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November 13, 2001
MEDIA CONTACT: Karen Blum
PHONE: 410-955-1534
E-MAIL: kblum@jhmi.edu
"This study has the potential to change how emergency departments triage patients with chest pain." – Nisha Chandra-Stobos, M.D.
For years, hospital emergency physicians have used nitrogylcerin as a gold
standard for identifying heart disease as a cause of chest pain. If a patient
presents with chest pain, and a nitroglycerin pill or spray under the tongue
relieves the pain within a few minutes, the likely diagnosis is coronary artery
disease (CAD).
Now a Johns Hopkins study is challenging that belief. Of 459 patients who came
to the emergency department at Hopkins' Bayview Medical Center between February
and June of this year complaining of chest pain, nitroglycerin relieved chest
pain in about 39 percent of patients, whether or not they turned out to have
heart disease. Overall, nitroglycerin was only 28 percent accurate in predicting
CAD as the source of pain. These findings will be presented Nov. 12 at the American
Heart Association's annual Scientific Sessions in Anaheim, Calif.
"This study has the potential to change how emergency departments triage patients with chest pain," says Nisha Chandra-Stobos, M.D., senior author of the study and director of the coronary intensive care unit at Bayview. "Our data suggest that despite the commonly held belief, pain relief with nitroglycerin does not predict coronary artery disease and should not be used to guide diagnosis."
Nitroglycerin works by relaxing the veins (reducing the amount of blood that
returns to the heart and easing the heart's workload) and arteries (increasing
the heart's blood supply). It's the drug most often used for the one in five
patients who comes to the ED complaining of chest pain.
The patients studied had an average age of 58. Forty-six percent were male;
44 percent were smokers; 25 percent were diabetic and 38 percent had a known
history of CAD. After initial treatment with nitroglycerin, 261 (57 percent)
underwent further cardiac testing. In those with confirmed significant CAD,
39 percent had chest pain relief from nitroglycerin, compared with 38 percent
of patients who showed no evidence of coronary artery disease. Among those diagnosed
with CAD, just 34.6 percent with a known history of CAD or newly diagnosed with
CAD had chest pain relief from nitroglycerin. The frequency of diabetes, traditional
CAD risk factors and medication use was similar in patients with or without
chest pain relief from nitroglycerin.
Charles A. Henrikson, M.D., first author of the study and a cardiology fellow
at Hopkins, says, "Nitroglycerin is still fine to use for patients with
chest pain, but physicians must follow them through additional testing to determine
whether they truly have CAD."
Other study authors were Eric E. Howell, David E. Bush, Glenn Meininger, J. Shawn Miles and Andrew Bushnell.
Abstract #101662: "Debunking a Myth: Failure of Nitroglycerin-Relieved Chest Pain to Predict Coronary Artery Disease."
Related Web Sites:
Johns Hopkins Bayview Medical Center - Division of Cardiology
http://www.jhbmc.jhu.edu/cardiology/cardiology.html
American Heart Association Scientific Sessions
http://www.scientificsessions.org/