Response to Nitroglycerin Does Not Predict Cardiac Chest Pain
Date First Published:
October 1, 2010
Last Updated:
October 1, 2010
Report by:
Linh T Le, Medical Student (Oregon Health Science University)
Search checked by:
MEDLINE 1996 to September Week 2 2010 using the OVID interface. , Oregon Health Science University
Three-Part Question:
In [patients with chest pain] does [responding to nitroglycerin] predict [cardiac chest pain]?
Clinical Scenario:
A 47 year old man arrives to the emergency department with severe chest pain. His chest pain significantly improves with sublingual nitroglycerin. You wonder if the relief of patient’s chest pain with nitroglycerin has any prognostic value in the diagnosis of cardiac chest pain.
Search Strategy:
MEDLINE 1996 to September Week 2 2010 using the OVID interface.
[(exp cardiac chest pain OR cardiac chest pain.mp. OR MI.mp OR exp myocardial ischemia OR myocardial ischemia.mp OR coronary artery disease.mp OR exp angina pectoris) AND (exp nitroglycerin OR nitroglycerin.mp)] LIMIT to human and English.
[(exp cardiac chest pain OR cardiac chest pain.mp. OR MI.mp OR exp myocardial ischemia OR myocardial ischemia.mp OR coronary artery disease.mp OR exp angina pectoris) AND (exp nitroglycerin OR nitroglycerin.mp)] LIMIT to human and English.
Outcome:
23 articles of which 20 were irrelevant or of insufficient quality. The three remaining papers are shown in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Chest pain relief by nitroglycerin does not predict active coronary artery disease Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, Bushnell AC, Chandra-Strobos N. 2003 USA | 459 consecutive patients admitted from the ED for chest pain who received NTG | Single-center, prospective observational cohort study | Relief of CP in 39% of total patients | 4 months clinical outcome were similar in patient with or without CP relief with NTG. Relief of chest pain after NTG does not predict active CAD and should not be used to guide diagnosis | Highly subjective self-reported pain using the scale of 0-10 which has many difficulties and interpretation and recall. Also there may be a work-up bias as physicians were aware of the CP response to NTG |
| Relief of CP in 35% of patient with active CAD | |||||
| Relief of CP in 41% of patient without active CAD | |||||
| Chest pain in emergency department patients: If the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? Steele R, McNaughton T, McConahy M, Lam J. 2006 USA | 270 adult patients presenting to the ED with active chest pain who received NTG | Single-center, prospective cohort study | Relief of CP in 66% of total patients | NTG response had 72% sensitivity, 37% specificity, 34% PPV and 75% NPV for cardiac CP. Relief of CP with NTG does not distinguish between cardiac and non-cardiac CP. | Cannot eliminate selection bias based on exclusion criteria – excluding patients with lower likelihood of disease. While non-cardiac disease was defined as absence of objective findings, this does not completely rule out disease. |
| Of those with relief – 34% had cardiac CP while 66% did not | |||||
| Of those with no relief – 25% had cardiac CP and 75% did not | |||||
| Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain Diercks DB, Boghos E, Guzman H, Amsterdam EA, Kirk JD 2005 USA | 664 consecutive chest pain patients in ED | Single center, prospective cohort study | Out of the total patients: 18% - cardiac related CP; 19% - no change; 31% - minimal reduction; 22% - moderate reduction; 28% - significant or complete reduction | No significant difference in overall response rates. The response of CP to NTG was not a reliable indicator of a cardiac etiology | Incomplete follow-up may have underestimated the predictive value of pain response to NTG. Assumptions that patient with a negative ECG and troponin I ruled out cardiac related CP though this may not completely rule out disease. The self-reporting numeric description pain scale is highly subjective. |
Author Commentary:
There are no randomised trials that address the question. The best evidence would appear to come from the above studies, which show that in patients from the general population presenting with chest pain, relief of pain with nitroglycerin is not a reliable diagnostic test and does not distinguish between cardiac and non- cardiac chest pain. Therefore, it should not be assumed that patients who do not have relief of chest pain with nitroglycerin are less likely to be suffering from a cardiac cause.
Bottom Line:
Relief of chest pain with nitroglycerin does not predict cardiac etiology.
References:
- Henrikson CA, Howell EE, Bush DE, Miles JS, Meininger GR, Friedlander T, Bushnell AC, Chandra-Strobos N.. Chest pain relief by nitroglycerin does not predict active coronary artery disease
- Steele R, McNaughton T, McConahy M, Lam J.. Chest pain in emergency department patients: If the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain?
- Diercks DB, Boghos E, Guzman H, Amsterdam EA, Kirk JD. Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain