Buccal or nitrate spray for the pre-hospital patient
Date First Published:
September 15, 2003
Last Updated:
October 24, 2003
Report by:
Matthew Hillis, Paramedic (Royal Berkshire Ambulance NHS Trust)
Search checked by:
tbc, Royal Berkshire Ambulance NHS Trust
Three-Part Question:
In [pre-hospital patients with cardiac chest pain] is [buccal nitrate better than a nitrate spray] at [relieving chest pain]
Clinical Scenario:
An ambulance is called to a patient suffering from acute chest pain, which is diagnosed as cardiac in origin.The pt has taken a spray of their own GTN with little effect, and you wonder whether a buccal GTN preparation would be more effective at relieving the pain?
Search Strategy:
({exp nitroglycerin/ AND exp coronary disease/) AND (buccal$.mp AND spray$.mp})
(exp nitroglycerin/ AND exp coronary disease/ AND buccal$.mp)
(exp nitroglycerin/ AND exp coronary disease/ AND spray$.mp)
({exp nitroglycerin/ AND exp coronary disease/) AND (exp mouth mucosa/ OR exp administration, buccal/}) Limit to Human and english
(exp nitroglycerin/ AND exp coronary disease/ AND buccal$.mp)
(exp nitroglycerin/ AND exp coronary disease/ AND spray$.mp)
({exp nitroglycerin/ AND exp coronary disease/) AND (exp mouth mucosa/ OR exp administration, buccal/}) Limit to Human and english
Search Details:
Medline 1966-2003 Using OVID Interface.
Outcome:
A total of 3 papers were found which had some relevance.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| A comparison of buccal nitroglycerin and sublingual nitroglycerin in the prophylaxis and treatment of exertional (situation-provoked) angina pectoris. Bray CL. Jain S. Faragher EB. Myers P. MacIntyre P. Rae A. Goldman M. Alcorn M. May-91 UK | 47 Pts with acute coronary syndrome (angina pectoris) | Multicentre, double blind study | Buccal GTN is better prophylactically | Less frequent angina attacks and more a more prolonged duration of effect | The pts used their own interpretation of pain and pain relief rather than a scoring system |
| Buccal versus sublingual nitroglycerin administration in the treatment of angina pectoris: a multicentre study. Ryden L. Schaffrath R. 1987 September Sweden | 113 pts with stable angina pectoris | Randomized, multicentre comparitative study | Both formulations are comparable | However Buccal GTN has a more prophylactic effect due to its duration of action | The trial used stepped doses of GTN. Depending on effectiveness. Also no direct comparison of SL GTN vs. BGTN |
| Efficacy of sustained-release buccal nitroglycerin in pts with angina pectoris. New and long acting therapy demonstrated by exercise. Greengart A. Lichstein E. Hollander G. Bolton S. Sanders M. 1983 March USA | 16 patients with known coronary artery disease | Randomized, double blind study | Buccal GTN is an effective method of administering GTN for rapid & prolonged effect | With a reduction in angina pectoris and increased exercise duration (at least 5 hours) | Small number of patients |
Author Commentary:
There is a large volume of data regarding GTN and coronary artery disease and that GTN is proven to be effective in relieving angina pectoris. There is not an overwhelming collection of evidence about different drug delivery systems and whether one is more effective than the other.
However it is possible to state that BGTN and SLGTN are equally effective at relieving acute coronary chest pain/angina. Yet BGTN is proven to be more effective over a longer period of time than single dose SLGTN.
However it is possible to state that BGTN and SLGTN are equally effective at relieving acute coronary chest pain/angina. Yet BGTN is proven to be more effective over a longer period of time than single dose SLGTN.
Bottom Line:
There is moderate evidence to prove that Buccal GTN is more effective at controlling exertional angina chest pain due to its longer acting duration. It also has less side effects like headache. And Increases a patients exertional tolerance due to its delivery system.
References:
- Bray CL. Jain S. Faragher EB. Myers P. MacIntyre P. Rae A. Goldman M. Alcorn M.. A comparison of buccal nitroglycerin and sublingual nitroglycerin in the prophylaxis and treatment of exertional (situation-provoked) angina pectoris.
- Ryden L. Schaffrath R.. Buccal versus sublingual nitroglycerin administration in the treatment of angina pectoris: a multicentre study.
- Greengart A. Lichstein E. Hollander G. Bolton S. Sanders M.. Efficacy of sustained-release buccal nitroglycerin in pts with angina pectoris. New and long acting therapy demonstrated by exercise.