Use of Sublingual Nitroglycerin: Have We Forgotten the Basics?

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Use of Sublingual Nitroglycerin: Have We Forgotten the Basics?

Melinda Matthews, DNP, ANP-BCEast Carolina Heart Institute @ East Carolina University

East Carolina Heart Institute @ ECU

CLINICAL INTEREST

• 29 years – cardiology nurse • 13 years - hospital cardiology

• 16 years - nurse practitioner … ambulatory cardiology

• DNP Study … clinically relevant• Nitro: Why Aren’t We Prescribing It?

• SLNTG prescribing “might be a good target for a global practice-improvement initiative” (Walton-Shirley, 2014, p. 1).

• Who needs it?

• Who should get it?

• How to take it?

• When to refill it?

• When not to take it?

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1. The learner will be able to describe the impact of angina on patients seen in clinical practice:

• Disease: what is angina• Prevalence: US, Office Visits• Angina: affects quality of life,

long-term anxiety, depression, and functional capacity

• Costs re: patients with CAD (with angina).

2. The learner will be able to review the 2012 and 2014 AHA/ACC Guideline for the Diagnosis and Management of Stable Ischemic Heart Disease (Specifically, the Guideline Directed Medical Therapy):

• SLNTG

OBJECTIVES:

3. The learner will be able to describe the four areas of patients’ deficits in the use of SLNTG for the self-management of angina:

• SLNTG as premedication for effort-induced angina

• SLNTG and the use of phosphodiesterase inhibitors

• Dosing intervals for the use of SLNTG

• Replacement of SLNTG

4. The learner will be able to describe the use of a chest pain action plan

OBJECTIVES:

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1. The learner will be able to describe the impact of angina on patients seen in clinical practice:• Disease – what is angina

• Prevalence – US, Office Visits

• Angina – affects:• Quality of life• Long-term anxiety • Depression• Functional capacity

• Costs re: patients with CAD (with angina).

OBJECTIVE

ANGINA – WHAT IT IS.Angina [aka, stable ischemic heart disease (SIHD); chronic stable angina (CSA)]

TYPICAL ANGINA: • Discomfort (pressure, tightness, heaviness, fullness)• Location: Midsternal/substernal/retrosternal• Precipitated by: exertion/emotional distress• Relieved by: rest and/or NTG tab / spray • Other sites – see image

ATYPICAL SYMPTOMS:

• Fatigue• Indigestion• Lightheadedness• Nausea

• Dyspnea• Weakness• +/- chest pain/pressure• More common in women

https://www.youtube.com/watch?v=NK9HXu9g5qA

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THE IMPACT of ANGINA: Prevalence

•CAD – leading cause of death•Initial manifestation: angina (Camm et al., 2015)

•1 in 3 - CVD•17 million - CHD•10 million - angina (Fihn, et al., 2012; Go, et al, 2014; Mozaffarian, 2016).

•Lifetime risk of developing CAD after 40•32% for women•49% in men (Tobin, 2010).

THE IMPACT of ANGINA: Prevalence

• 1 / 5 patients w / intensive treatment for MI - angina 1 year later (Fihn et al., 2012).

• Patients’ perception of angina vs.

• Providers’ perception that pt having angina • CADENCE (Coronary Artery Disease in gENeral practiCE)

study (Beltrame, Weekes, Morgan, Tavella, & Spertus, 2009)

CANADIAN CARDIOVASCULAR SOCIETY GRADING OF ANGINA PECTORIS

http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/Ang_Gui_1976.pdf


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NYHA CLASSIFICATION OF FUNCTIONAL CAPACITY AND

OBJECTIVE ASSESSMENT

http://my.americanheart.org/professional/StatementsGuidelines/ByPublicationDate/PreviousYears/Classification-of-Functional-Capacity-and-Objective-Assessment_UCM_423811_Article.jsp#.VqUCQfkrLIU

THE SAQ

Spertus, Winder, Dewhurst, Deyo, Prodzinski, McDonell, & Fihn, 1995

ONLINE VERSION OF SAQ: MYHEALTHOUTCOMES.COM

http://myhealthoutcomes.com/

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ONLINE VERSION OF SAQ: MYHEALTHOUTCOMES.COM


SPEAK FROM THE HEART

(WEBSITE)

https://www.speakfromtheheart.com/angina-tools/angina-checklist

THE IMPACT of ANGINA: Quality of Life (QoL)

•Patients CSA - decreased QoL (Fihn et al., 2012).

•CADENCE study: • Weekly or daily angina - lower scores on the SAQ - worse

QoL

• compared

• Minimal angina (< less than 1 X / week over prior 4 weeks; Beltrame, Weekes, Morgan, Tavella, & Spertus, 2009)

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THE IMPACT of ANGINA …

•Long-term anxiety, depression, and impaired physical function (Jesperson, Albidldstrom, Hwvelplund &

Prescott, 2013).

• Higher prevalence of persistent angina in patient with diffuse non-obstructive CAD or normal coronary arteries than those with

obstructive CAD.

Patients with persistent angina were: • More depressed• More anxious• More physically limited

THE IMPACT of ANGINA: INCREASE UTILIZATION ofHEALTHCARE RESOURCES

•Direct/indirect costs for CVA/Stroke: $315 billion (Go, et al., 2014)

•Cost due to: •ED visit•Clinic visit•Revascularization procedures•Pharmacy costs (Kempt, Buysman, & Brixner, 2011).

•MERLIN-TIMI 36 trial• stable angina frequency & resource utilization - 5460

stable outpatients • SAQ 4 months after ACS • followed - additional 8 months. (Arnold et al., 2009)

•Pts without angina - $2982• Monthly angina: $4000• Weekly angina: $4500• Daily angina: $7000

THE IMPACT of ANGINA: INCREASE UTILIZATION of HEALTHCARE RESOURCES

Increased costs - recurrent hospitalizations & revascularizations

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SELF-MANAGEMENT of ANGINALiterature suggests:

• Sublingual NTG (SLNTG) is a mainstay for self-management of angina (Fihn et al., 2012).

•Discordance between guideline recommendations & actual practice in prescribing SLNTG (Gallagher et al., 2010; Zimmerman, Fass,

Katz, Low, & Franklin, 2009).

• Opportunities for further education with patients in the use of SLNTG (Gallagher et al., 2010; Zimmerman, Fass, Katz, Low, & Franklin, 2009).

2. The learner will be able to review the 2012 and 2014 AHA/ACC Guideline for the Diagnosis and Management of Stable Ischemic Heart Disease (Specifically, the Guideline Directed Medical Therapy):

• SLNTG

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The Guidelines

The Guidelines

The Guidelines

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• Minimize death• Maximizing health

& function.

MAIN GOALS - TREATING SIHD PATIENT:

Specifically ….

•Reduce premature CV death

•Prevent complications

•Maintain / restore -

•Level of activity

•Functional capacity

•Satisfactory QoL – as defined by patient

• Eliminate ischemic symptoms.

•Minimize costs of heath care

These goals can be achieved w/ 5 strategies:

•Educate patients

•Identify and treat conditions

•Modify risk factors

•Use evidence-based pharmacological treatment

•Use of revascularization / PCI or CABG when indicated to improve patient’s health status & survival.

http://www.heart.org/HEARTORG/Conditions/My-Life-Check---Lifes-Simple-7_UCM_471453_Article.jsp#.VqPZPPkrLIU

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http://www.heart.org/HEARTORG/Conditions/My-Life-Check---Lifes-Simple-7_UCM_471453_Article.jsp#.VqPZPPkrLIU

MY LIFE CHECK ®

PATIENT EDUCATION …

CLASS I (should include) recommendation re: patient education

1. Individualized education plan to include:

a. Medication adherence

b. Medication management & CV risk reduction

c. Review therapeutic options

d. Appropriate exercise

e. Self-monitoring skills

f. Recognition of worsening CV symptoms & and appropriate actions to take.

2. Patients w/ SIHD should be educated about these lifestyle elements – see Simple 7 elements.

(Fihn et al., 2009)

PATIENT EDUCATION …

CLASS IIa (reasonable to include): Education Recommendations include:

a.Diet education.

b.Recognition of stress and depression

c. Behavioral mgmt. of stress and depression

d.Evaluation & treatment of major depressive disorders when indicated.

(Fihn et al., 2009)

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GUIDELINE DIRECTED MEDICAL THERAPY

(GDMT)

The Guidelines

Fihn et al., 2009, p. e57

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The Guidelines

No additions re: the use of SLNTG found in the 2014 Guidelines.

The Guidelines

All patients with SIHD should be prescribed sublingual nitroglycerin tablets or spay for immediate relief of

angina.

Nitroglycerin use …. Since 1879

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TABS SPRAY

Usual dose: 0.3 to 0.6 mg; • Repeat every 5 mins• Max of 3 tabs (or 1.5 mg PRN)

0.4 mg; 1 to 2 sprays prn• Up to 3 doses 5 mins apart.

Onset - (mins): 2 to 5 Onset - (mins): 2 to 5

Duration - (mins): 10 to 30 Duration - (mins): 10 to 30

Side effects/tolerability:• Headache, flushing, dizziness

Side effects/tolerability:• Lower incidence / intensity - headache• Occasional taste disturbances

Common to Both:

• Overdose may lead to postural hypotension/ paradoxical angina• Avoid with PDE5 inhibitors (Viagra type meds)• Cautious in severe AS; avoid in HOCM

NITROGLYCERIN TABS vs. SPRAY

Boden, Padala, Cabral, Bushchmann & Sidhu, 2015

3. The learner will be able to describe the four areas of patients’ deficits in the use of SLNTG for the self-management of angina:

• SLNTG - premedication - effort-induced angina

• SLNTG - phosphodiesterase inhibitors

• Dosing intervals - SLNTG

• Replacement - SLNTG

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FOUR THEMES IDENTIFIED

1. SLNTG - premedication - effort-induced angina (Fan et al., 2009;

Gallagher et al., 2010)

• Straight from the Guideline: “effective for prevention of effort-induced angina when administered 5-10 minutes before activity, w/ relief lasting approximately 30-40 minutes” (Fihn et al., 2012, p. e102).

• Fan et al.’s (2009) improve SLNTG knowledge - provide self-manage angina• Only 24% of participants knew they could use SLNTG to prevent activity-related

chest pain.

• Gallagher and Colleagues (2010) • Estimates of 15-37% of patients with suspected or confirmed diagnosis of

coronary artery disease (CAD) - no prescription – SLNTG• 43% - SLNTG education - Nursing provided (37%)• Lacked knowledge - SLNTG pre-medicating prevent CP


2. SLNTG and the use of phosphodiesterase inhibitors (Fihn et al.,

2012; Gallagher, et al., 2010),

• Co-administration - sildenafil, tadalafil, or vardenafil - avoided altogether w/ long-acting nitrate (LAN; such as Imdur) administration • 24 hrs – after sildenafil (Viagra)• 48 hrs - after tadalafil (Cialis) - SLNTG• Unsure - time interval after vardenafil (Levitra) has not been

determined (Fihn et al., 2012, p. e102)

• Gallagher et al., 2010: 12% - participants - sildenafil• 33 % - knew - SLNTG should not be used concurrently• 75 % - knew - use - SLNTG concurrently - nitroglycerin patches

JACK NICHOLAS – VIAGRA SCENE

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3. Dosing intervals for the use of SLNTG (Fihn et al., 2012; Fan et al., 2009; Gallagher et

al., 2010, 2013)

• 2012 Guidelines: suggest up to 3 SLNTG before calling EMS. (Fihn et al., 2012, p. e102). • 2013 STEMI Guidelines: suggest calling EMS after first NTG – delays getting help

(O’Gara et al., 2013, Rosenberg, 2005)

• Fan et al. (2009): • 56% reported no ongoing education – SLNTG• ~ 48% did not know the correct dosing sequence - SLNTG.

• Gallagher 2010 and 2013• 2010: ~ 70% knew the correct sequence of dosing and/or maximum dosage per

episode • 2013: only 50% knew the recommended doses of SLNTG, even after the standard

educational intervention and that NTP could be used together

4. Replacement of SLNTG (Fihn et al., 2012; Gallagher et al., 2010; Zimmerman et al., 2000)

2012 SIHD Guideline:

• Keep in original bottle

• Keep cool/dry (not refrigerated)

• Do NOT use after 6-12 months after opening

Gallagher et al. (2010):• 67% knew to keep the SLNTG in its original container • 51% knew when the SLNTG would expire.

Zimmerman et al. (2000): • 38% of the participants did not have a prescription for SLNTG • 23% of patients with SLNTG had tablets that were at least one year old.


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4. The learner will be able to describe the use of a chest pain action plan

Akyildiz, Z. I., & Ergene, O. (2014). Frequency of angina and quality of life in outpatients with stable coronary artery

disease in Turkey: Insights from the PULSE study. Acta Cardiologica, 69(3), 253-259. doi:10.2143/ac.69.3.3027827

American Heart Association. (2016). Classification of Functional Capacity and Objective Assessment. Retrieved from

American Heart Association:

http://my.americanheart.org/professional/StatementsGuidelines/ByPublicationDate/PreviousYears/Classification-

of-Functional-Capacity-and-Objective-Assessment_UCM_423811_Article.jsp#.VqUCQfkrLIU

American Heart Association, Inc. (2016). My Life Check - Life's Simple 7. Retrieved from American Heart Association:

Conditions: http://www.heart.org/HEARTORG/Conditions/My-Life-Check---Lifes-Simple-7_UCM_471453_Article.jsp#.VqVaoPkrLIV

Arnold, S. V., Morrow, D. A., Lei, Y., Cohen, D. J., Mahoney, E. M., Braunwald, E., & Chan, P. S. (2009). Economic impact of

angina after an acute coronary syndrome: Insights from the MERLIN-TIMI 36 trial. Circulation: Cardiovascular

Quality and Outcomes, 2, 344-353. doi:10.1161/CIRCOUTCOMES.108.829523

Beltrame, J. F., Weekes, A. J., Morgan, C., Tavella, R., & Spertus, J. A. (2009). The prevalence of weekly angina among

patients with chronic stable angina in primary care practices: The coronary artery disease in general practice

(CADENCE) study. Archives of Internal Medicine, 169(16), 1491-1499.

Boden, W. E., Padala, S. K., Buschmann, I. R., & Sidhu, M. S. (2015). Role of short-activng nitroglycerin in the management of ischemic heart disease. Drug Desgn, Development and Therapy, 9, 4793-4805.

References

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ReferencesCamm, A. J., Manolis, A., Ambrosio, G., Daly, C., Komajda, M., Lopex de Sa, E., . . . Tamargo, J. (2015). Unresolved issues

in the management of chronic stable angina. International Journal of Cardiology, 201, 200-207.

doi:10.1016/j.ijcard.2015.08.045

Canadian Cardiovascular Society Grading of Angina Pectoris. (n.d.). Retrieved from


Fan, M.-I., Mitchell, M., & Cooke, M. (2009). Cardiac patients' knowledge and use of sublingual glyceryl trinitrate

(SLGTN). Australian Journal of Advanced Nursing, 26(3), 32-38.

Fihn, S. D., Blankenship, J. C., Alexander, K. P., Bittl, J. A., Byrne, J. G., Fletcher, B. J., . . . Smith, P. K. (2014). 2014

ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients

with stable ischemic heart disease: A report of the American College of Cardiology/American Heart Association

task force on practice ... Circulation, 130, 1749-1767. doi:10.1161/CIR.0000000000000095

Fihn, S. D., Gardin, J. M., Abrams, J., Berra, K., Blandenship, J. C., Dallas, A. P., & ... Williams, S. V. (2012). 2012

ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic

heart disease: A report of the American College of Cardiology Foundation/American Heart Association task force

on practice guidelines,. Journal of the American College of Cardiology, 60(24), e44 -e164.

Gallagher, R., Belshaw, J., Kirkness, A., Roach, K., Sadler, L., & Warrington, D. (2010). Sublingual nitroglycerin practices in

patients with coronary artery disease in Australia. Journal of Cardiovascular Nursing, 25(6), 480-486.

doi:10.1097/JCN.0b013e3181dc82ac

ReferencesGallagher, R., Belshaw, J., Kirkness, A., Warrington, D., Sadler, L., & Roach, K. (2013). Evaluation of a brief educational

intervention to improve knowledge of sublingual nitroglycerin in cardiac rehabilitation patients. European

Journal of Cardiovascular Nursing, 12(6), 529-535. doi:10.1177/1474515112473694

Gilead Sciences, Inc. (2015). chronic angina checklist. Retrieved from Speak from the heart about your angina:

https://www.speakfromtheheart.com/angina-tools/angina-checklist

Go, A. S., Mozaffarian, D., Roger, V. L., Benjamin, E. J., Berry, J. D., Blaha, M. J., . . . Turner, M. B. (2014). Heart disease

and stroke statistics -- 2014 update: A report from the American Heart Association. Circulation, 129, e28-e129.

doi:10.116/01.cir.0000441139.02102.80

Jespersen, L., Abildstrøm, S. Z., Hvelplund, A., & Prescott, E. (2013). Persistent angina: Highly prevalent and

associated with long-term anxiety, depression, low physical functioning, and quality of life in stable angina

pectoris. Clinical Research in Cardiology, 102, 571-581. doi:10.1007/s00392-013-568-z

Kempf, J., Buysman, E., & Brixner, D. (2011). Health resource utilization and direct costs associated with angina for

patients with coronary artery disease in a US managed care setting. American Health & Drug Benefit, 4(6), 353-

361.

Mozaffarian, D., Benjamin, E. J., Go, A. S., Arnett, D. K., Cushman, M., Das, S. R., . . . Turner, M. B. (2016). Heart Disase

and Stroke Statistics - 2016 Update: A report from the American Heart Association. Circulation, 133, 000-000.

doi:10.1161/CIR.0000000000000.350

References

Murrell, W. (1879). Nitro-glycerine as a remedy for angina pectoris. The Lancet, 80-81.

O'Gara, P. T., Kushner, F. G., Ascheim, D. D., Casey, D. E., Chung, M. K., de Lemos, J. A., . . . Zhan, D. X. (2013). 2013

ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American

college of cardiology foundation/American heart association task force on practice guidelines. Journal of

Americal College of Cardiology, e78–140. doi:10.1016/j.jacc.2012.11.019

Rosenberg, J. M. (2005). Clinical Q&A - Sublingual nitroglycerin: Are we counseling patients properly? Retrieved from

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are-we-counseling-patients-properly?page=full

Spertus, J. A., Winder, J. A., Dewhurst, T., Deyo, R. A., Prodzinski, J., McDonell, M., & Fihn, S. D. (1995). Development

and evaluation of the Seattle angina Questionnaire: A new functional status measure for coronary artery

disease. Journal of American College of Cardiology (JACC), 25, 333-341.

The Epimetrics Group, LLC. (2009-16). My Health Outcomes. Retrieved from My Health Outcomes:


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ReferencesTobin, K. J. (2010). Stable angina pectoris: What does the current clinical evidence tell us? The Journal of the American

Osteopathic Association, 110(7), 364-370.

Walton-Shirley, M. (2014). Nitro: Why aren't we prescribing it? Retrieved March 14, 2014, from Medscape:

http://www.medscape.com/viewarticle/821702_print

Zimmerman, F. H., Fass, A. E., Katz, D. R., Low, M., & Franklin, B. A. (2009). Nitroglycerin prescription and potency in

patients participating in exercise-based cardiac rehabilitation. Journal of Cardiopulmonary Rehabilitation and

Prevention, 29(6), 376-379.

Use of Sublingual Nitroglycerin: Have We Forgotten the Basics?

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