Alternative medical treatment for patients with angina pectoris and adverse reactions to beta blockers. Usefulness of nifedipine

Mild heart failure: diagnosis and treatment

CHF afflicts 15 million persons worldwide despite advances made in its diagnosis and treatment. A thorough physical examination and basic, noninvasive evaluation are essential for establishing the diagnosis of heart failure and for designing an optimal, individualized treatment regimen. Although digitalis and diuretics continue to be used commonly for the treatment of CHF of all severities, the use of vasodilators and ACE inhibitors has increased dramatically, as they are used more widely and earlier in the course of the illness. Because the RAA system contributes significantly to the altered cardiovascular hemodynamics and symptomatology characteristic of heart failure, the ACE inhibitors provide a rational approach to therapy for many patients. Results of controlled clinical trials have shown that selected vasodilators and ACE inhibitors can improve survival in patients with CHF and that patients receiving ACE inhibitors show sustained improvement in clinical class, exercise tolerance, and hemodynamics. Thus the therapeutic spectrum available to the clinician dealing with patients with CHF has broadened substantively over the past decade.

Calcium channel antagonism and beta blockade in combination--a therapeutic alternative in cardiovascular disorders. A review

Calcium-channel antagonists and beta-adrenergic blocking agents have become important modalities in the cardiovascular therapeutic armamentarium. These drugs are often administered as monotherapy to a wide range of cardiological patients with angina pectoris, hypertension, arrhythmias, congestive heart failure, and other diseases. Since within each class these drugs exhibit pharmacologic differences, it follows that their effectiveness varies in different disease states and that they exhibit a wide variety of side effects. In an attempt to optimize therapy, the individual drugs from these two classes can be combined; and the efficaciousness and side-effect profile of various combinations between calcium-channel antagonists and beta blockers are discussed in this review. Recommendations as to which patients may benefit from a combination and as to which patients may be harmed by the combination therapy will be made. Very few studies have compared the safety and efficacy of a single agent with the combination and with placebo in a controlled randomized fashion. To determine which therapy is superior and to determine which combination one should recommend under what circumstances, such placebo-controlled, randomized trials are a necessity, and will hopefully be performed although the complexity is enormous.

Once-daily therapy for angina pectoris with nifedipine gastrointestinal therapeutic system. Dosing and clinical efficacy

The nifedipine gastrointestinal therapeutic system (GITS) is a promising new formulation that provides continuous release of nifedipine over the course of 24 hours with once-daily dosing. Results from a 14-week, open-label, crossover multicenter trial completed by 91 patients with chronic stable angina pectoris demonstrate that patients treated with standard nifedipine capsules may be switched to equivalent total 24-hour doses of nifedipine GITS and achieve comparable or improved efficacy (due to improved compliance) with a more favorable side-effects profile. Furthermore, in a subset of 10 patients who underwent sequential exercise testing, exercise responses obtained throughout 12 weeks of treatment with nifedipine GITS were comparable to measurements obtained during treatment with nifedipine capsules and demonstrated that tolerance did not occur. These patients also experienced significantly fewer vasodilatory side effects during treatment with nifedipine GITS compared with nifedipine capsules. Thus, nifedipine GITS represents a sound pharmacologic approach to the management of ischemic disease; and with once-daily dosing and a favorable side-effect profile this agent affords the potential for better patient compliance and efficacy without concern about the development of tolerance.

The role of nitrates, beta blockers, and calcium antagonists in stable angina pectoris

Numerous controlled studies have shown that nitrates, beta blockers, and calcium antagonists are effective in the treatment of stable angina pectoris. The pharmacokinetics, pharmacodynamics, and hemodynamic effects of these agents are different, and thus combination therapy offers additive improvement and also counterbalancing of the undesirable side effects of each drug. The choice of therapy depends on the severity of symptoms, associated diseases, compliance, side effects, and status of left ventricular function. The main mechanism of improvement is a decrease in myocardial oxygen consumption, though an increase in coronary blood flow is another potential reason for the use of calcium blockers. This review considers the properties of these drugs, their mechanism of action, and the results of randomized studies.

Atenolol with and without nifedipine in the treatment of angina pectoris. Preliminary report

Atenolol and nifedipine have been shown to be effective single agents in angina pectoris, but reports suggest that additional benefits may be conferred by combining the 2 drugs. Therefore, to establish that the combination regimen was at least as effective as either atenolol or nifedipine alone, a multicentre study was performed to compare the treatment regimens in 94 patients with characteristic chest pain compatible with a diagnosis of stable angina pectoris which was provoked by effort and relieved by glyceryl trinitrate. After 4 weeks on atenolol 50 mg twice daily, the patients were randomised to receive, in a double-blind crossover fashion, atenolol 50 mg twice daily either with or without sustained release nifedipine 20 mg twice daily for 4 weeks. Compared with entry, all treatments apparently reduced the number of anginal attacks per week and the number of glyceryl trinitrate tablets taken. It was notable that blood pressure in patients during the study was normal. Treatment with atenolol or the combination appeared to improve exercise tests measured by time to onset of pain, time to greater than or equal to 1mm ST segment depression and duration. The ST segment depression was substantially lower on the fixed combination compared with atenolol alone; ST segment depression during exercise was recorded in 82% of patients after atenolol and 75% after the combination, compared with 100% on entry. There was a substantial improvement in the number of patients rendered pain free: 29% on atenolol and 42% on combination. There was little difference between treatments in terms of adverse effects.(ABSTRACT TRUNCATED AT 250 WORDS)