By Adam Schneeweiss MD, Marija Weiss DSc (auth.)

Nitrates were for a few years the cornerstone of cardiovascular remedy for varied symptoms. not just have nitrates stood the attempt of time for remedy of persistent strong angina pectoris, however the symptoms for them have markedly ex­ panded. They now comprise all different types of angina pectoris and myocardial ischemia, congestive center failure and hypertensive emergencies. The invaluable results of nitrates in most of these stipulations consequence from their vasodilatory houses, however it continues to be uncertain no matter if the critical or peripheral results predominate within the thera­ peutic mechanism. lately nitrates were proven to satisfy an important requirement for every and each drug - to minimize mortality. a wide scale research published that isosorbide dinitrate, mixed with hydralazine, lowered long term mortality via 28% in sufferers with congestive center failure. This discovering will surely stimulate examine on nitrates, and it'd be anticipated that curiosity in those medicines will markedly elevate. The basically used nitrates in scientific perform are nitroglycerin and the com­ plex natural nitrates, frequently isosorbide dinitrate. The natural mononitrates are actually below scientific research, and isosorbide-5-mononitrate (IS-5-MN) seems to be specially promising.

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This goes without saying for drugs such as beta-adrenoreceptor blockers and calcium antagonists, which are considered first line antihyper- Nitrates Compared and Combined with Other Antianginai Drugs 33 tensive drugs. Even nitrates are effective in certain forms of hypertension, such as isolateOd systolic hypertension in the elderly. Drugs that have been developed purely for treatment of hypertension, such as the angiotensin converting enzyme inhibitors (ACEI) are now evaluated for treatment of angina pectoris, with variable results.

2. Coronary Spasm Until about 20 years ago angina was generally believed to result almost exclusively from increased myocardial oxygen demand in the presence of a fixed atherosclerotic coronary stenosis. Even after the first descriptions of angina at rest and of variant angina [76, 77] these conditions were considered to be limited to a small number of patients. Only in the past 15 years have they been recognized as affecting large numbers of patients. Extensive studies of angina at rest followed the development of calcium antagonists, which were considered very effective in this condition.

Increase in myocardial blood supply. It is the delicate interplay between the pathophysiology in any individual patient and the relative effect of drugs on either mechanism that determines the suitability of a specific drug for an individual patient. Pretreatment systemic arterial pressure is a determinant of myocardial oxygen demand (afterload) and supply (coronary perfusion pressure). Obviously it is a major factor affecting the therapeutic response to various anti anginal drugs. Except for nitrates all anti anginal drugs are also antihypertensive drugs.

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