Nitrates as part of medical therapy and cardiac rehab for patients with chronic chest pain

In this article, the use of nitrates in patients with coronary artery disease is reviewed in details. Both the benefits and limitations of nitrate therapy are discussed, as well as the effect of nitrate therapy on cardiac rehabilitation.

CAD (Coronary Artery Disease) is a major cause of death worldwide, but also seriously affects quality of life. Many patients frequently experience chest pain during exercise, or even at rest. This is referred to as angina. Nitrates (e.g. nitroglycerin) are commonly used to relieve angina symptoms. They do so by expanding blood vessels, thus improving the blood supply to the heart muscle. Nitrates can be either short- or long-acting, and come in the form of sublingual tablets, sprays, patches, or ointments.

An important aspect of CAD treatment is cardiac rehabilitation. The goal of cardiac rehabilitation is to slow or reverse the damaging effects of CAD. Lifestyle changes are the mainstay cardiac rehabilitation. This includes dietary changes, smoking cessation, and regular exercise. It is assumed that better control of angina symptoms helps patients exercise regularly without fear of pain, and improves cardiac rehabilitation.

Nitrates are often given to relieve anginal pain when it occurs, referred to as SOS use. However, as discussed in the present article, they can also be used in a preventative manner. This improves the ability to exercise, and prevents exercise-induced pain. Patients often refrain from activity or exertion to avoid angina, rather than use nitrates as a protective measure and persist exercising.

In a review of 48 trials enrolling 8940 patients, it was found that cardiac rehabilitation was associated with a 20% reduction in overall mortality (from all causes), and a 26% reduction in mortality from cardiac causes.

In other trials, the use of nitrates before exercise delayed the onset of angina, and in some patients prevented pain entirely during exercise. This shows the importance of including nitrates as part of the optimal medical therapy (OMT) given to patients with CAD.

In summary, this review emphasized the benefit of incorporating nitrates into rehabilitation programs for patients with stable CAD. Nitrates improve exercise tolerance in patients with chornic angina. The use of nitrates before exercise allows patients with angina to pursue with the program and achieve its goals.

The trials reviewed in this article included small groups of participants. Reaching conclusions requires larger trials rather than assembling few small ones into one review.

Frequent use of nitrates has its downsides. These include hypotension (a drop in the blood pressure) and tolerance (when the drug becomes ineffective). Consult with your doctor on the proper use of nitrates to help you cope with cardiac rehabilitation.