Spectrum of acute hemodynamic effects of nifedipine in severe congestive heart failure

Elkayam, Uri; Weber, Laura; McKay, Charles R.; Rahimtoola, Shahbudin H.

doi:10.1016/0002-9149(85)91185-3

Cited by 92 publications

(18 citation statements)

References 27 publications

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“…These drugs have not improved symptoms of HF or enhanced exercise tolerance (580)(581)(582)(583)(584), and short-and long-term treatment with these drugs (even the use of sustained-release or vasoselective preparations) has increased the risk of worsening HF and death in patients with LV dysfunction (114,(585)(586)(587)(588)(589)(590)(591)(592)(593). Therefore, most calcium channel blockers should be avoided in patients with HF, even when used for the treatment of angina or hypertension.…”

Section: Recommendations Concerning Management Of Patients With Anginmentioning

confidence: 99%

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

Hunt

Abraham

Chin³

et al. 2005

Circulation

1,971

773

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Section: Recommendations Concerning Management Of Patients With Anginmentioning

confidence: 99%

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

Hunt

Abraham

Chin³

et al. 2005

Circulation

1,971

773

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“…However, since hemodynamic deterioration in patients with heart failure has also been described with other calcium entry-blocking agents in patients with heart failure,7' 24 this could also be related to the negative inotropic effect of diltiazem and needs further investigation. It is of importance that side effects were relieved in all but one patient 24 to 48 hr after a reduction of the dose of diltiazem from 360 to 240 mg/day. In one patient headaches persisted in spite of dose reduction and necessitated discontinuation of diltiazem therapy.…”

Section: Discussionmentioning

confidence: 93%

Efficacy and safety of medium- and high-dose diltiazem alone and in combination with digoxin for control of heart rate at rest and during exercise in patients with chronic atrial fibrillation.

Roth¹,

Harrison²,

Mitani³

et al. 1986

Circulation

166

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We evaluated the efficacy and the safety of medium-(240 mg/day) and high-dose (360 mg/day) diltiazem alone and in combination with digoxin when used for control of heart rate in 12 patients with chronic atrial fibrillation. Medium-dose diltiazem was comparable to therapeutic dose of digoxin at rest (88 ± 19 vs 86 + 12 beats/min) but superior during peak exercise (154 23 vs 170 + 20 beats/min; p < .05). High-dose diltiazem resulted in better control of heart rate than digoxin both at rest (79 17 beats/min; p < .05) and exercise (136 + 25 beats/min; p < .05) but was associated with side effects in 75% of the patients. Combined therapy of digoxin and diltiazem enhanced the effect of digoxin alone and resulted in significantly better control of heart rate at rest (67 + 16 beats/min with medium-dose and 65 + 15 beats/min with high-dose diltiazem) and during peak exercise (132 + 32 and 121 ± 24 beats/min, respectively). However, the difference in heart rate between these two doses was not significant. Reduction of heart rate combined with concomitant effect on blood pressure resulted in a significant fall in pressure-rate product at rest from 10,077 + 1708 mm Hg/min on digoxin alone to 7877 + 1818 mm Hg/min after the addition of medium-dose diltiazem (p < .05) and during exercise from 25,670 + 3606 to 18,439 4115 mm Hg/min (p < .05). Continued therapy with digoxin combined with diltiazem 240 mg/day for 21 ± 8 days in nine patients showed persistent effect on heart rate and blood pressure without any toxic manifestations or change in serum digoxin (1.5 + 0.4 vs 1.3 + 0.4 ng/ml) or plasma diltiazem concentrations (204 72 vs 232 129 ng/ml). In conclusion, medium-dose diltiazem when combined with digoxin is an effective and safe regimen for the treatment of patients with chronic atrial fibrillation and enhances digoxin-mediated control of heart rate both at rest and during exercise. Circulation 73, No. 2, 316-324, 1986. DIGITALIS has been used traditionally as a drug of choice for control of ventricular rate in patients with atrial fibrillation.1 2 Although the drug is valuable at rest, it is less effective in the control of heart rate response to exercise or other stress-related situations.3 1 4Recent studies have demonstrated that the direct effect of verapamil on slowing atrioventricular nodal conduction results in a better control of exercise heart rate in patients with atrial fibrillation.3 5,6 The

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“…Similarly, a comparison of change in hemodynamic indices of LV systolic function in the same patients with heart failure following a similar reduction in SVR with hydralazine and nifedipine [24] resulted in a significantly smaller augmentation of stroke volume, cardiac output and LV stroke work index with nifedipine, demonstrating the clinical relevance of its negative inotropic effect. Further evaluation of the hemodynamic profile of nifedipine in two large series of patients [18,25] showed acute hemodynamic and clinical deterioration after a single dose of 20-50 mg in 19 and 29% of the patients, respectively. Hemodynamic response could not be predicted from baseline hemodynamic data and LV ejection fraction in one study [18].…”

Section: Clinical Experience With Calcium Antagonists In Heart Failurementioning

confidence: 99%

“…Although the initial experience with the use of nifedipine in CHF led some investigators to conclude [10][11][12][13][14][15][16][17] that the negative inotropic effect of nifedipine could be offset by its vasodilatory effect, further evaluation in larger groups of patients demonstrated the clinical relevance of the cardiodepressant effect of the drug [18][19][20][21]. Comparison of nifedipine with nitroprusside [22] demonstrated a smaller augmentation in cardiac output and a larger decrease in systemic blood pressure with nifedipine despite a similar reduction in SVR.…”

Section: Clinical Experience With Calcium Antagonists In Heart Failurementioning

confidence: 99%

Calcium Channel Blockers in Heart Failure

Elkayam

1998

Cardiology

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A considerable effort has been made in the last 15 years to evaluate the safety and efficacy of calcium channel blockers (CCBs) in the treatment of patients with chronic congestive heart failure (CHF). Available studies have provided strong evidence for a potential detrimental effect of the first-generation calcium antagonists in patients with CHF, indicating the need for great caution when these drugs are used in patients with significant depression of left ventricular systolic function. A number of second-generation CCB have demonstrated a strong vasodilatory effect and favorable hemodynamic action but failed to show a similar improvement in exercise capacity, morbidity and mortality. Moreover, drugs such as nicardipine and nisoldipine have resulted in a detrimental effect in some patients and, therefore, cannot be considered safe when used in patients with moderate-to-severe heart failure. Available information from the V-HeFT III study demonstrate a lack of an unfavorable effect of felodipine on exercise tolerance in patients with chronic heart failure. Although mortality rate was similar in both the felodipine and the placebo group, because of the relatively small number of patients in this study, no clear conclusion can be drawn regarding the effect of felodipine on mortality in patients with CHF. An encouraging signal regarding a potential role of CCB in the treatment of chronic heart failure has been provided by the recently completed PRAISE study. This prospective large-scale study demonstrated the safety of amlodipine, a long-acting dihydropyridine derivative, when used in patients with heart failure due to coronary artery disease. Furthermore, this study demonstrated a substantial reduction in mortality in patients with CHF due to nonischemic cardiomyopathy and provided a strong indication for a potential therapeutic benefit of amlodipine when added to standard CHF therapy in this patient population. No clear explanation is available at the present time regarding the reason for the deleterious effect demonstrated with some of the dihydropyridines and the contrasting benefit seen with amlodipine. Finally, more information regarding the safety and efficacy of dihydropyridines should become available in the next year. The PRAISE II study is ongoing and will provide further information regarding the therapeutic role of amlodipine in patients with nonischemic dilated cardiomyopathy. The MACH-1 study is evaluating the effect of mibefradil, a predominant T-type channel blocker with an ideal activity profile, on morbidity and mortality in patients with chronic CHF.

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Spectrum of acute hemodynamic effects of nifedipine in severe congestive heart failure

Cited by 92 publications

References 27 publications

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult

Efficacy and safety of medium- and high-dose diltiazem alone and in combination with digoxin for control of heart rate at rest and during exercise in patients with chronic atrial fibrillation.

Calcium Channel Blockers in Heart Failure

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