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Does Nitroglycerin Response Have Diagnostic Value in the ER?

Chest-pain relief with nitroglycerin might not mean what you think it does.

Sublingual nitroglycerin is a common frontline therapy for patients with chest pain. Does symptom relief by nitroglycerin necessarily mean that the pain was caused by coronary artery disease? To answer this question, researchers prospectively studied 459 consecutive patients who presented with chest pain to the emergency department of an urban community teaching hospital and who then received sublingual or spray nitroglycerin (0.4 mg).

Symptom relief was defined as a 50% decrease in self-reported pain within 5 minutes of nitroglycerin administration. Active CAD was defined as any serum troponin T elevation, coronary angiography showing stenosis of 70%, a positive exercise-test result, or diagnosis by the attending physician with confirmation by a blinded cardiologist.

The cause of chest pain was determined to be active CAD in 31% of patients, not to be active CAD in 60%, and to be unclear in 9%. Nitroglycerin relieved chest pain in 39% of patients: 35% of those with active CAD and 41% of those without active CAD. At 4 months, the incidences of death, subsequent MI, and coronary revascularization (either individually or combined) did not differ significantly between nitroglycerin-responsive and -unresponsive patients.

Comment: These prospective, observational results suggest that in a general population admitted to an ER with chest pain, symptom relief by nitroglycerin does not predict active CAD. Therefore, response to nitroglycerin in the ER should be used cautiously as a guide to further therapy. Nitroglycerin clearly has therapeutic value, but its diagnostic value in the acute care setting is limited.

— Joel M. Gore, MD

Published in Journal Watch Cardiology February 13, 2004

Citation(s):

Henrikson CA et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 2003 Dec 16; 139:979-86.

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• Medline abstract (Free)

Gibbons RJ. Nitroglycerin: Should we still ask? Ann Intern Med 2003 Dec 16; 139:1036-7.

• Original article (Subscription may be required)
• Medline abstract (Free)