By Dr. Adam Schneeweiss, Dr. Marija Weiss (auth.)
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Some of these patients responded better to intravenous nitroglycerin [80, 81]. Transdermal administration was also found to be effective. 4 in ten patients with vasospastic angina pectoris. The most effective form of nitrate administration is by the intracoronary route. Buxton and coworkers  reported that intracoronary administration of nitroglycerin relieved ergonovine-induced coronary spasm refractory to other forms of administration of the drug. Pepine and colleagues  reported that intracoronary nitroglycerin was effective in treating patients with spontaneously occurring coronary spasm refractory to sublingual Unstable Angina Pectoris 33 and intravenous nitroglycerin.
3. Methods to Prevent Tolerance in Angina Pectoris Tolerance has been attributed mainly to constantly high levels of nitrates in the plasma. Therefore it is reasonable to try to prevent the development of tolerance by regimens of intermittent administration, resulting in fluctuations in plasma levels of nitrates. This method is the principal means to prevent tolerance. Another method is the use oflow-dose regimens, but it is limited by poor efficacy of very low doses. One of the popular interval regimens consists of 20 mg ISDN twice daily, morning and midday.
It is most important to simultaneously study clinical, electrocardiographic and hemodynamic effects. Such a trial has been reported by Ohlmeier et al  who performed serial cardiac catheterizations during bicycle exercise in patients with angina pectoris treated with various nitrate formulations for 2 weeks. The initial effect of ISDN, IS-5-MN and oral nitroglycerin on the response of pulmonary arterial pressure to exercise and on ST-segment depression was attenuated after 2 weeks of treatment.