The Pharmaceutical Journal
Vol 272 No 7286 p179
14 February 2004

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Withdrawal of long-acting nitrates is safe in stable angina

POEM series

Clinical question Is it safe to withdraw long-acting nitrates from patients with stable angina who may no longer need them?

Bottom line There is little risk in withdrawing patients with stable angina from long-acting nitrates as long as they have access to rescue medication and can restart the medication if they have recurrent angina. Patients with a low ejection fraction may be at higher risk of recurrence.

Synopsis There are many patients who have been taking nitrates for stable angina for a long time. How safe is it to withdraw the nitrate if, say, the patient wants to try sildenafil (Viagra)?

In this randomised controlled trial, haemodynamically stable patients taking long-term nitrates for symptom relief who had been free of angina for at least three months were randomised to either abrupt discontinuation of the nitrate or continued treatment in a 2:1 ratio. Most were taking a long-acting oral nitrate once or twice a day, with a mean daily dose of 41–45mg per day. At the end of the three-month study period, eight of 80 patients in the withdrawal group and two of 40 in the continued treatment group had recurrent angina and had to use their rescue medication, a short-acting nitrate spray (10 per cent vs 2 per cent; P=0.141). This study is limited by the lack of blinding and failure to disclose information about allocation concealment.

It is possible that a much larger study would reveal more hazards of nitrate discontinuation but, at least in this group of 80 patients, to do so was safe and generally well tolerated. An estimate for a 95 per cent confidence interval for 0/80 deaths is 3/80, or 3.7 per cent. The authors note that most of the patients with recurrent angina had a low ejection fraction, although this trend was not statistically significant.

Level of evidence 2c (outcomes research).

Reference

George J, Kitzis I, Zandorf D et al. Safety of nitrate withdrawal in angina-free and hemodynamically stable patients with coronary artery disease. Chest 2003;124:1652–57.

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