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Three Part Question

In [pre-hospital patients with cardiac chest pain] is [buccal nitrate better than a nitrate spray] at [relieving chest pain]

Clinical Scenario

An ambulance is called to a patient suffering from acute chest pain, which is diagnosed as cardiac in origin.The pt has taken a spray of their own GTN with little effect, and you wonder whether a buccal GTN preparation would be more effective at relieving the pain?

Search Strategy

({exp nitroglycerin/ AND exp coronary disease/) AND (buccal$.mp AND spray$.mp})
(exp nitroglycerin/ AND exp coronary disease/ AND buccal$.mp)
(exp nitroglycerin/ AND exp coronary disease/ AND spray$.mp)
({exp nitroglycerin/ AND exp coronary disease/) AND (exp mouth mucosa/ OR exp administration, buccal/}) Limit to Human and english
Medline 1966-2003 Using OVID Interface.

Search Outcome

A total of 3 papers were found which had some relevance.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Bray CL et al May 1991 UK	47 Pts with acute coronary syndrome (angina pectoris)	Multicentre, double blind study	Buccal GTN is better prophylactically	Less frequent angina attacks and more a more prolonged duration of effect	The pts used their own interpretation of pain and pain relief rather than a scoring system
Ryden L. Schaffrath R. 1987 September Sweden	113 pts with stable angina pectoris	Randomized, multicentre comparitative study	Both formulations are comparable	However Buccal GTN has a more prophylactic effect due to its duration of action	The trial used stepped doses of GTN. Depending on effectiveness. Also no direct comparison of SL GTN vs. BGTN
Greengart A. et al 1983 March USA	16 patients with known coronary artery disease	Randomized, double blind study	Buccal GTN is an effective method of administering GTN for rapid & prolonged effect	With a reduction in angina pectoris and increased exercise duration (at least 5 hours)	Small number of patients

Comment(s)

There is a large volume of data regarding GTN and coronary artery disease and that GTN is proven to be effective in relieving angina pectoris. There is not an overwhelming collection of evidence about different drug delivery systems and whether one is more effective than the other. However it is possible to state that BGTN and SLGTN are equally effective at relieving acute coronary chest pain/angina. Yet BGTN is proven to be more effective over a longer period of time than single dose SLGTN.

Clinical Bottom Line

There is moderate evidence to prove that Buccal GTN is more effective at controlling exertional angina chest pain due to its longer acting duration. It also has less side effects like headache. And Increases a patients exertional tolerance due to its delivery system.

References

1. Bray CL. Jain S. Faragher EB. Myers P. MacIntyre P. Rae A. Goldman M. Alcorn M. A comparison of buccal nitroglycerin and sublingual nitroglycerin in the prophylaxis and treatment of exertional (situation-provoked) angina pectoris. European Heart Journal. 12 Suppl A:16-20, 1991 May.
2. Ryden L. Schaffrath R. Buccal versus sublingual nitroglycerin administration in the treatment of angina pectoris: a multicentre study. European Heart Journal. 8 (9):995-1001, 1987 September.
3. Greengart A. Lichstein E. Hollander G. Bolton S. Sanders M. Efficacy of sustained-release buccal nitroglycerin in pts with angina pectoris. New and long acting therapy demonstrated by exercise. Chest March 1983. 83 (3): 472-9.