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Angina - stable - Management
Which calcium-channel blocker is recommended?
- Monotherapy (when a beta-blocker is contraindicated or not tolerated): expert opinion suggests using a rate-limiting calcium-channel blocker (CCB) (diltiazem or verapamil) in preference to a dihydropyridine CCB. Reasons for this include [Fox et al, 2006a]:
- Rate-limiting CCBs, such as verapamil and diltiazem, have the additional action of decreasing myocardial contractility and heart rate.
- Dihydropyridine CCBs can sometimes cause reflex tachycardia, which may increase angina symptoms, although this is more likely to be a problem with short-acting dihydropyridines than with longer-acting preparations.
- Combination therapy
- People taking a beta-blocker: prescribe a dihydropyridine CCB (amlodipine, felodipine, or modified-release nifedipine).
- People not taking a beta-blocker: a rate-limiting CCB may be preferred (see above).
- If the person has concomitant heart failure: prescribe a amlodipine or felodipine.
Basis for recommendation
Rate-limiting calcium-channel blockers (CCBs)
- Rate-limiting CCBs (verapamil and diltiazem) may be preferred as monotherapy in people who cannot take a beta-blocker because these drugs also reduce myocardial contractility, heart rate, and atrioventricular node conduction [Fox et al, 2006a; SIGN, 2007].
- Verapamil is contraindicated in combination with a beta-blocker; diltiazem should only be combined with a beta-blocker on the advice of a cardiologist (see Drug interactions for more information).
- Rate-limiting CCBs are contraindicated in people with heart failure (see Cautions and contraindications for more information).
Dihydropyridines
- Long-acting dihydropyridines (such as amlodipine) or modified-release formulations of short-acting CCBs (such as nifedipine or felodipine) should be used to minimize fluctuations of plasma concentrations and increased cardiovascular effects [Eisenberg et al, 2004; Fox et al, 2006a].
- There is conflicting evidence on the safety of nifedipine in people with angina. A meta-analysis suggests that nifedipine monotherapy or short-acting nifedipine in combination with other drugs for angina may increase the risk of cardiovascular events [Stason et al, 1999].
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