The role of triple therapy in patients with chronic stable angina pectoris.

Despite the proven effectiveness of calcium-channel and beta-blockers as monotherapy in patients with chronic stable angina pectoris, some patients remain symptomatic. Such patients have been shown to benefit from the application of combined treatment with beta-blockers and nitrates or, more recently, beta-blockers plus calcium-channel blockers. There have been few studies evaluating the long-term effectiveness of the combination of calcium blockers and nitrates, but available evidence suggests that symptoms of excessive vasodilation such as orthostatic hypotension may limit the usefulness of this approach. Recently, the additional benefit of adding a calcium blocker to therapy of patients with chronic stable angina who remain symptomatic on beta-blockers and nitrates has been demonstrated. Side effects related to vasodilation were the major limiting feature of this triple therapy. Thus, a triple therapy regimen may be of value in selected patients who do not respond to the combination of beta-blockers and nitrates or beta-blockers plus calcium blockers. However, caution must be exercised in patients with reduced left ventricular function and conduction system disease, since such patients have been excluded from the reported studies.