Buccal nitrates in left ventricular failure
Date First Published:
April 30, 2002
Last Updated:
July 1, 2003
Report by:
Dhurga Gnanasegaram, Senior Clinical Fellow (Manchester Royal Infirmary)
Search checked by:
Jon Argall, Manchester Royal Infirmary
Three-Part Question:
[In a patient with left ventricular failure] are [buccal nitrates equivalent to a nitrate infusion] for [preload reduction]?
Clinical Scenario:
You are called to see a 60 year old man who has been increasingly breathless for a week. Examination reveals him to be mildly dyspnoeic at rest with a raised JVP and bibasal creps. There is evidence of ischaemia on his ECG. The CXR shows upper lobe diversion and Kerley B lines. You wonder whether buccal suscard would be an appropriate alternative to a GTN infusion.
Search Strategy:
Medline 1966-04/03 using the OVID interface.
Search Details:
[(exp nitrates OR nitrate.mp OR exp nitroglycerin OR nitroglycerin.mp OR exp vasodilator agents OR GTN.mp OR glyceryl trinitrate.mp OR exp isosorbide dinitrate OR Isoket.mp OR Suscard.mp) AND {(buccal.mp OR exp mouth mucosa OR exp administration, buccal) AND (exp injections, intravenous OR intravenous.mp OR IV.mp)} AND (exp heart failure, congestive OR heart failure.mp OR LVF.mp OR left ventricular failure.mp OR congestive cardiac failure.mp OR exp ventricular dysfunction, left OR exp ventricular dysfunction OR exp pulmonary oedema)] LIMIT to human AND English language.
Outcome:
Altogether 7 papers were found, of which 5 were reviews of nitrates rather than comparative studies. The 2 remaining publications consisted of a summary report and full article relating to the same trial. the results of this trial are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Nitrate therapy for left ventricular failure complicating acute myocardial infarction: a haemodynamic comparison of intravenous, buccal and transdermal delivery systems. Verma SP, Silke B, Reynolds GW et al. 1989, UK | 36 male patients with acute LVF secondary to recent MI (<10 hours) in CCU IV vs buccal vs transdermal GTN Average doses over 90 mins: IV 12.9mg, buccal 5mg, dermal 20mg |
PRCT | Left heart filling pressures | All three groups reduced | Only 36 patients Different doses of buccal, IV and dermal GTN (based on previous studies) IV dose individually titrated; buccal and dermal doses predetermined |
| Cardiac output | No reduction in any group | ||||
| BP | 3 patients had BP falls in buccal group but with no clinical deterioration |
Author Commentary:
There is very limited evidence available to allow direct comparison between intravenous and buccal routes.
Bottom Line:
Buccal nitrates produce an immediate reduction in preload (comparable with intravenous GTN).
References:
- Verma SP, Silke B, Reynolds GW et al.. Nitrate therapy for left ventricular failure complicating acute myocardial infarction: a haemodynamic comparison of intravenous, buccal and transdermal delivery systems.