The AHA Guidelines and Scientific Statements Handbook

The AHA Guidelines and Scientifi c Statements Handbook

6 Sublingual nitroglycerin or nitroglycerin spray is
recommended for the immediate relief of angina.
(Level of Evidence: B)
7 Calcium antagonists or long-acting nitrates is rec-
ommended as initial therapy for reduction of symp-
toms when beta-blockers are contraindicated. (Level
of Evidence: B) (Figure 1.3)
8 Calcium antagonists or long-acting nitrates is
recommended in combination with beta-blockers
when initial treatment with beta-blockers is not suc-
cessful. (Level of Evidence: B) In case of beta-blocker
intolerance or poor effi cacy attempt monotherapy
with a calcium channel blocker (Level of Evidence:
A), long acting nitrate (Level of Evidence: C), or
nicorandil. (Level of Evidence: C) (Tables 1.13 and
1.14).
9 If the effects of beta-blocker monotherapy are
insuffi cient, add a dihydropyridine calcium channel
blocker. (Level of Evidence: B)

10 Calcium antagonists and long-acting nitrates

are recommended as a substitute for beta-blockers

if initial treatment with beta-blockers leads to

unacceptable side effects. (Level of Evidence:

C)

11 Angiotensin receptor blockers are recommended

for patients who have hypertension, have indica-

tions for but are intolerant of ACE inhibitors, have

heart failure, or have had a myocardial infarction

with left ventricular ejection fraction less than or

equal to 40%. (Level of evidence: A)

12 Aldosterone blockade is recommended for

use in post-MI patients without signifi cant renal

dysfunction or hyperkalemia who are already

receiving therapeutic doses of an ACE inhibi-

tor and a beta blocker, have a left ventricular

ejection fraction less than or equal to 40%, and

have either diabetes or heart failure. (Level of

Evidence: A)

Ardissino 1995 (633)Arnman 1982 (634)

Bjerle 1986 (635)

Bowles 1983 (636)Crake 1988 (637)

De Devitiis 1987 (638)Di Somma 1996 (639)

Findlay 1983 (640)Findlay 1986 (641)Findlay 1987 (642)

Frishman 1982 (643)Frishman 1992 (644)

Hauf-Zachariou 1997 (537)

Higginbotham 1989 (645)

Humen 1991 (646)Johnson 1981 (647)

Kawanishi 1992 (552)

Kenny 1985 (648)

Livesley 1973 (649)

Lynch 1980 (650)McGill 1986 (651)

Nadazin 1994 (652)

Pflugfelder 1987 (653)

Rae 1985 (654)

Savonitto 1996 (562)Southall 1982 (655)Steffensen 1993 (554)

van der Does 1992 (656)

van Dijk 1988 (657)

von Arnim 1995 (561)

Wallace 1998 (544)Wheatley 1985 (656)

Summary

Trial

8.0

3.0

–2.0

–7.0

Mean Difference (<0 Favors B-Blockade)

–12.0

Fig. 1.3 Beta-blockers versus calcium antagonists: angina relief.
Source: Heidenreich PA, for the UCSF-Stanford Evidence-based Practice Center (AHCPR).