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"The Pain Was Relieved by Nitro": Helpful Information?

Results from this study defy conventional wisdom about patients who present with chest pain to emergency departments.

Relief with nitroglycerin is thought by some to be characteristic of anginal chest pain. What is the prognostic value of this clinical observation? Researchers in Maryland prospectively studied 459 patients who received nitroglycerin (0.4 mg) after they presented with chest pain to an emergency department.

Symptom relief was defined as 50% decrease in self-reported chest pain within 5 minutes of receiving nitroglycerin. Active CAD was defined as 70% stenosis on cardiac catheterization; any serum troponin T elevation; a positive exercise-test result; or physician diagnosis of CAD, confirmed by a cardiologist who was blinded to nitroglycerin-relief status.

Active CAD was present in 141 patients (31%). Nitroglycerin relieved chest pain in 181 patients (39%): 35% of those with active CAD (sensitivity) and 41% of those without active CAD (specificity, 59%). Likelihood ratios indicated that neither relief nor lack of relief with nitroglycerin predicted active CAD.

Comment: The authors point out that some practice guidelines include nitroglycerin relief as a feature to consider when determining chest-pain etiology, but that prognostic decision rules generated by some research studies have not included nitroglycerin relief. In this study, nitroglycerin response had no prognostic or diagnostic value in patients who presented with chest pain to the ED. However, an editorialist notes that the pathophysiology of chronic stable angina differs from that of acute coronary syndromes and that for outpatients with ongoing chest pain that could be anginal, nitroglycerin response does help to estimate the probability of CAD.

— Richard Saitz, MD, MPH, FACP, FASAM

Published in Journal Watch General Medicine January 16, 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.

• Original article (Subscription may be required)
• 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)