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Angina - stable - Management
Managing calcium-channel blockers
Which calcium-channel blocker is recommended?
- Monotherapy (when a beta-blocker is contraindicated or not tolerated): a rate-limiting calcium-channel blocker (CCB) may be preferred.
- Combination therapy
- People taking a beta-blocker: prescribe a dihydropyridine (amlodipine, felodipine, or modified-release nifedipine).
- People not taking a beta-blocker: a rate-limiting CCB may be preferred.
- If the person has concomitant heart failure: prescribe a amlodipine or felodipine.
In depth
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).
In depth
What adverse effects are associated with calcium-channel blockers, and how can they be managed?
- Vasodilatory adverse effects (facial flushing, headaches, postural hypotension, and ankle swelling) can occur; they are more common with dihydropyridine calcium-channel blockers (CCBs) than rate-limiting CCBs.
- Vasodilatory effects usually reduce in severity with continued treatment, although ankle swelling often persists.
- Diuretics should not be routinely prescribed for ankle oedema, as they only partially reduce ankle oedema caused by CCBs.
- Verapamil commonly causes constipation.
- Advise the person to eat more fibre (such as fruit, vegetables, cereals, and wholemeal bread), to try to drink at least 12 cups (equivalent to eight glasses or eight mugs) of liquid a day, and to avoid drinks with a high caffeine content (because these can make constipation worse).
In depth
What key drug interactions should I be aware of?
- Beta-blockers
- The combination of a beta-blocker and verapamil should not be prescribed.
- The combination of a beta-blocker and diltiazem should only be prescribed on specialist advice.
- Digoxin
- Verapamil and verapamil: reduce the digoxin dose by one-third to one-half and monitor digoxin concentrations.
- Diltiazem and digoxin: monitor for signs of digoxin toxicity.
- Grapefruit
- Advise the person to avoid grapefruit juice, whole grapefruit, and grapefruit products.
In depth
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