Transdermal nitroglycerin products commercially available in the USA are listed in the table below. These patches, which look like adhesive bandages, are often applied over the precordium, but they can be attached to any hairless area of the skin, except distal parts of the extremities. Individual patients vary in their absorption of nitroglycerin from the skin; the amounts delivered (the doses) are average figures.

The FDA has approved a sublingual powder formulation of nitroglycerin (GoNitro – Espero) for prevention or acute relief of an attack of angina pectoris. It is the first powder formulation of nitroglycerin to become available in the US. Most patients with angina use sublingual nitroglycerin tablets (Nitrostat, and generics). Translingual spray formulations of nitroglycerin (NitroMist, Nitrolingual Pumpspray, and generics) are also available.

The FDA has approved a lingual aerosol formulation of nitroglycerin (NitroMist – Akrimax) for acute relief of an attack or acute prophylaxis of angina pectoris. It is the second nitroglycerin lingual spray to become available in the US; Nitrolingual Pumpspray was approved in 1985. Most patients with angina use sublingual nitroglycerin tablets.

The FDA has approved the use of nitroglycerin ointment 0.4% (Rectiv – ProStrakan/Aptalis) for treatment of moderate to severe pain associated with chronic anal fissure; the same drug is marketed as Rectogesic in Europe. Nitroglycerin ointment 2% (Nitro-Bid) is available in the US for prevention of angina.

Nesiritide, a recombinant human B-type natriuretic peptide (BNP), has been approved by the FDA of intravenous (IV) treatment of patients with decompensated congestive heart failure who have dyspnea at rest or with minimal exertion (New York Heart Association class IV).

Many nitrates, beta-blockers, and calcium-channel blockers have now been approved by the US Food and Drug Administration for treatment of stable angina pectoris. The table beginning on page 112 lists the individual drugs, their dosage, and their cost.

Clevidipine (Cleviprex - The Medicines Company), a dihydropyridine calcium channel blocker (CCB), has been approved by the FDA for intravenous (IV) use in lowering high blood pressure. It is the second IV CCB to be marketed in the US; nicardipine has been available in an IV formulation (Cardene IV) for more than 10 years. Like IV nicardipine, clevidipine will probably be used mainly for urgent treatment of hypertension in intensive care units, operating rooms and emergency departments.

Hypertensive emergencies include hypertensive encephalopathy, intracranial hemorrhage with hypertension, aortic dissection, acute pulmonary edema with hypertension, acute cardiac ischemia with hypertension, malignant hypertension and severe hypertension after vascular surgery; hypertensive crisis due to pheochromocytoma or occurring during pregnancy is not discussed in this review. Although immediate reduction of blood pressure is necessary in hypertensive emergencies, an excessive decrease may cause stroke, myocardial infarction or visual changes. Most experienced clinicians aim...

A recent editorial in The New England Journal of Medicine commented on the negative results of a clinical trial (published in the same issue) of nesiritide, a drug that had been approved by the FDA in 2001 (conditionally approved by Health Canada in 2007) for relief of dyspnea in patients with acutely decompensated heart failure. The authors of the recent clinical trial concluded: "On the basis of these results, nesiritide cannot be recommended for routine use in the broad population of patients with acute heart failure."1 The editorialist lamented the inadequacy of the data that had led to...

Bepridil hydrochloride (Vascor - McNeil Pharmaceutical/Wallace Laboratories), a calcium-channel blocking agent chemically unrelated to verapamil (Calan, and others), nifedipine (Procardia, and others), or other drugs in this class, was recently approved by the US Food and Drug Administration for oral treatment of chronic stable angina pectoris. Because of its potential adverse effects, the labeling recommends reserving the drug for patients who fail to respond optimally to or are intolerant of other antianginal agents.