By Adam Schneeweiss MD, Marija Weiss DSc (auth.)
Nitrates were for a few years the cornerstone of cardiovascular remedy for varied symptoms. not just have nitrates stood the attempt of time for remedy of persistent strong angina pectoris, however the symptoms for them have markedly ex panded. They now comprise all sorts of angina pectoris and myocardial ischemia, congestive middle failure and hypertensive emergencies. The helpful results of nitrates in some of these stipulations consequence from their vasodilatory houses, however it continues to be doubtful even if the significant or peripheral results predominate within the thera peutic mechanism. lately nitrates were proven to satisfy an important requirement for every and each drug - to minimize mortality. a wide scale examine printed that isosorbide dinitrate, mixed with hydralazine, lowered long term mortality via 28% in sufferers with congestive middle failure. This discovering will surely stimulate learn on nitrates, and it'd be anticipated that curiosity in those medications will markedly elevate. The essentially used nitrates in medical perform are nitroglycerin and the com plex natural nitrates, normally isosorbide dinitrate. The natural mononitrates are actually lower than scientific research, and isosorbide-5-mononitrate (IS-5-MN) seems to be specially promising.
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Increase in myocardial blood supply. It is the delicate interplay between the pathophysiology in any individual patient and the relative effect of drugs on either mechanism that determines the suitability of a specific drug for an individual patient. Pretreatment systemic arterial pressure is a determinant of myocardial oxygen demand (afterload) and supply (coronary perfusion pressure). Obviously it is a major factor affecting the therapeutic response to various anti anginal drugs. Except for nitrates all anti anginal drugs are also antihypertensive drugs.
Recently Distante et al  reported a preliminary study in patients with vasospastic angina, showing that oral IS-5-MN, 20 or 40 mg, is an effective therapeutic agent for prevention of myocardial ischemia due to vasospasm induced by ergonovine or isometric stress test. This study is discussed further in the chapter on mononitrates. In summary, nitrates are effective in relief and prevention of vasospastic angina pectoris, within the well-known limitations of all forms of conservative medical treatment in this unstable condition.
All these findings indicate that nitrates are superior to other anti anginal and anti-ischemic drugs for treatment of myocardial ischemia in normotensive patients. This recommendation is supported by the extremely low incidence of aggravation of ischemia during chronic oral nitrate therapy. 6. Combined Therapy Combined therapy with beta-adrenoreceptors and calcium antagonists produces an additive antianginal effect only in patients with normal or mildly impaired left ventricular function who remain symptomatic despite optimal treatment with a single agent alone [70x].