William E. Strauss, MD; Alfred F. Parisi, MD
During the past decade, the therapy for stable angina pectoris has greatly expanded with the introduction of the calcium-channel blockers. Initially studied as monotherapy, these agents have been regularly used in combination with other antianginal medications, most notably the beta-adrenergic blockers. Although there are pharmacologic rationales for combining these agents, in daily practice, the major impetus for combination therapy is continuing angina during monotherapy. At least one well-conducted double-blind study was done to confirm that diltiazem, verapamil, and nifedipine each can markedly improve both subjective and objective measures of efficacy when used in combination with a beta-blocker. However, individual patient responses are of chief importance. Many persons do better with monotherapy than with combination treatment. The offsetting hemodynamic effects of nifedipine and a beta-blocker generally work well together; however, minor side effects are not infrequent. In the patient with underlying conduction system disease, this combination is clearly preferable. Diltiazem with a beta-blocker is usually well-tolerated, with a low incidence of adverse effects, similar to the experience with diltiazem monotherapy. Verapamil in conjunction with a beta-blocker warrants the greatest concern; approximately 10% to 15% of patients will have significant bradycardia, heart block, hypotension, or congestive failure. When these agents are used concurrently, reduced dosages, especially of the beta-blocker, will likely result in a lower incidence of adverse effects with maintained efficacy.
Strauss WE, Parisi AF. Combined Use of Calcium-Channel and Beta-Adrenergic Blockers for the Treatment of Chronic Stable Angina: Rationale, Efficacy, and Adverse Effects. Ann Intern Med. 1988;109:570–581. doi: https://doi.org/10.7326/0003-4819-109-7-570
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Published: Ann Intern Med. 1988;109(7):570-581.
Cardiology, Coronary Heart Disease.
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Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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