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. 

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.

Dr. Lown was absolutely right! Over the past few years, in fact, I’ve spent countless hours foolishly suffering needlessly while trying to postpone that first nitro dose for just this reason: pure, unadulterated, frightened denial.

Yet as Dr. Lown advises, nitroglycerin is most helpful when taken at the first onset of chest discomfort – rather than after it has been present for several minutes.

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.

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 it’s also highly diluted for safe handling.

Ironically, many years later, Alfred Nobel – the scientist who had first used nitro in the dynamite his company patented – was prescribed nitroglycerin for his own chronic angina pain.

A few months before his death in 1896, Nobel wrote to a friend:

  ”  Isn’t it the irony of fate that I have been prescribed nitroglycerin to be taken internally? They call it Trinitrin, so as not to scare the chemist and the public.”

♥

IMPORTANT: 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 new 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, 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

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

  1. After seeing this section on Nitro, I went and bought a spray to keep with me all the time. I am surprised that neither my cardiologist nor the hospital recommended keeping and taking Nitro after they discharged me post-stenting on March 11th this year. Wonder why!

    I haven’t used the spray yet as the niggling “stretch” pain from the stent is only irritating at best. I can do fast walks (4+ mph) or even a slow jog with no breathlessness or chest discomfort. . . so not exactly sure when I need to take the nitro. The stent stretch pain is highly localised to an exact spot near the heart, very mild but irritating nevertheless, and I don’t know if Nitro will solve that.

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    1. Hello Sree – I too wonder why every heart patient (especially with a newly-implanted stent!) who is discharged from the hospital wouldn’t take home a recommendation for nitro!! As Dr. Lown explains in this article, this has been a very safe and cost-effective medication for over 100 years.

      I can’t offer you medical advice, but if I were in your shoes, I might try a little experiment next time you’re noticing this irritating stretch pain: try taking a dose of your nitro to see if it has any effect at all on that spot near your heart. Just follow the instructions Dr. Lown gave for taking it (i.e. sit down, lean forward, etc) as it may cause temporary light-headedness. It may have an effect, it may not. Meanwhile, take care and stay safe. . .

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      1. Thank you. Will do as you suggest as a test, but am seriously hoping that I will not have to take it 🙂

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  2. I’m going through this now. Been to the ER many times. Was finally admitted to hospital and had MIBI tests. Told no blockage, so must be fibromylagia. I disagreed. Asked if I had COVID in the past. I did, so now claims it’s Long COVID and my heart is fine. Released and now the fight for my life continues.

    It escalated so fast. Took 10 days to finally get CT Scan to check for clots and MIBI tests for heart. I have to stay laying down to get some relief from symptoms. Fortunately when I was released I was given a prescription. A bit odd considering the doctor claims I have fibro, then suggested Long COVID. Anyway, grateful to have it. It makes me feel better when I am lying down but as soon as I walk, symptoms are back. Based on what I read that is called unstable angina.

    I was never given nitro spray the entire time I was in the hospital. Not even after the stress MIBI test when I was in so much pain. I was given morphine and told to drink lots of coffee.

    I had nitro spray on two visits in ER and it helped. Of course back to ER again when symptoms appeared. Was so happy to finally get admitted……only to be gaslighted by a different doctor.

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    1. Hello Sue – I’m sorry that you’ve had to endure all of this – yet still no definitive answers. It’s ironic that during the first year of COVID, many doctors dismissed the very notion of Long COVID. Is it now becoming the default misdiagnosis to label any puzzling symptom?

      I’m not a physician so cannot comment specifically on your experience, but I can say very generally that unstable angina is defined as chest pain or other cardiac symptoms that occur with little or no exertion. Stable angina is defined as symptoms that come on with exertion, and then lessen with rest – which sounds like what you describe as your situation.

      We know that many of the symptoms reported by people diagnosed with Long COVID symptoms are strikingly similar to fibromyalgia and its close cousin, chronic fatigue syndrome. Researchers have long suspected that these conditions are triggered by certain viruses.

      Whether your distressing symptoms are heart-related or not hasn’t been confirmed. But something is causing them. I hope you can solve the mystery soon.

      Take care, stay safe. . . ♥

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  4. I can use nitro effectively for chest pressure brought on by exertion – for example, when I had to wrestle the snow blower in the aftermath of a blizzard earlier this year, I made sure my tiny bottle of pills were in my coat pocket instead of my pants pocket like usual.

    As soon as I felt the pressure coming on, I popped a pill under my tongue and continued on. But it does NOTHING for my chest pain, which occurs several times a month; if I called 911 for every time I tried the “rule of 3” on my chest pain, I’d have to just rent a bed in the ER. I’ve brought up this issue to 3 different cardiologists. One said the pressure was more concerning; one just shrugged and lumped me a category of having complex issues without having any medical or surgical treatment suggestsions; and another (Mayo Clinic) told me it was acid reflux (NOT!!!!).

    What do you do when you have “issues” that no doctor understands and is willing to try to address? I’d be happy to be told there’s nothing serious about this, but surely it does indicate lack of oxygen to the heart, and sometimes it’s incredibly painful – this from someone who’s been through 2 rotator cuff repairs and was told I have a high pain tolerance.

    I’d even be – not happy, but understanding – that there’s no known cause and no known treatment, if that’s the case. At least I’d know….

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    1. Hello Holly – so it sounds like your nitro is doing the trick for angina brought on by exertion (the ‘regular’ stable angina pain) but not for chest pain that comes on at rest? I’ve had a number of blog readers who have had identical experiences, which means 1. you are not alone! OR 2. a lot of doctors are missing the reasons for these serious symptoms, OR 3. that there simply may not be an explicable reason. Chest pain that hits “several times a month” – my first thought (I AM NOT A DOCTOR THOUGH!!) was variant angina, or vasospasm.

      I live with coronary microvascular disease and have countless episodes of (really dreadful) chest pain per month, sometimes several in one day on a really bad day. I’ve learned over the years NOT to call 911 for every episode (like you, I’d definitely be bunking out in the ER if I did that!) and based on results, I am still here 10 years after being diagnosed, so…

      But I do know that I experience a level of pain that’s now just “normal” for me, yet the vast majority of people would be heading straight to Emergency for… I’ve learned that like you, I seem to have a spectacular pain threshold! I’ve also learned that if I delay taking my nitro, it’s SO MUCH harder to get on top of the pain compared to if I take nitro at the very very first twinge. “Nitro is your friend…” as I like to say.

      The website UP TO DATE has an interesting and comprehensive overview to help figure out if chest pain is heart-related or not – keeping in mind that everybody is different, so reality may differ, but generally speaking, they say:

      “Ischemic chest pain is usually not felt in any specific spot, but rather throughout the chest. The patient may actually have difficulty describing the exact location of the pain. Cardiac pain often involves the center of the chest or upper abdomen. It is less likely to be cardiac ischemia if the pain is felt only on the right or left side, or not in the center of the chest, or if the patient is able to point with a finger to one area of pain, or if eating a meal helps to reduce the pain.”

      You may have already been doing this, but a Symptom Journal might be a good idea (record date, time of day, what you were doing/eating/drinking/feeling in the hours leading up to the start, location/nature of the pain, etc.) Sometimes a pattern emerges in angina that does not respond to nitro.

      Hang in there, Holly…

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      1. Thanks for the long reply. I had subscribed for notifications of responses, but it doesn’t work.

        I asked my heart failure specialist whether it might be cardiac microvascular disease and he shrugged and said there’s no treatment so it doesn’t matter; another time I suggested vasospasm and got the same result. I have too many other health battles to fight to worry about that attitude, I guess, but it’s frustrating to not at least be validated in the pain I feel and the lack of treatment.

        Yes, been doing a journal, but it shows absolutely no pattern – and I’ve gotten good at noticing patterns in my health, to say the least. As for location of the pain, it’s dead center in my chest, usually with a warning pain in my right cheekbone, then my right jaw, then the chest. Often the pain comes in waves. Usually the entire episode lasts 15-20 minutes but sometimes it’s just 5-10, and sometimes it’s a horrific 30 or more.

        I’m OK with doctors telling me they don’t know why something is; I get frustrated with the indifferent shrug, or trying to make out my issue isn’t related to their field of expertise. I’ve seen that happen so often.

        I have to remind myself it’s not as bad as when doctors make me worse by insisting on a course of “treatment” I know will be detrimental, and is. I’ve promised myself I won’t go down that road again, because it’s led me to death’s door at least once.

        Thanks for your time,

        Holly

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        1. Hello again Holly – you brought up such an interesting point: is it preferable to be greeted with an indifferent shrug or the wrong treatment? Both are awful! My vote: it’s a tie. The wrong treatment can, as you know, be downright dangerous, AND no physician should EVER respond to ANY patient with an INDIFFERENT SHRUG…

          That response “There’s no treatment so it doesn’t matter“ makes me cringe. I simply cannot image that heart failure doc saying such a thing out loud to a male patient. There are in fact a number of medications that are regularly recommended for MVD (you may be already taking one or more of them). Has anybody ever suggested you look into TENS therapy?

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          1. No one has suggested TENS to me (which happens to have been the first post on your blog I ever read, and then I followed the blog).

            My chest pain isn’t yet daily, though the episodes are increasing in frequency – 1-2 times a week – and in severity, though there are also “blips” where yes, there’s pain, but it’s not enough to slow me down, and lasts only 5 minutes or so. But the average is probably 20 minutes of moderate-to-severe pain (my very subjective scale :).

            I just googled MVD again, and reread the American Heart Association doesn’t suggest any treatment that’s not already being done, which is what I knew from previous searches. I guess, as with my autonomic neuropathy issues (including cardiac), I just want an official diagnosis so I will get more respect from medical professionals.

            This particular heart failure specialist used to be more engaged – I saw him for about 9 months in 2015, and he was great, negotiating with me, taking my concerns and needs seriously. These days he is just as nice overall, and takes all the time I want, but not necessarily how much time i need. The whole practice is different, though many of the staff are the same. I communicate mostly with the nurses, which would be OK if they would talk slower so I can write things down – yes, I do insist on them repeating things I didn’t quite get, but they also change their stories on medication dosage changes.

            I wish they would use their portal, it would make my life so much easier and would be a great time saver for them, allowing them to spend more time with needier patients.

            It would also have been nice if SOMEONE, ANYONE, in the health care system, had warned me my heart failure could decompensate from a relatively minor illness.

            Ah, well, you can tell I don’t have much of anyone to talk to about all this 🙂 Thanks for listening, and I will keep the TENS in mind if I get to the point where the pain is daily or lasts significantly longer.

            Holly

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            1. Hi Holly – “an official diagnosis so I will get more respect from medical professionals” – doesn’t seem like too much to ask, and also implies that without a concrete diagnosis, your symptoms are not taken seriously. Yet SOMETHING is causing those symptoms!

              Re the TENS therapy: I’m now writing an updated article on TENS given that there has been a growing number of studies on using this therapy across a broad range of painful medical conditions. Some studies have ‘inconclusive’ results, some have ‘positive’ responses, but one common problem is that some researchers have studied TENS therapy set at relatively LOW levels of power, while others have tested at HIGHER levels, so many studies are comparing apples to oranges. Duh….

              Frankly, because there is no funding from Pharma for studying non-drug, non-invasive options like TENS, I’m not holding my breath… In our hospital’s Regional Pain Clinic, we are taught many effective pain self-management techniques that are also non-drug and non-invasive (and are thus likely NOT recommended by the majority of physicians who do not have specific pain management training… )

              Meanwhile, there is simply no downside in getting yourself a TENS unit to try it out (except for the approx $100 initial cost and the occasional battery replacement).

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              1. Wow, I had no idea they were so inexpensive! But how would I use one? These episodes can hit any time of day or night, with the only warning being pain in my right cheekbone, then jaw, and sometimes I don’t even get that. It seems silly to be wired 24/7 for something that happens so unpredictably, and currently averaging about 6-8 times a month. I will keep it in mind, though, in case the frequency, duration, and pain level increase.

                You’re so right that symptoms don’t seem to be taken seriously if there’s not a diagnosis, and in my case there’s a lot of pass the buck going on on top of that (to quote the reports from Mayo Clinic, “I defer to neurology” and “I defer to endocrinology”, the two main departments I saw). I know I should see a hearing specialist (much-worsened tinnitus since being on max doses of loop diuretics – and I was told my HF specialist doesn’t know about other classes of diuretics for combination therapy!!!); a gastro for the worsening diarrhea (the one I saw before was only interested in removing my gallbladder because of gallstones even though I’m asymptomatic at this time); and an RA for Lupus (I have the classic butterfly rash and many other symptoms but my antibodies are mostly 0). But I’m just too tired to keep fighting and the number of doctor appointments seem to rise exponentially. I can’t drive to these people anymore (many are at least a 90-minute drive one way, with my endo being 4 1/2 hours and other specialists I’d have to see at least 5 hours or out of state), and it means a lot of time off from work for my husband. Fortunately, his workplace is flexible and supportive, but it’s a cut in income for us.

                🙂

                Sure wish I could thank you in person for your support!

                Holly

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                1. Hi again Holly – in answer to your first question: I can only answer according to how my own cardiologist and pain specialist recommend TENS therapy for me: I used to turn it on (attached to a clip on my belt) every morning and walk around with it on all day, until bedtime. Then, eventually, I’d ‘experiment’ only wearing it when I could anticipate, based on past results, that my symptoms might really flare up (during cold weather or long walks, for example). Now I wear it off and on, based on when vague symptoms first start up. Keep this mind, as you say… Best of luck to you…

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                  1. Thanks for the additional information, Carolyn. I will keep the idea of TENS in my mind for if my symptoms continue increasing. Nice to know there is a treatment that will likely help if I end up needing it!

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    2. Holly, how have you been feeling, since your message above? My dad is having breath issues, doctor to doctor, test to test, they still don’t know.. Very upsetting, as his daughter

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  5. Having read this article it has given me a better understanding of how to use my spray. In the past, have only used it when I had severe chest pains which, subsequently, ended up in hospitalization.

    During the past few weeks I have had a severe tightness of my chest which has caused me severe anxiety. This morning I felt so bad I decided to use my spray.

    The relief was fantastic, so much so that the tightness has disappeared together with my anxiety and I am so much more relaxed.

    Thank you so much for your article which has helped me so much.

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  6. I take Xanax for anxiety and panic disorder. Had one yesterday, took everything I had to not jump outta my skin. I have nitro tablets, got a little heaviness in my chest, no pain no where, had a bad anxiety attack with panic attack. should I have taken one to help the Xanax.

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    1. I’m not a physician, Scott so can’t comment specifically on whether nitro would have helped. The first question when adding a drug that’s not prescribed for a specific issue should not be ‘Will it help the Xanax?’ but should ALWAYS be “Will it harm me by combining these two drugs?”

      Never a good idea to just keep piling on pharmaceuticals, no matter how desperate the symptoms seem, so you are smart to ask the question first.

      We know that issues like esophageal spasms are often seen in people with panic disorders, and that these spasms can sometimes respond to nitro (which is a vasodilator = dilates blood vessels). But nitro is used for cardiac angina, and is not the most effective way to treat GERD (gastro-esophageal reflux disease) even if you have been diagnosed with that.

      Best idea: double check with your physician first to make sure there is no potential for any dangerous drug-drug interaction, and also to rule out a possible esophageal problem. Meanwhile, your local pharmacist and also Drugs.com are good resources for medication questions.

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    2. I know you posted awhile ago but this suggestion might still help. I too have panic attacks and one non rx thing that helps was something a therapist suggested.

      She said when I am having that jump out of my skin feeling I should do something physical like jumping jacks or marching or pumping my arms, anything to get my body to physically match the way I’m feeling. Then literally splash ice water on my face and arms to stop the fight/flight feeling then to finally do my relaxation breathing.

      This has worked for me. I was concerned about the exercising as it was soon after my myocardial bridge was diagnosed, but as my therapist pointed out my body was already in physical overdrive, I was just matching my actions to the feelings the panic/ anxiety caused.

      I’m happy to have a non drug strategy to try when this happens to me.

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      1. Hi Nancy – I love these suggestions from your therapist (assuming that it’s physically safe to try them, of course). I suspect that it’s far more stressful to feel that “jump out of my skin” feeling but try desperately to remain calm at all costs! Jumping, yelling into a pillow, ice water – let’s see if they help!

        Thanks for this – take care, stay safe. . . ♥

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      1. Hello Carolyn, I don’t know how to make a original comment and not reply to some else’s post so i hope this doesn’t conflict with anything …but I think I might have angina, I haven’t gone to the doctor yet but I’m planning later this week, I’ve been experiencing pain since probably 7 or 8, and the pain suddenly arises when i take a normal breath and i have to hold it so it can pass, I’m 16 going on 17 now and I’m getting really bad flare ups where the pain travels to my neck jaw back and my left arm mostly sometimes right, would i be a good candidate for nitroglycerin or is it just stress or anything else?

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        1. Hello Aidan – I’m not a physician so can’t comment specifically on your symptoms. Only your physician can help you to solve this mystery. I can say very generally that it would be highly unusual for a person your age to be experiencing angina symptoms – not impossible, just rare. The other good news is that about 85% of all chest pain admissions to hospital turn out to be NOT heart-related at all. Still, something is causing your symptoms – you just don’t quite know what that is yet. Here’s a list of some of the possible causes of these symptoms.
          Best of luck to you this week at your doctor’s.

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    2. I’m having agina pains now in Taiwan age 70. Stent in my heart from 2009 heart attack in Taiwan. Question. Re o.6 nitro pills I just took 3 in movie theater. Feel fine now. 4 pm. If more pains come today, can I take 3 more little white pills. ? What is max amount in one day? Just 3 per 15 minutes or 6 okay or 9? Also my blood pressure today is 128/87. But another number below the reading said 96. The pharmacist told me 90 is normal. Is 96 dangerous and what does it stand for,? Blood vessel problems,,? Help. Danny bloom retired reporter cli-fi.net

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  8. I was diagnosed with CHF (congestive heart failure) back in 2014 along with COPD. In Feb 2018 my COPD diagnosis was rescinded by a specialist who deals with lung and spine ailments. Referred to a Rheumatic specialist who, with 4 yrs of X-rays and Cat-scan, determined I have advanced Ankylosing Spondylitis (fusing of the spine) where my rib cage is basically fixed with little to no expansion. A.S. in its advanced stage causes heart problems which takes me back to my CHF.

    If it wasn’t for the Nitro spray, which I have now taken regularly almost on a daily basis, I believe I would be taking a lot more meds than I would like. Yes, this little bottle of nitro does the trick for me, especially in the cold climate of Northern Ontario where I live, never leave home without it. I’m not at the stage of having to wear a patch yet, but I won’t mind if I have to.

    I used to be one of those who would not take my nitro till the last moment, but after reading this article at the beginning of 2018 I have made a habit of being proactive with it.

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    1. So glad you found this article a year ago, AJ! You bring up such an important point: the fear we sometimes have about taking nitro at the first hint of symptom. Instead we try to suffer through – while the remedy for our suffering is right beside us! Best of luck to you in 2019…

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    2. AJ – Can I ask how they diagnosed you with COPD? My dad is 85, the past month, is feeling very winded, and has these… trying to get his breath… episodes, that is scary.

      So, we have done the doctor route, the heart doctor, and the ER at hospital. they say the EKG, and chest xray are not showing anything, that they cant diagnose him.. why this is happening.

      Make matters worse, this has affected his mouth, so he cannot eat solids, just soups etc, and is losing weight. As he explains it, his tongue muscle, when it needs to move/chew food around, get achy/and very tired, takes him a half hour to eat anything that has substance to it. Awful to see, more awful though, is to see him losing the weight.

      A month ago, more or less, I have pictures of him on my cell phone, healthy/happy, now the past 30 days been on the decline. Doctors cannot figure it out 😦

      Concerned daughter here. thanks

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      1. Hi Christine.

        Just read your comment. Hopefully, this comes in time and is useful to you both.

        Disclaimer: I’m not a doctor; just using life experience as a guide. Please consult your Dad’s medical professional/s before considering/implementing any of the following:

        Best to start with the least invasive, and see about what might be needed next.

        Usually when swallowing/eating issues come up, I first think of going to an experienced Speech Therapist. His Primary Care Physician should be able to write an Rx for your Dad to see one.

        Speech Therapists are trained in the physical aspects of how the mouth, tongue, etc, work. It seems worth a try, since he’s complaining about tongue issues. Maybe the Speech Therapist might be able to direct you to a particular specialty. According to https://www.healthtap.com/questions/954655-what-kind-of-doctor-treats-the-tongue/, it could be one of 3 (an ear, nose and throat doctor, a dentist, and/or an oral surgeon).

        While you’re waiting for the appointment/s, maybe Dad could be switched to stew-like meals (still liquid, but thickened with pulverized vegetables like potatoes and carrots), along with high-calorie liquid meal supplements in between, or possibly switching him temporarily to a high calorie liquid diet until you can see the specialist/s, but again, please talk with his doctor first.

        Did a search on “high calorie liquid diet.” The first 3 results were:

        https://healthfully.com/288431-high-calorie-liquid-diet.html

        https://nutrineat.com/high-calorie-liquid-diet

        Click to access High-Calorie-Liquid-Diet.pdf

        God bless.

        M

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        1. Thanks Maria for sharing those helpful suggestions for Christine’s Dad. It’s very upsetting to watch a loved one lose weight because they’re not eating as they should. The specialists you mention are trained to look at all areas of the mouth and tongue so would be useful resources.

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      1. I was worried that I was going to die soon because I have to take Nitro almost every day, but after reading your article, I have found peace and am no longer afraid.

        Nitro is my friend, Thank you so much.

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    1. Hi Mary – apparently Dr. Lown gives an example of a patient who took 5 doses per day for 30 years, never another angina attack. Personally, I have occasionally had the odd day like that, but never that many doses every day. The ‘rule of 3’ for each specific episode of angina is explained in this post. Some people with more frequent angina episodes every day should discuss the possibility of wearing a nitro patch with their physician.

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    1. Hello Carol – it’s always a good idea to double-check with your own doctor first, but I can tell you generally that many of us have stents and use nitro regularly to help manage angina symptoms.

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      1. Does anyone else get angina like symptoms (indigestion , nausea) delayed after physical exertion? Especially on a hot day.
        I’m talking half an hour or so after. (1 MI , 1 stent 15 years ago)
        Nitro spray seems to relieve the awful nausea. Thanks

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        1. I’m not a physician, Peter, but I can tell you generally that there is indeed something known as exercise heartburn, as you describe. Lots of potential remedies for this available online, e.g. here.

          If these tips don’t help, see your GP…

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  12. Hi Carolyn

    Any advice on radium treatment effects on heart or stents? I am due to start radium for breast cancer in the next few weeks and am worried as my lumpectomy was on left side of the right breast. I have had 4 stents successfully over the past 7 years and do take a nitro spray, as Dr Lown’s excellent advice. I did ask the cancer surgeon and he laughed and said as the heart is on your left side it’s not likely. Hes a lovely man and a great doctor and I have great faith in him, so I am just asking if you know of anything I ought to know.
    Brenda

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    1. Hello Brenda – I’m not a physician so cannot comment specifically on your own situation, but I do know that most research that does conclude a link between breast cancer treatments and higher risk for heart disease suggest that the risks are higher when it’s the left breast being treated (same side as the heart) and dependent on the exposure to radiation in the treatment. There is an entire new field of medicine known as cardio-oncology whose specialists focus specifically on this link. I haven’t been able to find data on right breast radiation risks in a patient already living with heart disease, so perhaps your cardiologist is correct (although I do wish doctors wouldn’t “laugh” at our perfectly reasonable questions about a very frightening diagnosis!)

      Best of luck to you in your further treatment…

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  13. Came out of hospital today after my recent first heart attack, been given nitro spray and I’m one of the many who are really anxious about when I should use it, and hoping I really don’t need to, feeling a bit better now I’ve read your article, thank you very much. 🙂

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    1. Hi Chris! Just barely home from the hospital! Take it easy during the next week or two as you get your brain wrapped around what has just happened… It’s not uncommon in the early days to have some ‘stretching pain’ in your chest following a stent, so don’t be alarmed if you feel that. It’s likely just your body adjusting to and healing from the procedure. As time goes by, if you do experience some chest pain (angina), remember that nitro is your friend. That’s what it’s there for.

      Everything seems so new to you right now. But you’ve taken a good first step just by sitting down to find more info (and finding this blog). You might find this 4-part series for the freshly-diagnosed heart patient helpful. Your only job right now is to very gradually become the world expert in your diagnosis! Best of luck to you…

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  15. I’m very glad that I read this article. My husband had Nitro pills prescribed after open heart surgery. We realize we haven’t been using it to get the full benefits.

    Thank you for the correct information.

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  16. Thank you for this. It is the best, most reassuring advice on the web.

    I was diagnosed with angina on Friday and have been afraid to take Nitro in case it might do damage if I don’t really need it. Today I walked up a hill and an hour later I’m still light-headed, my breathing is a little labored. Blood pressure is up in the 150’s, even though I took my daily meds only a few hours ago.

    So I just used the spray once and wouldn’t you believe it, my breathing is a little better and I feel less sweaty and tense. I guess it takes awhile to know how much is placebo effect and how much is real. But this sense of relief feels very real and it is wonderfully reassuring to feel good.

    From now on, I’ll use the spray once before I go out walking as it will do no damage but seems to have a positive result. I don’t get headaches from it so far, just a slight discomfort but hardly noticeable.

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    1. You made my day, Jim! I love it when heart patients take Dr. Lown’s advice and (surprise, surprise!) it works! As you get more experience in taking your nitro, you’ll have an even better sense of how it’s working. And as you’ve already learned, taking nitro before you are planning to exert yourself can be a way to stay on top of angina symptoms instead of, as I used to do, white-knuckle it through an angina episode somehow just wishing that the pain would go away nicely on its own…

      As I like to now say, “Nitro is your friend!”

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      1. I’ve used the spray now on three occasions and each time my breathing feels better almost immediately. I still have a little tightness in the chest but about a half hour later, even that subsides a little. This is a little miracle. What I thought was a re-emergence of asthma is more easily treated this way than with a pesky asthma inhaler. It isn’t asthma after all.

        Thank you again! I have been educated. You have made my day, week, month, year.

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  17. Hi my sister is getting a lot of chest pain, it’s sort of behind her heart under her breast going round her back and into her arm. She has a gtn (nitro) spray and is using it up to 5 times a day. Doc gave her an ECG, haven’t got results yet. Should she go to hospital?

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    1. Hello Audrey – I’m not a physician so I cannot comment specifically on your sister’s distressing symptoms, but I can say generally that if symptoms are getting worse with exertion but then settle down with rest, that’s a classic sign of heart-related angina. If these symptoms worsen, or come on during rest – yes, she should go to the hospital (at the very least, see her GP immediately. There are many possible causes of chest pain;, right now you don’t know if these symptoms are heart-related or not. But if her symptoms continue or worsen, it’s better to be safe than sorry.

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      1. Hello.. doing this Sept 24, 2021 ..

        My dad is on the nitroglycerin patch, 0.2 mg. been on them for like 3 days, he doesn’t think it’s been a big help… As of yet anyway.

        I put the patch on him, prior to leaving to work daily. . If his EKG and chest Xray show nothing, then how can we figure this out? Is it a heart or a lung issue, why he is so winded? and quickly has to sit down, after a short walk from garage to inside the house.. and looks so panicked trying to get his breath.

        Live in Winnipeg, we even did the hospital, they do not really know, but at least gave us these patches to try. Affecting his tongue too, and it gets tired when trying to chew solid/food etc.. lost a bunch of weight. This is all in the past 30 days, otherwise prior, was fine, eating, able to walk (he is 85)

        Thanks,
        concerned daughter.

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        1. Hello Christine – sounds like this has been an alarming decline in your Dad’s condition over just 30 days. That’s pretty scary for a daughter to watch, while feeling helpless to know what to do.

          You’d mentioned that your Dad’s cardiac tests seemed “normal” but yet he was given nitro patches by the hospital. I’m not a physician so cannot comment specifically on your father’s situation – I’m guessing that your Dad’s symptoms included specific heart symptoms (e.g. chest pain, especially during physical exertion – e.g. climbing stairs, etc?)

          It may also help to remember that nitroglycerin is helpful in relieving symptoms by relaxing smooth muscles and discomfort causes by irritation or spasm of ANY smooth muscle in the body – whether in the heart muscle (angina), or a spasm in the esophagus (or in women, even in the uterus) – many smooth muscle pains could be relieved with nitroglycerin. That doesn’t help you much however in finding out what is causing the past 30 days of problems.

          If I were in your shoes, with so many questions and clearly a visible decline in your Dad’s health (especially food- and weight loss-related) I’d return to the doctor with your Dad a.s.a.p. and ask all the questions you have asked here (e.g. is this a heart or a lung issue?) Write this and all other questions you have down before you go. And do not leave the doctor’s office until you understand the answers. Something is causing these distressing symptoms – you and your Dad need to find out what!

          Good luck to both of you… ♥

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  18. Pingback: Catnip blog

  19. Hi, I live in Malaysia…I am 66 yes old, Gtn has certainly been a good friend…all the time. Besides, a CHF patient, bypassed….2 attacks 1-MF and 1 mild, I have been using GTN for a while… sometimes daily. Note, I do suffer from a bad hiatal hernia too…so I was told by my cardiologist that you do get relief from Vagal irritation as a result of hiatal hernia and reflux.

    Truly, this has been a wonder pill….But, I do follow up with all relevant check ups + medications..But, still struggling with my hiatal hernia + reflux… with slow improvements in my diet….

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    2. So, are you saying that if unsure whether reflux and/or hernia, if pain is not relieved by the nitro, it IS cardiac?

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      1. Hi Jane – actually, there are many of us heart patients living with refractory angina (that’s chest pain unrelieved by standard treatments/meds) for whom nitro does relieve pain, and heart patients for whom nitro does not work.

        In other words, symptoms can be heart-related whether nitro works or does not work. If it doesn’t work, it may be:
        A: NOT heart-related at all, but due to a non-cardiac cause
        B: related to a severe blockage of one or more coronary arteries which requires immediate emergency treatment.

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  20. I am 82, when I was 65 I had what was probably an MI but as I was living in Zimbabwe far from a town, I did not get to a Dr for 2 weeks. Big concern after ECG and recomendations to go to Johannesburg for cardiac cath – but no money and other family illness made this impossible. Moved to|UK where various meds have been tried to lower BP, but most have side effects and soon do not work well.

    As I have a degree including biochem, I decided to try GTN (nitro) spray – linked to only using when BP is above 150/85 – apart from the headache this works every time to bring BP below 140/80. I monitor BP around 5x daily.

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    1. Hello Christopher – I’m not a physician so of course cannot comment specifically on your case, but I can tell you generally that your GTN (nitro) spray can lower blood pressure (in some patients, this is an unwanted side effect that can lower BP too much, causing light-headedness or fainting!) I’m curious, however, about why you’re checking your BP five times a day. Twice-daily measurement is usually recommended for those with diagnosed high blood pressure (the first in the morning before eating or taking any medications, and the second in the evening). It seems that taking your readings five times a day might cause undue anxiety about your blood pressure – which can in turn raise your blood pressure…

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