Combination of nitrates with other antianginal drugs

The choice between beta-blockers, long-acting nitrates, and calcium antagonists for prophylactic treatment of stable angina pectoris is determined by several factors, including specific indications for and contraindications to a particular drug. In severe cases of angina, combined treatment is common. The theoretical advantages of combined therapy seem attractive; however, studies documenting the effects of some combinations are few or lacking. Combined use of nitrates and beta-blockers is a rational approach, because the pharmacological actions of the 2 drugs produce complementary haemodynamic effects. In short term studies favourable effects have been documented. Positive, but more variable effects have also been reported during long term treatment. Additive effects of nitrates and calcium antagonists have been found in angina produced by coronary artery spasm, but the effects of the combination in stable angina pectoris are not well documented. The combination may be more or less attractive, depending on the profile of action of the particular calcium antagonist used. It should be stressed that there are no studies of the efficacy of long term treatment with the combination of nitrates and calcium antagonists. Triple treatment is based more on clinical experience than on the effect documented in properly designed clinical studies. Even if additional beneficial effects can be obtained in patients on maximal doses of beta-blockers and nitrates when receiving calcium antagonists, it has been shown that triple therapy may not be optimal for certain patients.