Nitroglycerin

Author Information

An event is serious (based on the ICH definition) when the patient outcome is:

• * death

• * life-threatening

• * hospitalisation

• * disability

• * congenital anomaly

• * other medically important event

A 70-year-old woman developed hypotension during treatment with nitroglycerin for angina and unspecified long acting nitrates [not all indications and routes stated; dosages and durations of treatment to reactions onset not stated].

The woman had been treated in the hospital for COVID-19. She required ICU admission due to requirement of high flow nasal cannula. Afterwards, she was transferred to the ward after requirement of regular nasal cannula. She developed cardiac arrest and had increased oxygen requirements. She was kept on ventimask and received two rounds of cardiac pulmonary resuscitation. Her initial rhythm was found to be ventricular fibrillation. She was defibrillated and return of spontaneous circulation was achieved. Electrocariogram revealed ST elevations in the inferior leads. She was noted to be alert and oriented on initial evaluation. She did not require intubation after the arrest and was transferred to the intensive care unit. She received amiodarone and enoxaparin sodium [Lovenox]. On left heart catheterisation, her left anterior descending artery, left circumflex artery, distal diagonal vessel, right coronary artery and distal portion of the obtuse marginal were found to be severely spasmodic. She had recurrence of vasospasmic angina following the catheterization. She received treatment with nitroglycerin [nitro] drip and sustained relief of angina was achieved. She developed hypotension. Her anamnesis revealed home medications of unspecified long acting nitrates. Hypotension was attributed to nitroglycerin and unspecified long acting nitrates.

The woman received treatment with intravenous fluids and was responsive to the therapy. Unspecified long acting nitrates were discontinued. Few hours later, she became hypoxic and required diuresed to return to baseline oxygen requirement. She was started on norepinephrine drip to maintain mean arterial pressure. After she was loaded with amiodarone, nitroglycerin drip was discontinued. Amiodarone was switched to oral therapy. She was initiated on isosorbide dinitrate prior to discontinuation of nitroglycerin drip. Her BP stabilised and oral intake improved. She was restarted on her home medication of unspecified long-acting nitrates which were withheld on admission due to hypotension.