Chronic stable angina treatment beta blockers

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [4] Phone:617-632-7753; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [5]; John Fani Srour, M.D.; Jinhui Wu, M.D.

Mechanisms of benefit

• Beta blocking drugs decrease heart rate, blood pressure, and contractility and, as a result, reduce myocardial oxygen consumption.
• A slowing of heart rate is associated with an increased left ventricular perfusion time.
• Exercise induced increases in heart rate and blood pressure are also blunted. In patients with stable angina, beta adrenergic blocking agents increase exercise duration and the time to the onset of angina and of ST segment depression, although the double product threshold (heart rate multiplied by blood pressure) at which ischemia occurs remains unchanged.

Indications

• It is beneficial to start and continue beta blocker drug therapy indefinitely in all patients who have had myocardial infarction, acute coronary syndrome (ACS) or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated.
• Beta blocking agents with beta selectivity (such as metoprolol and atenolol) are preferable in patients with mild asthma, chronic obstructive pulmonary disease (COPD), insulin dependent diabetes mellitus (IDDM) or intermittent claudication. However, with increased doses of beta blockers, selectivity is lost and both types of beta receptors are blocked.

Contra-indications

• If administration of beta blockers induces symptomatic heart failure, they should be discontinued or the dose reduced.
• The sudden withdrawal of beta blocker therapy may result in worsening of angina (rebound effect) and precipitation of acute ischemic episodes; it is preferable to taper these medications gradually over 2 to 3 weeks.
• Severe bradycardia,
• Episodes of second or third degree atrioventricular (AV) blocks,
• Severe peripheral vascular disease

Dosage

• The effective dose of any beta blocker drug varies considerably from patient to patient.
• For an effective treatment, resting heart rate should be reduced to between 45 and 60 bpm (beats per minute) and heart rate should be below 90 beats per minute during moderate exercise, such as climbing two stairs at a normal pace.
• For maintenance therapy of stable angina, beta blocking drugs with a relatively long half-life are preferable.

Adverse effects

• Major side effects of beta blocker therapy include fatigue, impaired exercise tolerance, depression, insomnia, nightmares, and worsening claudication and bronchospasm.
• Beta blockers may increase the blood sugar level and impair insulin sensitivity, particularly when used concurrently with diuretics. They may decrease the reaction to hypoglycemia in patients with insulin dependent diabetes mellitus (IDDM).
• Beta blockers also may exert unfavorable effects on the blood lipid profile with an increase in triglycerides and reduction in high density lipoprotein (HDL-C). However, the clinical significance of these adverse changes in the lipid profile with beta blockers has not yet been defined.

ACC/AHA Guidelines- Pharmacotherapy to Prevent MI and Death and Reduce Symptoms (DO NOT EDIT)

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Class I 1. Beta-blockers should be started and continued indefinitely in all patients who have had MI, acute coronary syndrome, or left ventricular dysfunction with or without heart failure symptoms, unless contraindicated. (Level of Evidence: A) 2. Beta-blockers as initial therapy in the absence of contraindications in patients without prior MI. (Level of Evidence: B)

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ESC Guidelines- Pharmacological therapy to improve symptoms and/or reduce ischaemia in patients with stable angina (DO NOT EDIT)

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Class I 1. Test the effects of a beta-1 blocker, and titrate to full dose; consider the need for 24 h protection against ischemia. (Level of Evidence: A) 2. In case of beta-blocker intolerance or poor efficacy attempt monotherapy with a CCB (Level of evidence: A), long-acting nitrate (Level of evidence: C), or nicorandil. (Level of evidence: C) 3. If the effects of beta-blocker monotherapy are insufficient, add a dihydropyridine CCB. (Level of evidence: B) Class IIa 1. In case of beta-blocker intolerance try sinus node inhibitor. (Level of evidence: B) 2. If CCB monotherapy or combination therapy (CCB with beta-blocker) is unsuccessful, substitute the CCB with a long-acting nitrate or nicorandil. Be careful to avoid nitrate tolerance. (Level of evidence: C)

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ESC Guidelines- Pharmacological therapy to improve prognosis in patients with stable angina (DO NOT EDIT)

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Class I 1. Oral beta-blocker therapy in patients post-MI or with heart failure. (Level of Evidence: A)

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Vote on and Suggest Revisions to the Current Guidelines

• The Chronic Stable Angina Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Sources

• The ACC/AHA/ACP–ASIM Guidelines for the Management of Patients With Chronic Stable Angina

• TheACC/AHA 2002 Guideline Update for the Management of Patients With Chronic Stable Angina

• Guidelines on the management of stable angina pectoris: The Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology

• The 2007 Chronic Angina Focused Update of the ACC/AHA 2002 Guidelines for the Management of Patients With Chronic Stable Angina

References

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