctance to take that first dose. One equates an improvement in health with less nitro, especially when the wife becomes alarmed when I take it thinking I am having another heart attack.

    I am getting old enough to see the finish line from here and intend to use nitro to relieve any chest discomfort as needed or anticipated.

    This is a “timeless” article and should be read by more heart patients early in their journey.

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    1. Hello Terrence – you’ve had 30 years of experience getting to know how your nitro works for you! So true – generally speaking, we tend to think “healthy” means we can throw away our meds – except for our nitro! I love Dr. Lown’s observation: “the free use of nitroglycerin enables patients with angina to outlive their doctors!”

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  16. I am an LPN , I work 3 jobs, I am exhausted 24/7, I am overweight. I have hypothyroid hashimotos and fibromyalgia. I am also 50. If I stop moving for too long I hurt all over and have chest pain. Angina. I take my nitro spray approx 3 times a week for bricks on my chest feeling. It works great.

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    1. Hello… I am 87 years old, and had chest pain just a few weeks ago. I went to the emergency room, was told to lay down, and a nurse gave me my first nitroglycerin tablet ever, under my tongue. Since then, I have had a coronary artery cleaned out via a heart catheterization. The chest pain went away a few seconds after taking the tablet. All this I expected, from reading about this subject.

      But one aspect that was surprising and very pleasing to me, was that my brain “cleared up”. For about 2 years I have suffered from disequilibrium, and general overall foggy sensation in my brain, that is with me 24/7. So I am assuming the blood vessels in my brain were dilated by the nitro.

      I loved the gift of a “normal brain” feel, for just those few minutes. I will ask my cardiologist if I can use some form of nitroglycerin continuously, and hope for a helpful reply.

      Any suggestions?

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      1. Hi James and thanks for sharing your interesting experience here. I’m not a physician, so can’t comment on your nitro usage, but I can say that this seems like a remarkable and positive side effect! There are longterm nitroglycerin treatments (e.g. the nitro patch) typically used on patients with debilitating chest pain, but your cardiologist will be able to advise if you qualify for those as well. Best of luck to you!

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    3. You have a lot on your plate, Esme. I’m glad that your nitro works well for you – if only somebody could invent a ‘nitro’-like remedy that works as well for your other diagnoses! Take care of yourself….

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  17. Great article. Gives me good advice on the use of Nitro pills or spray. I always thought that when you had an episode, you had to wait to take your nitro. I always thought that you had to be careful of how much you should take. This article gave super advice on how to use it. After reading it, I showed it to my Cardiologist and he agreed with all written down and said he never even thought to tell his patients the proper way to use their nitro, and now he will.

    Yesterday after thinking I was having a Heart Attack, I was given nitro spray and it worked fast and it will be prescribed for me. Thank You so much for all you wrote. A job well done!

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    1. 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.

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  20. 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.

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    1. 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…

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