Verapamil and Beta Blocker Combination Therapy

Introduction to Combination Therapy

The American College of Cardiology suggests that the risks of combined therapy with verapamil and beta blockers may outweigh potential benefits, especially in patients with pre-existing left ventricular dysfunction, conduction system disease, pulmonary edema, elevated pulmonary arterial pressure, or marked outflow obstruction 1
The American College of Cardiology recommends caution when combining beta blockers and verapamil in patients with unstable angina/NSTEMI, and suggests that heart rate-slowing calcium channel blockers can be administered to patients without heart failure when beta blockers cannot be used 1

The American College of Cardiology states that there is no evidence that combined medical therapy with beta blockers and verapamil is more advantageous than using either drug alone for hypertrophic cardiomyopathy, and most clinicians favor using beta blockers over verapamil for initial treatment of exertional dyspnea 3, 5
The American College of Cardiology recommends that verapamil should be administered to patients who do not experience benefit from beta blockers or who have asthma, rather than adding it to ongoing beta blocker therapy 5

The American Heart Association, as published in Circulation, indicates that greater caution is indicated when combining a beta blocker and verapamil for refractory ischemic symptoms, and that a cautious approach is recommended if adding verapamil to beta blockers 1, 2
The American College of Cardiology suggests that when beta blockers are already being used, a cautious approach is recommended if adding verapamil, and that heart rate-slowing calcium channel blockers can be administered to patients without heart failure when beta blockers cannot be used 1, 2

The American College of Cardiology notes that for patients with hypertrophic cardiomyopathy and severe symptoms, some investigators discourage calcium antagonists and instead favor disopyramide (often with a beta blocker), and that disopyramide may be beneficial in patients with outflow obstruction who have not responded to beta blockers or verapamil 3, 4
The American College of Cardiology recommends that for unstable angina/NSTEMI, when beta blockers cannot be used, heart rate-slowing calcium channel blockers are preferred in the absence of significant left ventricular dysfunction 1