Calcium channel blockers in heart failure with reduced ejection fraction
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Calcium channel blockers should generally be avoided in patients with heart failure with reduced ejection fraction (HFrEF) since they provide no functional or mortality benefit and some first generation agents may worsen outcomes .
The clinical trials that have evaluated the use of calcium channel blockers in patients with HFrEF will be reviewed here. Calcium channel blockers have a better defined role in the treatment of HF due to diastolic dysfunction, which is discussed separately. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Calcium channel blockers'.)
FIRST GENERATION AGENTS
Calcium channel blockers might be expected to have beneficial effects in systolic HF by reducing peripheral vasoconstriction and thereby reducing left ventricular afterload. However, these agents also have negative inotropic activity and several studies demonstrated greater clinical deterioration in patients treated with nifedipine and diltiazem compared to placebo or isosorbide dinitrate [2,3]. As a result, these drugs have generally been avoided in patients with systolic HF, even for the treatment of coexisting angina or hypertension.
Nifedipine — The effect of nifedipine in heart failure with reduced ejection fraction (HFrEF) depends, in part, upon the baseline hemodynamic status of the patient. Short-term use of the drug can cause hemodynamic deterioration when there is evidence of more severe HF, as manifested by high plasma renin activity, hyponatremia, and elevated right atrial pressure .
The adverse effects of long-term therapy with nifedipine were illustrated in a randomized, double-blind, crossover study of 28 patients with New York Heart Association (NYHA) class II or III HFrEF (table 1); nifedipine, with and without isosorbide dinitrate, was compared to isosorbide dinitrate alone . Eight weeks of therapy with nifedipine alone or in combination with isosorbide dinitrate resulted in a significantly higher incidence of hospitalization (24 and 26 versus 0 percent with isosorbide dinitrate alone), episodes of worsening HF (9 and 21 versus 5), and premature discontinuation of therapy due to clinical deterioration or other side effects (29 and 19 versus 5 percent).
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