Anaesthetic management of patients with 
ischaemic heart disease for noncardiac surgery can be 
associated with many cardiovascular complications. 
Sublingual isosorbide dinitrate remains one of the 
mainstays of management in patients with angina and 
acute coronary syndrome. Here we present a case with 
ischemic heart disease, scheduled for non cardiac surgery, 
who received isosorbide dinitrate in the postoperative 
period and developed severe hypotension. The patient 
was known case of hypertension and ischemic heart 
disease which were controlled on medications. Dynamic 
hip screw fixation of left femur was done under spinal 
anaesthesia. There was one intraoperative episode of 
hypotension which was managed with vasopressor and 
inotrope. In the postoperative period, patient developed 
chest pain for which sublingual isosorbide dinitrate was 
given as per cardiologist's advice. He developed 
immediate drop of blood pressure which did not respond 
to fluid, blood transfusion or vasopressors. Later, she was 
transferred to intensive care unit where she required 
ventilatory support and correction of metabolic acidosis. 
After two days she was weaned off all vasopressor 
infusions and ventilatory support. This case report 
indicates that sublingual isosorbide dinitrate may cause  severe hypotension refractory to vasopressor in the 
postoperative period in patients with ischemic heart disease 
and coexisting anemia.