# The effect of nitrates in patients with coronary artery disease across different left ventricular ejection fractions

## TL;DR

This study finds that nitrates may increase risk of death and heart events in patients with coronary artery disease and low heart function.

## Contribution

The study reveals that nitrates are linked to worse outcomes specifically in patients with reduced left ventricular ejection fraction.

## Key findings

- Nitrates at discharge were associated with higher death and MACE rates in patients with LVEF <45%.
- No significant associations were found in patients with LVEF 45%–55% or >55%.
- The study suggests cautious use of nitrates in patients with reduced LVEF.

## Abstract

Long-acting nitrates are widely prescribed in coronary artery disease (CAD), yet their association with long-term outcomes remains controversial. Whether left ventricular ejection fraction (LVEF) modifies this relationship has not been well characterized.

We conducted a single-center retrospective cohort study using the Guizhou Provincial People's Hospital CAD database. Adults (≥18 years) who underwent coronary angiography between July 2012 and September 2016 and met angiographic criteria for CAD (≥50% stenosis in ≥1 proximal epicardial coronary artery) were eligible if LVEF and discharge medications were available. Patients were stratified by LVEF (<45%, 45%–55%, >55%) and by discharge prescription of any nitrate (mononitrate or dinitrate). The primary endpoint was all-cause death. The secondary endpoint was major adverse cardiovascular events (MACE), defined as a composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. Kaplan–Meier methods and multivariable Cox regression were used to evaluate associations.

Among 2,404 patients followed for 27.2 ± 13.5 months, 1,153 (48.0%) were discharged on nitrates. In the overall cohort, discharge on nitrates was not associated with all-cause death or MACE. In contrast, among patients with LVEF < 45%, nitrates at discharge were linked to higher cumulative incidences of all-cause death and MACE (log-rank P = 0.024 and 0.029, respectively) and remained independently associated after adjustment [all-cause death: hazard ratio (HR) 2.14, 95% confidence interval (CI) 1.15–3.96; MACE: HR 1.91, 95% CI 1.07–3.43]. No significant associations were observed in the LVEF 45%–55% or >55% strata.

In this CAD cohort, nitrates were commonly prescribed at discharge. An adverse association with long-term outcomes was confined to patients with reduced LVEF, supporting cautious use in this subgroup and highlighting the need for prospective confirmation.