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[Calcium antagonists in cardiovascular diseases--a valuable controversy, but unnecessary panic]
1Department of Internal Medicine, Ochsner Clinic, New Orleans, Louisiana, USA.
Insights
Short-acting calcium antagonists are not recommended for hypertensive patients due to severe risks. Long-acting formulations, however, show promise for essential hypertension management, as seen in the HOT trial.
Area of Science:
- Cardiology
- Pharmacology
- Hypertension Management
Context:
- The use of calcium antagonists in hypertension management has been a subject of debate.
- Concerns exist regarding the safety and efficacy of short-acting formulations, particularly nifedipine.
- The Hypertension Optimal Treatment (HOT) trial provided significant data on calcium antagonist-based therapies.
Purpose:
- To evaluate the safety and efficacy of different calcium antagonist formulations in hypertensive patients.
- To provide guidance on the appropriate use of calcium antagonists based on available evidence.
- To address the controversy surrounding calcium antagonists and their impact on patient care.
Summary:
- Short-acting calcium antagonists, including oral and sublingual nifedipine, should be discontinued for hypertensive emergencies due to risks of syncope, myocardial infarction, stroke, and death.
- Low-dose, long-acting calcium antagonist formulations appear safe and effective for essential hypertension.
- The HOT trial demonstrated that calcium-antagonist-based combination therapy significantly reduced blood pressure and cardiovascular mortality.
Impact:
- This evidence suggests a shift towards prioritizing long-acting calcium antagonists in hypertension treatment protocols.
- Physicians should be aware that not all blood pressure-lowering drugs equally reduce morbidity and mortality.
- Clear communication is vital to prevent patient panic and physician frustration regarding medication controversies.
Abstract:
Taking into consideration the available data in 1998, we believe that short-acting calcium antagonists should no longer be used in hypertensive patients. The practice of using oral or sublingual nifedipine in hypertensive emergency or pseudoemergency should be abandoned because it can lead to serious side effects such as syncope, myocardial infarction, stroke and even death. However, the use of a low dose of the long-acting formulations seems to be safe and promising in patients with essential hypertension. In the Hypertension Optimal Treatment (HOT) trial a calcium-antagonist based combination therapy reduced blood pressure by over 20 mmHg in most of the nearly 19,000 patients. Cardiovascular mortality in this study was with 3.8 per 1000 patient years clearlylower as compared to 6.5 per 1000 patient years reported in previous intervention trials. A long-acting dihydropyridine calcium antagonist was used in 78% of these patients. Clearly the calcium antagonists controversy was helpful in alerting physicians to the fact that hypertension remains a surrogate endpoint and that not all drugs that reduce blood pressure will reduce morbidity and mortality to the same extent. What was completely unnecessary, however, was the inappropriate news media coverage to the calcium blocker controversy that led to panic and confusion among patients and frustration among physicians. In this context we should perhaps remember the first rule in the treatment of Sir George Pickering: "Never frighten your patients."