What is the best choice for cardioprotection in a woman aged 75 years with episodic symptomatic angina, MI one year earlier and a sensitivity to nitroglycerin patches (i.e., skin erythema, burning, and itching) and spray (i.e., acute syncope)?

She also has allergy or adverse reaction to aspirin, ACE inhibitor, clopidogrel (Plavix) and telmisartan (Micardis). The patient has a low resting heart rate (58 beats/minute) and is on a maximum-tolerated dose of beta blocker.— Barbara Fox, FNP, Victoria, B.C.

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This is a complex situation. First, clarify her exact adverse reaction to ACE inhibitors and angiotensin II receptor blockers (ARBs). In the event of true histamine or angioedema, do not try any other drugs in this class. If it was dizziness, feeling poorly or the patient just didn’t like them, try another ACE inhibitor or ARB or aliskiren (Tekturna).

The choices for this patient’s angina are ranolazine (Renexa), which affects the sodium channel gates, or isosorbide mononitrate (Imdur, Ismo, Isotrate, Monoket) as a long-acting nitroglycerin (start low [30 mg], since there was syncope).

When multiple allergies prevent you from implementing all the guideline medications, remember that quality of life and education are the priorities. Explain why certain medications are being tried and what the expected outcomes are. Always ask about diet, exercise, and smoking. In cardiology, 80% of complications are preventable through lifestyle management.

The choice of beta blocker depends on the ejection fraction. If >40%, nebivolol (Bystolic) would be a great choice because of its effect on the nitric oxide pathway. If <40%, metoprolol succinate (Toprol) and carvedilol (Coreg) are the only choices. If the patient is diabetic, carvedilol and nebivolol are the only options. — Maria Kidner, DNP, FNP-C (156-8)