Anti-anginal, electrophysiologic and hemodynamic effects of combined beta-blocker/calcium antagonist therapy

Nitrates and beta-blockers have been the mainstay in the therapy of chronic stable angina pectoris for many years. Since an important number of patients remains symptomatic, new potent anti-ischemic agents like the calcium antagonists fulfil a great clinical need. Combined therapy with beta-blockers and calcium antagonists is attractive, since both classes of drugs have differing and eventually complementary modes of action. On the other hand, both have direct negative inotropic and chronotropic effects. We reviewed the anti-anginal, electrophysiologic and hemodynamic effects of combined treatment with a beta-blocker and verapamil or nifedipine. Combined therapy provides greater symptomatic relief than monotherapy with beta-blockers or slow channel blockers alone. While incidental adverse negative inotropic and chronotropic interactions have been reported, particularly when verapamil is involved, their hemodynamic interplay appears beneficial rather than detrimental in the majority of patients. Indeed, combined therapy is effective and safe, at least when a preserved or only moderately impaired left ventricular function is present. However, caution must be exercised in patients with more impaired left ventricular function, and combined therapy with verapamil must be avoided when conduction disturbances are likely to occur.