Intracoronary Nitroglycerin, the Forgotten Stepchild of Cardiovascular Guidelines Interview with:
Alec Vishnevsky, MD
Cardiology Fellow and First Author
Thomas Jefferson University Hospital
Michael P. Savage, MD FACC FSCAI FACP
Ralph J. Roberts Professor of Cardiology
Sidney Kimmel Medical College at Thomas Jefferson University
Director, Cardiac Catheterization Laboratory What is the background for this study? What are the main findings?

Response: Percutaneous coronary intervention (PCI) has been a mainstay treatment for patients with symptomatic coronary artery disease. While current guidelines emphasize the importance of periprocedural antithrombotic medications, they fail to mention the use of nitroglycerin prior to PCI to rule out coronary artery spasm as the etiology of a stenosis seen on coronary angiography. This distinction is paramount as it can avoid unnecessary stenting procedures.

In this case series, we described a series of patients presenting with chest pain and angiographically significant stenoses that resolved with administration of intracoronary nitroglycerin (IC NTG) prior to planned PCI. The study group consisted of 6 patients with a mean age of 52, all of whom had anginal symptoms and significant stenoses seen on coronary angiogram.  In each case, giving intracoronary nitroglycerin resulted in resolution of the stenosis, and all 6 patients were successfully managed medically without stenting. What should readers take away from your report?

Response: Coronary artery spasm is an under-recognized cause of chest pain syndromes, and should be suspected especially in younger patients with apparent single vessel coronary artery disease.  By simply administering nitroglycerin at the time of diagnostic angiography, we can avoid the risks of PCI and save patients from unnecessary stents.

When clinicians consider coronary spasm they think of patient’s with classic Prinzmetal’s angina (rest pain with transient ST elevation on ECG). None of the patients in this series had ST elevation on ECG. Cardiologists need to recognize that patients may have severe stenoses on cardiac catheterization which may be caused by vasospasm even though they do not have active chest pain or ischemic ECG changes. What recommendations do you have for future research as a result of this study?

Response: Analysis of larger series of patients are needed to determine which risk factors predispose patients to coronary artery spasm, as well as the optimum outpatient medical management of these patients. Is there anything else you would like to add?

Response: Intracoronary nitroglycerin should be an integral part of coronary angiography and prior to PCI in the setting of presumed significant coronary artery disease, and should be considered for inclusion in future ACC/AHA PCI guidelines.

No Disclosures Thank you for your contribution to the community.


Vishnevsky, A., et al. Unrecognized coronary vasospasm in patients referred for percutaneous coronary intervention: Intracoronary nitroglycerin, the forgotten stepchild of cardiovascular guidelines. Catheterization and Cardiovascular Interventions, March 2017 DOI: 10.1002/ccd.27034

Note: Content is Not intended as medical advice. Please consult your health care provider regarding your specific medical condition and questions.

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Last Updated on March 22, 2017 by Marie Benz MD FAAD