Chronic Stable Angina
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In his Clinical Practice article (June 16 issue),1 Abrams suggests that a 24-hour interval is warranted between the use of the phosphodiesterase inhibitors sildenafil, vardenafil, and tadalafil and the use of nitrates to prevent serious hypotension. However, Kloner2 differentiates among agents, recommending a 24-hour interval in the case of sildenafil or vardenafil, but at least 48 hours in the case of tadalafil.3
Under the heading "Areas of Uncertainty," Abrams questioned the role of ranolazine in the treatment of stable angina. There are at least two trials in which ranolazine is evaluated in this setting. In the Monotherapy Assessment of Ranolazine in Stable Angina trial,4 ranolazine reduced angina and objective evidence of ischemia among patients not taking other antianginal drugs, whereas in the Combination Assessment of Ranolazine in Stable Angina (CARISA) trial,5 ranolazine reduced the frequency and severity of angina and improved exercise duration among patients with stable angina who were receiving other antianginal therapy.
Pablo Aguiar-Souto, M.D.
Lorenzo Silva-Melchor, M.D.
Francisco J. Ortigosa-Aso, M.D.
Puerta de Hierro Hospital
28035 Madrid, Spain
aguiarsouto@hotmail.com
References
Abrams J. Chronic stable angina. N Engl J Med 2005;352:2524-2533.
Kloner RA. Cardiovascular effects of the 3 phosphodiesterase-5 inhibitors approved for the treatment of erectile dysfunction. Circulation 2004;110:3149-3155.
Kloner RA, Hutter AM, Emmick JT, Mitchell MI, Denne J, Jackson G. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol 2003;42:1855-1860.
Wolff AA. MARISA: Monotherapy Assessment of Ranolazine in Stable Angina. J Am Coll Cardiol 2000;35:Suppl A:408-408. abstract.
Chaitman BR, Pepine CJ, Parker JO, et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004;291:309-316.
The author replies: With regard to the length of time one has to wait before using nitrates after ingestion of tadalafil, a hemodynamic interaction between the phosphodiesterase type 5 inhibitor and sublingual nitroglycerin was present at 24 hours but had completely dissipated by 48 hours, with no intermediate data.1 This demonstrates that nitroglycerin compounds become safe to use at some time during the 24-to-48-hour time frame. It is reasonable and appropriate to take a cautious stance and adhere to the manufacturer's and guideline's warning to wait a full 48 hours after tadalafil ingestion.
Data from the CARISA trial show that ranolazine confers additional antianginal protection when used in combination with a beta-blocker or calcium-channel blocker.2 Ranolazine is currently under review by the Food and Drug Administration.
Jonathan Abrams, M.D.
University of New Mexico
Albuquerque, NM 87131
jabrams@salud.unm.edu
References
Kloner RA, Hutter AM, Emmick JT, Mitchell MI, Denne J, Jackson G. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol 2003;42:1855-1860.
Chaitman BR, Pepine CJ, Parker JO, et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004;291:309-316.
Under the heading "Areas of Uncertainty," Abrams questioned the role of ranolazine in the treatment of stable angina. There are at least two trials in which ranolazine is evaluated in this setting. In the Monotherapy Assessment of Ranolazine in Stable Angina trial,4 ranolazine reduced angina and objective evidence of ischemia among patients not taking other antianginal drugs, whereas in the Combination Assessment of Ranolazine in Stable Angina (CARISA) trial,5 ranolazine reduced the frequency and severity of angina and improved exercise duration among patients with stable angina who were receiving other antianginal therapy.
Pablo Aguiar-Souto, M.D.
Lorenzo Silva-Melchor, M.D.
Francisco J. Ortigosa-Aso, M.D.
Puerta de Hierro Hospital
28035 Madrid, Spain
aguiarsouto@hotmail.com
References
Abrams J. Chronic stable angina. N Engl J Med 2005;352:2524-2533.
Kloner RA. Cardiovascular effects of the 3 phosphodiesterase-5 inhibitors approved for the treatment of erectile dysfunction. Circulation 2004;110:3149-3155.
Kloner RA, Hutter AM, Emmick JT, Mitchell MI, Denne J, Jackson G. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol 2003;42:1855-1860.
Wolff AA. MARISA: Monotherapy Assessment of Ranolazine in Stable Angina. J Am Coll Cardiol 2000;35:Suppl A:408-408. abstract.
Chaitman BR, Pepine CJ, Parker JO, et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004;291:309-316.
The author replies: With regard to the length of time one has to wait before using nitrates after ingestion of tadalafil, a hemodynamic interaction between the phosphodiesterase type 5 inhibitor and sublingual nitroglycerin was present at 24 hours but had completely dissipated by 48 hours, with no intermediate data.1 This demonstrates that nitroglycerin compounds become safe to use at some time during the 24-to-48-hour time frame. It is reasonable and appropriate to take a cautious stance and adhere to the manufacturer's and guideline's warning to wait a full 48 hours after tadalafil ingestion.
Data from the CARISA trial show that ranolazine confers additional antianginal protection when used in combination with a beta-blocker or calcium-channel blocker.2 Ranolazine is currently under review by the Food and Drug Administration.
Jonathan Abrams, M.D.
University of New Mexico
Albuquerque, NM 87131
jabrams@salud.unm.edu
References
Kloner RA, Hutter AM, Emmick JT, Mitchell MI, Denne J, Jackson G. Time course of the interaction between tadalafil and nitrates. J Am Coll Cardiol 2003;42:1855-1860.
Chaitman BR, Pepine CJ, Parker JO, et al. Effects of ranolazine with atenolol, amlodipine, or diltiazem on exercise tolerance and angina frequency in patients with severe chronic angina: a randomized controlled trial. JAMA 2004;291:309-316.