Effects of nitroglycerin on regional O2 supply and O2 consumption in reperfused dog myocardium

Effect of intravenous nitroglycerin on cerebral saturation in high-risk cardiac surgery

PURPOSE

To determine whether or not intravenous nitroglycerin (IV NTG) can prevent a decrease in near-infrared spectroscopy (NIRS) values during cardiopulmonary bypass (CPB).

METHODS

We conducted a randomized double-blinded study in a tertiary academic center including 30 patients with a Parsonnet score>or=15 scheduled for a high-risk cardiac surgery. The patients were randomized to receive either IV NTG (initial dose of 0.05 microg.kg(-1).min(-1), followed by 0.1 microg.kg(-1).min(-1)) or placebo after anesthetic induction until the end of CPB. The primary outcome was a decrease of 10% in NIRS values during CPB.

RESULTS

Despite the absence of between-group difference in the mean cerebral oxygen saturation during CPB, there was a significant decrease in NIRS values during CPB in the placebo group, whereas mean NIRS values were maintained in the IV NTG group (-16.7% vs 2.3% in the NTG, P=0.019). Major hemodynamic variables were similar at corresponding time periods in both groups, while patients in the IV NTG group had higher CK-MB values and experienced greater blood loss during the first 24 hr postoperatively.

CONCLUSION

Intravenous nitroglycerin administration before and during CPB may prevent a decrease in NIRS values associated with CPB in high-risk cardiac surgery. Further studies are warranted to determine the efficacy and the risks associated with IV NTG infusion for this indication during CPB in high-risk patients.

The effect of nitroglycerin on pacing-induced changes in myocardial oxygen consumption and metabolic coronary vasodilation in patients with coronary artery disease

In the present study, we assessed the potential effect of nitroglycerin IV (NTG), a donor of exogenous nitric oxide, on metabolic coronary flow control in patients with coronary artery disease. In 12 patients scheduled for coronary artery surgery, arterial blood pressure, pulmonary capillary wedge pressure, coronary sinus blood flow (continuous thermodilution), myocardial oxygen supply (DVO2), and myocardial oxygen consumption (MVO2) were measured at sinus rhythm and in response to atrial pacing at 30 bpm greater than baseline sinus rate. These measurements were repeated during infusion of NTG 1 and 2 microg x kg(-1) x min(-1). At control, in the absence of NTG, MVO2 increased from 13.7 +/- 3.4 mL O2/min during sinus rhythm to 19.3 +/- 5.5 mL O2/min during pacing. NTG 1 and 2 microg x kg(-1) x min(-1) blunted the pacing-induced increase in MVO2 dose-dependently. During NTG 1 microg x kg(-1) x min(-1), MVO2 increased from 12.9 +/- 3.3 mL O2/min at sinus rhythm to 17.3 +/- 4.7 mL O2/min during pacing (P = 0.01 versus control pacing); during NTG 2 microg x kg(-1) x min(-1), MVO2 increased from 13.4 +/- 3.3 mL O2/min to 15.9 +/- 3.7 mL O2/min (P = 0.008 versus control pacing). However, the pacing-induced increase in DVO2 per mL O2/min increase in MVO2 (delta DVO2/delta MVO2), was significantly greater during the infusion of NTG 2 microg x kg(-1) x min(-1) (1.85 +/- 0.56; P = 0.023) compared with control (1.51 +/- 0.22). This was associated with an increase in coronary sinus hemoglobin oxygen saturation (30% +/- 5% at control pacing and 34% +/- 6% during pacing with NTG 2 microg x kg(-1) x min(-1); P = 0.018), which indicates that during the infusion of NTG, there was more metabolic coronary vasodilation than achievable solely on the basis of the metabolic stimulus.

IMPLICATIONS

Our findings suggest that nitroglycerin, a donor of exogenous nitric oxide, reduces pacing-induced increases in myocardial oxygen consumption and enhances metabolic coronary vasodilation in patients with coronary artery disease, in whom endogenous nitric oxide activity may be reduced.