The choice between sustained-release nitroglycerin and ranolazine for chest pain (angina) depends on the patient’s specific condition, type of angina, and clinical factors. Here’s a concise comparison to guide the decision:

Sustained-Release Nitroglycerin

• Mechanism: Nitroglycerin is a nitrate that dilates blood vessels, reducing cardiac preload and oxygen demand, thus relieving angina.
• Use: Primarily used for chronic stable angina to prevent chest pain episodes. It’s not for acute relief (sublingual nitroglycerin is used for that).
• Pros:
• Effective for reducing frequency of angina attacks.
• Well-established, long history of use.
• Cons:
• Risk of nitrate tolerance with continuous use, requiring a nitrate-free interval (e.g., 10-12 hours daily).
• Side effects: headaches, flushing, hypotension.
• Less effective if tolerance develops.
• Best for: Patients with predictable angina triggered by exertion, where prevention is needed.

Ranolazine

• Mechanism: Inhibits late sodium current in cardiac cells, reducing myocardial oxygen demand without significantly affecting heart rate or blood pressure.
• Use: Indicated for chronic stable angina, often as an add-on therapy when other treatments (e.g., beta-blockers, nitrates) are insufficient or not tolerated.
• Pros:
• No risk of tolerance like nitrates.
• Fewer hemodynamic side effects (e.g., no significant blood pressure drop).
• May benefit patients with microvascular angina or those intolerant to other drugs.
• Cons:
• Side effects: dizziness, nausea, constipation, QT prolongation (rare but serious).
• Contraindicated in patients with liver disease or those on certain medications (e.g., CYP3A4 inhibitors).
• More expensive than nitrates.
• Best for: Patients with refractory angina, those intolerant to nitrates or beta-blockers, or with microvascular dysfunction.

Which is Preferred?

• Guidelines (e.g., ACC/AHA):
• First-line therapies for chronic stable angina typically include beta-blockers or calcium channel blockers (CCBs), with nitrates or ranolazine as add-on or alternative options.
• Sustained-release nitroglycerin is preferred when angina is predictable and nitrate tolerance can be managed with a nitrate-free interval.
• Ranolazine is preferred in patients with persistent angina despite other therapies, those with nitrate intolerance, or when microvascular angina is suspected.
• Patient-specific factors:
• Nitroglycerin: Better for patients with exertional angina and no contraindications to nitrates.
• Ranolazine: Better for patients with complex angina (e.g., microvascular or refractory) or those who cannot tolerate nitrates.
• Comorbidities, drug interactions, and side effect profiles should guide the choice.

Recommendation

Consult a cardiologist to tailor therapy. Typically:

• Start with beta-blockers or CCBs for angina.
• Add sustained-release nitroglycerin if angina is exertion-related and manageable with a nitrate-free interval.
• Use ranolazine if angina persists, nitrates are not tolerated, or microvascular angina is suspected.