By attenuating the cardiac response to exercise, propra-nolol and other ( -blockers increase the amount of exercise that can be performed before angina develops. Although propranolol does not change the point of imbalance between oxygen supply and demand at which angina occurs, it does slow the rate at which the imbalance point is reached.
Propranolol is particularly indicated in the management of patients whose angina attacks are frequent and unpredictable despite the use of organic nitrates. Propranolol may be combined with the use of nitro-glycerin, the latter drug being used to control acute attacks of angina. The combined use of propranolol and organic nitrates theoretically should enhance the therapeutic effects of each and minimize their adverse effects (Table 17.4).
Propranolol and nadolol also have been used successfully in combination with certain calcium entry blockers, particularly nifedipine, for the treatment of secondary angina. Caution should be used, however, when combining a ( -blocker and a calcium channel blocker, such as verapamil or diltiazem, since the negative inotropic and chronotropic effects of this combination may lead to severe bradycardia, arteriovenous nodal block, or decompensated congestive heart failure.
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