You are on page 1of 18


19, 2017





The Role of Nitroglycerin and
Other Nitrogen Oxides in
Cardiovascular Therapeutics
Sanjay Divakaran, MD, Joseph Loscalzo, MD, PHD


The use of nitroglycerin in the treatment of angina pectoris began not long after its original synthesis in 1847. Since then,
the discovery of nitric oxide as a biological effector and better understanding of its roles in vasodilation, cell permeability,
platelet function, inflammation, and other vascular processes have advanced our knowledge of the hemodynamic
(mostly mediated through vasodilation of capacitance and conductance arteries) and nonhemodynamic effects of organic
nitrate therapy, via both nitric oxide–dependent and –independent mechanisms. Nitrates are rapidly absorbed from
mucous membranes, the gastrointestinal tract, and the skin; thus, nitroglycerin is available in a number of preparations for
delivery via several routes: oral tablets, sublingual tablets, buccal tablets, sublingual spray, transdermal ointment,
and transdermal patch, as well as intravenous formulations. Organic nitrates are commonly used in the treatment of
cardiovascular disease, but clinical data limit their use mostly to the treatment of angina. They are also used in the
treatment of subsets of patients with heart failure and pulmonary hypertension. One major limitation of the use of nitrates
is the development of tolerance. Although several agents have been studied for use in the prevention of nitrate tolerance,
none are currently recommended owing to a paucity of supportive clinical data. Only 1 method of preventing nitrate
tolerance remains widely accepted: the use of a dosing strategy that provides an interval of no or low nitrate exposure
during each 24-h period. Nitric oxide’s important role in several cardiovascular disease mechanisms continues to drive
research toward finding novel ways to affect both endogenous and exogenous sources of this key molecular mediator.
(J Am Coll Cardiol 2017;70:2393–410) © 2017 by the American College of Cardiology Foundation.

I n this review, we detail the discovery of nitro-
glycerin and its early use in the treatment of
angina; the history of the discovery of nitric
oxide (NO), its sources, and its roles; the mechanism
new therapeutic options in the treatment of cardio-
vascular disease.

of action, preparations, and hemodynamic and non- CORONARY ARTERY DISEASE
hemodynamic effects of the organic nitrates, as well
as their biotransformation; and the clinical uses and William Heberden is credited with coining the term
adverse effects of nitrate therapy, including toler- “angina pectoris” in 1772 (1). Joseph Priestley, an
ance. We conclude by outlining current and future English theologian and chemist, discovered NO 3
work investigating novel modulators of the NO– years later (2). Not until the next century, however,
soluble guanylyl cyclase (sGC)–cyclic guanosine was NO and its congeners, organic nitrates, linked to
Listen to this manuscript’s
monophosphate (cGMP) pathway that may result in the treatment of angina (3). Glyceryl trinitrate, or
audio summary by
JACC Editor-in-Chief
Dr. Valentin Fuster.

From the Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts. This work
was supported in part by National Institutions of Health grants HL61795 and GM107618 (to Dr. Loscalzo). Both authors have re-
ported that they have no relationships relevant to the contents of this paper to disclose.

Manuscript received September 7, 2017; accepted September 19, 2017.
2394 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

ABBREVIATIONS nitroglycerin, was first synthesized by NO IN THE CARDIOVASCULAR SYSTEM
AND ACRONYMS Ascanio Sombrero in Turin, Italy. In 1847, he
noted that “a very minute quantity put on HISTORY OF NO. In 1975, Diamond and Holmes
ALDH = aldehyde
the tongue produced a violent headache for showed that tissue levels of cyclic adenosine mono-
several hours” (4,5). Three year earlier, the phosphate (cAMP) were increased in rat myometrial
BH4 = tetrahydro-L-biopterin
French chemist Antoine Balard synthesized strips maintained in a state of sustained contracture.
cAMP = cyclic adenosine
monophosphate amyl nitrite (4). Frederick Guthrie, an En- They demonstrated that nitroglycerin could relax the
CAV1 = caveolin-1
glish chemist, explored the actions of amyl depolarized muscles without significantly increasing
nitrite and published in 1859 that when it cAMP levels and, therefore, concluded that changes
cGMP = cyclic guanosine
monophosphate was held near the nostrils, “after a lapse of in total tissue levels of cAMP were not responsible for
EDRF = endothelium-derived about 50 seconds, a sudden throbbing of the the uterine relaxation caused by nitroglycerin (10).
relaxing factor arteries of the neck is felt, immediately These investigators went on to show that nitroglyc-
eNOS = endothelial nitric oxide followed by a flushing of neck, temples, erin increased cyclic guanosine monophosphate
synthase and forehead and an acceleration action of (cGMP) levels in depolarized muscle (10). The
iNOS = cytokine-inducible the heart” (6). following year, Diamond and Blisard showed that 200
nitric oxide synthase
T. Lauder Brunton, a Scottish physician mmol/l nitroglycerin increased levels of cGMP by more
nNOS = neuronal nitric oxide
and medical scientist, first described the than 15-fold during relaxation of isolated strips of
clinical effectiveness of amyl nitrite (4,5,7). phenylephrine-contracted canine femoral arteries
NO = nitric oxide
Brunton began caring for patients with while having no significant effect on cAMP levels (11).
NOS = nitric oxide synthase
angina pectoris as a house physician at the In 1977, pharmacologist Ferid Murad and his col-
P450 = cytochrome P450
Edinburgh Royal Infirmary (7). At the time, leagues published their seminal work on modulating
many treatments, including therapeutic contractility in bovine tracheal smooth muscle
sGC = soluble guanylyl cyclase
bleeding, were being used to treat angina, showing that the guanylyl cyclase activators, sodium
VEGF = vascular endothelial
largely unsuccessfully. In 1867, Brunton nitrite, nitroglycerin, and sodium nitroprusside,
growth factor
published the first report of the use of amyl increased cGMP levels and relaxed tracheal smooth
nitrite in the treatment of angina pectoris (7,8). He muscle (12). They went on to demonstrate that solu-
believed “the relief produced by [therapeutic] tions of NO gas increased cGMP activity in soluble and
bleeding to be due to the diminution it occasioned in particulate preparations from various tissues in a
the arterial tension” and “that a substance which dose-dependent fashion, and that NO alone and
possesses the power of lessening it in such an in combination with sodium azide, sodium nitrite,
eminent degree as nitrite of amyl would probably hydroxylamine, and sodium nitroprusside increased
produce the same effect, and might be repeated cGMP levels to approximately the same degree;
as often as necessary without detriment to the they concluded that the 2 methods activate
patient’s health” (7,8). In 1903, Charles-Émile guanylyl cyclase through a “similar but undefined
François-Franck, a French physiologist, first mechanism” (13). Later, the same group postulated
suggested that amyl nitrite was a coronary vasodi- that “while the precise mechanism of guanylate
lator (7). cyclase activation by these agents is not known,
In 1879, William Murrell described the symptom- activation may be due to the formation of NO or
atic effects of placing drops of 1% solution of another reactive material since NO also increased
nitroglycerin in alcohol on the tongue (9). In addi- guanylate cyclase activity” (14).
tion to reporting that it relieved angina and pre- Working independently, Robert Furchgott and
vented subsequent attacks, he also reported the John Zawadzki published their observations on the
symptoms he felt when he “[tried] its action on importance of the endothelium in blood vessel
[himself]” (9). He described a “violent pulsation in relaxation in 1980 (4,15). They reported that acetyl-
[his] head” and noticed that his pulse was “much choline did not always produce blood vessel relaxa-
fuller than natural” (9). In 1914, Brunton, who tion in vitro, even though it was a potent vasodilator
originally thought angina was caused by hyperten- in vivo. They found that loss of relaxation in vitro
sion, acknowledged that the “dilating action of amyl was due to “unintentional rubbing of [the rabbit
nitrite and nitroglycerine upon the coronary vessels thoracic aorta’s] intimal surface against foreign
would readily explain the relief they offer in angina surfaces during its preparation.” When this mechan-
pectoris, even in cases where the blood-pressure is ical injury was avoided during preparation of the
normal” (7). tissue, it always relaxed in response to acetylcholine.
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2395
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

Therefore, they concluded that acetylcholine-
F I G U R E 1 Sources of NO
mediated relaxation of vascular smooth muscle
required the presence of endothelial cells (15).
Furchgott and his colleagues eventually proposed
that bradykinin and other molecules acting on the
endothelium caused relaxation of vascular smooth L-Citrulline NOS

muscle via a substance they termed endothelium-
derived relaxing factor (EDRF) (16). The link to NO, NO

however, was not yet appreciated (4).
Acidic environment
Louis Ignarro and Salvador Moncada indepen- (stomach, hypoxic/ischemic tissue)
dently discovered that EDRF is NO in 1987 (4,17).
After a series of experiments, Ignarro et al. (18,19) NO2–
stated that “EDRF released from artery and vein
Nitrate reductase
possesses identical biological and chemical properties
(oral flora)
as NO.” Moncada and colleagues suggested that EDRF
and NO were “identical” as “NO released from endo- NO3–
thelial cells is indistinguishable from EDRF in terms
of biological activity, stability, and susceptibility to
NO is a free radical that is synthesized by the family of NO synthases from L-arginine and
an inhibitor and to a potentiator” (20). Based on their
oxygen, yielding L-citrulline as a coproduct. In the blood vessel wall, NO is mainly
collective contributions to the field, the Nobel Prize in produced by endothelial nitric oxide synthase (NOS). There are 2 other isoforms of NOS
Physiology or Medicine was awarded to Furchgott, that also produce NO from L-arginine: neuronal NOS and cytokine-inducible NOS.
Ignarro, and Murad in 1998 “for their discoveries Additionally, bacterial flora present in the mammalian oral cavity is rich in nitrate
reductases and can convert dietary sources of nitrate to nitrite. In the extremely acidic
concerning NO as a signaling molecule in the cardio-
environment (pH #3) of the gastric lumen, protonation of nitrite can, in turn, yield
vascular system” (4).
nitrous acid, which can spontaneously decompose to NO. This pathway of NO generation
SOURCES OF NO. NO is a free radical that is synthe- is referred to as the enterosalivary nitrate circulation (nitrate-nitrite-NO pathway).
sized by the family of NO synthases from L-arginine NO ¼ nitric oxide; NO2 ¼ inorganic nitrite; NO3 ¼ inorganic nitrate.
and oxygen, yielding L-citrulline as a coproduct
(Figure 1) (21–23). In the blood vessel wall, NO is
mainly produced by endothelial nitric oxide synthase
(eNOS) (23,24). However, there are 2 other isoforms of Hemoglobin has enzymatic behavior as a nitrite
nitric oxide synthase (NOS) that also produce NO from reductase under hypoxic conditions and is a
L-arginine: neuronal nitric oxide synthase (nNOS) sensor and effector of hypoxic vasodilation (34). He-
and cytokine-inducible nitric oxide synthase (iNOS) moglobin’s maximal nitrite reduction rate occurs
(25–27). Although eNOS is the major NOS isoform that when hemoglobin is 40% to 60% saturated with
regulates vascular function, both nNOS and iNOS are oxygen (23,34). Cytochrome P 450 reductase causes NO
implicated as sources in certain tissues and environ- release by reducing nitrate, and can also facilitate
ments (23). For example, vascular injury induces generation of S-nitrosothiols (35).
expression of nNOS in the neointima and medial Bacterial flora present in the mammalian oral
smooth muscle cells, and the production of iNOS cavity is rich in nitrate reductases and can convert
within vascular smooth muscle cells after exposure dietary sources of nitrate to nitrite. In the extremely
to proinflammatory cytokines is a major cause of acidic environment (pH #3) of the gastric lumen,
vasodilation in sepsis (28,29). protonation of nitrite can, in turn, produce nitrous
S-nitrosothiols, such as S-nitrosoglutathione and acid, which can spontaneously decompose to NO
S-nitrosohemoglobin, are also sources of NO (23,24). (36,37). This pathway of NO generation is referred
Under certain conditions, such as in the presence to as the enterosalivary nitrate circulation (nitrate–
of trace transition metal ions or photolysis, nitrite–NO pathway) (Figure 1) and is a major
S-nitrosothiols decompose to liberate NO (30). In source of NO (38,39).
addition, S-nitrosothiols can undergo trans-S- NO’s ROLES. NO is a powerful vasodilator that in-
nitrosation with other thiol groups and thereby duces formation of cGMP by activating sGC in
modify cell or protein function (31–33). vascular smooth muscle cells (Figure 2) (13). cGMP can
Several proteins, such as hemoglobin, cytochrome bind to and enhance protein kinase G activity, cGMP-
P450 reductase, and cytochrome P 450 , can catalyze the gated ion channels, and cGMP-sensitive phosphodi-
reduction of nitrite or nitrate to generate NO (23). esterases (40). Protein kinase G promotes reuptake of
2396 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

F I G U R E 2 Regulation of Vascular Tone by NO

Endothelial Cell



NO Ca2+


Vascular Smooth
NO sGC cGMP cGMP-dep Kinase I
Muscle Cell

GMP ↓Ca2+


Vascular Smooth Muscle

NO is a powerful vasodilator that induces formation of cGMP by activating soluble sGC in vascular smooth muscle cells. cGMP can bind to and enhance
protein kinase G activity, cGMP-gated ion channels, and cGMP-sensitive phosphodiesterases. Protein kinase G promotes reuptake of cytosolic calcium into
the sarcoplasmic reticulum, the movement of calcium from the intracellular to the extracellular environment, and the opening of calcium-activated
potassium channels. These changes result in reduction of vascular tone as the reduction in intracellular calcium impairs myosin light chain kinase’s ability
to phosphorylate myosin, resulting in smooth muscle cell relaxation. ATPase ¼ adenosine triphosphatase; Ca2þ ¼ calcium ion; cGMP ¼ cyclic guanosine
monophosphate; cGMP-dep Kinase I ¼ cyclic guanosine monophosphate-dependent protein kinase I; eNOS ¼ endothelial nitric oxide synthase;
GMP ¼ guanosine monophosphate; GTP ¼ guanosine triphosphate; MLC ¼ myosin light chain; MLCK ¼ myosin light chain kinase; MLCP ¼ myosin light
chain phosphatase; MLC-Pi ¼ phosphorylated myosin light chain; NO ¼ nitric oxide; PDE ¼ phosphodiesterase; sGC ¼ soluble guanylyl cyclase.

cytosolic calcium into the sarcoplasmic reticulum, the activating platelet guanylyl cyclase and increasing
movement of calcium from the intracellular to the intraplatelet cGMP (46–49).
extracellular environment, and the opening of Finally, a greater understanding of the conse-
calcium-activated potassium channels (23). These quences of impaired NO synthesis can yield more
changes result in reduction of vascular tone as the information regarding the importance of NO’s role in a
reduction in intracellular calcium impairs myosin well-functioning cardiovascular system. For example,
light chain kinase’s ability to phosphorylate myosin, when low levels of its essential cofactor (6R)-5,6,7,8-
resulting in smooth muscle cell relaxation (41). tetrahydrobiopterin are present, eNOS produces
NO has several other important roles in the superoxide anion instead of NO in a process denoted
vasculature. For example, when vascular endothelial enzymatic uncoupling (50). eNOS uncoupling has been
growth factor (VEGF) binds to VEGF receptor-2, eNOS observed in animal models of cardiovascular disease
is activated and NO is formed (42–44). This NO is and in patients with cardiovascular risk factors, such
essential for VEGF function, as eNOS-deficient mice as hypertension and diabetes mellitus (51,52).
have markedly reduced vascular permeability and
angiogenesis (45). S-nitrosylation of b -catenin by NO MECHANISM OF ACTION OF NITRATES
modulates intercellular contacts between endothelial
cells, likely accounting for NO-dependent changes in Organic nitrates, such as nitroglycerin, isosorbide
endothelial permeability (42). NO and organic nitrates dinitrate, and isosorbide mononitrate, are rapidly
also impair platelet activation and aggregation by absorbed from several sites, such as the
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2397
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

F I G U R E 3 Chemical Structures of Key Nitrovasodilators




Isosorbide Isosorbide
Nitroglycerin Amyl nitrite
dinitrate mononitrate

O 2–

2Na+ Fe H

Pentaerythrityl Sodium
tetranitrate nitroprusside

Chemical structures of 7 key nitrovasodilators are shown.

gastrointestinal tract, mucous membranes, and skin, used in hospitalized patients with angina, hyperten-
depending on the preparation (53). These compounds sion, or heart failure (Figure 3, Table 1) (53,59).
are prodrugs with a nitrooxy (O-NO 2) moiety and are Nitroglycerin has a plasma half-life of approximately
metabolized to produce bioactive metabolites (54,55). 1 to 4 min; following hepatic and intravascular
The bioactivation of organic nitrates causes liberation metabolism, its biologically active metabolites have a
of NO, allowing them to serve as NO donors (55,56). half-life of approximately 40 min (53,60).
NO then causes vasodilation via its effect on vascular Isosorbide dinitrate is rapidly absorbed and
smooth muscle cells, and impairs platelet activation undergoes extensive first-pass metabolism by the
as previously discussed (13). liver, which results in low bioavailability (53,55).
Nitrates are also implicated in epigenetic regula- Sustained-release formulations have a slower rate of
tion of vasodilation, including specifically smooth absorption and can provide therapeutic plasma
muscle cell relaxation (57,58). Additionally, nitro- concentrations of the drug for up to 12 h (53).
glycerin has been shown to increase the activity of Oral isosorbide mononitrate is completely absorbed
histone acetylases with nitroglycerin-dependent and has 100% bioavailability as it avoids first-pass
vascular responses influenced by N 3-lysine acetyla- metabolism. This leads to a more predictable dose
tion of contractile proteins (58). response and plasma levels with less variation when
compared with other nitrates (55,61). Pentaerythrityl
PREPARATIONS tetranitrate is a long-acting organic nitrate available
in an oral formulation that acts within 10 to 20 min
Nitrates are rapidly absorbed from mucous mem- and has a duration of action of 8 to 12 h (57).
branes, the gastrointestinal tract, and the skin (55). Preclinical data suggested that pentaerythrityl
Thus, nitroglycerin is available in several prepara- tetranitrate may not cause nitrate tolerance (see the
tions for delivery via several routes: oral tablets, following text) or endothelial dysfunction; however,
sublingual tablets, buccal tablets, sublingual spray, the drug is not currently commonly used, as clinical
transdermal ointment, and transdermal patch; it is studies have not shown any clear benefit in patients
also available in intravenous formulations, which are with chronic, stable angina (62).
2398 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

the alveolar-capillary membrane and activates sGC in
T A B L E 1 Properties of Key Nitrovasodilators
the subjacent smooth muscle cells in the pulmonary
Time Until Duration of vasculature (71). N-diazeniumdiolates (NONOates) are
Drug Route/Formulation Dose Onset of Action Action
NO donors that are synthesized by reacting primary or
Nitroglycerin SL spray 0.4 mg 1–3 min 25 min
secondary amines with NO gas at high pressure and
SL tablet 0.3–0.8 mg 1–3 min 25 min
TD patch 0.2–0.8 mg/h 30 min 10–12 h low temperatures; hydrolysis causes spontaneous
IV infusion 5–400 mg/min Within 3–5 min decomposition under physiological conditions and
seconds releases NO (72–74). NO (as N 2O 3 or ONOO) can react
Isosorbide dinitrate PO IR tablet 5–80 mg 60 min 8h
PO SR tablet 40–160 mg 60 min 12 h
with thiols in vivo to form S-nitrosothiols, such as
Isosorbide mononitrate PO IR tablet 5–20 mg 30–45 min 6h S-nitrosocysteine and S-nitrosoglutathione (75).
PO SR tablet 30–240 mg 30–45 min 12–24 h S-nitrosothiol compounds can also be synthesized
Amyl nitrite Inhalation of 0.3 ml 30 s 3–15 min chemically by reacting thiols with nitrous acid. When
Pentaerythrityl PO tablet 10–80 mg 10–20 min 8–12 h
exposed to physiological fluids, S-nitrosothiols
tetranitrate decompose to release NO (72). Other newer classes of
Sodium nitroprusside IV infusion 0.3–10.0 mg/kg/min 1 min 6–12 min direct NO donors that are actively being studied
Nicorandil PO tablet 5–20 mg 30–60 min 12 h
include furoxans, benzofuroxans, and zeolites
IR ¼ immediate release; IV ¼ intravenous; PO ¼ oral; SL ¼ sublingual; SR ¼ sustained release; TD ¼ transdermal.

Nicorandil is a nicotinamide-nitrate ester whose ORGANIC NITRATES
chemical structure consists of a nicotinamide deriv-
ative combined with a nitrate moiety (55). Nicorandil Organic nitrates must undergo biotransformation
acts as both an NO donor and a K þATP channel to release a vasoactive molecule (78). The detailed
opener to provide antianginal effects (63). The bio- study of the biotransformation of nitroglycerin
activation of nicorandil occurs via the nicotinamide/ has suggested a high-potency pathway mediated
nicotinic acid pathway and involves NO generation by aldehyde dehydrogenase (ALDH)-2 and a low-
via denitration (64). Nicorandil also dilates the potency pathway mediated by other enzymes or
coronary microvasculature and peripheral resistance low-molecular-weight reductants (Figure 4) (78).
arterioles by causing vascular smooth cell hyperpo- The high-potency pathway is important at clinically
larization and closure of L-type voltage-gated relevant nitroglycerin concentrations (<1 m mol/l) and
calcium channels via its action on K þATP channels; is localized to the mitochondria. The mitochondrial
it is rapidly absorbed via the gastrointestinal tract, isoform of aldehyde dehydrogenase, ALDH-2, was
does not undergo first-pass metabolism, reaches found to be a key enzyme in the biotransformation of
maximal plasma concentration after 30 to 60 min, nitroglycerin via this pathway as it generates inor-
and has a half-life of approximately 52 min ganic nitrite and 1,2-glyceryl dinitrate from nitro-
(55,65,66). Nicorandil has an oral bioavailability glycerin (79). There are 3 proposed mechanisms for
of >75%, and its antianginal effects last approxi- the release of the vasoactive molecule via this
mately 12 h (55,64,67). pathway: nitrogen oxides are formed via reduction of
Sodium nitroprusside, which is 44% cyanide by inorganic nitrite; NO is formed directly in response to
weight, comprises a ferrous ion center complexed interaction with ALDH-2; and inorganic nitrite
with 5 cyanic moieties and a nitrosyl group (68). It is released from mitochondria may be reduced by
available intravenously and interacts with oxyhemo- xanthine oxidase in the cytoplasm to form NO (78).
globin to produce methemoglobin and spontaneously The low-potency pathway is important at supra-
release NO and cyanide (69,70). Sodium nitroprusside pharmacological nitroglycerin concentrations (>1 mmol/l),
causes direct venous and arterial vasodilation, is a is found in the smooth endoplasmic reticulum, and
potent pulmonary vasodilator, and is an inhibitor of leads to formation of measurable amounts of NO in
hypoxia-induced pulmonary vasoconstriction (68). It vascular tissues (80,81). In this pathway, nitroglyc-
has an almost immediate onset of action and a very erin is biotransformed by proteins such as deoxy-
short half-life: its effects dissipate within 1 to 2 min hemoglobin, deoxymyoglobin, cytochrome P 450 ,
(68). xanthine oxidase, glutathione-S-transferase, glycer-
Finally, there are several direct NO donors that aldehyde-3-phosphate dehydrogenase, or other
are already being used clinically, or have been ALDH isoforms; and by low-molecular-weight re-
synthesized and studied for use particularly in ductants such as cysteine, N-acetyl-cysteine, thio-
biomaterials. Inhaled NO gas diffuses rapidly across salicylic acid, and ascorbate (57,82–84).
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2399
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

F I G U R E 4 Bioactivation of Organic Nitrates

High potency nitrates Low potency nitrates
GTN, PETN high dose ISDN, ISDM

low dose


NO2– NOx
. Smooth
Mitochondrion Cyt Ox Endoplasmic Reticulum

NO cGMP cGK-I Relaxation

Organic nitrates must undergo biotransformation to release a vasoactive molecule via 1 of 2 pathways: a high-potency pathway mediated by ALDH-2, or a low-potency
pathway mediated by other enzymes or low-molecular-weight reductants. The high-potency pathway is important at clinically relevant nitroglycerin concentrations
(<1 mmol/l) and is localized to the mitochondria. The mitochondrial isoform of aldehyde dehydrogenase, ALDH-2, was found to be a key enzyme in the
biotransformation of nitroglycerin via this pathway as it generates inorganic nitrite (NO2) and 1,2-glyceryl dinitrate from nitroglycerin. There are 3 proposed
mechanisms for the release of the vasoactive molecule via this pathway: nitrogen oxides are formed via reduction of inorganic nitrite; nitric oxide is formed directly in
response to interaction with ALDH-2; and inorganic nitrite released from mitochondria may be reduced by xanthine oxidase in the cytoplasm to form NO. The
low-potency pathway is important at suprapharmacological nitroglycerin concentrations (> 1 mmol/l), is found in the smooth endoplasmic reticulum, and leads to
formation of measurable amounts of NO in vascular tissues. In this pathway, nitroglycerin is biotransformed by proteins such as deoxyhemoglobin, deoxymyoglobin,
cytochrome P450, xanthine oxidase, glutathione-S-transferase, glyceraldehyde-3-phosphate dehydrogenase, or other ALDH isoforms; and by low-molecular-weight
reductants such as cysteine, N-acetyl-cysteine, thiosalicylic acid, and ascorbate. Reproduced with permission from Munzel and Daiber (78). ALDH2 ¼ aldehyde
dehydrogenase-2; cGK-I ¼ cyclic guanosine monophosphate-dependent protein kinase I; Cyt Ox ¼ cytochrome c oxidase; GDN ¼ 1,2-glyceryl dinitrate;
GMN ¼ 1,2-glyceryl mononitrate; GTN ¼ glyceryl trinitrate (nitroglycerin); Hþ ¼ hydrogen ion; ISDM ¼ isosorbide mononitrate; ISDN ¼ isosorbide dinitrate;
NO2- ¼ inorganic nitrite; NOx ¼ nitrogen oxides; P450 ¼ cytochrome P450 enzyme(s); PEDN ¼ pentaerythrityl dinitrate; PEMN ¼ pentaerythrityl mononitrate;
PETN ¼ pentaerythrityl tetranitrate; PETriN ¼ pentaerythrityl trinitrate; XO ¼ xanthine oxidase; other abbreviations as in Figure 2.

HEMODYNAMIC EFFECTS OF NITRATES “suggesting the possibility that diastolic coronary
blood flow may be augmented by diminished extra-
The organic nitrates have several hemodynamic ef- vascular resistance to flow” (86).
fects that are mostly mediated through vasodilation Nitrates also dilate large- and medium-sized coro-
of capacitance veins and conductance arteries nary arteries and arterioles >100 m m in diameter. This
(Central Illustration) (53). In 1971, Parker et al. (85) effect reduces left ventricular systolic wall tension via
published the results of a study of hemodynamic decreasing afterload and, therefore, also decreases
indices and coronary blood flow at rest and during myocardial oxygen demand (53,87). The hemody-
exercise before and after administration of nitro- namic effects of nitrates on the coronary vasculature of
glycerin in 15 patients with coronary artery disease atherosclerotic patients also relieve angina. In 1972,
and concluded that nitroglycerin acted primarily by Horwitz, Herman, and Gorlin published a study of 70
reducing left ventricular oxygen requirements patients (49 with coronary artery disease and 21
through a reduction in left ventricular volume (85). without) with anginal chest pain and found that 76% of
NO-mediated dilation of capacitance veins decreases patients with coronary artery disease were regularly
ventricular pre-load, which results in reduction in relieved of their pain within 3 min, while only 19%
myocardial oxygen demand. In 1975, Greenberg et al. of those without coronary artery disease were
(86), after angiographic and hemodynamic assess- regularly relieved of their pain within 3 min (88).
ment of 10 patients, concluded that the mechanism of Nitrates dilate the epicardial coronary arteries,
action of nitroglycerin “seems to relate best to the including stenotic segments, and also improve blood
decrease in systolic wall tension.” They also found flow in coronary collaterals via decreasing resistance
that the end-diastolic wall tension decreased by 57%, to collateral flow (87,89). In 1964, Fam and McGregor
2400 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

C E NT R AL IL L U STR AT IO N Hemodynamic Effects of Nitroglycerin

↓ Myocardial O2 Consumption

↓ Preload ↓ Left ventricular
wall tension

↑ Subendocardial
blood flow

Vasodilation of large- and
Vasodilation of Vasodilation of conductance
medium-sized coronary
capacitance veins arteries
arteries and arterioles

Vasodilation of systemic and
Nitroglycerin → NO
pulmonary arterial beds

Dilation of stenotic
Improvement in coronary Epicardial coronary artery
epicardial coronary artery
collateral blood flow dilation

Divakaran, S. et al. J Am Coll Cardiol. 2017;70(19):2393–410.

The organic nitrates have several hemodynamic effects that are largely mediated through vasodilation of capacitance veins and conductance arteries. Seminal work in
the 1970s, as detailed in the main text, showed that nitroglycerin acts primarily by reducing left ventricular oxygen requirements through a reduction in left
ventricular volume. Nitric oxide (NO)–mediated dilation of capacitance veins decreases ventricular pre-load, which results in reduction in myocardial oxygen demand
and left ventricular wall tension. This results in an increase in subendocardial myocardial blood flow. Nitrates also dilate large- and medium-sized coronary arteries
and arterioles >100 mm in diameter. This effect reduces left ventricular systolic wall tension via decreasing afterload and, therefore, also decreases myocardial
oxygen demand. The hemodynamic effects of nitrates on the coronary vasculature also relieve angina. Nitrates dilate the epicardial coronary arteries, including
stenotic segments, and also improve blood flow in coronary collaterals via decreasing resistance to collateral flow. Nitrates, particularly sodium nitroprusside, can also
dilate the systemic arterial bed, and NO gas and sodium nitroprusside dilate the pulmonary vascular bed and inhibit hypoxia-induced pulmonary vasoconstriction.
O2 ¼ oxygen.

studied the effects of nitroglycerin and dipyridamole diameter, which reduces the risk of ischemia from
on coronary collateral blood flow in normal dogs coronary steal (91). Nitrates, particularly sodium
and dogs with chronic myocardial ischemia produced nitroprusside, can also dilate the systemic arterial bed,
by the placement of ameroid constrictors on the left and NO gas and sodium nitroprusside dilate the pul-
anterior descending and left circumflex arteries. monary vascular bed and inhibit hypoxia-induced
Unlike dipyridamole, they found that nitroglycerin pulmonary vasoconstriction (68).
“did not cause a significant reduction in either
retrograde flow or peripheral coronary pressure in NONHEMODYNAMIC EFFECTS OF NITRATES
spite of a greater fall in mean arterial pressure.”
Additionally, when arterial pressure was held The organic nitrates have also been found to have
constant, nitroglycerin caused a large increase of several important, nonhemodynamic effects. Inhibi-
retrograde flow in the dogs with chronic myocardial tion of platelet function by organic nitrates was first
ischemia (90). Importantly, the organic nitrates do not reported in 1967 by Hampton et al. (92), who showed
dilate coronary microvessels that are <100 m m in that nitroglycerin impairs platelet aggregation
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2401
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

in vitro. Subsequently, the organic nitrates have been difference in mortality in patients who received ni-
shown to inhibit platelet aggregation and function trate therapy (105). The ISIS-4 (Fourth International
by increasing intracellular cGMP and forming Study of Infarct Survival) randomized 58,050 pa-
S-nitrosothiols, which are potent activators of sGC tients presenting up to 24 h after the onset of a
and inhibitors of platelet aggregation (46,93). Organic suspected acute myocardial infarction in a 2-by-2
nitrates also have other antithrombotic effects, as factorial design that involved treatment with capto-
activation of sGC is accompanied by inhibition of pril, isosorbide mononitrate, magnesium sulfate,
agonist-mediated calcium flux, which results in a and/or placebo. There was no significant reduction in
reduction of fibrinogen binding to the glycoprotein mortality attributed to nitrate therapy (106). Of note,
Ilb/IIIa receptor of platelets (94). both the GISSI-3 and ISIS-4 trials were conducted in
Nitrates have also been found to have anti- the fibrinolytic era (i.e., prior to the percutaneous
inflammatory effects via NO’s role in the inflamma- coronary intervention era). By contrast, however, a
tory process (95). NO inhibits neutrophil adhesion meta-analysis of 10 trials, performed in the pre-
and chemotaxis in acute inflammation and modu- fibrinolytic era (and pre-dating the GISSI-3 and
lates microvascular permeability (96–99). However, ISIS-4 trials), of patients randomized to intravenous
increased expression of iNOS has been implicated in nitroglycerin or sodium nitroprusside in acute
chronic inflammatory conditions, as high-flux NO from myocardial infarction showed a reduction in mortal-
iNOS or its derivates in the inflammatory milieu (e.g., ity of 35% associated with nitrate therapy, with the
peroxynitrite) promotes adhesion molecule expres- greatest reduction in mortality occurring during the
sion and leukocyte–endothelial cell interactions, first week of follow-up (107).
among other pro-inflammatory mechanisms (99). Nitroglycerin is the drug most frequently used to
Finally, nitroglycerin has been shown to induce a treat acute episodes of angina. It is usually given as a
protective phenotype that limits damage after sublingual tablet, but is also available as a sublingual
ischemia and reperfusion. Nitroglycerin particularly spray. Sublingual nitroglycerin or nitroglycerin oral
protects against post-ischemic endothelial dysfunc- spray can also be used prior to angina-inducing ac-
tion, in part by impairing the opening of the mito- tivities to prevent the occurrence of acute angina
chondrial permeability transition pore (100,101). (53,108,109).
Winsor and Berger (110) studied 53 patients with
CLINICAL USES OF NITRATES documented angina, and concluded in 1975 that
controlled-release oral nitroglycerin provided a sta-
Organic nitrates, in intravenous, sublingual, and oral tistically significant clinical improvement of angina.
formulations, are often used in the management of In 1974, Reichek et al. (111) published their work on 14
acute coronary syndrome (102,103). Treatment with patients with angina pectoris and concluded that
nitrates causes vasodilation of the capacitance veins nitroglycerin ointment produced a significant in-
and results in reduced ventricular filling pressure, wall crease in exercise capacity, which persisted for at
tension, and myocardial oxygen demand (53). As pre- least 3 h. Several studies have also shown an
viously discussed, nitrates also dilate the epicardial improvement in exercise capacity without angina via
coronary arteries, which improves coronary blood use of transdermal preparations (112–116). Taken
flow, particularly in ischemic zones (87,89). together, all of these studies support the use of oral
These well-demonstrated physiological effects organic nitrates to increase exercise tolerance, pre-
notwithstanding, randomized controlled trial data vent angina, and improve chronic stable angina. In
supporting a clinical outcome benefit for the use of current practice, isosorbide dinitrate and isosorbide
nitrates in acute coronary syndrome are lacking. The mononitrate are often used for these indications (53).
GISSI-3 (Gruppo Italiano per lo Studio della Soprav- Although not available in the United States, nic-
vivenza nell’Infarto Miocardico 3) trial randomly orandil is used in the treatment of chronic, stable
assigned 19,394 patients with acute myocardial angina in other countries. In the IONA (Impact of
infarction in a 2-by-2 factorial design to intravenous Nicorandil in Angina) trial, treatment with nicorandil
nitroglycerin followed by a nitrate patch or placebo, in patients with stable angina statistically signifi-
as well as to lisinopril or placebo. The primary study cantly reduced the primary endpoint of coronary
endpoint of mortality at 6 weeks demonstrated no death, nonfatal myocardial infarction, or unplanned
significant benefit of nitrate therapy. The subset of hospitalization for angina (117).
patients receiving combination therapy with lisino- The established treatment for Prinzmetal variant
pril and nitrates, however, had the lowest mortality angina, or coronary artery spasm, is therapy with
in the trial (104). At 6 months, there was no calcium-channel blockers. Long-acting oral nitrates
2402 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

have also been found to be helpful, and it is thought Cochrane review does not support its use for respi-
that their vasodilatory effects are additive to calcium- ratory failure in pre-term infants (129).
channel blockade in this setting (118,119).
Intravenous nitroglycerin and sodium nitroprus- NITRATE TOLERANCE
side are used to treat patients hospitalized with hy-
pertensive urgency and emergency with preference to One major problem with the use of nitrates is the
sodium nitroprusside, as it induces more arterial development of tolerance, which is defined as “the
vasodilation than nitroglycerin. Although nitrates loss of hemodynamic and anti-anginal effects during
have generally not been proven useful in the man- sustained therapy” (53). Tolerance occurs following
agement of hypertension, they are considered one of chronic exposure to all nitrates and results in
the drug classes-of-choice for patients with hyper- “complete or markedly diminished anti-anginal and
tension and stable angina (120). They should ideally anti-ischemic effects throughout the 24-h period of
be used in combination with beta-blockers, or alone if long-term therapy” (130). In 1980, Thadani et al. (131)
beta-blockers are contraindicated or cause unaccept- reported their studies of tolerance to oral isosorbide
able side effects (120). dinitrate and showed that both partial circulatory
Nitrates were previously considered first-line ther- tolerance to isosorbide dinitrate and cross-tolerance
apy for patients with acute heart failure with normal or to nitroglycerin developed rapidly during treatment
high blood pressures owing to their previously with isosorbide dinitrate given every 6 h. They went
described hemodynamic effects on the venous and on to report similar findings regarding its antianginal
arterial systems, pre-load, and afterload (121). A recent effect 2 years later (132). Subsequent studies reported
Cochrane review, however, found no significant dif- similar findings with different formulations of nitrate
ference between nitrate vasodilator therapy and therapy (61,115,130,133–138).
alternative interventions for the treatment of acute The cause of nitrate tolerance is still incompletely
heart failure syndromes with regard to symptom relief understood, but several hypotheses exist. One hy-
and hemodynamic variables (122). Given the striking pothesis argues that chronic treatment with organic
results of the African-American Heart Failure Trial nitrates triggers supersensitivity to vasoconstrictors,
however, the combination of hydralazine and iso- which attenuates the vasodilator effects of nitrates.
sorbide dinitrate, together with angiotensin- This action is mediated by increased autocrine levels
converting enzyme inhibitors, beta-blockers, and of endothelin within the vasculature, with the sub-
aldosterone antagonists, is recommended by current sequent activation of phospholipase C and protein
guidelines for African-Americans who require further kinase C. These pathways lead to increased actomy-
blood pressure control and relief of symptoms from osin activity and myocyte contractility. Additionally,
New York Heart Association functional class III or IV agonist-driven calcium-dependent activation of the
chronic heart failure (120,123,124). This combination RhoA/Rho kinase pathway contributes to vasocon-
can also be useful clinically in patients with chronic striction via inhibition of myosin light chain phos-
systolic heart failure who cannot be given angiotensin- phatase (139–141).
converting enzyme inhibitors or angiotensin receptor Another hypothesis for the mechanism of
blockers (124). nitrate tolerance is that chronic therapy with organic
Inhaled NO gas has several clinical uses in adults. It nitrates desensitizes sGC (142,143). S-nitrosylation of
has a well-established role in vasoreactivity testing in sGC is a means by which “memory” of NO exposure
patients with pulmonary arterial hypertension. This is retained in smooth muscle cells, resulting in
testing is helpful to identify patients who may decreased responsiveness to NO, and could be a
respond to therapy with calcium-channel blockers mechanism of NO tolerance (139–144). Nitroglycerin
(71,125). Although robust data are lacking, inhaled NO metabolism also promotes the production of reactive
gas is also used in patients both with and without a oxygen species. Oxidation of thiol groups in the
prior diagnosis of pulmonary hypertension with acute active site of ALDH-2 by these reactive derivatives has
hypoxemic respiratory failure to improve ventilation- been observed during chronic nitroglycerin treat-
perfusion matching (126). Inhaled NO has an estab- ment. This post-translational modification may cause
lished role in the treatment of severe persistent inhibition of ALDH-2 enzyme activity, which can lead
pulmonary hypertension of the newborn, and a to both reduced nitroglycerin biotransformation and
recently published Cochrane review also supports its efficacy (139,145–147).
use in the treatment of term and near-term infants Additionally, continuous treatment with nitro-
with hypoxic respiratory failure who do not have a glycerin has been shown to cause NO synthase
diaphragmatic hernia (127,128). By contrast, a recent dysfunction, likely through the reduced
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2403
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

bioavailability of tetrahydrobiopterin (148). NO syn- including sodium thiosulfate, sodium nitrite, amyl
thase dysfunction can cause superoxide anion for- nitrite, and hydroxocobalamin, as well as potential
mation. If not effectively mitigated by superoxide antidotes that are undergoing development, such as
dismutases, increased superoxide anion formation sulfanegen sodium. Sodium thiosulfate is available
can lead to the formation of peroxynitrite anion intravenously, and acts as a sulfur donor to plasma
(through reaction with NO), which is a highly reactive rhodanase, an enzyme that transforms cyanide to
intermediate that promotes oxidant stress and re- thiocyanate, a nontoxic derivative (168). Intravenous
duces NO bioavailability (139,149,150). sodium nitrite and inhaled amyl nitrite are methe-
Nitrate therapy–induced increases in phosphodi- moglobin generators, and methemoglobin’s strong
esterase activity have also been implicated in the affinity for cyanide binding is the rationale for their
development of tolerance (151). As previously dis- use as antidotes (169). Hydroxocobalamin is available
cussed, nitroglycerin is metabolized to NO, which intravenously and contains a cobalt moiety, which
activates sGC to increase cGMP. Phosphodiesterase avidly binds to intracellular cyanide forming cyano-
decreases cGMP levels, and, therefore, NO-induced cobalamin (169–171). Sulfanegen sodium is a prodrug
vasodilation is attenuated by its activity. of 3-mercaptopyruvate that converts cyanide to
Finally, pseudotolerance also complicates chronic thiocyanate (168,172). It was shown to be effective in
treatment with organic nitrates. This adaptive phe- reversing cyanide toxicity in a juvenile pig model, but
nomenon is not considered true vascular tolerance work is ongoing to develop it into an antidote that is
because it occurs in response to every form of vaso- safe for use in humans (173).
dilator therapy. Pseudotolerance is marked by Additionally, there are certain clinical situations
neurohormonal activation, increased catecholamine in which nitrates should not be used, or should be
release rates and circulating catecholamine levels, used with extreme caution. Nitrates should not
sodium retention, and intravascular volume expan- be given to patients who have used a phosphodies-
sion (139,152). terase inhibitor, such as sildenafil or tadalafil, within
Although several agents have been studied for use 24 to 48 h due to the risk of severe hypotension
in the prevention of nitrate tolerance, none are (174,175). Nitrates should also be avoided in
currently recommended due to a paucity of supportive suspected causes of right ventricular infarction, as
clinical data (130,136,153–160). Only 1 method nitrate-induced dilation of the venous capacitance
of preventing nitrate tolerance remains widely beds could cause hypotension given the need for
accepted: the use of a dosing strategy that provides an high filling pressures in this setting (176). Patients
interval of no or low nitrate exposure during each 24-h with hypertrophic cardiomyopathy should not be
period (116,130,137,161–163). Nitrate tolerance is placed on nitrate therapy, as it can increase outflow
rapidly reversed during a nitrate-free interval (53,164). tract obstruction by decreasing pre-load and
ventricular volumes (177).
In addition to the development of tolerance, there are NO-sGC-cGMP PATHWAY
other important considerations to treatment with
organic nitrates. Common side effects of nitrate The organic nitrates have been and continue to be
therapy include headache, flushing, lightheadedness, mainstays in the treatment of several acute and
and postural hypotension. When sodium nitroprus- chronic cardiovascular conditions. Although many of
side is infused, it interacts with oxyhemoglobin to the organic nitrates have been used clinically for de-
form methemoglobin and releases NO and cyanide. cades, there are several new drugs and drug classes
Therefore, patients receiving sodium nitroprusside that have been approved recently or are currently
must be monitored for manifestations of both cyanide being studied that have the potential to add to the list
toxicity, such as altered mental status, seizure, and of modulators of the NO-sGC-cGMP pathway (178).
metabolic acidosis; and methemoglobinemia, such Their methods of modulation of this pathway are
as cyanosis, headache, fatigue, and lethargy summarized in Figure 5.
(68,69,165,166). Cyanide toxicity from sodium nitro- Caveolin-1 (CAV1) is the main coat protein of cav-
prusside therapy is rare and is unlikely if the cumu- eolae, which are invaginations in the plasma mem-
lative dose of nitroprusside does not exceed brane implicated in several biological processes,
0.5 mg/kg/h. Large-infusion doses of nitroglycerin including signaling, in endothelial cells (178–182).
can also cause methemoglobinemia (167). There are eNOS activity is decreased when bound to CAV1
several antidotes available to treat cyanide toxicity, (183,184). Cavnoxin, a peptide that activates eNOS,
2404 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

F I G U R E 5 Novel Ways of Modulating the NOsGC-cGMP Pathway

Increase Introduce Enhance Modulate the Inhibit NADH- Disrupt hemoglobin
Reverse eNOS
Endogenous Cavnoxin-like transcription of enterosalivary cytochrome b5 α’s binding site for
Cavnoxin peptides eNOS nitrate circulation reductase 3 eNOS

eNOS Fe2+-hemoglobin α
activation to
Fe3+-hemoglobin α

Increase endogenous NO production Increase NO bioavailability

Stimulate sGC

Increase cGMP Decrease cGMP
production breakdown

Several novel modulators of the NO-sGC-cGMP pathway are undergoing active investigation, and the details are summarized in the main text. Methods of increasing
endogenous cavnoxin production or introducing synthesized cavnoxin-like peptides could increase endogenous NO production. Transcriptional enhances of eNOS, the
small molecules AVE3085 and AVE9488, have increased endogenous NO production, reversed eNOS uncoupling, and decreased eNOS production of superoxide anion in
mice. The enterosalivary nitrate circulation (nitrate-nitrite-NO pathway) is a source of NO that is derived from dietary inorganic nitrate intake, and production of NO
from this pathway is enhanced by hypoxia and acidosis. Research dedicated to exploring therapeutic options, such as prebiotics, probiotics, and antimicrobial agents,
that can modulate the microbiome and the nitrate-nitrite-NO pathway in heart failure, pulmonary hypertension, hypertension, obesity, and other cardiovascular
disease states is ongoing. Increasing the bioavailability of endogenous NO is another potential approach to modulating the NO-sGC-cGMP pathway. The oxidized form of
hemoglobin-a has a much lower affinity for NO than the reduced form, and, therefore, allows eNOS-generated NO to diffuse to underlying vascular smooth muscle
cells. Because NADH-cytochrome b5 reductase 3 reduces Fe3þ–hemoglobin-a to Fe2þ–hemoglobin-a, a potential way to increase NO bioavailability would be to inhibit
NADH-cytochrome b5 reductase 3. Another possible strategy would be to disrupt the binding site of hemoglobin-a for eNOS, and a small peptide, hemoglobin-aX, has
been developed as just such an inhibitor. Finally, modulating the NO-sGC-cGMP pathway in an NO-independent fashion is also being studied. The ciguats modulate sGC
activity to increase cGMP production independently of NO. The phosphodiesterases hydrolyze the phosphodiester bond of cGMP. Inhibition of these enzymes de-
creases cGMP breakdown. NADH ¼ nicotinamide adenine dinucleotide; Fe ¼ iron; other abbreviations as in Figure 2.

was identified by studying the key residues in CAV1 oxidized form of hemoglobin-a has a much lower af-
responsible for inhibition of eNOS function (185). In finity for NO than the reduced form, and, therefore,
wild-type mice, cavnoxin increases NO levels, causes a allows eNOS-generated NO to diffuse to underlying
reduction in vascular tone, and lowers systemic blood vascular smooth muscle cells (178,187). Nicotinamide
pressure (185). Therefore, novel methods of increasing adenine dinucleotide (NADH)–cytochrome b5
endogenous cavnoxin production or introducing reductase 3 reduces Fe3þ–hemoglobin-a to Fe 2þ–
synthesized cavnoxin-like peptides could be a prom- hemoglobin-a . Therefore, yet another potential
ising way to increase endogenous NO production. way to increase NO bioavailability would be
Another approach to increasing endogenous NO is to inhibit NADH-cytochrome b5 reductase 3. Still
to increase NO bioavailability by affecting hemoglo- another possible strategy would be to disrupt the
bin- a ’s ability to complex with eNOS. In the micro- binding site of hemoglobin- a for eNOS; a small pep-
circulation, hemoglobin-a forms a macromolecular tide, hemoglobin-a X, has been developed for this
complex with eNOS and controls the flux of purpose. Hemoglobin- a X has been found to decrease
bioavailable NO (178,186). The reduced Fe 2þ–O2 – blood pressure in mice and dilate constricted arteri-
hemoglobin-a reacts with NO rapidly and generates oles isolated from patients with hypertension
nitrate and the oxidized Fe3þ–hemoglobin- a . This (186,188).
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2405
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

Modulating the transcription, and therefore, NOsGC stimulator that is approved for clinical
translation of NOS is another focus of research and use (196). Riociguat is currently approved for the
development efforts to augment levels of endoge- treatment of pulmonary arterial hypertension and
nous NO. Two small molecules, AVE3085 and inoperable chronic thromboembolic pulmonary hy-
AVE9488, have been identified as transcriptional pertension (178,197,198). There are ongoing trials of
enhancers of eNOS that bind its promoter (178,189). In riociguat’s potential role in the treatment of pulmo-
apolipoprotein E knockout mice, 12 weeks of treat- nary hypertension and heart failure. Other NOsGC-
ment with AVE9488 or AVE3085 reduced atheroscle- stimulating ciguats that are being studied include
rotic plaque formation. Treatment of these mice with vericiguat, which was shown to decreased circulating
AVE9488 also reversed eNOS uncoupling, increased levels of N-terminal pro–B-type natriuretic peptide
vascular content of the essential eNOS cofactor in patients with worsening chronic systolic heart
tetrahydro-L-biopterin (BH4 ), and reduced vascular failure, as well as nelociguat, IW-1973, and IW-1701
cuff-induced neointima formation (189). Four weeks (178,199,200).
of treatment with AVE3085 was shown to attenuate Cinaciguat was identified as an NOsGC activator
cardiac remodeling in an experimental mouse model via high-throughput screening (201,202). Its clinical
involving aortic banding to induce remodeling (190). use has been limited due to significant hypotension.
Finally, 9 weeks of treatment with AVE9488 was In a placebo-controlled trial of 139 patients admitted
shown to improve left ventricular remodeling and with acute, decompensated, systolic heart failure,
contractile dysfunction in an experimental myocar- cinaciguat significantly decreased pulmonary capil-
dial infarction rat model (191). lary wedge pressure, right atrial pressure, pulmo-
As referred to in the previous text with regard to nary vascular resistance, and systemic vascular
treatment with AVE9488, reversing eNOS uncoupling resistance, and also significantly increased cardiac
is desired as it decreases eNOS production of super- index. However, the trial was stopped prematurely
oxide anion (50). Tetrahydrobiopterin has been due to an increased occurrence of hypotension at
shown to improve endothelial dysfunction in patients cinaciguat doses >200 m g/h (203). At lower doses,
with type 2 diabetes mellitus and in patients on cinaciguat has been shown to decrease systemic
cyclosporine A after cardiac transplantation (52,192). blood pressure without improving dyspnea or
However, a study of 49 patients randomized to cardiac index in patients with acute heart failure,
receive 400 mg/day of BH4 , 700 mg/day of BH 4, or therefore limiting its use in this population (204).
placebo for 2 to 6 weeks before coronary artery bypass Another NOsGC activator that is under development
graft surgery found no effect of BH 4 treatment on is ataciguat (178).
vascular function or superoxide production (193). Another class of NOsGC-cGMP pathway modula-
More research is needed to explore alternative ways tors is the phosphodiesterases. These enzymes
to reverse eNOS uncoupling and, thereby, increase inhibit the pathway by hydrolyzing the phospho-
NO production and decrease superoxide anion diester bond of cGMP (178,205). There are 4 phos-
production. phodiesterase 5 inhibitors in current clinical use that
Ignarro et al. (194) showed that sGC activity could inhibit cGMP breakdown: sildenafil, vardenafil,
be modulated in an NO-independent fashion by pro- tadalafil, and avanafil. All 4 are approved for use in
toporphyrin IX, an sGC activator. Protoporphyrin IX erectile dysfunction. Sildenafil and tadalafil are also
was never used clinically due to its severe photo- used for pulmonary arterial hypertension, and
sensitizing effect (178). However, a recently devel- tadalafil is approved for use in benign prostatic
oped class of drugs called the ciguats also modulate hyperplasia (178). Work is ongoing to develop addi-
the NO–sGC–cGMP pathway similarly in an NO- tional phosphodiesterase inhibitors, including in-
independent fashion (178). There are 2 subgroups of hibitors of nonselective phosphodiesterases and
ciguats: NOsGC stimulators (which bind NOsGC and cGMP-selective phosphodiesterases (phosphodies-
act through allosteric regulation) and NOsGC activa- terases 5, 6, and 9) (178).
tors (which occupy the heme binding site of NOsGC Finally, as discussed above, the enterosalivary ni-
and work additively with NO) (178). Lificiguat was the trate circulation (nitrate–nitrite–NO pathway) is a
first NOsGC stimulator that was identified when it source of NO that is derived from dietary inorganic
was found to stimulate sGC in rabbit platelets during nitrate intake (38,39,206). Production of NO from this
a small-molecule screen designed to identify novel pathway is enhanced by hypoxia and acidosis
platelet aggregation inhibitors (195). Further work to (207,208). There is, therefore, interest in studying the
improve the solubility and efficacy of lificiguat led to use of inorganic nitrates to improve exercise capacity,
the development of riociguat, which is the only particularly in patients with heart failure with
2406 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

preserved left ventricular ejection fraction (206). In symptoms despite the paucity of evidence of benefit
addition, there is ongoing research dedicated to on hard clinical endpoints. As research and develop-
exploring therapeutic options, such as prebiotics, ment of new ways to modulate the NO-sGC-cGMP
probiotics, and antimicrobial agents, that can modu- pathway continue, it may be time to revisit the
late the microbiome and the nitrate–nitrite–NO study of nitrates in large, prospective clinical trials in
pathway in heart failure, pulmonary hypertension, the percutaneous coronary intervention era.
hypertension, obesity, and other cardiovascular dis-
ACKNOWLEDGMENT The authors thank Ms.
ease states (39).
Stephanie Tribuna for expert technical assistance.
The use of nitrates in cardiovascular disease has a Department of Medicine, Brigham and Women’s
long and storied history. They continue to play a Hospital, 75 Francis Street, Boston, Massachusetts 02115.
major role in current clinical practice to improve E-mail:


1. Heberden W. Some account of a disorder of the 14. Katsuki S, Arnold W, Mittal C, Murad F. Stim- 25. Andrew PJ, Mayer B. Enzymatic function of
breast. Medical Transactions. London: Royal Col- ulation of guanylate cyclase by sodium nitroprus- nitric oxide synthases. Cardiovasc Res 1999;43:
lege of Physicians; 1772:59–67. side, nitroglycerin and nitric oxide in various tissue 521–31.
preparations and comparison to the effects of
2. Priestley J. Experiments and observations on 26. Alderton WK, Cooper CE, Knowles RG. Nitric
sodium azide and hydroxylamine. J Cyclic Nucle-
different kinds of air. 2nd ed. London: J. Johnson, oxide synthases: structure, function and inhibition.
otide Res 1977;3:23–35.
1775. Biochem J 2001;357:593–615.
15. Furchgott RF, Zawadzki JV. The obligatory role
3. Steinhorn BS, Loscalzo J, Michel T. Nitroglycerin 27. Förstermann U, Sessa WC. Nitric oxide syn-
of endothelial cells in the relaxation of arterial
and nitric oxide—a rondo of themes in cardiovas- thases: regulation and function. Eur Heart J 2012;
smooth muscle by acetylcholine. Nature 1980;
cular therapeutics. N Engl J Med 2015;373: 33:829–37. 837a–d.
277–80. 28. Morishita T, Tsutsui M, Shimokawa H, et al.
16. Cherry PD, Furchgott RF, Zawadzki JV, Vasculoprotective roles of neuronal nitric oxide
4. Marsh N, Marsh A. A short history of nitro- Jothianandan D. Role of endothelial cells in synthase. FASEB J 2002;16:1994–6.
glycerine and nitric oxide in pharmacology and relaxation of isolated arteries by bradykinin. Proc
physiology. Clin Exp Pharmacol Physiol 2000;27: Natl Acad Sci U S A 1982;79:2106–10. 29. Spink J, Cohen J, Evans TJ. The cytokine
313–9. responsive vascular smooth muscle cell enhancer
17. Ignarro LJ. Biological actions and properties of of inducible nitric oxide synthase. Activation by
5. Berlin R. Historical aspects of nitrate therapy. endothelium-derived nitric oxide formed and nuclear factor-kappa B. J Biol Chem 1995;270:
Drugs 1987;33 Suppl 4:1–4. released from artery and vein. Circ Res 1989;65: 29541–7.
6. Guthrie F. Contributions to the knowledge of 30. Singh RJ, Hogg N, Joseph J, Kalyanaraman B.
the amyl group. 1. Nitryl of amyl and its 18. Ignarro LJ, Buga GM, Wood KS, Byrns RE, Mechanism of nitric oxide release from S-nitrosothiols.
derivatives. J Chem Soc 1859;11:245–52. Chaudhuri G. Endothelium-derived relaxing factor J Biol Chem 1996;271:18596–603.
produced and released from artery and vein is ni-
7. Fye WB. T. Lauder Brunton and amyl nitrite: a 31. Scharfstein JS, Keaney JF, Slivka A, et al.
tric oxide. Proc Natl Acad Sci U S A 1987;84:
Victorian vasodilator. Circulation 1986;74:222–9. In vivo transfer of nitric oxide between a plasma
protein-bound reservoir and low molecular weight
8. Brunton TL. On the use of nitrite of amyl in
19. Ignarro LJ, Byrns RE, Buga GM, Wood KS. thiols. J Clin Invest 1994;94:1432–9.
angina pectoris. Lancet 1867;2:97.
Endothelium-derived relaxing factor from pulmo-
32. Liu Z, Rudd MA, Freedman JE, Loscalzo J.
9. Murrell W. Nitro-glycerine as a remedy for nary artery and vein possesses pharmacologic and
S-transnitrosation reactions are involved in the
angina pectoris. Lancet 1879;113:80–1. chemical properties identical to those of nitric
metabolic fate and biological actions of nitric
oxide radical. Circ Res 1987;61:866–79.
10. Diamond J, Holmes TG. Effects of potassium oxide. J Pharmacol Exp Ther 1998;284:526–34.
chloride and smooth muscle relaxants on tension 20. Palmer RM, Ferrige AG, Moncada S. Nitric
33. Handy DE, Loscalzo J. Nitric oxide and post-
and cyclic nucleotide levels in rat myometrium. oxide release accounts for the biological activity of
translational modification of the vascular prote-
Can J Physiol Pharmacol 1975;53:1099–107. endothelium-derived relaxing factor. Nature 1987;
ome: S-nitrosation of reactive thiols. Arterioscler
11. Diamond J, Blisard KS. Effects of stimulant and Thromb Vasc Biol 2006;26:1207–14.
relaxant drugs on tension and cyclic nucleotide 21. Loscalzo J. The identification of nitric oxide as
34. Huang Z, Shiva S, Kim-Shapiro DB, et al.
levels in canine femoral artery. Mol Pharmacol endothelium-derived relaxing factor. Circ Res
Enzymatic function of hemoglobin as a nitrite
1976;12:668–92. 2013;113:100–3.
reductase that produces NO under allosteric
22. Stamler JS, Singel DJ, Loscalzo J. Biochemistry control. J Clin Invest 2005;115:2099–107.
12. Katsuki S, Murad F. Regulation of adenosine
of nitric oxide and its redox-activated forms.
cyclic 3’,5’-monophosphate and guanosine cyclic 35. Li H, Liu X, Cui H, Chen YR, Cardounel AJ,
Science 1992;258:1898–902.
3’,5’-monophosphate levels and contractility in Zweier JL. Characterization of the mechanism of
bovine tracheal smooth muscle. Mol Pharmacol 23. Zhao Y, Vanhoutte PM, Leung SW. Vascular cytochrome P450 reductase-cytochrome P450-
1977;13:330–41. nitric oxide: Beyond eNOS. J Pharmacol Sci 2015; mediated nitric oxide and nitrosothiol generation
129:83–94. from organic nitrates. J Biol Chem 2006;281:
13. Arnold WP, Mittal CK, Katsuki S, Murad F. Ni-
tric oxide activates guanylate cyclase and in- 24. Chen K, Pittman RN, Popel AS. Nitric oxide in
creases guanosine 3’:5’-cyclic monophosphate the vasculature: where does it come from and 36. Maron BA, Tang SS, Loscalzo J. S-nitrosothiols
levels in various tissue preparations. Proc Natl where does it go? A quantitative perspective. and the S-nitrosoproteome of the cardiovascular
Acad Sci U S A 1977;74:3203–7. Antioxid Redox Signal 2008;10:1185–98. system. Antioxid Redox Signal 2013;18:270–87.
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2407
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

37. Spiegelhalder B, Eisenbrand G, Preussmann R. 52. Heitzer T, Krohn K, Albers S, Meinertz T. 69. Smith RP, Kruszyna H. Nitroprusside produces
Influence of dietary nitrate on nitrite content of Tetrahydrobiopterin improves endothelium- cyanide poisoning via reaction with hemoglobin.
human saliva: possible relevance to in vivo for- dependent vasodilation by increasing nitric oxide J Pharmacol Exp Ther 1974;191:557–63.
mation of N-nitroso compounds. Food Cosmet activity in patients with type II diabetes mellitus.
70. Ivankovich AD, Miletich DJ, Tinker JH. Sodium
Toxicol 1976;14:545–8. Diabetologia 2000;43:1435–8.
nitroprusside: metabolism and general consider-
38. Lundberg JO, Weitzberg E, Gladwin MT. The 53. Parker JD, Parker JO. Nitrate therapy for stable ations. Int Anesthesiol Clin 1978;16:1–29.
nitrate-nitrite-nitric oxide pathway in physiology angina pectoris. N Engl J Med 1998;338:520–31.
71. Ichinose F, Roberts JD, Zapol WM. Inhaled ni-
and therapeutics. Nat Rev Drug Discov 2008;7: 54. Bogaert MG. Pharmacokinetics of organic tric oxide: a selective pulmonary vasodilator: cur-
156–67. nitrates in man: an overview. Eur Heart J 1988;9 rent uses and therapeutic potential. Circulation
39. Koch CD, Gladwin MT, Freeman BA, Suppl A:33–7. 2004;109:3106–11.
Lundberg JO, Weitzberg E, Morris A. Enter- 55. Tarkin JM, Kaski JC. Vasodilator therapy: 72. Naghavi N, de Mel A, Alavijeh OS, Cousins BG,
osalivary nitrate metabolism and the microbiome: nitrates and nicorandil. Cardiovasc Drugs Ther Seifalian AM. Nitric oxide donors for cardiovascu-
intersection of microbial metabolism, nitric oxide 2016;30:367–78. lar implant applications. Small 2013;9:22–35.
and diet in cardiac and pulmonary vascular health.
56. Fung HL, Chung SJ, Bauer JA, Chong S, 73. Hrabie JA, Keefer LK. Chemistry of the nitric
Free Radic Biol Med 2017;105:48–67.
Kowaluk EA. Biochemical mechanism of organic oxide-releasing diazeniumdiolate (“nitro-
40. Carvajal JA, Germain AM, Huidobro-Toro JP, nitrate action. Am J Cardiol 1992;70:4B–10B. sohydroxylamine”) functional group and its
Weiner CP. Molecular mechanism of cGMP-
57. Daiber A, Münzel T. Organic nitrate therapy, oxygen-substituted derivatives. Chem Rev 2002;
mediated smooth muscle relaxation. J Cell Phys-
nitrate tolerance, and nitrate-induced endothelial 102:1135–54.
iol 2000;184:409–20.
dysfunction: emphasis on redox biology and 74. Varu VN, Tsihlis ND, Kibbe MR. Basic science
41. Webb RC. Smooth muscle contraction and oxidative stress. Antioxid Redox Signal 2015;23: review: nitric oxide—releasing prosthetic mate-
relaxation. Adv Physiol Educ 2003;27:201–6. 899–942. rials. Vasc Endovascular Surg 2009;43:121–31.
42. Thibeault S, Rautureau Y, Oubaha M, et al. 58. Colussi C, Scopece A, Vitale S, et al. P300/CBP 75. Al-Sa’doni H, Ferro A. S-Nitrosothiols: a class
S-nitrosylation of beta-catenin by eNOS-derived associated factor regulates nitroglycerin- of nitric oxide-donor drugs. Clin Sci (Lond) 2000;
NO promotes VEGF-induced endothelial cell dependent arterial relaxation by N(ε)-lysine acet- 98:507–20.
permeability. Mol Cell 2010;39:468–76. ylation of contractile proteins. Arterioscler
76. Scatena R, Bottoni P, Pontoglio A, Giardina B.
43. Papapetropoulos A, García-Cardeña G, Thromb Vasc Biol 2012;32:2435–43.
Pharmacological modulation of nitric oxide
Madri JA, Sessa WC. Nitric oxide production con- 59. den Uil CA, Brugts JJ. Impact of intravenous release: new pharmacological perspectives, po-
tributes to the angiogenic properties of vascular nitroglycerin in the management of acute tential benefits and risks. Curr Med Chem 2010;17:
endothelial growth factor in human endothelial decompensated heart failure. Curr Heart Fail Rep 61–73.
cells. J Clin Invest 1997;100:3131–9. 2015;12:87–93.
77. Serafim RA, Primi MC, Trossini GH, Ferreira EI.
44. Ziche M, Morbidelli L, Choudhuri R, et al. Nitric 60. Armstrong PW, Moffat JA, Marks GS. Arterial- Nitric oxide: state of the art in drug design. Curr
oxide synthase lies downstream from vascular venous nitroglycerin gradient during intravenous Med Chem 2012;19:386–405.
endothelial growth factor-induced but not basic infusion in man. Circulation 1982;66:1273–6.
fibroblast growth factor-induced angiogenesis. 78. Munzel T, Daiber A. Pharmacology of nitro-
61. Thadani U, Hamilton SF, Olson E, et al. vasodilators. In: Bryan N, Loscalzo J, editors. Ni-
J Clin Invest 1997;99:2625–34.
Duration of effects and tolerance of slow-release trite and Nitrate in Human Health and Disease. 2nd
45. Fukumura D, Gohongi T, Kadambi A, et al. isosorbide-5-mononitrate for angina pectoris. Am edition. New York: Humana Press, 2017:349.
Predominant role of endothelial nitric oxide syn- J Cardiol 1987;59:756–62.
thase in vascular endothelial growth factor- 79. Chen Z, Zhang J, Stamler JS. Identification of
62. Münzel T, Meinertz T, Tebbe U, et al. Efficacy
induced angiogenesis and vascular permeability. the enzymatic mechanism of nitroglycerin bio-
of the long-acting nitro vasodilator pentaerithrityl
Proc Natl Acad Sci U S A 2001;98:2604–9. activation. Proc Natl Acad Sci U S A 2002;99:
tetranitrate in patients with chronic stable angina
46. Loscalzo J. N-acetylcysteine potentiates inhi- pectoris receiving anti-anginal background ther-
bition of platelet aggregation by nitroglycerin. apy with beta-blockers: a 12-week, randomized, 80. Kleschyov AL, Oelze M, Daiber A, et al. Does
J Clin Invest 1985;76:703–8. double-blind, placebo-controlled trial. Eur Heart J nitric oxide mediate the vasodilator activity of
2014;35:895–903. nitroglycerin? Circ Res 2003;93:e104–12.
47. Mendelsohn ME, O’Neill S, George D,
63. Taira N. Nicorandil as a hybrid between ni- 81. Mülsch A, Bara A, Mordvintcev P, Vanin A,
Loscalzo J. Inhibition of fibrinogen binding to
trates and potassium channel activators. Am J Busse R. Specificity of different organic nitrates to
human platelets by S-nitroso-N-acetylcysteine.
Cardiol 1989;63:18J–24J. elicit NO formation in rabbit vascular tissues and
J Biol Chem 1990;265:19028–34.
organs in vivo. Br J Pharmacol 1995;116:2743–9.
48. Pigazzi A, Heydrick S, Folli F, Benoit S, 64. Frydman A. Pharmacokinetic profile of
nicorandil in humans: an overview. J Cardiovasc 82. Münzel T, Daiber A, Mülsch A. Explaining the
Michelson A, Loscalzo J. Nitric oxide inhibits
Pharmacol 1992;20 Suppl 3:S34–44. phenomenon of nitrate tolerance. Circ Res 2005;
thrombin receptor-activating peptide-induced
phosphoinositide 3-kinase activity in human 65. Brodmann M, Lischnig U, Lueger A, Stark G,
platelets. J Biol Chem 1999;274:14368–75. Pilger E. The effect of the Kþ agonist nicorandil on 83. Daiber A, Wenzel P, Oelze M, Münzel T. New
peripheral vascular resistance. Int J Cardiol 2006; insights into bioactivation of organic nitrates,
49. Folts JD, Stamler J, Loscalzo J. Intravenous
111:49–52. nitrate tolerance and cross-tolerance. Clin Res
nitroglycerin infusion inhibits cyclic blood flow
Cardiol 2008;97:12–20.
responses caused by periodic platelet thrombus 66. Akai K, Wang Y, Sato K, et al. Vasodilatory
formation in stenosed canine coronary arteries. effect of nicorandil on coronary arterial micro- 84. Daiber A, Münzel T, Gori T. Organic nitrates
Circulation 1991;83:2122–7. vessels: its dependency on vessel size and the and nitrate tolerance—state of the art and future
involvement of the ATP-sensitive potassium developments. Adv Pharmacol 2010;60:177–227.
50. Förstermann U, Münzel T. Endothelial nitric
oxide synthase in vascular disease: from marvel to channels. J Cardiovasc Pharmacol 1995;26:541–7.
85. Parker JO, West RO, Di Giorgi S. The effect of
menace. Circulation 2006;113:1708–14. 67. Frydman AM, Chapelle P, Diekmann H, et al. nitroglycerin on coronary blood flow and the he-
Pharmacokinetics of nicorandil. Am J Cardiol 1989; modynamic response to exercise in coronary artery
51. Higashi Y, Sasaki S, Nakagawa K, et al. Tetra-
63:25J–33J. disease. Am J Cardiol 1971;27:59–65.
hydrobiopterin enhances forearm vascular
response to acetylcholine in both normotensive 68. Friederich JA, Butterworth JF. Sodium nitro- 86. Greenberg H, Dwyer EM, Jameson AG,
and hypertensive individuals. Am J Hypertens prusside: twenty years and counting. Anesth Analg Pinkernell BH. Effects of nitroglycerin on the
2002;15:326–32. 1995;81:152–62. major determinants of myocardial oxygen
2408 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

consumption. An angiographic and hemodynamic 103. Curfman GD, Heinsimer JA, Lozner EC, Impact Of Nicorandil in Angina (IONA) randomised
assessment. Am J Cardiol 1975;36:426–32. Fung HL. Intravenous nitroglycerin in the treat- trial. Lancet 2002;359:1269–75.
ment of spontaneous angina pectoris: a prospec-
87. Brown BG, Bolson E, Petersen RB, Pierce CD, 118. Stern S, Bayes de Luna A. Coronary artery
tive, randomized trial. Circulation 1983;67:
Dodge HT. The mechanisms of nitroglycerin spasm: a 2009 update. Circulation 2009;119:
action: stenosis vasodilatation as a major compo- 2531–4.
nent of the drug response. Circulation 1981;64: 104. Gruppo Italiano per lo Studio della Soprav-
119. Lombardi M, Morales MA, Michelassi C,
1089–97. vivenza nell’Infarto Miocardico. GISSI-3: effects of
Moscarelli E, Distante A, L’Abbate A. Efficacy of
lisinopril and transdermal glyceryl trinitrate singly
88. Horwitz LD, Herman MV, Gorlin R. Clinical isosorbide-5-mononitrate versus nifedipine in
and together on 6-week mortality and ventricular
response to nitroglycerin as a diagnostic test for preventing spontaneous and ergonovine-induced
function after acute myocardial infarction. Lancet
coronary artery disease. Am J Cardiol 1972;29: myocardial ischaemia. A double-blind, placebo-
149–53. controlled study. Eur Heart J 1993;14:845–51.
105. Gruppo Italiano per lo Studio della Soprav-
89. Goldstein RE, Stinson EB, Scherer JL, 120. Rosendorff C, Lackland DT, Allison M, et al.
vivenza nell’Infarto Miocardico. Six-month effects
Seningen RP, Grehl TM, Epstein SE. Intraoperative Treatment of hypertension in patients with coro-
of early treatment with lisinopril and transdermal
coronary collateral function in patients with cor- nary artery disease: a scientific statement from the
glyceryl trinitrate singly and together withdrawn
onary occlusive disease. Nitroglycerin responsive- American Heart Association, American College of
six weeks after acute myocardial infarction: the
ness and angiographic correlations. Circulation Cardiology, and American Society of Hypertension.
GISSI-3 trial. J Am Coll Cardiol 1996;27:337–44.
1974;49:298–308. J Am Coll Cardiol 2015;65:1998–2038.
106. ISIS-4 (Fourth International Study of Infarct
90. Fam M, McGregor M. Effect of coronary 121. Singh A, Laribi S, Teerlink JR, Mebazaa A.
Survival) Collaborative Group. ISIS-4: a rando-
vasodilator drugs on retrograde flow in areas of Agents with vasodilator properties in acute heart
mised factorial trial assessing early oral captopril,
chronic myocardial ischemia. Circ Res 1964;15: failure. Eur Heart J 2017;38:317–25.
oral mononitrate, and intravenous magnesium
355–64. sulphate in 58,050 patients with suspected acute 122. Wakai A, McCabe A, Kidney R, et al. Nitrates
91. Harrison DG, Bates JN. The nitrovasodilators. myocardial infarction. Lancet 1995;345:669–85. for acute heart failure syndromes. Cochrane
New ideas about old drugs. Circulation 1993;87: Database Syst Rev 2013:CD005151.
107. Yusuf S, Collins R, MacMahon S, Peto R. Ef-
1461–7. fect of intravenous nitrates on mortality in acute 123. Taylor AL, Ziesche S, Yancy C, et al. Combi-
92. Hampton JR, Harrison MJ, Honour AJ, myocardial infarction: an overview of the rando- nation of isosorbide dinitrate and hydralazine in
Mitchell JR. Platelet behaviour and drugs used in mised trials. Lancet 1988;1:1088–92. blacks with heart failure. N Engl J Med 2004;351:
cardiovascular disease. Cardiovasc Res 1967;1: 2049–57.
108. Kimchi A, Lee G, Amsterdam E, Fujii K,
101–7. Krieg P, Mason DT. Increased exercise tolerance 124. Yancy CW, Jessup M, Bozkurt B, et al. 2013
93. Schafer AI, Alexander RW, Handin RI. Inhibi- after nitroglycerin oral spray: a new and effective ACCF/AHA guideline for the management of heart
tion of platelet function by organic nitrate vaso- therapeutic modality in angina pectoris. Circula- failure: executive summary: a report of the
dilators. Blood 1980;55:649–54. tion 1983;67:124–7. American College of Cardiology Foundation/
109. Sandler G, Ilahi MA, Lawson CW. Glyceryl American Heart Association Task Force on practice
94. Loscalzo J. Antiplatelet and antithrombotic guidelines. J Am Coll Cardiol 2013;62:e147–239.
trinitrate in angina pectoris. Lancet 1963;1:1130–6.
effects of organic nitrates. Am J Cardiol 1992;70:
18B–22B. 110. Winsor T, Berger HJ. Oral nitroglycerin as a 125. Barst RJ, Gibbs JS, Ghofrani HA, et al. Upda-
prophylactic antianginal drug: clinical, physiologic, ted evidence-based treatment algorithm in pul-
95. Kumar S, Singh RK, Bhardwaj TR. Therapeutic monary arterial hypertension. J Am Coll Cardiol
and statistical evidence of efficacy based on a
role of nitric oxide as emerging molecule. Biomed 2009;54:S78–84.
three-phase experimental design. Am Heart J
Pharmacother 2017;85:182–201.
1975;90:611–26. 126. Hill NS, Preston IR, Roberts KE. Inhaled
96. Lefer AM, Lefer DJ. Nitric oxide. II. Nitric oxide therapies for pulmonary hypertension. Respir Care
111. Reichek N, Goldstein RE, Redwood DR,
protects in intestinal inflammation. Am J Physiol 2015;60:794–802; discussion 802–5.
Epstein SE. Sustained effects of nitroglycerin
ointment in patients with angina pectoris. Circu- 127. Barrington KJ, Finer N, Pennaforte T, Altit G.
97. Cherla RP, Ganju RK. Stromal cell-derived lation 1974;50:348–52. Nitric oxide for respiratory failure in infants born
factor 1 alpha-induced chemotaxis in T cells is at or near term. Cochrane Database Syst Rev 2017;
112. Scardi S, Camerini F, Pandullo C, Pollavini G.
mediated by nitric oxide signaling pathways. 1:CD000399.
Efficacy of continuous and intermittent trans-
J Immunol 2001;166:3067–74.
dermal treatment with nitroglycerin in effort 128. Kinsella JP, Steinhorn RH, Krishnan US, et al.
98. Adachi R, Matsui S, Kinoshita M, et al. Nitric angina pectoris: a multicentric study. The Collab- Recommendations for the use of inhaled nitric
oxide induces chemotaxis of neutrophil-like HL- orative Nitro Group. Int J Cardiol 1991;32:241–8. oxide therapy in premature newborns with severe
60 cells and translocation of cofilin to plasma 113. Klemsdal TO, Gjesdal K. The effect of trans- pulmonary hypertension. J Pediatr 2016;170:
membranes. Int J Immunopharmacol 2000;22: dermal nitroglycerin on exercise tolerance in rela- 312–4.
855–64. tion to patch application time—a meta-analysis. 129. Barrington KJ, Finer N, Pennaforte T. Inhaled
99. Granger DN, Kubes P. Nitric oxide as antiin- Cardiovasc Drugs Ther 1992;6:641–9. nitric oxide for respiratory failure in preterm in-
flammatory agent. Methods Enzymol 1996;269: 114. Parker JO, VanKoughnett KA, Fung HL. fants. Cochrane Database Syst Rev 2017;1:
434–42. Transdermal isosorbide dinitrate in angina pecto- CD000509.

100. Gori T, Di Stolfo G, Dragoni S, et al. The ris: effect of acute and sustained therapy. Am J 130. Thadani U. Challenges with nitrate therapy
mechanism of nitrate-induced preconditioning. Cardiol 1984;54:8–13. and nitrate tolerance: prevalence, prevention, and
Clin Hemorheol Microcirc 2008;39:191–6. 115. Thadani U, Hamilton SF, Olson E, et al. clinical relevance. Am J Cardiovasc Drugs 2014;14:
Transdermal nitroglycerin patches in angina pec- 287–301.
101. Gori T, Di Stolfo G, Sicuro S, et al. Nitroglyc-
erin protects the endothelium from ischaemia and toris. Dose titration, duration of effect, and rapid
131. Thadani U, Manyari D, Parker JO, Fung HL.
reperfusion: human mechanistic insight. Br J Clin tolerance. Ann Intern Med 1986;105:485–92.
Tolerance to the circulatory effects of oral iso-
Pharmacol 2007;64:145–50. 116. DeMots H, Glasser SP. Intermittent trans- sorbide dinitrate. Rate of development and cross-
dermal nitroglycerin therapy in the treatment of tolerance to glyceryl trinitrate. Circulation 1980;
102. Karlberg KE, Saldeen T, Wallin R,
chronic stable angina. J Am Coll Cardiol 1989;13: 61:526–35.
Henriksson P, Nyquist O, Sylvén C. Intravenous
nitroglycerin reduces ischaemia in unstable angina 132. Thadani U, Fung HL, Darke AC, Parker JO. Oral
pectoris: a double-blind placebo-controlled study. 117. IONA Study Group. Effect of nicorandil on isosorbide dinitrate in angina pectoris: comparison
J Intern Med 1998;243:25–31. coronary events in patients with stable angina: the of duration of action and dose-response relation
JACC VOL. 70, NO. 19, 2017 Divakaran and Loscalzo 2409
NOVEMBER 7, 2017:2393–410 Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics

during acute and sustained therapy. Am J Cardiol 148. Gori T, Burstein JM, Ahmed S, et al. Folic calcium antagonists: potential role of rebound
1982;49:411–9. acid prevents nitroglycerin-induced nitric oxide ischemia during the nitrate-free period. J Am Coll
synthase dysfunction and nitrate tolerance: a hu- Cardiol 1995;25:349–55.
133. Steering Committee, Transdermal Nitroglyc-
man in vivo study. Circulation 2001;104:1119–23.
erin Cooperative Study. Acute and chronic anti- 163. Thadani U, Maranda CR, Amsterdam E, et al.
anginal efficacy of continuous twenty-four-hour 149. Hink U, Oelze M, Kolb P, et al. Role for per- Lack of pharmacologic tolerance and rebound
application of transdermal nitroglycerin. Am J oxynitrite in the inhibition of prostacyclin synthase angina pectoris during twice-daily therapy with
Cardiol 1991;68:1263–73. in nitrate tolerance. J Am Coll Cardiol 2003;42: isosorbide-5-mononitrate. Ann Intern Med 1994;
1826–34. 120:353–9.
134. Parker JO, Fung HL. Transdermal nitroglyc-
erin in angina pectoris. Am J Cardiol 1984;54: 150. Warnholtz A, Mollnau H, Heitzer T, et al. 164. Parker JO, Fung HL, Ruggirello D, Stone JA.
471–6. Adverse effects of nitroglycerin treatment on Tolerance to isosorbide dinitrate: rate of devel-
135. Thadani U, Lipicky RJ. Ointments and trans- endothelial function, vascular nitrotyrosine levels opment and reversal. Circulation 1983;68:
dermal nitroglycerin patches for stable angina and cGMP-dependent protein kinase activity in 1074–80.
pectoris. Cardiovasc Drugs Ther 1994;8:625–33. hyperlipidemic Watanabe rabbits. J Am Coll Car-
165. Cortazzo JA, Lichtman AD. Methemoglobi-
diol 2002;40:1356–63.
136. Thadani U, Lipicky RJ. Short and long-acting nemia: a review and recommendations for man-
oral nitrates for stable angina pectoris. Car- 151. Kim D, Rybalkin SD, Pi X, et al. Upregulation agement. J Cardiothorac Vasc Anesth 2014;28:
diovasc Drugs Ther 1994;8:611–23. of phosphodiesterase 1A1 expression is associated 1043–7.
with the development of nitrate tolerance. Circu-
137. Chrysant SG, Glasser SP, Bittar N, et al. 166. Coleman MD, Coleman NA. Drug-induced
lation 2001;104:2338–43.
Efficacy and safety of extended-release isosorbide methaemoglobinaemia. Treatment issues. Drug
mononitrate for stable effort angina pectoris. Am 152. Parker JD, Farrell B, Fenton T, Cohanim M, Saf 1996;14:394–405.
J Cardiol 1993;72:1249–56. Parker JO. Counter-regulatory responses to
167. Kaplan KJ, Taber M, Teagarden JR, Parker M,
continuous and intermittent therapy with nitro-
138. Zimrin D, Reichek N, Bogin KT, et al. Anti- Davison R. Association of methemoglobinemia and
glycerin. Circulation 1991;84:2336–45.
anginal effects of intravenous nitroglycerin over intravenous nitroglycerin administration. Am J
24 hours. Circulation 1988;77:1376–84. 153. Thadani U. Nitrate tolerance, rebound, and Cardiol 1985;55:181–3.
their clinical relevance in stable angina pectoris,
139. Münzel T, Steven S, Daiber A. Organic 168. Hottinger DG, Beebe DS, Kozhimannil T,
unstable angina, and heart failure. Cardiovasc
nitrates: update on mechanisms underlying vaso- Prielipp RC, Belani KG. Sodium nitroprusside in
Drugs Ther 1997;10:735–42.
dilation, tolerance and endothelial dysfunction. 2014: A clinical concepts review. J Anaesthesiol
Vascul Pharmacol 2014;63:105–13. 154. Katz RJ, Levy WS, Buff L, Wasserman AG. Clin Pharmacol 2014;30:462–71.
Prevention of nitrate tolerance with angiotension
140. Münzel T, Giaid A, Kurz S, Stewart DJ, 169. Cummings TF. The treatment of cyanide
converting enzyme inhibitors. Circulation 1991;83:
Harrison DG. Evidence for a role of endothelin 1 poisoning. Occup Med (Lond) 2004;54:82–5.
and protein kinase C in nitroglycerin tolerance. 170. Petrikovics I, Budai M, Kovacs K,
Proc Natl Acad Sci U S A 1995;92:5244–8. 155. Boden WE, Finn AV, Patel D, Peacock WF,
Thompson DE. Past, present and future of cyanide
Thadani U, Zimmerman FH. Nitrates as an integral
141. Oelze M, Knorr M, Kröller-Schön S, et al. antagonism research: From the early remedies to
part of optimal medical therapy and cardiac
Chronic therapy with isosorbide-5-mononitrate the current therapies. World J Methodol 2015;5:
rehabilitation for stable angina: review of current
causes endothelial dysfunction, oxidative stress, 88–100.
concepts and therapeutics. Clin Cardiol 2012;35:
and a marked increase in vascular endothelin-1
263–71. 171. Thompson JP, Marrs TC. Hydroxocobalamin in
expression. Eur Heart J 2013;34:3206–16.
cyanide poisoning. Clin Toxicol (Phila) 2012;50:
156. Dakak N, Makhoul N, Flugelman MY, et al.
142. Mülsch A, Busse R, Bassenge E. Desensitiza- 875–85.
Failure of captopril to prevent nitrate tolerance in
tion of guanylate cyclase in nitrate tolerance does
congestive heart failure secondary to coronary 172. Nagasawa HT, Goon DJ, Crankshaw DL,
not impair endothelium-dependent responses. Eur
artery disease. Am J Cardiol 1990;66:608–13. Vince R, Patterson SE. Novel, orally effective
J Pharmacol 1988;158:191–8.
cyanide antidotes. J Med Chem 2007;50:6462–4.
157. Dupuis J, Lalonde G, Lemieux R, Rouleau JL.
143. Molina CR, Andresen JW, Rapoport RM,
Tolerance to intravenous nitroglycerin in patients 173. Belani KG, Singh H, Beebe DS, et al. Cyanide
Waldman S, Murad F. Effect of in vivo nitroglycerin
with congestive heart failure: role of increased toxicity in juvenile pigs and its reversal by a new
therapy on endothelium-dependent and indepen-
intravascular volume, neurohumoral activation prodrug, sulfanegen sodium. Anesth Analg 2012;
dent vascular relaxation and cyclic GMP accumu-
and lack of prevention with N-acetylcysteine. J Am 114:956–61.
lation in rat aorta. J Cardiovasc Pharmacol 1987;
Coll Cardiol 1990;16:923–31.
10:371–8. 174. Kloner RA. Cardiovascular effects of the 3
158. Münzel T, Holtz J, Mülsch A, Stewart DJ, phosphodiesterase-5 inhibitors approved for the
144. Sayed N, Baskaran P, Ma X, van den Akker F,
Bassenge E. Nitrate tolerance in epicardial arteries treatment of erectile dysfunction. Circulation
Beuve A. Desensitization of soluble guanylyl
or in the venous system is not reversed by N- 2004;110:3149–55.
cyclase, the NO receptor, by S-nitrosylation. Proc
acetylcysteine in vivo, but tolerance-independent
Natl Acad Sci U S A 2007;104:12312–7. 175. Kostis JB, Jackson G, Rosen R, et al. Sexual
interactions exist. Circulation 1989;79:188–97.
dysfunction and cardiac risk (the Second Princeton
145. Sydow K, Daiber A, Oelze M, et al. Central
159. Parker JO, Farrell B, Lahey KA, Rose BF. Consensus Conference). Am J Cardiol 2005;96:
role of mitochondrial aldehyde dehydrogenase
Nitrate tolerance: the lack of effect of 85M–93M.
and reactive oxygen species in nitroglycerin
N-acetylcysteine. Circulation 1987;76:572–6.
tolerance and cross-tolerance. J Clin Invest 2004; 176. Ondrus T, Kanovsky J, Novotny T, Andrsova I,
113:482–9. 160. Packer M, Lee WH, Kessler PD, Gottlieb SS, Spinar J, Kala P. Right ventricular myocardial
Medina N, Yushak M. Prevention and reversal of infarction: from pathophysiology to prognosis.
146. Daiber A, Oelze M, Coldewey M, et al.
nitrate tolerance in patients with congestive heart Exp Clin Cardiol 2013;18:27–30.
Oxidative stress and mitochondrial aldehyde
failure. N Engl J Med 1987;317:799–804. lehrad M, et al.
dehydrogenase activity: a comparison of pentaer- 177. Zemanek D, Tomasov P, Be
ythritol tetranitrate with other organic nitrates. 161. Fox KM, Dargie HJ, Deanfield J, Maseri A, for Comparison of sublingual isosorbide dinitrate and
Mol Pharmacol 2004;66:1372–82. the Transdermal Nitrate Investigators. Avoidance Valsalva maneuver for detection of obstruction in
of tolerance and lack of rebound with intermittent hypertrophic cardiomyopathy. Arch Med Sci 2015;
147. Wenzel P, Hink U, Oelze M, et al. Role of
dose titrated transdermal glyceryl trinitrate. Br 11:751–5.
reduced lipoic acid in the redox regulation of
Heart J 1991;66:151–5.
mitochondrial aldehyde dehydrogenase (ALDH-2) 178. Kraehling JR, Sessa WC. Contemporary ap-
activity. Implications for mitochondrial oxidative 162. Freedman SB, Daxini BV, Noyce D, Kelly DT. proaches to modulating the nitric oxide-cGMP
stress and nitrate tolerance. J Biol Chem 2007; Intermittent transdermal nitrates do not improve pathway in cardiovascular disease. Circ Res 2017;
282:792–9. ischemia in patients taking beta-blockers or 120:1174–82.
2410 Divakaran and Loscalzo JACC VOL. 70, NO. 19, 2017

Nitroglycerin and Nitric Oxide in Cardiovascular Therapeutics NOVEMBER 7, 2017:2393–410

179. Frank PG, Pavlides S, Lisanti MP. Caveolae 190. Chen Y, Chen C, Feng C, et al. AVE 3085, a ejection fraction: the SOCRATES-REDUCED ran-
and transcytosis in endothelial cells: role in novel endothelial nitric oxide synthase enhancer, domized trial. JAMA 2015;314:2251–62.
atherosclerosis. Cell Tissue Res 2009;335:41–7. attenuates cardiac remodeling in mice through the
201. Stasch JP, Schmidt P, Alonso-Alija C, et al.
Smad signaling pathway. Arch Biochem Biophys
180. Gratton JP, Bernatchez P, Sessa WC. Cav- NO- and haem-independent activation of soluble
eolae and caveolins in the cardiovascular system. guanylyl cyclase: molecular basis and cardiovas-
Circ Res 2004;94:1408–17. 191. Fraccarollo D, Widder JD, Galuppo P, et al. cular implications of a new pharmacological prin-
Improvement in left ventricular remodeling by the ciple. Br J Pharmacol 2002;136:773–83.
181. Yu J, Bergaya S, Murata T, et al. Direct evi-
endothelial nitric oxide synthase enhancer
dence for the role of caveolin-1 and caveolae in 202. Wunder F, Stasch JP, Hütter J, Alonso-
AVE9488 after experimental myocardial infarc-
mechanotransduction and remodeling of blood Alija C, Hüser J, Lohrmann E. A cell-based cGMP
tion. Circulation 2008;118:818–27.
vessels. J Clin Invest 2006;116:1284–91. assay useful for ultra-high-throughput screening
192. Ramzy D, Rao V, Tumiati LC, et al. Tetrahy- and identification of modulators of the nitric
182. Parton RG, Simons K. The multiple faces of drobiopterin prevents cyclosporine-induced vaso- oxide/cGMP pathway. Anal Biochem 2005;339:
caveolae. Nat Rev Mol Cell Biol 2007;8:185–94. motor dysfunction. Transplantation 2005;79: 104–12.
183. García-Cardeña G, Martasek P, 876–81.
203. Erdmann E, Semigran MJ, Nieminen MS, et al.
Masters BS, et al. Dissecting the interaction 193. Cunnington C, Van Assche T, Shirodaria C, Cinaciguat, a soluble guanylate cyclase activator,
between nitric oxide synthase (NOS) and et al. Systemic and vascular oxidation limits the unloads the heart but also causes hypotension in
caveolin. Functional significance of the nos efficacy of oral tetrahydrobiopterin treatment in acute decompensated heart failure. Eur Heart J
caveolin binding domain in vivo. J Biol Chem patients with coronary artery disease. Circulation 2013;34:57–67.
1997;272:25437–40. 2012;125:1356–66.
204. Gheorghiade M, Greene SJ, Filippatos G,
184. Ju H, Zou R, Venema VJ, Venema RC. Direct 194. Ignarro LJ, Wood KS, Wolin MS. Activation et al. Cinaciguat, a soluble guanylate cyclase
interaction of endothelial nitric-oxide synthase of purified soluble guanylate cyclase by proto- activator: results from the randomized, controlled,
and caveolin-1 inhibits synthase activity. J Biol porphyrin IX. Proc Natl Acad Sci U S A 1982;79: phase IIb COMPOSE programme in acute heart
Chem 1997;272:18522–5. 2870–3. failure syndromes. Eur J Heart Fail 2012;14:
185. Bernatchez P, Sharma A, Bauer PM, Marin E, 195. Ko FN, Wu CC, Kuo SC, Lee FY, Teng CM. YC- 1056–66.
Sessa WC. A noninhibitory mutant of the caveolin- 1, a novel activator of platelet guanylate cyclase.
205. Uzunov P, Weiss B. Separation of multiple
1 scaffolding domain enhances eNOS-derived NO Blood 1994;84:4226–33.
molecular forms of cyclic adenosine-3’,5’-mono-
synthesis and vasodilation in mice. J Clin Invest
196. Frey R, Mück W, Unger S, Artmeier-Brandt U, phosphate phosphodiesterase in rat cerebellum by
Weimann G, Wensing G. Single-dose pharmacoki- polyacrylamide gel electrophoresis. Biochim Bio-
186. Keller TC, Butcher JT, Broseghini-Filho GB, netics, pharmacodynamics, tolerability, and safety phys Acta 1972;284:220–6.
et al. Modulating vascular hemodynamics with an of the soluble guanylate cyclase stimulator BAY
206. Chirinos JA, Zamani P. The nitrate-nitrite-NO
alpha globin mimetic peptide (HbaX). Hyperten- 63-2521: an ascending-dose study in healthy male
pathway and its implications for heart failure and
sion 2016;68:1494–503. volunteers. J Clin Pharmacol 2008;48:926–34.
preserved ejection fraction. Curr Heart Fail Rep
187. Straub AC, Lohman AW, Billaud M, et al. 197. Ghofrani HA, Galiè N, Grimminger F, et al. 2016;13:47–59.
Endothelial cell expression of haemoglobin a Riociguat for the treatment of pulmonary arterial
207. Maher AR, Milsom AB, Gunaruwan P, et al.
regulates nitric oxide signalling. Nature 2012;491: hypertension. N Engl J Med 2013;369:330–40.
Hypoxic modulation of exogenous nitrite-induced
473–7. 198. Ghofrani HA, D’Armini AM, Grimminger F, vasodilation in humans. Circulation 2008;117:
188. Straub AC, Butcher JT, Billaud M, et al. He- et al. Riociguat for the treatment of chronic 670–7.
moglobin a/eNOS coupling at myoendothelial thromboembolic pulmonary hypertension. N Engl
J Med 2013;369:319–29. 208. Modin A, Björne H, Herulf M, Alving K,
junctions is required for nitric oxide scavenging
Weitzberg E, Lundberg JO. Nitrite-derived ni-
during vasoconstriction. Arterioscler Thromb Vasc 199. Breitenstein S, Roessig L, Sandner P, tric oxide: a possible mediator of ’acidic-
Biol 2014;34:2594–600. Lewis KS. Novel sGC stimulators and sGC activa- metabolic’ vasodilation. Acta Physiol Scand
tors for the treatment of heart failure. Handb Exp 2001;171:9–16.
189. Wohlfart P, Xu H, Endlich A, et al. Anti-
Pharmacol 2017;243:225–47.
atherosclerotic effects of small-molecular-weight
compounds enhancing endothelial nitric-oxide 200. Gheorghiade M, Greene SJ, Butler J, et al.
synthase (eNOS) expression and preventing eNOS Effect of vericiguat, a soluble guanylate cyclase KEY WORDS angina, nitrate,
uncoupling. J Pharmacol Exp Ther 2008;325: stimulator, on natriuretic peptide levels in patients nitrate-nitrite-NO pathway, nitric oxide,
370–9. with worsening chronic heart failure and reduced nitroglycerin, soluble guanylyl cyclase