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Secondary and tertiary prevention with calcium antagonists in coronary artery disease
1Division of Cardiology, University Clinics, Kantonsspital Basle, Switzerland.
Insights
Calcium antagonists show mixed results for secondary prevention after myocardial infarction, with some improving survival in patients without heart failure. Their anti-atherosclerotic effects in coronary artery disease remain largely disappointing in clinical trials.
Area of Science:
- Cardiology
- Pharmacology
Background:
- Calcium antagonists are evaluated for cardiovascular disease prevention.
- Their role in secondary prevention post-myocardial infarction and tertiary prevention in coronary artery disease is under review.
Purpose of the Study:
- To review multicentre studies on the therapeutic value of calcium antagonists.
- To assess their efficacy in reducing cardiovascular complications and retarding atherosclerosis.
Main Methods:
- Review of recent multicentre studies and clinical trials.
- Analysis of data from trials like SPRINT, DAVIT II, MDPIT, and INTACT.
Main Results:
- Calcium antagonists yielded variable results in secondary prevention post-myocardial infarction.
- Verapamil and diltiazem showed benefits in patients without heart failure, unlike nifedipine in the SPRINT trial.
- Clinical anti-atherosclerotic effects were generally disappointing, though nifedipine showed some reduction in new lesion development.
Conclusions:
- Calcium antagonists have a limited, specific role in secondary prevention post-myocardial infarction.
- Their anti-atherosclerotic effects in coronary artery disease require further investigation.
- Patient selection, particularly regarding heart failure, is crucial for therapeutic benefit.
Abstract:
Recent multicentre studies evaluating the therapeutic value of calcium antagonists in reducing the incidence of cardiovascular complications after myocardial infarction (secondary prevention) and in retarding the development of atherosclerosis in coronary artery disease (tertiary protection) are reviewed. The prognosis of patients after acute myocardial infarction can be improved not only by interventional measures such as aortocoronary bypass surgery or percutaneous transluminal catheter angioplasty, but also by various drugs. Numerous studies have shown that beta-blockers and platelet aggregation inhibitors can reduce mortality and reinfarction rates. Calcium antagonists in secondary prevention trials after acute myocardial infarction, however, have produced variable results. Whereas the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) [Israeli SPRINT Study Group 1988] with nifedipine showed no beneficial effect of the drug, studies with verapamil in the Danish Verapamil Infarction Trial II (DAVIT II) [Danish Study Group on Verapamil in Myocardial Infarction 1990] and diltiazem in the Multicentre Diltiazem Postinfarction Trial (MDPIT) [Multicenter Diltiazem Postinfarction Trial Research Group 1988] as secondary prevention have demonstrated improvements in survival and cardiovascular complications, but these improvements were restricted to patients without heart failure. In view of the ability of calcium antagonists to reduce atheroma progression in coronary artery disease in animal models, the antiatherosclerotic effects of these agents in clinical studies have generally been disappointing. In the International Nifedipine Trial on Antiatherosclerotic Therapy (INTACT) [Lichtlen et al. 1990], however, nifedipine treatment was associated with a 28% reduction in new lesion development, but did not affect the development of severe lesions. Similar results have been obtained with nicardipine.