Angina: ß-blockers, nitrates and calcium antagonists are not clearly different.

Clinical bottom line (level 1a-)

  1. Patients with stable angina who are given beta-blockers have no clear difference in cardiac death or MI, than those given calcium antagonists.
  2. Patients given nitrates are more likely to have to withdraw due to adverse effects (NNH = 34 at unknown) .
  3. There is no clear difference in cardiac death and MI, or adverse effects between nitrates and calcium antagonists.
  4. There is no clear difference in cardiac death and MI, or adverse effects between beta-blockers and nitrates.
Heidenreich et al: Journal of the American Medical Association 1999; 281 (20): 1927-1936
Expires March 2003

The study

Systematic review of Randomised controlled trials of
  • Patients: stable angina
  • Intervention: beta-blockers, calcium antagonists and nitrates compared with beta-blockers, calcium antagonists or nitrates
  • Outcome: efficacy and safety


    • Articles found in English using MEDLINE and EMBASE, 1966 to 1997 (search terms: MeSH headings angina pectoris and angina, plus randomized controlled trial, random, controlled clinical trial and double-blind. ) and Reviewed cited references of retrieved articles to identify relevant studies.

    Selection criteria: as above
    Appraisal criteria: detailed in text
    Articles excluded if: Duration less than a week, studies of 1 drug versus placebo, comparison of different dosage of same drug, 1 drug versus a 2 drug combination, and studies using a study medication during a run-in period prior to randomisation.

    90 articles were included.

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    cardiac death or MI- ß -blockers vs calcium antagonists unknown 57
    (1.84%)    		 59
    (1.93%)    		 -5.00%
    (-50.0% to 27.0%)    		 -0.09%
    (-0.77% to 0.59%)    		 -1146
    (NNT = 130 to infinity;
    NNH = 168 to infinity)
    withdrawal due to adverse effects- ß -blockers vs calcium antagonists unknown 239
    (8.50%)    		 317
    (11.4%)    		 -34.0%
    (-57.0% to -14.0%)    		 -2.91%
    (-4.48% to -1.34%)    		 -34
    (-75 to -22)
    cardiac death or MI-nitrates vs calcium antagonists unknown 0
    (0.00%)    		 0
    (0.00%)    		 %
    (% to %)    		 0.00%
    (0.00% to 0.00%)
    withdrawal due to adverse effects- nitrates vs calcium antagonists unknown 12
    (3.53%)    		 9
    (2.65%)    		 25.0%
    (-76.0% to 68.0%)    		 0.87%
    (-1.73% to 3.48%)    		 114
    (NNT = 58 to infinity;
    NNH = 29 to infinity)
    cardiac death or MI- ß -blockers vs nitrates unknown 1
    (0.78%)    		 1
    (0.78%)    		 0.00%
    (-1482% to 94.0%)    		 0.00%
    (-2.14% to 2.14%)
    (NNT = 47 to infinity;
    NNH = 47 to infinity)
    withdrawal for adverse effects- ß -blockers vs nitrates unknown 6
    (4.84%)    		 13
    (10.5%)    		 -117%
    (-452% to 15.0%)    		 -5.65%
    (-12.2% to 0.94%)    		 -18
    (NNT = 8 to infinity;
    NNH = 107 to infinity)

    Citation

    1. Heidenreich PA, McDonald KM, Hastie T, et al: Meta-analysis of trials comparing ß-blockers, calcium antagonists, and nitrates for stable angina. Journal of the American Medical Association 1999; 281 (20): 1927-1936
    Contributor: Clare Wotton and Musab Hayatli, January 2000
    Reviewer: Dwight Peretz

    Clinical Question.
    Patient stable angina
    Intervention or Exposure beta-blockers, calcium antagonists and nitrates
    Comparison beta-blockers, calcium antagonists or nitrates
    Outcome efficacy and safety, mortality, MI