Long-term beta-blocker treatment is well tolerated, has proven benefit in SIHD by reducing ischemic burden and threshold, and improves survival in patients with LV dys- function or history of MI.757,765,766 When prescribed in com- bination with agents that block the renin-angiotensin-aldoste- rone system, beta blockers are the preferred agents for the treatment of angina in patients with LV dysfunction after MI and in patients with heart failure, on the basis of documented improvements in survival and ventricular A meta-analysis of comparison trials between beta block- ers and calcium channel blockers (dihydropyridine and non- dihydropyridine agents) showed negligible differences in the rate of death or MI over relatively brief durations of admin- istration (ie, 6 wk to 6 mo), although patients with heart failure, heart block, or significant pulmonary disease were excluded from the meta-analysis.420 Beta blockers were found to exhibit an advantage with regard to control of angina and withdrawals from therapy due to adverse events, a problem that was most pronounced with nifedipine.420 Calcium chan- nel blockers, however, have not been shown to improve survival after MI, as beta blockers have, but have been shown to offer protection against severe angina and to reduce the risk of reinfarction after MI.849 851 Adherence to beta-blocker therapy can be influenced by the occurrence of adverse effects such as fatigue, lethargy, sexual dysfunction, or sleep disturbances. Although beta blockers have the potential to worsen symptoms in patients with significant depressive illness or PAD, these effects are observed rarely in clinical practice. For patients with severe PAD or those with vasospastic (Prinzmetal s) angina, wors- ening symptoms due to vasoconstriction from unopposed alpha-adrenergic activity can be avoided by using beta blockers with alpha-adrenergic blocking (eg, labetalol or carvedilol) or direct vasodilator (eg, nebivolol) properties. 4.4.3.1.2. Calcium Channel Blockers. 