Unstable angina: diltiazem was probably as good as propranolol in reducing angina attacks.

Clinical bottom line (level 1b-)

  1. In patients with unstable angina, diltiazem may be as effective as propranolol in reducing angina attacks.
Andre-Fouet et al: European Heart Journal 1983; 4: 691-698
Expires June 2003

The study

Unblinded concealed randomised trial with intention-to-treat
Setting: coronary care unit, acute hospital, France

70 patients (aged range 39 to 83 years; mean 60, 87% male) unstable angina, defined as :
  • appearance of new onset angina
  • aggravation less than one month previously of angina


Excluded if
  • MI within one month
  • contraindication to beta-blockers
  • treatment during previous months with amiodarone or perhexiline
  • atrial fibrillation or flutter, sinus bradycardia or AV block
  • congestive heart failure, aortic valvular disease
  • anaemia (Hb <10 g/dl), current thyroid disease, renal or hepatic failure


    • Control Group: (n = 36, 36 analysed): propranolol 40 mg twice daily po. Dose was increased until anginal attacks disappeared or 360 mg per day was reached
    Experimental Group: (n = 34, 34 analysed): diltiazem 60 to 120 mg twice daily po. Dose was increased until anginal attacks disappeared or 540 mg per day was reached.
    Patients were treated with heparin, oral antidiabetics, diuretics, sublingual nitroglycerin, analgesia and sedatives as required. Use of long acting nitrates was not permitted. All patients had intermittent infusions of heparin (3000 to 5000 units every three hours). All anti-anginal medication was stopped until ECG changes were recorded during spontaneous chest pain.
    100% followed for 1-10 days

    The evidence

    Outcome Time to outcome CEREERRRR
    (95% CI)    		ARR
    (95% CI)    		NNT
    (95% CI)
    continuation of angina attacks 1-10 days 18
    (50.0%)    		 11
    (32.4%)    		 35%
    (-16% to 64%)    		 17.7%
    (-5.03% to 40.3%)    		 6
    (NNT = 2 to infinity;
    NNH = 20 to infinity)

    Comments

    1. Management of unstable angina has changed since this study- patients are now routinely given aspirin and continuous heparin. Medication is usually continued and not stopped on admission.
    2. Short follow-up and small numbers mean that diltiazem may be potentially more harmful than propranolol. Other studies have shown that diltiazem has no effect on reducing mortality unlike beta-blockers.

    Citation

    1. Andre-Fouet X, Usdin JP, Gayet CH, et al: Comparison of short-term efficacy of diltiazem and propranolol in unstable angina at rest- a randomised trial in 70 patients. European Heart Journal 1983; 4: 691-698
    Search Terms: unstable angina and diltiazem in Cochrane
    Contributor: Chris Ball and Clare Wotton, June 2000
    Reviewer: William Rhoton

    Clinical Question.
    Patient unstable angina
    Intervention or Exposure diltiazem
    Comparison propranolol
    Outcome continuation of angina attacks