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Antihypertensive therapy and myocardial infarction: focus on calcium antagonists
Insights
Antihypertensive therapy reduces stroke and myocardial infarction. However, beta-blockers are effective for secondary prevention post-myocardial infarction, not primary prevention in hypertension, and calcium antagonists show no overall benefit in secondary prevention trials.
Area of Science:
- Cardiology
- Pharmacology
- Public Health
Background:
- Effective antihypertensive therapy is known to reduce stroke and myocardial infarction incidence.
- Beta-blockers demonstrate a preventive effect in secondary prevention post-myocardial infarction, but this benefit may not extend to primary prevention in hypertension.
- Data on the secondary preventive effect of calcium antagonists in humans is limited.
Purpose of the Study:
- To review the evidence for the secondary preventive effects of antihypertensive drugs, specifically beta-blockers and calcium antagonists.
- To assess the role of different drug classes in primary versus secondary prevention of cardiovascular events in hypertensive patients.
Main Methods:
- Review of existing literature and clinical trial data.
- Analysis of placebo-controlled trials for verapamil and nifedipine in secondary prevention.
- Consideration of ongoing trials and future research directions.
Main Results:
- Two large trials with verapamil and nifedipine in secondary prevention did not show an overall treatment benefit.
- The secondary preventive effect of beta-blockers is established, but its applicability to primary prevention in hypertension is questionable.
- Ongoing trials are investigating calcium antagonists further.
Conclusions:
- Current evidence does not support an overall secondary preventive benefit for calcium antagonists.
- Management of hypertension should focus on blood pressure normalization and addressing other cardiovascular risk factors, particularly smoking.
- Large-scale trials may not definitively select specific drugs for cardiac event reduction in hypertension management.
Abstract:
Effective antihypertensive therapy has recently been shown to reduce not only the incidence of stroke, but also myocardial infarction irrespective of the drug(s) used. The well-documented preventive effect of beta-blockers in patients who suffered a myocardial infarction (secondary prevention) cannot be extended to patients with hypertension without overt coronary artery disease (primary prevention), except perhaps for non-smoking men. Despite strong experimental evidence, information on a possible secondary preventive effect of calcium antagonists in man is scant, and two double-blind placebo-controlled trials in secondary prevention with verapamil (320 mg) in a total of 1436 patients and nifedipine (30 mg) in 2279 patients did not reveal an overall treatment benefit. There are another six on-going trials. In the management of hypertension, large-scale trials may never help in selecting a particular drug for cardiac event reduction, and probably for many years the goals will be to normalize blood pressure with increased emphasis on the need to remedy other cardiovascular risk factors, in particular smoking.