First line drugs in chronic stable effort angina—the case for newer, longer-acting calcium channel blocking agents

The American College of Cardiology-American Heart Association Committee recommends first line beta-adrenergic blocking agents for chronic stable effort angina. This article reassesses some critical evidence that is new or could have been neglected by the Committee. In particular, the putative role of calcium channel blocking agents (CCBs) is reexamined. Additional evidence is culled from articles not cited by the Committee, together with added reference to recent trials. Safety, side-effects and tolerability are issues that are evaluated. Mortality data are reviewed with the aid of a meta-analysis of all placebo-controlled trials on long acting CCBs. The advice of the committee may need to be reconsidered in view of recent evidence on the tolerability and benefits in hypertension of newer, longer-acting, second-generation CCBs. Of the older agents, verapamil has been shown to be the best with regard to safety and efficacy. Especially in the elderly, angina is often associated with hypertension, with evidence showing dihydropyridine CCBs and beta-adrenergic blocking agents to be similarly effective. Beta-blockers may have undesirable side effects such impotence and impaired exercise ability, despite their proven protective effects in postinfarct patients and in heart failure. The choice of drug should be keyed to the needs and the pathophysiology of the individual patient.