Severe angina pectoris and BETA-blocker-induced bradycardia treated with an artificial pacemaker

A 54-year-old man, who was treated with propranolol for severe angina pectoris, developed severe symptomatic bradycardia during this treatment. Coronary angiography revealed severe coronary artery stenosis, but a bypass operation was judged to be technically impossible. When propranolol was withdrawn, the effort angina deteriorated and anginal pains even developed at rest. A favourable symptomatic effect was obtained with a combined regimen of propranolol and a permanent demand pacemaker. Nitroglycerin consumption was reduced from about 20 to less than 3 tablets a day. His condition remained stable during the observation period of 44 months. The symptomatic effect of a beta-blocking agent combined with a permanent pacemaker is considered to be due to the reduced inotropic and chronotropic effect of propranolol during exercise as well as the elimination of a bradycardia-induced angina at rest. Placebo effect to a certain extent cannot be excluded.