Accordingly to New York Times journalist Natasha Singer, approximately four million prescriptions for nitroglycerin were written in the US in 2009. The American HeartAssociation statistics show that approximately nine million Americans were living with angina that same year.Scores of patients receive a new diagnosis of coronary artery disease, suffer a heart attack, undergo a stent implant, or receive a new diagnosis of ischemic cardiomyopathy annually. If we do the math, this means that millions of coronary artery disease patients have never owned a single bottle of nitro. Many more are walking around with nitro prescriptions greater than a year old. It seems to me that nitroglycerin prescribing might be a good target for a global practice-improvement initiative. To understand why the lack of having available nitro is more than a mere inconvenience, read on.
The patient came to the ER for chest pain, not once but twice. He was a 75-year-old white man with no prior cardiac history. He was told his pain was a "hiatus hernia" at each ER visit. When he finally saw a second family physician as an outpatient, he was referred to a cardiologist. Even that didn't go well. The angiographer struggled with his newly adopted radial approach, undervisualized the coronary arteries, and sent the patient back to a telemetry bed to rest prior to discharge. A cath-lab tech told a senior partner who just happened to walk through the lab that he thought he saw a tight coronary lesion that was missed.
The senior partner reviewed the film and walked down the hall to find the patient parked in a wheelchair, waiting for hospital discharge. "You aren't going home, are you?" he asked. "Well, yes I am," replied the patient. "I've been told I'm fine, but I don't understand where the pain is coming from. Besides, the hospital says Medicare won't pay for me to stay."
The senior cardiologist replied, "If you have any more pain whatsoever, please return to the hospital immediately." The patient left with his family. Later that evening, the patient received a phone call from the senior cardiologist, who again seemed concerned, even regretful, that he had allowed him to go home. When the patient's daughter heard that the senior cardiologist had expressed concern a second time at her father's discharge, she insisted that he return to see that cardiologist the next day.
During that office visit, the troponin levels drawn from the hospital admission two days prior were confirmed as elevated. It was explained to the family that the patient had indeed suffered a heart attack. Again, concern was expressed, and plans were made for him to be recatheterized as an outpatient. "You don't mean you are sending him home again, do you?" asked the son, a bit irritated. "Well, he's not having pain now, so I think he can go home with one of you," responded the senior cardiologist. Then, turning toward the patient, he said, "Remember, if you experience any more pain, you come right back in."
That was the last time any of the patient's healthcare providers saw him alive. When the patient experienced chest pain a few days later, the family called 911. They did not deliver nitro while they waited far too long for the ambulance to arrive because they didn't have any. It was never mentioned during any of the family doctors' office visits or the two ER visits. Incredibly, it wasn't prescribed upon discharge from the hospital with leaking troponin or at the second cardiologist's office visit during which a recath was planned. The EMR system did not catch the omission. Understandably, the patient's family has lots of questions about the events surrounding his death, but one of them is simple: "Why didn't anyone prescribe nitro?" Many will correctly argue that the lack of a nitro prescription was the least of the issues with this patient's treatment plan, it's still a good question.
My wake-up call on the underuse of nitro came on the morning the World Trade Center fell in New York. I was called to see a patient with a five-year history of angina. Despite his claim of having received many stents in cath labs scattered across the US, he had never been given a single prescription of nitroglycerin. I was so astounded that I picked up the phone while standing at the patient's bedside and called my office secretary. "Please laminate eight signs that say the following: 'If you've ever had a diagnosis of angina, pain due to heart artery blockage, angioplasty, heart bypass surgery, a stent, or a heart attack, please ask us about a nitro prescription." Underneath it, the sign asks: "Is your nitro 'old'?" along with appropriate warnings not to take nitro if "Cialis, Viagra, or Levitra" have been prescribed (unless specific instructions have been given).
Those laminated signs have triggered hundreds of conversations about nitro in our office. There is no better captive audience than a bored patient in an exam room chair, staring at the wall in front of them as they've leafed through a moderately worn 2012 Time magazine for the second time. My sign has also generated a lot of conversation about erectile dysfunction. It's given my cardiac patients courage and permission to broach both subjects.
Treat Nitro Like a Furby
In my greater than 20 years of caring for patients, I've been amazed at the number of bona fide card-carrying stent patients who've never owned a bottle of nitro. On several occasions, patients have told me that their CV surgeon advised against carrying nitro "because you won't need it." (Graft failure rate is around 2% per year, so perhaps the same logic should apply to never wearing a seat belt?). I wonder how many ER visits for angina could have been avoided if the patient had just popped a sublingual dose of nitro, obtained relief, sat home to finish watching the Superbowl, and then contacted his cardiologist for a conversation the next day?
How many dollars have been wasted on hospital admissions because we didn't think to prescribe it? How often do we ask our patients if they need a refill? (Cue the tiny brown bottle coming out of a pocket or purse to be thrust into the air between the patient and the overhead light like a Ryder Cup trophy.)
Nitro is cheap, so there isn't much of an excuse not to prescribe it, except in cases of tight aortic stenosis, ultralow blood pressure, severe hypertrophic cardiomyopathy, severe pulmonary hypertension, severe dehydration, or patients on daily erectile-dysfunction meds. I ask my patients to treat nitro like it's a Furby . There are several things it doesn't tolerate, like heat, light, moisture, or being jostled around. Nitro needs to live in its own bottle, and I tell patients to be aware that it ages rapidly. That "tingle under the tongue" is not a reliable guarantee that it's working. I recommend that patients discard their nitro and get a new bottle every year, if they are sedentary, indoorsy-type patients. Jackhammer operators, farmers, and the like are instructed to change it out every six months or sooner. Most don't.
I instruct patients to be careful taking nitro if they suspect they are dehydrated, because significant blood pressure drops can occur (rarely fainting). Every patient who plans to use nitro should sit down. Those who may be prone to dizziness or syncope or who are first-time users should lie down and call someone to check on them in a few minutes or stay on the phone line with them. They should put a tablet under the tongue every 15 minutes or so, give or take depending on the impact it has on their pain. I explain the "strike three and you are out of there" rule, meaning you need to call 911 if that third nitro does not garner relief.
When I prescribe nitro to my male patients, I tell them, "Don't give it to your friends if they are taking erectile-dysfunction meds or have taken those types of meds within 48 to 72 hours" (depending on which one they are taking). Otherwise, I encourage them to be generous to others who have chest pain but have perhaps forgotten their nitro. I also take the time to refute that old wives' tale that "if you take it and your head hurts, it's not your heart." Nothing could be further from the truth. I explain to them that nitro isn't a very "smart" drug because it engorges all arteries and when you engorge a brain artery it causes a migraine-type pain in a small percentage of patients, so I advise them to keep Tylenol handy.
To take the mystery and some anxiety out of nitro use that is fairly common with first-time users, I form an "O" sign with my left hand, then I place my other fingers inside it to simulate a partial blockage in a heart artery. I then explain that when nitro reaches the vessel, it expands it, leaving room between the "blockage and the vessel wall" that allows blood to get to their aching heart muscle. That visual (though oversimplified) goes a long way in reassuring patients with coronary artery disease of the wisdom and logic of actually opening the pill bottle.
I also encourage patients regarding other uses for nitro: to occasionally lower persistently elevated blood pressure (if they are asymptomatic) and to buy time until "morning or Monday" if they are reluctant to strike out to the ER. I also warn them to literally cover their mouths if they have taken an erectile-dysfunction med and then find it necessary to call EMS because a good EMS team will burst through the door with their nitro-guns blazing for a chest-pain run. I assure them that other preps such as calcium-channel blockers and opiates can be used to quiet their chest pain instead.
According the website GoodRx, a bottle of 25 nitro tablets costs anywhere from $8.79 to $10.31, with a "cash cost" of $11. An ER visit costs thousands. Our lack of prescribing those tiny white pills or the spray that comes in a ruby red bottle can cost lives. One may argue that the lack of nitro prescribing isn't a life-threatening issue. I counter that many times in the cath lab, I've relieved ST elevation from spasm or during an episode of ischemia with a simple sublingual dose. I challenge anyone to show me a randomized placebo-controlled trial that demonstrates that nitro isn't beneficial. When someone finally does a study that looks at how many patients with angina or coronary artery disease arrive at the ER door for treatment of chest pain with no nitro prescription, in this Affordable Care Act–driven medical economy, I bet we would write or e-prescribe the heck out of it. Meanwhile, why don't we take it upon ourselves as the good practitioners we are to start prescribing more of it today?
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Cite this: Nitro: Why Aren't We Prescribing It? - Medscape - Mar 10, 2014.