Angina Patients With Heart Failure

Coronary artery disease leads to myocardial infarction
which causes weakness of the heart muscle, and some
patients over time develop heart failure. These patients
are difficult to treat because they are not candidates for
bypass surgery. Medical therapy must be used judiciously.
Nitrates, in particular cutaneous nitrates, applied 14 h
daily, plus a small dose of a beta-blocking drug along with
an ACE inhibitor and a diuretic, are beneficial for many
patients. Beta-blockers should be avoided in patients with
severe heart failure, but those with mild-to-moderate heart
failure gain major relief. Recent randomized clinical trials
have shown the beta-blockers, carvedilol, metoprolol, and
bisoprolol effective in reducing mortality rates and
hospitalization.
In patients with an ejection fraction less than 35%,
digoxin is indicated. Calcium antagonists should be
avoided. Verapamil and diltiazem are contraindicated
because of reduced cardiac contractility and the possibility
of precipitating heart failure. Other calcium antagonists
including amlodipine and nifedipine should be avoided
because they may precipitate heart failure

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