Nicorandil - An updated review of its use in ischaemic heart disease with emphasis on its cardioprotective effects

Nicorandil is a drug with both nitrate-like and ATP-sensitive potassium-cha nnel (K(+)ATP) activating properties. By virtue of this dual mechanism of a ction, the drug acts as a balanced coronary and peripheral vasodilator and reduces both preload and afterload, The K(+)ATP channel has been shown to be involved in the phenomenon of myoc ardial preconditioning, and studies in animal models of ischaemia-reperfusi on-induced myocardial stunning or infarction indicate that nicorandil has c ardioprotective effects. Studies in patients undergoing percutaneous transl uminal coronary angioplasty (PTCA) have shown that the administration of ni corandil reduces ST-segment elevation during ischaemia. Nicorandil significantly improved the results of exercise tolerance tests v ersus baseline in patients with stable effort angina pectoris in early nonc omparative trials. The drug also improved the results of exercise tolerance tests relative to placebo in early randomised, double-blind, placebo-contr olled trials. In randomised, double-blind comparative studies in patients with angina pec toris, nicorandil has demonstrated equivalent efficacy, as measured by exer cise tolerance testing, to isosorbide di- and mononitrate, metoprolol, prop ranolol, atenolol, diltiazem, amlodipine and nifedipine, The effects of nicorandil on various aspects of myocardial recovery from is chaemic damage caused by acute myocardial infarction have been investigated in the short term. Regional left ventricular (LV) wall motion, a marker of myocardial function, was significantly improved in nicorandil recipients r elative to control. The main adverse event associated with nicorandil as treatment for angina p ectoris is headache. This can be minimised by commencing nicorandil at a lo w dose in patients prone to headache. There have been infrequent case repor ts of mouth ulcers in patients receiving nicorandil; causality has not been conclusively established, but product prescribing information indicates th at an alternative treatment should be considered if persistent aphthous or severe mouth ulceration occurs. Thus, nicorandil remains a useful background therapy for patients with angi na pectoris, The drug has also demonstrated potential cardioprotective effe cts when used as part of an intervention strategy directly after acute myoc ardial infarction in high-risk patients. Further large scale longer term st udies of nicorandil in this latter indication are awaited with interest.