REBEL EM – Emergency Medicine Blog
Health & Fitness:Medicine
REBEL Cast Ep124: Nitrates in Right Sided MIs?
Background: Nitrates can help improve symptoms and ischemia in the setting of acute myocardial infarction. Current teaching holds that nitrates should be avoided in patients with potential right ventricular myocardial infarction (RVMI), due to the risk of decreasing preload and precipitating hypotension. This belief is based on a single 1989 study of 40 patients with RVMI and endorsed by both the AHA and ESC guidelines [2].
In that 1989 study, of the 40 patients with RV infarction 20 had a decrease in blood pressure of ≥30mmHg and associated symptoms after the administration of nitrates (SL, Oral, Transdermal, or IV) and 20 did not. The conclusion of this paper was that inferior AMI with RV involvement has a strong association with hypotensive response to nitrates. The major issue is the study is limited by the fact that we are given no information on dosage and multiple routes of administration making clinical application difficult. Better data is needed to guide management.
REBEL Cast 124: Nitrates in Right Sided MIs?Click here for Direct Download of the Podcast
Paper: Wilkinson-Stokes M et al. Adverse Events From Nitrate Administration During Right Ventricular Myocardial Infarction: A Systematic Review and Meta-Analysis. Emerg Med J 2023. PMID: 36180168
Clinical Question: Is giving nitrates to patients with right ventricular myocardial infarction (RVMI) associated with increased adverse events compared with nitrate administration to patients with myocardial infarctions in other regions of the heart?
What They Did:
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Author Conclusion: “This review suggests that the AHA and ESC contraindications are not supported by evidence. Key limitations include all studies having concomitant inferior and RVMI, not evaluating beneficial effects and very low certainty of evidence. As adverse events are transient and easily managed, nitrates are a reasonable treatment modality to consider during RVMI on current evidence.”
Clinical Take Home Point: From a clinical perspective, the potential benefit of analgesia and reduced sympathetic stimulation in the setting of RVMI seems to outweigh the potential of transient hypotension with the use of nitrates. Although better studies are needed, this systematic review and meta-analysis argues against a contraindication against nitrates in the setting of RVMI and maybe one of precaution.
References:
For More Thoughts on This Topic Checkout:
Post Peer Reviewed By: Anand Swaminathan, MD (Twitter/X: @EMSwami)
The post REBEL Cast Ep124: Nitrates in Right Sided MIs? appeared first on REBEL EM - Emergency Medicine Blog.
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