Relief of Chest Pain with Nitroglycerin - Is It Predictive of Coronary Artery Disease (CAD) or Cardiac Chest Pain?

Summary:

Relief of "chest pain" after administration of sublingual or topical nitroglycerin has not been shown to be predictive of the presence of coronary artery disease (CAD) or cardiac chest pain. This is a consistent finding among 4 different studies.

The diagnostic sensitivity of nitroglycerin to determine cardiac chest pain is 72% (64%-80%), and the specificity is 37% (34%-41%).
Therefore, a clinician should not rely on the subjective improvement of "chest pain" as having any diagnostic or predictive capability in determining if the patient's chest pain is of cardiac etiology.
Based on a combination of current guidelines, the above is supported as well and thus we should only use nitroglycerin to improve "continued ischemic pain" in patients presenting with chest pain and who do not have contraindications.

Editor-in-Chief: Anthony J. Busti, MD, PharmD, FNLA
Editor: Dylan Kellogg, MD
Last Reviewed: August 2015

Supporting Guidelines
2014 AHA/ACC NSTEMI Guidelines: "Patients with NSTE-ACS with continuing ischemic pain should receive sublingual nitroglycerin (0.3 mg to 0.4 mg) every 5 minutes for up to 3 doses, after which an assessment should be made about the need for intravenous nitroglycerin if not contraindicated (216-218). (Level of Evidence: C)" Reference: Amsterdam EA et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014:[Epub ahead of print]. PubMed 2010 AHA/ACC ACLS Guidelines: "A reduction in chest pain following nitroglycerin administration may be unrelated to the presence or absence of ACS, and should not be used as a diagnostic test or strategy in the prehospital or ED setting." Reference: O'Connor RE et al. Part 9. Acute Coronary Syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010;122:S422-S465. PubMed

Supporting Guidelines

2014 AHA/ACC NSTEMI Guidelines:
"Patients with NSTE-ACS with continuing ischemic pain should receive sublingual nitroglycerin (0.3 mg to 0.4 mg) every 5 minutes for up to 3 doses, after which an assessment should be made about the need for intravenous nitroglycerin if not contraindicated (216-218). (Level of Evidence: C)"
- Reference: Amsterdam EA et al. 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014:[Epub ahead of print]. PubMed
2010 AHA/ACC ACLS Guidelines:
"A reduction in chest pain following nitroglycerin administration may be unrelated to the presence or absence of ACS, and should not be used as a diagnostic test or strategy in the prehospital or ED setting."
- Reference: O'Connor RE et al. Part 9. Acute Coronary Syndromes: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Circulation 2010;122:S422-S465. PubMed

Landmark or Original Studies

Shry EA et al. Usefulness of the response to sublingual nitroglycerin as a predictor of ischemic chest pain in the emergency department. Am J Cardiol 2002;90:1264-1266. PubMed

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Henrikson CA et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 2003;139(12):979-86. PubMed

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Steele R et al. Chest pain in the emergency department patients: if the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? CJEM 2006;8(3):164-9. PubMed

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