Redistribution of Myocardial Blood Flow With Topical Nitroglycerin in Patients With Coronary Artery Disease

Abstract

Background Unlike nonselective coronary vasodilators, nitroglycerin (GTN) is said to exert its primary vasodilatory effect on epicardial conductance vessels. Thus, in experimental models of coronary occlusion GTN appears to preferentially direct blood flow to poststenotic zones of ischemia. This phenomenon has, to date, not been tested in humans. Using positron emission tomography we examined the effect of transdermal GTN on global and regional myocardial perfusion in patients with angiographically proven coronary artery disease. Methods and Results Myocardial perfusion with [ 13 N]ammonia was estimated from dynamic time-activity curves at baseline and 3 hours following application of either a 0.4 mg/h GTN skin patch (n=10) or a placebo patch (n=10) in a double-blind parallel design. From resliced cross-sectional images, regional flow, expressed as [ 13 N]ammonia retention, was estimated from 216 myocardial sectors. Ischemia was defined as a significant reduction (>2 SDs from average counts/pixel in maximally perfused zones) in [ 13 N]ammonia retention within 10 contiguous myocardial sectors coupled with an increase or no change in counts derived from [ 18 F]fluorodeoxyglucose. There was no change in global myocardial blood flow as expressed by [ 13 N]ammonia retention following either placebo (0.61±0.14 to 0.62±0.12 min −1 ) or GTN (0.75±0.22 to 0.74±0.19 min −1 ). Conversely, there was a significant increase in the proportion of blood flow to the ischemic zones with GTN (73.9±12.6% to 94.9±17.8%; P <.05). No change in the distribution of blood flow to either ischemic or nonischemic zones was observed with placebo. A slight but insignificant decrease in [ 13 N]ammonia retention in nonischemic zones was observed with GTN (1.01±0.31 to 0.93±0.26 min −1 ). Conclusions This study suggests that under resting conditions topical GTN alters myocardial perfusion by preferentially increasing flow to areas of reduced perfusion with little or no change in global myocardial perfusion in patients whose angina is responsive to GTN.