Myocardial Infarction - Diagnosis - Sublingual Nitroglycerin

1/16/2008

Question:  Is the application of sublingual nitroglycerin an accurate diagnostic test for suspected MI?

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<1>

Unique Identifier [PMID]: 17320010

Authors: Steele R. McNaughton T. McConahy M. Lam J.

Institution: Loma Linda University Medical Center, Loma Linda, California 92354, USA.

Title: Chest pain in emergency department patients: if the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain?.

Source: CJEM Canadian Journal of Emergency Medical Care. 8(3):164-9, 2006 May.

Abstract: INTRODUCTION: It is often believed that chest pain relieved by nitroglycerin is indicative of coronary artery disease origin. OBJECTIVE: To determine if relief of chest pain with nitroglycerin can be used as a diagnostic test to help differentiate cardiac chest pain and non-cardiac chest pain. DESIGN: Prospective observational cohort study with a 4-week follow-up of patients enrolled. SETTING: Academic tertiary care hospital, with 60,000 visits/year. INCLUSION CRITERIA: Adult patients presenting to the emergency department with active chest pain who received nitroglycerin and were admitted for chest pain. EXCLUSION CRITERIA: Patients with acute myocardial infarction diagnosed after obtaining an ECG, patients whose chest pain could not be quantified, those for whom no cardiac work-up was done, or those who received emergent cardiac catheterization. RESULTS: 270 patients were enrolled. Nitroglycerin relieved chest pain in 66% of the subjects. The diagnostic sensitivity of nitroglycerin to determine cardiac chest pain was 72% (64%-80%), and the specificity was 37% (34%-41%). The positive likelihood ratio for having coronary artery disease if nitroglycerin relieved chest pain was 1.1 (0.96-1.34). Telephone follow-up at 4 weeks was performed, with a 95% follow-up rate. CONCLUSIONS: Relief of chest pain with nitroglycerin is not a reliable diagnostic test and does not distinguish between cardiac and non-cardiac chest pain.

Publication Type: Journal Article.
 

<2>

Unique Identifier [PMID]: 15940087

Authors: Diercks DB. Boghos E. Guzman H. Amsterdam EA. Kirk JD.

Institution: Division of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, CA 95817, USA. dbdiercks@ucdavis.edu

Title: Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain.

Source: Annals of Emergency Medicine. 45(6):581-5, 2005 Jun.

Abstract: STUDY OBJECTIVE: We determine whether the change in numeric descriptive scale for pain after sublingual nitroglycerin use can predict cardiac etiology of chest pain. METHODS: A prospective study of a convenience sample of patients who had chest pain, presented to the emergency department from May 24, 2001, to April 30, 2002, and received sublingual nitroglycerin during their evaluation was performed. The 11-point numeric descriptive scale for chest pain was recorded before and after the initial dose of sublingual nitroglycerin. Cardiac-related pain was defined as chest pain in a patient with a discharge diagnosis of myocardial infarction or the diagnosis of coronary artery disease based on a positive diagnostic study (cardiac catheterization or noninvasive stress imaging). Change in the numeric descriptive scale was divided into 4 categories: (1) significant/complete reduction; (2) moderate reduction; (3) minimal reduction; and (4) no change. RESULTS: The study cohort was composed of 664 patients: 345 women (52%) and 319 men (48%), mean age 52 years (+/-12.4 years). Cardiac-related chest pain was identified in 122 patients (18%). In the overall patient population, 125 (19%) patients had no change in pain, 206 (31%) patients had minimal reduction, 145 (22%) patients had moderate reduction, and 188 (28%) patients had significant or complete reduction in pain. There was no significant difference in any subgroup of numeric descriptive scale response to sublingual nitroglycerin administration in patients with and without a diagnosis of cardiac chest pain. CONCLUSION: In this convenience sample, the response of chest pain to sublingual nitroglycerin was not a reliable indicator of a cardiac etiology.

Publication Type: Clinical Trial. Journal Article.
 

<3>

Unique Identifier [PMID]: 15313756

Authors: Evans AT. Reilly BM.

Title: Chest pain relief by nitroglycerin.[comment].

Source: Annals of Internal Medicine. 141(4):324; author reply 324, 2004 Aug 17.

Publication Type: Comment. Letter.
 

<4>

Unique Identifier [PMID]: 15117167

Authors: Anonymous.

Title: Chest pain relief by nitroglycerin doesn't predict active coronary artery disease.

Source: Cleveland Clinic Journal of Medicine. 71(4):280, 2004 Apr.

Publication Type: Comparative Study. Journal Article.
 

<5>

Unique Identifier [PMID]: 14678917

Authors: Henrikson CA. Howell EE. Bush DE. Miles JS. Meininger GR. Friedlander T. Bushnell AC. Chandra-Strobos N.

Institution: Johns Hopkins Bayview Medical Center, Baltimore, Maryland 21224, USA.

Title: Chest pain relief by nitroglycerin does not predict active coronary artery disease.[see comment].

Source: Annals of Internal Medicine. 139(12):979-86, 2003 Dec 16.

Abstract: BACKGROUND: The belief that chest pain relief with nitroglycerin indicates the presence of active coronary artery disease is common. However, this hypothesis has not been tested. OBJECTIVE: To define the diagnostic and prognostic value of chest pain relief with nitroglycerin. DESIGN: Prospective observational cohort study. SETTING: Urban community teaching hospital. PATIENTS: 459 consecutive patients with chest pain admitted through the emergency department who received nitroglycerin from emergency services personnel or an emergency department nurse. Follow-up was obtained by telephone contact at 4 months. MEASUREMENTS: Chest pain relief was defined as a decrease of at least 50% in patients' self-reported pain within 5 minutes of the initial dose of sublingual or spray nitroglycerin. Active coronary artery disease was defined as any elevated serum enzyme levels, coronary angiography demonstrating a 70% or greater stenosis, or a positive exercise test result. RESULTS: Nitroglycerin relieved chest pain in 39% of patients (181 of 459). In patients with active coronary artery disease as the likely cause of their chest pain, 35% (49 of 141) had chest pain relief with nitroglycerin. In contrast, in patients without active coronary artery disease, 41% (113 of 275) had chest pain relief (P > 0.2). Four-month clinical outcomes were similar in patients with or without chest pain relief with nitroglycerin (P > 0.2). CONCLUSIONS: These data suggest that, in a general population admitted for chest pain, relief of pain after nitroglycerin treatment does not predict active coronary artery disease and should not be used to guide diagnosis.

Publication Type: Journal Article. Research Support, U.S. Gov't, P.H.S..
 

<6>

Unique Identifier [PMID]: 12450614

Authors: Shry EA. Dacus J. Van De Graaff E. Hjelkrem M. Stajduhar KC. Steinhubl SR.

Institution: Cardiology Division, Brooke Army Medical Center, San Antonio, Texas 78234-6200, USA. Shry@cen.amedd.army.mil

Title: Usefulness of the response to sublingual nitroglycerin as a predictor of ischemic chest pain in the emergency department.

Source: American Journal of Cardiology. 90(11):1264-6, 2002 Dec 1.

Publication Type: Comparative Study. Evaluation Studies. Journal Article.