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Angina - stable - Management
Who should avoid taking calcium-channel blockers?
- Rate-limiting calcium-channel blockers (verapamil and diltiazem) are contraindicated in people with:
- Heart failure.
- Bradycardia or atrioventricular block.
- Cardiac outflow obstruction (significant aortic stenosis or obstructive hypertrophic cardiomyopathy): vasodilatation may result in reduced cardiac output.
- Dihydropyridine calcium-channel blockers should not be started in people with uncontrolled heart failure (but amlodipine and felodipine can be used if heart failure is stable).
Basis for recommendation
These recommendations are based on information in the manufacturer's Summary of Product Characteristics [ABPI Medicines Compendium, 2009d; ABPI Medicines Compendium, 2009e] and on expert opinion in published reviews [Eisenberg et al, 2004; Thadani, 2004].
Heart failure
- All calcium-channel blockers (CCBs) can precipitate heart failure in people with heart failure because of their negative inotropic effects [Eisenberg et al, 2004].
- Verapamil and diltiazem should not be used in people with heart failure.
- Dihydropyridines rarely aggravate heart failure (any negative inotropic effect is offset by a reduction in left ventricular work). However, they should not be started in people with uncontrolled heart failure.
Cardiac outflow obstruction (significant aortic stenosis or obstructive hypertrophic cardiomyopathy)
- Vasodilatation may result in reduced cardiac output. Although people with hypertrophic cardiomyopathy may benefit from treatment with verapamil or diltiazem (by reducing obstruction), CCBs should only be initiated by a cardiologist in people with left ventricular outflow obstruction.
High-degree atrioventricular block
- Verapamil and diltiazem may induce complete atrioventricular block [Thadani, 2004].
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