Nifedipine is a strong arterial vasodilator with a favorable side-effect profile. The substance has especially been tested in hypertensive anginal patients when added to ß-blockade [1]. In a large placebo-controlled trial long-acting nifedipine in patients with stable coronary artery disease was shown to be safe and significantly reduced the need for coronary angiography and cardiovascular interventions (ACTION trial). There are only few contra-indications to nifedipine (i.e. severe aortic stenosis, obstructive cardiomyopathy, or heart failure) and combination with ß-blockade is advisable. Vasodilatory side-effects of nifedipine include headache and ankle swelling (Table 4.2). Amlodipine has a long half-life and is well tolerated. It is therefore an attractive once-a-day anti-anginal and antihypertensive agent compared to other CCBs that need to be taken twice or three times daily. In patients with coronary artery disease and normal blood pressure (n = 1,991), amlodipine reduced cardiovascular events in a 24-month trial compared to placebo (CAMELOT trial, [2]).

The phenylalkylamine calcium channel blocker verapamil has a wide range of approved indications such as exercise induced angina, vasospastic angina, unstable angina pectoris, supraventricular tachycardias and hypertension. Although good safety is suggested, there may be a risk of heart block, bradycardia or heart failure. Compared with metoprolol, the anti-anginal properties were similar [3]. Compared with atenolol in patients with hypertension and coronary artery disease, verapamil caused less new onset of diabetes mellitus, fewer anginal attacks [4], and less depression [5]. It should, however be noted, that ß-Blockade combined with verapamil is not recommended due to the risk of heart block. In such instances, ß-blockers should be combined with dihydropyridine CCBs. Due to its low side-effect profile, diltiazem has advantages, compared with verapamil, in the treatment of exercise induced angina pectoris [6]. As mentioned above, diltiazem combines the properties of verapamil and dihydropyridines (i.e. negative inotropic effect and peripheral vasodilation). Outcome studies comparing diltiazem and verapamil are currently not available. Diltiazem should not be used in combination with a ß-blocker and the use is also not recommended in patients with coronary artery disease and impaired left ventricular function. The concomitant use of a dihydropyridine CCB together with a ß-blocker has been shown to be beneficial in patients with chronic stable angina. This has recently been confirmed in a meta-analysis by Belsey et al. [7]. Moreover, the current ESC guidelines on the management of patients with stable coronary artery disease recommend using CCBs as first-line treatment to control heart rate and symptoms [8].