Pentaerythrityl tetranitrate (PETN): a better nitrate?

This Editorial refers to ‘Efficacy of the long acting nitro vasodilator pentaerithrityltetranitrate in patients with chronic stable angina pectoris receiving antianginal background therapy with betablockers: a 12-weeks, randomized, double-blind, placebo controlled trial’, by Munzel et al . doi:10.1093/eurheartj/eht384 Today, patients with coronary artery disease can expect to live longer and with less symptom burden than their counterparts of 30 years ago. This is because of better medical therapies and better revascularization strategies. However, the stalwarts of medical anti-anginal therapy—the β-blockers, calcium channel blockers, and nitrates—are not without their problems. Nitrates, although effective at relieving acute anginal pain and well established as a mainstay of chronic angina therapy, may have particular problems.1,2 One problem with nitrates is that traditional nitrate use can increase oxidative stress and so induce endothelial dysfunction.1 In addition to endothelial dysfunction, another major practical problem with nitrate is nitrate tolerance.2 Furthermore, a review of 52 693 patients from the Global Registry of Acute Coronary Evidence shows that longer-term use of nitrates is associated with fewer ST elevation myocardial infarctions but more non-ST elevation acute coronary syndromes.3 One hypothesis is that nitrates might pre-condition the heart more towards ischaemic episodes. Newer medical therapies—or new applications of existing therapies—are therefore needed to reduce the symptom burden in chronic stable angina and, if possible, to improve prognosis. This need is particularly relevant to those who have run out of revascularization options. This is the approach …