MECHANISMS FOR THE IN VIVO ANTIPLATELET EFFECTS OF ORGANIC NITRATES
Organic nitrates (nitroglycerin, isosorbide dinitrate) are inhibitors of platelet function more effective in vivo than in vitro (Am J Cardiol 1984; 53:1683), the in vivo effect requiring concentrations 10-100 times lower than in vitro. We have previously excluded that such difference is due to elicitation by nitrates of prostacyclin synthesis in human endothelial cells or vascular fragments (Circulation 1985; 71:176). In the present study we evaluated alternative explanations: that the difference is due (1) to generation of more active drug metabolites; (2) to synergism between nitrates and prostacyclin in the inhibition of platelet function. Isosorbide dinitrate (ISDN) and its two main in vivo metabolites, isosorbide-2-mononitrate (IS-2-MN) and isosorbide-5-mononitrate (IS-5-MN), were compared in their ability to inhibit platelet aggregation and thromboxane (TX) B2 formation (RIA) in respone to threshold doses of ADP, adrenaline, collagen, arachidonic acid and thrombin in citrated platelet-rich plasma. The same tests were performed in 10 healthy volunteers before, during (at 5, 15 and 30 min) and after infusion of the three drugs at 8 mg/h for 30 min in 3 different days. Finally, the concentration of prostacyclin (and its stable analogue Iloprost) added in vitro to platelets, and required to inhibit platelet aggregation by 50% (IC50) after 5 min pre-incubation of platelets with nitrates was determined. In vitro incubation of platelets with IS-2-MN resulted in greater inhibition of both aggregation and TX formation (by ADP and adrenaline) than with ISDN and IS-5-MN. At 10−7M, only IS-2-MN significantly inhibited aggregation (−12%, P< 0.05) and TX formation (from 9.2±1.8 to 5.9± 0.6 ng/ml) by ADP, while minimum effective concentrations were 10−7M for ISDN and 10−7m for IS-5-MN. These in vitro differences are unlikely to be the explanation of in vivo findings, since IS-2-MN, ISDN and IS-5-MN were equipotent when administered in vivo (complete abolition of secondary wave after ADP and adrenaline at 30 min of infusion). At supra-threshold doses of all the aggregating agents, all three drugs, at 10−7M, decreased IC50 for prostacyclin from 2.9± 1.3 to 0.32± 0.18 nM (P< 0.01). Synergim with prostacyclin is most likely to account, at least partially, for in vivo antiplatelet effects by organic nitrates.