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Full Title: An Evaluation of Beta-Blockers, Calcium Antagonists, Nitrates, and Alternative Therapies for Stable Angina
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Objective: Stable angina is a major health problem that affects over 7 million adults in the United States, with an estimated 350,000 new cases annually. The American College of Cardiology, American Heart Association, and American College of Physicians established a committee to develop guidelines for the diagnosis and treatment of stable angina. This committee of experts in cardiology and internal medicine and the investigators from the University of California, San Francisco (UCSF)-Stanford Evidence-based Practice Center (EPC) prioritized two topics for a thorough systematic review of the literature. The first topic concerned the relative efficacy and tolerability of treatment with beta-blockers, calcium antagonists, and long-acting nitrates for patients who have stable angina. The second topic dealt with the efficacy of alternative therapies in patients who have stable angina.
Search Strategy: The authors identified published studies from 1966 through 1997 by searching the MEDLINE® and EMBASE databases and by reviewing manually the bibliographies of identified articles.
Selection Criteria: For the review of traditional therapies, studies that compared two agents from different anti-anginal drug classes (beta-blockers, calcium antagonists, and nitrates) and that were at least 1 week in duration were reviewed. Studies were selected if they reported one of the following outcomes: cardiac death, myocardial infarction, angina frequency, nitroglycerin use, exercise duration, or adverse events leading to withdrawal. For the review of alternative therapies, the authors included all randomized trials of alternative therapies compared with placebo, nitrates, calcium antagonists, or beta-blockers in patients who had stable angina.
Data Collection and Analysis: For the review of traditional therapies, 91 studies met the inclusion criteria. Each study was abstracted by two independent reviewers. The data were pooled using odds ratios for discrete data and mean differences for continuous data. Studies of calcium antagonists were grouped by duration of action (short- vs. long-acting) and type of drug (nifedipine vs. nonnifedipine).
Main Results: Rates of cardiac death or myocardial infarction were similar (odds ratio 0.97 [0.67,1.38]), but events were few; the median trial duration was 4 weeks. Beta-blockers provided greater angina relief than calcium antagonists did: mean difference in episodes per week was 0.31 (95 percent confidence interval: 0.00, 0.62). Beta-blockers were discontinued after adverse events less often than calcium antagonists were (odds ratio 0.72 [95 percent confidence interval: 0.60, 0.86]). Trials comparing nifedipine with beta-blockers showed a significantly greater benefit for angina relief for beta-blockers and a decrease in adverse events leading to study withdrawal. Commonly reported side effects were similar or greater in patients taking calcium antagonists compared with patients taking beta-blockers. Randomized trials of alternative therapies for patients who had stable angina were too small and too few to allow conclusions to be drawn.
Conclusions: In trials of patients who had stable angina, beta-blockers provided equivalent or greater angina relief than calcium antagonists and were associated with fewer adverse events. No differences were documented in mortality or myocardial infarction, but trial duration was too short to define clinically important effects on these endpoints. There were too few studies of nitrates and alternative therapies to draw conclusions.
An Evaluation of Beta-Blockers, Calcium Antagonists, Nitrates, and Alternative Therapies for Stable Angina
Evidence-based Practice Center: University of California at San Francisco (UCSF)-Stanford
Topic Nominators: American College of Cardiology, American Heart Association Task Force on Practice Guidelines, American College of Physicians
Current as of November 1999