One thing that always surprised me in cardiac rehabilitation was the understanding of using Nitroglycerin (nitro). I think over the years I saw and heard every way imaginable to ensure nitro tablet wouldn’t work if needed. Or the other one is when patients would carry it for years and then not use it when it is most appropriate to use. The take home message is if you are having discomfort that you suspect is heart related use a nitro ASAP.
How Nitro works:
Nitroglycerin dilates blood vessels that supply the areas of the heart where there is not enough oxygen thereby delivering oxygen to the heart tissue that needs it most. The dilation of veins and arteries reduces the amount of blood returning to the heart so that the heart does less work and requires less blood and oxygen. Dilation of the arteries lowers the pressure in the arteries against which the heart must pump. As a consequence, the heart works less and requires less blood and oxygen.
How to store Nitro:
Here is the thing Nitro is a very volatile compound. It breaks down rapidly with light, heat, oxygen, time and exposure to plastic. It is packed in a glass vial because plastic will leach the active ingredient out of it and all you have left is the inert ingredients that hold the tablet together. Therefore don’t transfer it to a container that is plastic, don’t put a couple in a baggy and put them in your wallet. Yes it is a pain in the butt to carry the bottle everyday, but find a way, or use a metal nitro vial which you can wear around your neck.
Heat will break down the nitro tablets. If you carry your Nitro in your pants pocket every day the heat from your body will gradually make the nitro less potent. What I teach patients is to take a good marker and write on the bottle the date three months from when they started to carry the bottle. That is when it should be considered to replace. Sometimes it can go six months, but if you look at the bottle…hold it up to the light, don’t open it…and the tablets are looking powdery or crumbled….then replace the bottle. If you leave them in your pocket and they go through the dryer…time to replace. If you leave them in your car and your car is 100* or more…replace the bottle. That was a common one…”I leave them in the glove box in my car.” NO NO NO!
If you have opened the bottle you have exposed the tablets to oxygen. Oxygen breaks down the nitro. Once the bottle has been opened, label the bottle for six months from the time you opened it. Replace the bottle at six months. A story I would frequently hear that would make me cringe would be when a patients loved one or child would say ” I poured a couple in a paper cup and have them in my cupboard in case they need one while at my house”…UHG!!!! Won’t work sorry!
The bottle is brown to prevent sunlight from destroying the tablets as well. Don’t transfer them to any other bottle, there is a reason they come this way.
When to use Nitro:
The most common mistake in using nitro is when patients would tell me the pain wasn’t bad enough to use it. The instructions for nitro don’t say wait until the discomfort is 9 out of 10, the instructions are to use the nitro if you have heart symptoms that do not go away with rest. This means any heart discomfort, no matter how minor if is present for 5 minutes, would indicate using the nitro. If you wait until you are really in pain, you probably will have damage done to the heart. The point of this drug is to prevent the damage to the heart by improving the blood flow preventing damage from occurring.
- Sit down
- Place one tablet under the tongue – most people experience a burning or tingling feeling under the tongue, a headache, a flushed feeling….If you experience this you should always experience this, as this indicates your nitro is fresh.
- Wait 5 minutes – if the symptoms resolved rest a bit then gradually become active again
- If the symptoms persist use a second nitro table, again wait 5 minutes, if needed take a third 5 minutes later
- If you took a third nitro and still have symptoms call 9-1-1.Try to do some deep relaxing breathing, and thinking try not to panic. It’s a good time to use those relaxations skills.
- Chew an adult strength aspirin while you wait for paramedics
One discussion I frequently have with patients goes as follows: You may carry your nitro faithfully for years and never need it, but if and when you do need it, you want it to be fresh so it can work. On the other hand some will need to use occasional nitro. This isn’t a bad thing. Your physician prescribed it for a reason. Use it!!!! There are common times when people need one…Exposure to cold air, Exertion that is strenuous, Emotional Stress, and after Eating a large heavy meal. Where the medical community get concerned is if you are requiring 2-3 nitro to clear your symptoms, if you are having more frequent symptoms, or if your symptoms are coming on at rest or waking your from your sleep. The escalation in symptoms should be reported to your physician ASAP.
Keep a log of your nitro use. Put on your log, the date, what you were doing when the symptoms occurred, and how many nitro it took to clear the symptoms. When you have a followup appointment with either your cardiologist or your primary care physician present them with the log. Sometimes we are able to find a pattern, do your symptoms come on at a certain time of day? Thus we can probably adjust medication timing to prevent this. Do they come on with a certain level of exertion? We call this your angina threshold and we watch to see is the threshold improving or worsening. Often through exercise we can improve the angina threshold.
What about long acting nitro?
There are long acting nitroglycerin medications that slowly release nitro into your system throughout the day. These are usually taken during the hours you are up and active. Rarely are they used twice a day, as your body needs a period of time in which it is free of nitro, or else it gets to where the nitro doesn’t work as effectively. It is still ok to use the fast acting nitro if you are on this medication.
What about the headache from taking Nitro?
Take a Tylenol. The headache won’t kill you but the heart attack might.