Welcome to Dr. Warrick's podcast channel. Warrick is a practicing cardiologist and author with a passion for improving care by helping patients understand their heart health through education. Warrick believes educated patients get the best health care. Discover and understand the latest approaches and technology in heart care and how this might apply to you or someone you love. My name is Dr. Warrick Bishop and normally I would welcome you to my consulting room. But today I'd like to welcome you to my home. I've got home and decided that because of a couple of patients who I saw today, I'd really like to share with you an important bit of understanding about the spray we use under the tongue for angina chest pain. Now that spray is called glycerol trinitrate spray or GTN. You will have heard of it. It used to come as little tablets and we used to ask patients to put it under the tongue. That preparation, glycerol trinitrate, is actually the basis of what we use to make gunpowder or explosives, TNT. So it certainly has a bang to it. One of the things it does do as a side effect is it can give you a bit of a headache because it is a vasodilator. It dilates the blood vessels. That's how it dilates the blood vessels and helps the heart get more blood and therefore reduce pain. So we refer to it as sublingual. GTN glycerol trinitrate and these days because it comes in a spray the spray lasts much longer than the tablets used to use used to last and so that's why we use that. So what I want to share with you is how I view using the spray under the tongue. Lots of patients get given the spray by their GPs and by accident emergency doctors and in situations where there's a concern about chest pain. But let me share with you how I tend to think about it. Let's rewind a little bit and think about angina first. There are two main types of angina. The first type of angina is what we would call stable angina. It's the sort of angina that my grandfather used to have many years ago. My grandfather used to walk 200 metres, up a slight incline and he'd get pain in the chest. He would stop, the pain would go, he'd walk 200 metres, get the pain, he would stop, the pain would go, he would walk a further 200 metres, the pain would come, he would stop, the pain would go. This was his stable angina and that occurred day after day. for week after week in a stable fashion for months at a time. It was predictable. It was stable. Certainly if my grandpa had walked 200 metres up an incline, taken a puff of his spray, he may well have been able to go further. In that situation, using a spray under the tongue, the sublingual GTN, under the tongue to go further, is telling us that this patient may well be being under-treated with their normal anti-anginal preparations. So my recommendation is for someone like my grandfather who went 200 metres up an incline and then had pain, maybe he needs to see his cardiologist to get a refinement of exactly what his anti-anginal medications are so he can walk further. So, although it is possible to use the sublingual spray in that stable situation, it doesn't make a lot of sense. It makes more sense to go back and see the cardiologist and have your medications adjusted to get a better outcome, better endurance, better exercise capacity. Let's put stable angina aside. And let's agree that perhaps sublingual GTN spray has a small role but really it's not crux in the management of stable angina. Let's now come to unstable angina, the other situation where chest pain can occur. When we talk about unstable angina, what we're talking about is chest pain that comes on unexpectedly, somewhat out of the blue. with no regularity, no predictability to it. These are the sort of chest pains that occur when someone has a warning sign of a heart attack. So angina that comes on with minimal exertion, that's out of character. Maybe my grandpa's angina pain coming on at 5, 10, 15 or 20 metres rather than his 200 metres. on one day, when only days earlier, he could go the 200 metres. This is a change. This is an unstable characteristic. Importantly, unstable angina can certainly occur at rest. And it can occur with minimal exertion. Imagine if you have unstable angina. If that pain comes on at rest and you're at home on a Sunday evening, and you take a spray or two of your sublingual GTN. Well, we know that sublingual GTN can reduce angina, can dilate the blood vessels and alleviate pain. Well, if you take that spray under the tongue and it alleviates your pain, does that mean you can now relax and forget about the pain? Does that mean that your risk of heart attack has been removed? What I put to you is that yes the sprain of the tongue may alleviate the pain but the process underneath in unstable angina is most likely to be a plaque that has ruptured with an irregularity on it where clot may be briefly forming and then breaking and moving on allowing flow to re-establish. In that situation that is a highly unstable and dangerous situation. To my mind, if you're at home and you have that unstable angina pain at rest, if the spray under the tongue helps, that is not a reassurance. That is just a confirmation that you really need to be in the hospital being checked out properly. Today I had two patients who took spray under their tongue thinking everything will be fine because the pain went away. They had no understanding of how significant pain at rest can be and what a red flag or an alarm bell it really is in the setting of potential heart attack and progression to heart attack. So the take home message is the spray under the tongue. It has a role but please be aware in the stable situation it's really not. the best management for improving stable angina symptoms. You need to go back and see your cardiologist and get your therapy sorted out so that you've got best exercise capacity possible. In the unstable situation a spray under the tongue does not fix the problem underneath. It is masking those symptoms. It is Simply removing the pain when the process underneath may well be the beginnings of a heart attack. So please don't rest assured with the spray under the tongue in the unstable coronary situation. I hope that makes a bit of sense to you. explain all this to my patients when I give them the spray under the tongue. I really don't want them to use it as a sense of security if it alleviates pain, in fact on the contrary. But I do want them to understand that unstable angina is a serious and an alarming situation that needs more investigation in a hospital as soon as possible. So there's a little bit about the spray under the tongue. our sublingual glycerol trinitrate or sublingual GTN. I hope you understand that in the context of stable versus unstable angina. I hope it's made a bit of sense. Please don't sit at home spraying under the tongue if you're getting chest pain. Get yourself to hospital. By all means use the sprays but please understand where they fit in in your care. I hope you found today's talk on Sublingual GTN, Stable and Unstable Angina, informative and educational. I would like to thank you for joining me. If you have any queries or questions, drop us a note and let us know. If you've got any ideas for future podcasts or videocasts, please also let us know. As always, I'd like to wish you the very best. Thank you for joining me and goodbye. You have been listening to another podcast from Dr. Warrick. Visit his website at drWarrickbishop.com for the latest news on heart disease. If you love this podcast, feel free to leave us a review.
