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It has been reported that only the exo-epoxide effectively interacts with DNA and was at least 500-fold more potent as a mutagen than the endo stereoisomer

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There is also a minimal risk of digoxin-induced cardiac arrhythmias

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Enzymatic degradation of the donor (such as mitochondrial aldehyde dehydrogenase) triggers the generation of NO from organic nitrates, although some non-enzymatic mechanisms (such as thiol reactions) are also thought to play a minor role [47]