From the Guidelines
I strongly recommend verifying the patient's claim and issuing a new prescription for Nitrostat 0.4 mg tablets immediately, as this medication is crucial for managing acute angina in a 76-year-old patient with apparent cardiac history. The patient's denial of possessing the medication and the reported collection of the medication by emergency medical responders (EMR) during the last hospital visit for chest pain should be investigated by checking hospital records to confirm if the medication was indeed collected and documented.
According to the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1, nitroglycerin is recommended for the relief of angina symptoms. The standard regimen for Nitrostat (nitroglycerin) is 0.4 mg sublingually at the onset of chest pain, which can be repeated every 5 minutes for up to 3 doses, as stated in the 2012 ACCF/AHA focused update incorporated into the ACCF/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 1. If pain persists after 3 doses, the patient should seek emergency care.
Given the prison setting, a clear protocol should be established for the patient to access this medication during an angina episode, including proper storage and documentation of use. Nitrostat works by dilating blood vessels, increasing blood flow to the heart muscle, and reducing cardiac workload, which is particularly important in elderly patients with coronary artery disease, as noted in the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1. The medication's absence could pose a significant risk to this patient if he experiences acute angina.
Key points to consider:
- Verify the patient's claim and hospital records regarding the collection of Nitrostat 0.4 mg tablets.
- Issue a new prescription for Nitrostat 0.4 mg tablets if the patient truly has no medication.
- Establish a clear protocol for the patient to access the medication during an angina episode in the prison setting.
- Ensure proper storage and documentation of the medication's use.
- Educate the patient on the proper use of Nitrostat, including the standard regimen of 0.4 mg sublingually at the onset of chest pain, which can be repeated every 5 minutes for up to 3 doses.
From the Research
Patient Profile
- The patient is a 76-year-old male with a history of chest pain
- He was found to be in possession of Nitrostat 0.4 mg tabs without a current active prescription
- The patient denies having any tabs and reports that the EMR took them during his last hospital visit for chest pain
Medication Overview
- Nitrostat (nitroglycerin) is a medication used to treat angina pectoris 2
- It is a long-acting nitrate that can be effective in preventing angina episodes, but may cause nitrate tolerance or attenuation with repeated dosing 2
- Alternative medications for angina prevention include beta-blockers, calcium channel blockers, and ranolazine 3, 4
Treatment Guidelines
- The American Heart Association/American College of Cardiology guidelines recommend beta-blockers as the initial drug therapy for prevention of angina pectoris 3
- Long-acting nitrates or calcium channel blockers may be prescribed when beta-blockers are contraindicated or not tolerated 3
- Ranolazine may be used in combination with beta-blockers for prevention of angina when initial treatment is not successful 3
Comparative Effectiveness
- Studies have compared the effectiveness of long-acting nitrates and calcium channel antagonists in patients with normal or mildly diseased coronary arteries 5
- Results suggest that long-term treatment with long-acting nitrates may produce less favorable effects on coronary endothelial function and constrictive response to acetylcholine compared to calcium channel antagonists 5