From the Guidelines
Glyceryl Trinitrate (GTN) should be used cautiously in patients with ST-Elevation Myocardial Infarction (STEMI) and is not routinely recommended as first-line therapy, regardless of the location of the MI. The use of GTN in STEMI patients is primarily for symptom relief of chest pain and to reduce preload in patients with pulmonary edema or hypertension, as stated in the 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction 1.
The administration of GTN can be done sublingually (400 mcg tablet or spray) or intravenously (starting at 5-10 mcg/min, titrated up to 200 mcg/min) for patients with STEMI and hypertension or heart failure (HF), as mentioned in the guideline 1. However, GTN is contraindicated in patients with:
- Hypotension (systolic BP <90 mmHg)
- Right ventricular infarction
- Severe bradycardia or tachycardia
- Those who have taken phosphodiesterase-5 inhibitors within the previous 24-48 hours
Key points to consider when using GTN in STEMI patients include:
- GTN works by dilating coronary arteries and reducing preload through venodilation, which decreases myocardial oxygen demand
- GTN may provide temporary relief of chest pain, but it has not been shown to improve mortality outcomes in STEMI patients
- GTN should not delay definitive reperfusion therapy such as primary percutaneous coronary intervention or fibrinolysis
- Blood pressure should be monitored closely during administration, and the medication should be discontinued if significant hypotension occurs, as recommended by the guideline 1.
From the FDA Drug Label
WARNINGS The benefits of sublingual nitroglycerin in patients with acute myocardial infarction or congestive heart failure have not been established. If one elects to use nitroglycerin in these conditions, careful clinical or hemodynamic monitoring must be used because of the possibility of hypotension and tachycardia. The role of Glyceryl Trinitrate (GTN) in patients with ST-Elevation Myocardial Infarction (STEMI) is not established, and its use in this condition requires careful clinical or hemodynamic monitoring due to the risk of hypotension and tachycardia 2.
From the Research
Role of Glyceryl Trinitrate (GTN) in STEMI
- GTN is a first-line treatment for angina pectoris and acute myocardial infarction (MI), including ST-Elevation Myocardial Infarction (STEMI) 3.
- The use of GTN in STEMI patients is based on its ability to cause vasodilation and increase blood flow to the myocardium, which helps to reduce the severity of the infarction 3.
- However, continuous delivery of GTN can result in tolerance, limiting its use 3.
GTN Use in Inferior STEMI
- A study published in 2016 found that GTN administration to patients with inferior STEMI is not associated with a higher rate of hypotension compared to patients with STEMI in other territories 4.
- The study suggested that computer interpretation of inferior STEMI cannot be used as the sole predictor for patients who may be at higher risk for hypotension following GTN administration 4.
GTN Use in STEMI Regardless of Location
- The European Society of Cardiology (ESC) guidelines for the management of STEMI do not differentiate between the location of the STEMI when it comes to GTN administration 5.
- The guidelines recommend the use of GTN as part of the initial management of STEMI, regardless of the location of the infarction 5.