Use of calcium antagonists to treat heart failure

One can summarize the current status of calcium antagonists to treat heart failure as follows: Usually there is a favorable acute response to these drugs in heart failure patients but long-term effects in the patients treated with nifedipine, diltiazem, and verapamil have produced rather disappointing results. Thus, they should not be used routinely in heart failure patients. Their main problems were related to the negative inotropic effects of the drugs, the lack of reduction in ventricular filling pressure, and activation of the neurohumoral systems which have an adverse effect on cardiovascular performance, for example, renin-angiotensin. In contrast, the second-generation calcium antagonists have more selective vasodilating properties and fewer negative inotropic properties, which, I believe, justifies their use in selected heart failure patients. Unfortunately, there are no large randomized controlled long-term trials to evaluate morbidity and mortality in heart failure patients treated with these agents. One can rationalize that the symptomatic elderly patient with isolated diastolic dysfunction can be treated effectively with calcium antagonists but, once again, there are no major trials evaluating any drug in the management of patients with isolated diastolic function not due to hypertrophic cardiomyopathy. Rationale for using calcium antagonists could be best supported in patients with active ischemic heart disease and symptoms of heart failure. In this instance the coronary vasodilator effects may relieve myocardial ischemia and, by that mechanism, improve myocardial systolic and diastolic function.