Effect of intravenous nitroglycerin on heparin dosage requirements in coronary artery disease

Patients admitted to the coronary care unit who received both intravenous nitroglycerin and heparin were studied to evaluate heparin dosage requirements. Physicians ordered all nitroglycerin and heparin doses as well as coagulation studies without knowledge of this study. Activated partial thromboplastin time (APTT) values obtained during steady-state heparin administration were considered therapeutic if the ratio of APTT/APTT-baseline was ≥1.5. Sixty patients with myocardial infarction or unstable angina were included in the study. The initial therapeutic heparin dose of 1,014 ± 151 units/hour produced an APTT ratio of 2.0 ± 0.5. At the time of the initial therapeutic dose, the nitroglycerin dose was 110 ± 108 μg/min. There was a significant correlation between the initial therapeutic dose and both total (r = 0.56; p = 0.0001) and lean (r = 0.26; p < 0.05) body weight. Comparison of patients with nitroglycerin doses < and ≥100 μg/min revealed a significant difference in the initial therapeutic dose (971 ± 147 vs 1,077 ± 136 U/hour, p < 0.01), but not the initial therapeutic dose standardized to total body weight (14.0 ± 2.5 vs 13.5 ± 2.7 U/kg/hour). Similarly, analysis of variance revealed a significant difference in the initial therapeutic dose (p < 0.05), but not the initial therapeutic dose standardized to weight among 5 different nitroglycerin dosage ranges (10 to 533 μg/min). Neither aspirin use, thrombolytic therapy nor decreasing or discontinuing the nitroglycerin dose significantly affected heparin requirements. Thus, contrary to prior reports, clinically significant heparin resistance induced by nitroglycerin was not found.