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Buccal nitrates in left ventricular failure
  1. Dhurga Gnanasegaram, Senior Clinical Fellow,
  2. Jon Argall, Senior Clinical Fellow
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK;


    A short cut review was carried out to establish whether buccal and intravenous nitrates are equally effective at preload reduction in patients with left ventricular failure. Seven papers were found using the reported search, of which one presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this best paper is tabulated. A clinical bottom line is stated.

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    Report by Dhurga Gnanasegaram,Senior Clinical FellowChecked by Jon Argall, Senior Clinical Fellow

    Clinical scenario

    You are called to see a 60 year old man who has been increasingly breathless for a week. Examination reveals him to be mildly dyspnoeic at rest with a raised JVP and bibasal creps. There is evidence of ischaemia on his ECG. The chest radiograph shows upper lobe diversion and Kerley B lines. You wonder whether buccal suscard would be an appropriate alternative to a GTN infusion.

    Three part question

    [In a patient with left ventricular failure] are [buccal nitrates equivalent to a nitrate infusion] for [preload reduction]?

    Search strategy

    Medline 1966–04/03 using the OVID interface. [(exp nitrates OR OR exp nitroglycerin OR OR exp vasodilator agents OR OR glyceryl OR exp isosorbide dinitrate OR OR AND {( OR exp mouth mucosa OR exp administration, buccal) AND (exp injections, intravenous OR OR} AND (exp heart failure, congestive OR heart OR OR left ventricular OR congestive cardiac OR exp ventricular dysfunction, left OR exp ventricular dysfunction OR exp pulmonary oedema)] LIMIT to human AND English language.

    Search outcome

    Altogether seven papers were found, of which five were reviews of nitrates rather than comparative studies. The two remaining publications consisted of a summary report and full article relating to the same trial. The results of this trial are shown in table 4.

    Table 4


    There is very limited evidence available to allow direct comparison between intravenous and buccal routes.


    Buccal nitrates produce an immediate reduction in preload (comparable with intravenous GTN).

    Report by Dhurga Gnanasegaram,Senior Clinical FellowChecked by Jon Argall, Senior Clinical Fellow


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