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.