By Dr. Adam Schneeweiss, Dr. Marija Weiss (auth.)
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Extra resources for Advances in Nitrate Therapy
In discussing the use of anti-ischemic agents in acute myocardial infarction it should be remembered that interventional cardiology has changed the classical course of acute myocardial infarction. Thrombolysis, percutaneous transluminal coronary angioplasty and early surgical revascularization have made most pharmacologic, early-intervention studies irrelevant, as in few patients does myocardial infarction follow its natural pattern. Therefore, new secondary prevention studies are required, not after acute "complete" myocardial infarction but after successful interventions preventing the development of such an event.
Partial vascular tolerance may be observed in the presence of preserved antianginal effect. Moreover, it should be remembered that in all studies demonstrating partial cross tolerance, this has been demonstrated for only one hemodynamic parameter, such as systolic blood pressure. Such findings cannot be applied for the whole spectrum of cardiovascular effects of nitrates. This subject is discussed further in the section on vascular tolerance to nitrates. Long-Term Use of Nitrates in Angina Pectoris 41 Thadani et al  reported that in patients with chronic stable angina pectoris the first dose of ISDN, 15 mg, reduced systolic blood pressure by 36 mmHg.
3 L min-1 m-2• This hemodynamic improvement was associated with sustained improvement in exercise capacity and in ST -segment depression. Long-Term Use of Nitrates in Angina Pectoris 37 Recently Distante et al  used a different approach to study the possibility of tolerance to long-term nitrate therapy. They evaluated the hemodynamic response to an acute infusion oflSDN, 1 mg/min, up to a maximal dose oflO mg, in eight patients with vasospastic angina chronically treated with high doses of transdermal ISDN, 150-300 mg daily.