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VIEWPOINT

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

^a Heart Research Unit and Hatter Institute, MRC Inter-University Cape Heart Research Group, Cape Heart Center, University of Cape Town, Cape Town, South Africa

Manuscript received December 20, 1999; revised manuscript received May 8, 2000, accepted July 10, 2000.

Reprint requests and correspondence: Dr. L. H. Opie, Cape Heart Centre, University of Cape Town Medical School, Observatory, Cape Town 7925, South Africa
opie{at}capeheart.uct.ac.za

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.

Abbreviations and Acronyms   ACC = American College of Cardiology   ACE = angiotensin-converting enzyme   AHA = American Heart Association   CAPARES = Coronary AngioPlasty Amlodipine REStenosis Study   CCB = calcium channel blocking agent   CHD = coronary heart disease   DAVIT = DAnish Verapamil Infarct Trial   DHP = dihydropyridine   PRAISE = Prospective Randomized Amlodipine Survival Evaluation   PREVENT = Prospective Randomized Evaluation of the Vascular Effects of Norvasc Trial   STOP = Swedish Trial in Old Patients

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