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Anti-Anginal Drugs–Beliefs and Evidence
Study Questions:
What is the evidence accumulated over the past 50 years since the introduction of propranolol for the efficacy of one anti-anginal agent compared with another?
Methods:
The investigators performed a systematic review of English-written articles over the past 50 years in Medline and Embase, following preferred reporting items and the Cochrane collaboration approach. They included double-blind randomized studies comparing parallel groups on treatment of angina in patients with stable coronary artery disease, with a sample size of at least 100 patients (50 patients per group), with a minimum follow-up of 1 week and an outcome measured on exercise testing, with duration of exercise being the preferred outcome.
Results:
Thirteen studies fulfilled the study selection criteria. Nine studies involved between 100 and 300 patients (2,818 in total), and a further four enrolled >300 patients. Evidence of equivalence was demonstrated for the use of beta-blockers (atenolol), calcium antagonists (amlodipine, nifedipine), and channel inhibitor (ivabradine) in three of these studies. Taken all together, in none of the studies, there was evidence that one drug was superior to another in the treatment of angina or to prolong total exercise duration.
Conclusions:
The authors concluded that there is a paucity of data comparing the efficacy of anti-anginal agents.
Perspective:
This study reports that there are minimal data comparing the efficacy of anti-anginal agents. The little available evidence suggests that no anti-anginal drug is superior to another, and equivalence has been shown only for three classes of drugs, i.e., beta-blockers (atenolol), calcium antagonists (amlodipine, nifedipine), and If channel inhibitors (ivabradine). Guidelines appear to make recommendations mostly from clinical beliefs and consensus. Based on this and other evidence, the medical therapy of angina should be personalized and tailored towards the individual with an understanding of the likely pathophysiological mechanisms and comorbidities. For example, in those with heart failure, a beta-blocker may be preferred, whereas patients with diabetes may be better served with a calcium blocker, which may provide more effective blood pressure lowering.
Clinical Topics: Heart Failure and Cardiomyopathies, Prevention, Stable Ischemic Heart Disease, Atherosclerotic Disease (CAD/PAD), Acute Heart Failure, Chronic Angina
Keywords: Adrenergic beta-Antagonists, Amlodipine, Angina Pectoris, Angina, Stable, Atenolol, Benzazepines, Blood Pressure, Calcium Channel Blockers, Coronary Artery Disease, Diabetes Mellitus, Exercise Test, Heart Failure, Myocardial Ischemia, Nifedipine, Propranolol, Primary Prevention
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