Despite a clear benefit when applied in patients with chronic coronary artery disease or ischemic left heart failure, there are no data from randomized placebo-controlled trials that demonstrate an effect of nitrates with respect to symptom relief or reduction in morbid events in patients with unstable angina. In patients receiving continuous nitrates, tachyphylaxis may be seen as early as 24-48 h after initiation. This problem can be managed by increasing the dose as needed until symptom relief is achieved. Once a patient has been pain-free for 24 h, it is advisable to switch to a topical or oral form of nitrate therapy, with a nitrate-free interval of 6-8 h/d.
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