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Concomitant diseases in elderly hypertensives: the position of nicardipine
1Centre d'Investigation Clinique, INSERM-CHU, University Henri Poincaré, Nancy, France.
Insights
Calcium antagonists, particularly nicardipine, show promise for treating elderly hypertension and related cardiovascular issues. However, recent studies question the safety of short-acting calcium antagonists in hypertensive patients.
Area of Science:
- Cardiology
- Geriatrics
- Pharmacology
Background:
- Aging leads to cardiovascular changes like isolated systolic hypertension and target-organ damage.
- These changes include cardiac hypertrophy, heart failure, coronary artery disease, arrhythmias, cerebrovascular diseases, peripheral vascular diseases, and renal insufficiency.
Purpose of the Study:
- To evaluate the potential advantages of dihydropyridine calcium antagonists in elderly patients with hypertension.
- To explore the specific benefits and limitations of nicardipine in this population.
- To address the controversy surrounding short-acting calcium antagonists.
Main Methods:
- Review of clinical practice and studies on calcium antagonists in the elderly.
- Analysis of nicardipine's effects on vascular function, cardiac parameters, and specific cardiovascular diseases.
- Consideration of recent case-control studies on short-acting calcium antagonists.
Main Results:
- Dihydropyridine calcium antagonists are suggested for elderly hypertension due to potential efficacy in low-renin states and better tolerability.
- Nicardipine demonstrates vasodilatory, anti-ischemic, antiplatelet, and hemorrheological effects, potentially improving cognitive function and reducing left ventricular mass and arrhythmias.
- Nicardipine may benefit elderly hypertensives with coronary artery disease but is generally not recommended for congestive heart failure; its long-term renal protection is unclear.
- Recent studies suggest a possible increased risk of myocardial infarction and mortality with short-acting calcium antagonists.
Conclusions:
- Nicardipine offers potential benefits for elderly hypertension and associated cardiovascular conditions, but further prospective trials are needed.
- The safety of short-acting calcium antagonists in hypertensive patients remains a subject of debate requiring rigorous investigation.
Abstract:
AGE-RELATED CARDIOVASCULAR CHANGES: Age-related changes in vascular structure and function may contribute to isolated systolic hypertension and target-organ damage. These include cardiac hypertrophy, systolic as well as diastolic dysfunction, congestive heart failure, coronary artery disease, cardiac arrhythmias, cerebrovascular diseases, peripheral vascular diseases and renal insufficiency. POTENTIAL ADVANTAGES OF CALCIUM ANTAGONISTS IN THE ELDERLY: Dihydropyridine calcium anatagonists have been advocated as first choice agents for the treatment of hypertension in the elderly on the grounds that (1) they may be more active in lowering blood pressure because of the predominantly low renin status in elderly hypertensives, (2) they may be better tolerated because side effects related to the activation of the sympathetic system may be less frequent because of attenuation of baroflexes during ageing and (3) they may have beneficial effects on a variety of concomitant cardiovascular diseases which are frequently present in the elderly. These assumptions, however are not always proven in clinical practice. ADVANTAGES OF NICARDIPINE: Additional to its potent vasodilatator action, nicardipine has anti-ischemic effects in both the coronary and the cerebral circulation, including antiplatelet and hemorrheological effects, and protection at ther cellular level against calcium overload and ischemia. The results of a large number of studies in cerebrovascular insufficiency suggest that nicardipine, may favourably affect the cerebral circulation and may improve the patient's cognitive function. Nicardipine may decrease left ventricular mass by about 4-12% and may reduce both the frequency and the severity of arrhythmias. The anti-anginal effects of nicardipine are well established. The drug is also able to decrease the progression of new atherosclerotic lesions in coronary arteries and is consequently potentially beneficial in elderly hypertensives with coronary artery disease. Nicardipine has no clinically significant negative inotropic effect. Nevertheless, in congestive heart failure, the use of calcium antagonists is usually not recommended because of the lack of clinical benefit and of possible harmful effects, including sympathetic and renin-angiotensin system stimulation. Although kidney protection may be provided by a strict and long-term control of blood pressure, the effects of nicardipine on long-term protection of renal function are not clear at present. RECENT CONTROVERSY CONCERNING SHORT-ACTING CALCIUM ANTAGONISTS: Much-debated recent case-control studies suggest that hypertensive patients treated with short-acting calcium antagonists may have an increased incidence of myocardial infarction and possibly of cardiovascular and total mortality. However, only well designed prospective comparative trials can answer this question.