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Treatment should be started with a beta-blocker rather than a diuretic. Propranolol may increase oxygen requirements by increasing left ventricular fiber length, end diastolic pressure, and the velocity and extent of myocardial contraction. Inderal reduces the energy used by the heart to pump blood around the body, and so reduces the heart's need for oxygen, which means it can also be used in the management of angina. Inderal is usually used in combination with clonidine to lower blood pressure, there is a risk of a rebound increase in blood pressure if the clonidine is stopped. If Propranolol is taken with calcium channel blockers such as verapamil, nifedipine or diltiazem, there may be an increased risk of slow heart rate, tremor and nausea. This combination can cause severely high blood pressure and heart failure. In concentrations producing beta-adrenergic blockade, which appears to be due to a reduction of the elevated outflow pressure gradient which is exacerbated by beta-adrenergic receptor stimulation.
