Intractable angina pectoris. Combined therapy with propranolol and permanent pervenous pacemaker

ANGINA pectoris is a manifestation of myocardial hypoxia1caused by an imbalance between myocardial oxygen demand and available oxygen supply. In some patients, increased sympathetic tone and heart rate cause oxygen-wasting and provoke recurrent attacks of anginal chest pains at lower levels of physical activity.2-3Selective blockade of excessive cardiac sympathetic responses by specific β-adrenergic receptor blocking agents, eg, propranolol hydrochloride, has been shown to reduce the frequency and severity of ischemic chest pains and to increase the effort tolerance in these patients.4-6Unfortunately, the higher dose of propranolol required to control the symptoms of angina pectoris in some of these patients may lead to severe symptomatic bradycardia.7Three such patients (Table) were treated with propranolol and the use of a permanent pervenous pacemaker (rate, 60 beats per minute), with good control of anginal pains. Comment Several advantages derive from the combined use of a pervenous