Medical Treatment of Myocardial Ischemia in Coronary Artery Disease: effect of Drug Regime and Irregular Dosing in the CAPE II Trial - CAPE II
The goal of this study was to assess the safety and efficacy of amlodipine and diltiazem compared to the combination of amlodipine/atenolol and diltiazem/isosorbide 5-mononitrate on exercise and ambulatory myocardial ischemia during regular therapy and after omission of medication.
Patients with >4 ischemic episodes or >20 min of ST segment depression on 72-h electrocardiogram were assigned to receive amlodipine (10 mg QD) or diltiazem (300 mg QD) for 14-weeks in a double-blind randomized fashion. Following this period atenolol (100 mg QD) was added to amlodipine and isosorbide 5-mononitrate (100 mg QD) was added to diltiazem. Ischemia was assessed by 72 hour ambulatory electrocardiogram as well as by exercise testing performed after both phases, on treatment and after a 24-h drug-free interval (after these therapies were stopped for 24 hours).
Monotherapy with amlodipine and diltiazem were associated with similar efficacy with respect to ischemic symptoms and ambulatory and exercise ischemia. Additional reductions of ischemic episodes were seen with combination therapy, with amlodipine/atenolol being superior to diltiazem/isosorbide 5-mononitrate. Further, the combination of amlodipine/atenolol had greater efficacy during the drug-free interval with maintenance of ischemia reduction than with diltiazem/isosorbide 5-mononitrate.
Among patients who frequently forget to take medication or take their drugs irregularly, amlodipine alone or in combination with beta-blocker was associated with a reduction in ischemia. Beta-blockers are currently considered first line of treatment for improving ischemic symptoms. Therefore, the relevant information in this trial is that either amlodipine or diltiazem are reasonable choices for a patient with an absolute contraindication to taking a beta-blocker.
Deanfield JE, Detry JM, Sellier P, et al for the CAPE II Trial Investigators. Medical Treatment of Myocardial Ischemia in Coronary Artery Disease: effect of Drug Regime and Irregular Dosing in the CAPE II Trial. J Am Coll Cardiol 2002;40:917-25.
Keywords: Diltiazem, Myocardial Ischemia, Amlodipine, Electrocardiography, Isosorbide, Exercise Test
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