Journal of the American College of Cardiology Vol. 52, No.

4, 2008
© 2008 by the American College of Cardiology Foundation ISSN 0735-1097/08/$34.00
Published by Elsevier Inc. doi:10.1016/j.jacc.2008.04.019

VIEWPOINT

Nitrate-Induced Toxicity and Preconditioning

A Rationale for Reconsidering the Use of These Drugs
Tommaso Gori, MD, PHD,*† John D. Parker, MD, FACC‡
Siena, Italy; Mainz, Germany; and Toronto, Ontario, Canada

Although organic nitrates have been clinically used for more than a century, findings in the last decade have rad-
ically challenged our traditional view concerning the mechanism(s) of their clinical effects and implications.
While their hemodynamic properties are well known, the knowledge that nitrates possess previously unexpected
nonhemodynamic effects is a unique opportunity of which clinicians should be aware but, at the same time, it
also provides a rationale to worry about previously unanticipated clinical consequences of long-term treatment
with these drugs. (J Am Coll Cardiol 2008;52:251–4) © 2008 by the American College of Cardiology
Foundation

Organic nitrates are among the oldest and yet most com-
monly used drugs in the chronic therapy of patients with
angina and heart failure. Their use is based on 2 assump-
tions that remain, after decades of research, unproven. The
first is an assumption of overall clinical safety: the majority
of physicians believe that chronic therapy with organic
nitrates is associated with an improvement in symptoms and
has neutral or potentially beneficial effects on long-term
patient outcome. A corollary of this concept is that nitrate
tolerance is considered simply as the loss of a beneficial
effect as opposed to the expression of potentially deleterious
modifications such as sympathetic activation, increased
oxidative stress, or endothelial dysfunction (discussed later).
The second assumption is that the therapeutic effects of
these drugs depend exclusively on changes in hemodynamic
parameters (principally dilation of capacitance veins and
conduit arteries).
Recently, both of these postulates have come under
scrutiny as recent lines of evidence document that organic
nitrates have previously unanticipated nonhemodynamic
effects. Importantly, these changes have dichotomous im-
plications, as confirmed by human in vivo studies. Some of
these effects are protective (e.g., a protection that is similar
to ischemic preconditioning), but others are potentially
harmful, including increased oxidative stress (1), endothelial
dysfunction (2), and cardiac autonomic dysfunction (3). In
From the *Department of Internal, Cardiovascular, and Geriatric Medicine, Univer-
sity of Siena, Siena, Italy; †Medizinische Klinik, University of Mainz, Mainz,
Germany; and the ‡Division of Cardiology, Department of Medicine, Mount Sinai
and University Health Network Hospitals, University of Toronto, Toronto, Ontario,
Canada. Dr. Gori is the recipient of a grant from the Italian Ministry of Research. Dr.
Parker holds a Career Investigator Award from the Heart and Stroke Foundation of
Ontario, Canada.
Manuscript received January 4, 2008; revised manuscript received March 26, 2008,
accepted April 3, 2008.
light of continued widespread use, we believe that these
notions should be discussed, and that the traditional views
concerning chronic therapy with organic nitrates should be
critically revised.
Challenging the first of the postulates above, Münzel
et al. (1) reported in 1995 that the sustained administration
of nitroglycerin (glyceryl trinitrate) causes increased oxygen
free radical bioavailability, a finding that led to the oxidative
stress hypothesis of nitrate tolerance (reviewed in Münzel
et al. [1], Gori and Parker [2], and Fig. 1). The accumula-
tion of oxygen free radicals during chronic nitroglycerin
therapy has been associated with endothelial dysfunction,
with an increased arterial sensitivity to vasoconstrictors and
with the development of abnormalities in a number of
important enzymes involved in the regulation of vascular
homeostasis, including the superoxide dismutase, protein
kinase C, matrix metalloproteinases, and prostaglandin
synthase (1,2). Furthermore, prolonged exposure to nitro-
glycerin has been shown to shift the physiologic balance
between the sympathetic and vagal nervous systems in the
modulation of cardiac heart rate and heart rate variability
toward a prevalence of the sympathetic system, impairing
baroreflex function and heart rate variability (3). Of note,
such modifications should be considered relevant because
they have been associated with an increased incidence of
arrhythmias and a worse prognosis when observed in pa-
tients with coronary artery disease and/or heart failure (4).
Two observations emphasize the clinical importance of
these findings. First, they have been observed (or repro-
duced) in patients with coronary artery disease: for instance,
nitroglycerin therapy enhances coronary artery vasoconstric-
tor responses to acetylcholine (5) and peripheral conduit
arterial responses to angiotensin II and phenylephrine (6).
Second, these deleterious effects are not limited to
tolerance-inducing dosages: therapy with both nitroglyc-
252 Gori and Parker JACC Vol. 52, No. 4, 2008
Chronic Therapy With Organic Nitrates July 22, 2008:251–4

Figure 1 Nitrate-Induced Nonhemodynamic Effects

Schematic representation of nitrate effects as shown in human studies. Prolonged nonintermittent administration causes a variety of modifications that lead to nitrate
tolerance. A unifying hypothesis for an oxidative stress– based physiopathology of these modifications has been recently proposed (22). Intermittent administration also
causes modifications that might alter vascular homeostasis. One single administration has been associated with induction of preconditioning. EC ⫽ endothelial cell;
EPC ⫽ endothelial progenitor cell; NO ⫽ nitric oxide; ROS ⫽ reactive oxygen species.

erin and isosorbide mononitrate, using formulations and
dosing regimens that are commonly employed clinically,
have also been shown to lead to the development of
endothelial dysfunction (5,7). In aggregate, these vascular
abnormalities seem to play a major role in the develop-
ment of nitrate tolerance and the decreased anginal
threshold observed in some patients during the daily
nitrate-free interval (rebound angina [8]) (Fig. 1). Fur-
ther, they suggest that we should not a priori assume that
the effects of nitrates in terms of patient prognosis are
necessarily neutral, and emphasize the need for large-
scale trials testing the effects of long-term nitrate therapy.
Challenging the second of the postulates mentioned
earlier, organic nitrates have beneficial implications that go
far beyond their impact on cardiac loading conditions. In
particular, intravenous or transdermal administration of
nitroglycerin has been shown to trigger a protective pheno-
type that is similar to that induced by ischemic pre-
conditioning and persists up to 48 to 72 h after interruption
of nitrate therapy: a single 2- to 4-h application of nitro-
glycerin protects the vascular endothelium from experimen-
tal ischemia and reperfusion injury in healthy volunteers (9),
and it has been associated with reduced electrocardiographic
and echocardiographic evidence of ischemia during both
coronary angioplasty and physical exercise in ischemic heart
disease patients (10,11). Surprisingly, this nonhemody-
namic property of nitrates seems to be mediated by release
of oxygen free radicals, because administration of antioxi-
dants blocks it (9). Because ischemic preconditioning (and
its clinical correlate, pre-infarction angina) have been shown
to be important determinants of patient prognosis (12), the
possibility that such a protective state could be induced
pharmacologically using “atypical” dosing regimens (for
instance by administering nitrates for 2 to 4 h per day in
patients at high risk of coronary events) has a clinical
potential that deserves being tested in large-scale trials.
Recent experimental findings provide some insight into
the mechanism(s) of these unexpected effects (Fig. 2) and
have important implications regarding how nitrates should
be used. The evidence of a beneficial preconditioning effect
of nitrates suggests that we should develop a new conceptual
framework for these drugs: acute nitroglycerin administra-
JACC Vol. 52, No. 4, 2008 Gori and Parker 253
July 22, 2008:251–4 Chronic Therapy With Organic Nitrates

Figure 2 The Mechanism of the Dichotomous Biological Effects of Nitrates

When administered acutely, nitroglycerin is biotransformed in the mitochondrial matrix by the aldehyde dehydrogenase (ALDH) to release a nitric oxide–related species
(NOx). At the same time, nitroglycerin causes uncoupling of the mitochondrial respiratory chain and a burst of oxygen free radicals (ROS). Acutely, nitroglycerin activates
a cascade that results in a phenotypic protection that is similar to ischemic preconditioning. The sudden increased bioavailability of nitric oxide and oxygen free radicals
seems to have a critical role in the cascade that leads to nitrate preconditioning. Of note, isosorbide mononitrate, which has an extramitochondrial bioactivation (and
ROS production), does not cause preconditioning (23). On chronic administration, nitrate-induced ROS production causes a number of adverse effects, which include
rebound ischemia, endothelial and autonomic dysfunction, and oxidation of a critical thiol group in the active site of ALDH, resulting in impaired nitrate biotransformation
and nitrate tolerance. GTN ⫽ nitroglycerin; ISMN ⫽ isosorbide mononitrate.

tion, by exposing the mitochondrial milieu to subtoxic
quantities of oxygen free radicals, leads to the induction of
several genes that cause anti-ischemic protection, resulting
in a phenotype similar to ischemic preconditioning
(9,10,13). At the same time, the accumulation of these free
radical species over prolonged periods of time, as occurs
during chronic nitrate therapy, has the potential to cause the
negative effects described earlier (1,2). Taken together,
these lines of evidence suggest that nitrate-induced oxy-
gen free radical production seems to explain both of the
acutely protective— but chronically deleterious— effects of
these drugs.
The importance of nitrate-induced modifications in vas-
cular homeostasis should be seen in the context of their
clinical effects, because they provide a mechanistic back-
ground for: 1) the preconditioning mimetic, protective
properties of nitrates against both demand-induced and
low-flow myocardial ischemia; 2) the development of nitrate
tolerance; and 3) the adverse effects on endothelial and
vascular function induced by prolonged nitrate treatment.
This latter consideration serves to emphasize that there is
scant evidence concerning the long-term clinical outcome of
nitrate therapy. In the setting of stable angina pectoris, the
focus of clinical research has been on how to prevent
tolerance, and the largest studies of organic nitrates were
underpowered for outcome data, all involving small patient
populations with follow-up periods of only a few weeks
(8,14,15). Studies in post-infarction patients, although
larger than those performed in chronic angina, have in-
volved follow-up periods too short to assess the true clinical
impact of nitrate-induced endothelial dysfunction, auto-
nomic impairment, and preconditioning: 6 weeks for the
GISSI (Gruppo Italiano Studio Sopravvivenza Infarto)-3
and 4 weeks for the ISIS (International Study of Infarct
Survival)-4 trial (16,17). Emphasizing the need for data
regarding the outcome of chronic nitrate therapy, the only 2
randomized studies available with a treatment period longer
than 12 months did show that continuous nitrate therapy
increases the incidence of cardiac events (18) and that a
trend in the same direction is observed after intermittent
administration (19), but these results cannot be considered
conclusive in the absence of a double-blind, placebo-
controlled design.
The previously discussed considerations emphasize the
need for 2 areas of transitional research. First, there has
never been a large-scale, double-blind, placebo-controlled,
randomized trial with a treatment period long enough to
address the issue of either efficacy or safety in patients with
stable coronary artery disease. Clinicians should be aware
that there is biological plausibility, founded in human data,
to warrant these studies (or at least, to warrant caution in the
use of nitrates). By contrast, evidence exists that these
254 Gori and Parker
Chronic Therapy With Organic Nitrates
toxic phenomena might be offset by the use of drugs that
have antioxidant properties or that prevent nitrate-induced
reactive oxygen species production. For instance, in patients
with chronic heart failure, the benefit of isosorbide dinitrate
combined with hydralazine is clear (20,21). The use of these
drugs should be considered when prescribing nitrates. The
second area that should be explored is whether the ability of
nitrates to protect from ischemia and reperfusion injury can
be turned into a long-term protection, in a form of chronic
pharmacologic preconditioning. While it is accepted that
free radical– based mechanisms underlie aspects of cardio-
vascular protection and disease, the observation that organic
nitrates modify production and regulatory functions of these
elusive mediators provides a unique opportunity to explore
previously unanticipated approaches to the utilization of
these drugs.
Reprint requests and correspondence: Dr. Tommaso Gori,
Department of Internal, Cardiovascular, and Geriatric Medicine,
University of Siena, Via Ciacci 42, Siena, Tuscany 53100, Italy.
E-mail: tommaso.gori@utoronto.ca.
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Key Words: nitroglycerin y ischemia y angina y preconditioning.