Meta-Analysis of Trials for Stable Angina

Source: Heidenreich PA, et al. JAMA 1999;281:1927-1936.

Despite many years of use of the three traditional classes of anti-anginal medications, none has emerged as distinctly superior. Because of demonstrated reductions in post-MI mortality with beta-blockers, consensus has generally suggested them as first-line therapy. Since some patients, especially those with bronchospastic lung disease, tolerate calcium channel blockade better than beta blockade, this class of agents also sometimes holds first-choice status. This study analyzed by meta-analysis all randomized trials (1966-1997) of at least one week duration, which compared at least two of the three different drug classes.

Most of the analyzed studies were beta blocker vs. calcium antagonists. Comparing outcomes of cardiac death, MI, angina episodes, use of nitroglycerin, and exercise time, neither class of drug emerged significantly superior. The only statistically significant difference between the classes was in respect to withdrawal for adverse events, for which beta blockers fared more favorably than calcium antagonists.

Studies comparing nitrates with calcium antagonists did not show any significant between-class differences; similarly, although comparisons between beta-blockers and nitrates were the least frequent, no clear advantage of either class emerged.

Comment by Louis Kuritzky, MD

Since all three classes are equally efficacious, the fact that beta-blockers enjoyed more favorable withdrawal rates suggests that they remain first-choice therapy.