Context

Which drug is most effective as a first-line treatment for stable angina is not known.

Objective

To compare the relative efficacy and tolerability of treatment with {beta}-blockers, calcium antagonists, and long-acting nitrates for patients who have stable angina.

Data Sources

We identified English-language studies published between 1966 and 1997 by searching the MEDLINE and EMBASE databases and reviewing the bibliographies of identified articles to locate additional relevant studies.

Study Selection

Randomized or crossover studies comparing antianginal drugs from 2 or 3 different classes ({beta}-blockers, calcium antagonists, and long-acting nitrates) lasting at least 1 week were reviewed. Studies were selected if they reported at least 1 of the following outcomes: cardiac death, myocardial infarction, study withdrawal due to adverse events, angina frequency, nitroglycerin use, or exercise duration. Ninety (63%) of 143 identified studies met the inclusion criteria.

Data Extraction

Two independent reviewers extracted data from selected articles, settling any differences by consensus. Outcome data were extracted a third time by 1 of the investigators. We combined results using odds ratios (ORs) for discrete data and mean differences for continuous data. Studies of calcium antagonists were grouped by duration and type of drug (nifedipine vs nonnifedipine).

Data Synthesis

Rates of cardiac death and myocardial infarction were not significantly different for treatment with {beta}-blockers vs calcium antagonists (OR, 0.97; 95% confidence interval [CI], 0.67-1.38; P=.79). There were 0.31 (95% CI, 0.00-0.62; P=.05) fewer episodes of angina per week with {beta}-blockers than with calcium antagonists. {beta}-Blockers were discontinued because of adverse events less often than were calcium antagonists (OR, 0.72; 95% CI, 0.60-0.86; P.001). The differences between {beta}-blockers and calcium antagonists were most striking for nifedipine (OR for adverse events with {beta}-blockers vs nifedipine, 0.60; 95% CI, 0.47-0.77). Too few trials compared nitrates with calcium antagonists or {beta}-blockers to draw firm conclusions about relative efficacy.

Conclusions

{beta}-Blockers provide similar clinical outcomes and are associated with fewer adverse events than calcium antagonists in randomized trials of patients who have stable angina.

By the year 2050, the population of the United States is projected to be approximately half white and half non-white. Yet the knowledge of child development within ethnic minority groups lags markedly behind knowledge of child development for white Americans, and it is increasingly clear that the rich diversity within minority groups is masked by studies focusing on between-group comparisons. Children of Color: Research, Health, and Public Policy Issues, a collection of original essays, brings together researchers from the fields of education, family and child ecology, nursing, psychology, sociology, pediatrics, anthropology, and social work to explore the rich cultural, familial, and individual diversity of all ethnic minority groups. The essays were generated by round table discussions sponsored by the Society for Research in Child Development and the Irving Harris Foundation, and they cover a broad range of topics including immigration policy, social policy, health status of immigrant infants, children and families, and educational policies related to minority children.

Also a 1998 research report: Medical Advisory Panel, TEC Program, Blue Cross Blue Shield Association

Stable angina is a major health problem that affects over 7 million adult men and women in the United States, with an estimated 350,000 cases annually. Symptomatic therapy is targeted at either reducing oxygen demand by decreasing the work of the heart or increasing oxygen supply by dilating coronary arteries. Acute treatment of an angina episode consists of rest and often sublingual nitroglycerin. Chronic treatment to prevent symptoms has consisted of one or a combination of beta-blockers, calcium antagonists, and long-acting nitrates.

The choice of a first-line anti-anginal drug has been controversial because all three classes have been shown to be effective in relieving symptoms. There are few long-term trials comparing these drugs in controlled studies, and it is unclear whether any of the drug classes decrease mortality or myocardial infarction in patients with stable angina.

To address these important issues, the University of California, San Francisco-Stanford, Evidence-based Practice Center (EPC) conducted a thorough, systematic review and synthesis of the literature on treatment of stable angina and developed an evidence report on the topic. The topic was nominated by the American College of Cardiology, the American Heart Association, and the American College of Physicians. The EPC worked with the nominators' guideline committee to prioritize two topics for this project:

The relative efficacy and safety of beta-blockers, calcium antagonists, and long-acting nitrates in patients who have stable angina.

The efficacy of alternative therapies in patients who have stable angina.