Comparison of the degree of hemodynamic tolerance during intravenous infusion of nitroglycerin versus nicorandil in patients with congestive heart failure

Background Continuous exposure to organic nitrates is associated with substantial tachyphylaxis. This study compares the development of tolerance during continuous intravenous treatment with nitroglycerin versus nicorandil over a 24-hour period, Methods and Results Twenty patients with congestive heart failure and pulmonary capillary wedge pressure (PCWP) greater than or equal to 18 mm Hg were randomly assigned to nitroglycerin or nicorandil in a double-blind, crossover study. Doses were titrated to obtain a reduction of PCWP of at least 30% and then maintained. The mean pretreatment PCWP for nitroglycerin was 25.4 +/- 6.7 mm Hg, decreasing to 19.0 +/- 6.8 mm Hg at 24 hours. The values For nicorandil were 24.3 +/- 6.3 mm Hg and 15.6 +/- 4.5 mm Hg, respectively. Between-treatment difference was significant (p < 0.01). The difference between the minimal PCWP value and the 24-hour PCWP value For nitroglycerin was 5.1 mm Hg vs 1.4 mm Hg for nicorandil (p < 0.005), The mean systemic vascular resistance was 1418 +/- 355 dynes.sec.cm(-5) before nitroglycerin infusion, decreasing to 1312 +/- 353 dynes.sec.cm(-5) at 24 hours. Corresponding values for nicorandil were 1420 +/- 366 dynes.sec.cm(-5) and 967 +/- 274 dynes.sec.cm(-5). Between-treatment difference was significant (p = 0.005). Tachyphylaxis developed in 12 (60%) patients during nitroglycerin infusion versus three patients (15%) during nicorandil infusion. Conclusion This study demonstrates that intravenous nicorandil administration results in significantly less hemodynamic tolerance over a 24-hour period compared with nitroglycerin. This finding may represent a clinical advantage for nicorandil in the short-term treatment of patients with congestive heart failure.