Unstable angina non ST elevation myocardial infarction calcium channel blockers
 |
Intern Survival Guide |
|
Unstable angina / NSTEMI Microchapters |
|
Differentiating Unstable Angina/Non-ST Elevation Myocardial Infarction from other Disorders |
|
Special Groups |
|
Diagnosis |
|
Laboratory Findings |
|
Treatment |
|
Antitplatelet Therapy |
|
Additional Management Considerations for Antiplatelet and Anticoagulant Therapy |
|
Risk Stratification Before Discharge for Patients With an Ischemia-Guided Strategy of NSTE-ACS |
|
Mechanical Reperfusion |
|
Discharge Care |
|
Case Studies |
|
Unstable angina non ST elevation myocardial infarction calcium channel blockers On the Web |
|
FDA on Unstable angina non ST elevation myocardial infarction calcium channel blockers |
|
CDC onUnstable angina non ST elevation myocardial infarction calcium channel blockers |
|
Unstable angina non ST elevation myocardial infarction calcium channel blockers in the news |
|
Blogs on Unstable angina non ST elevation myocardial infarction calcium channel blockers |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.; Smita Kohli, M.D.; Neil Gheewala, M.D. [3]
Overview
Calcium channel blockers (CCBs) consist of three subclasses: Dihydropyridines (e.g., nifedipine, amlodipine), Phenylalkylamines (e.g., verapamil), and Benzothiazepines (e.g., diltiazem).
Mechanism of Benefit
- CCBs inhibit both myocardial and vascular smooth muscle contraction.
- They also cause AV block and sinus node slowing.
The degree of these effects varies amongst the three classes with nifedipine and amlodipine having the most peripheral arterial dilatory effects but few or no AV or sinus node effects, whereas verapamil and diltiazem having prominent AV and sinus node effects and but only some peripheral arterial dilatory effects.
Although different CCBs are structurally and, potentially, therapeutically diverse, superiority of 1 agent over another in unstable angina/NSTEMI has not been demonstrated, except for the increased risks posed by rapid-release, short-acting dihydropyridines such as nifedipine.
Indications
- Calcium channel blockers may be used to control ongoing or recurring ischemia-related symptoms in patients who already are receiving adequate doses of nitroglycerine (NTG) and beta blockers, in patients who are unable to tolerate adequate doses of 1 or both of these agents, and in patients with variant angina.
- Definitive evidence for a benefit of CCBs in unstable angina/NSTEMI is predominantly limited to symptom control.
- When beta blockers cannot be used, and in the absence of clinically significant LV dysfunction, heart rate slowing CCBs are preferred.[1]
2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) [2]
| Class I |
| "1. In patients with NSTE-ACS, continuing or frequently recurring ischemia, and a contraindication to beta blockers, a nondihydropyridine calcium channel blocker (CCB) (e.g., verapamil or diltiazem) should be given as initial therapy in the absence of clinically significant LV dysfunction, increased risk for cardiogenic shock, PR interval greater than 0.24 second, or second- or third degree atrioventricular block without a cardiac pacemaker. (Level of Evidence: B)" |
| "2. Oral nondihydropyridine calcium antagonists are recommended in patients with NSTE-ACS who have recurrent ischemia in the absence of contraindications, after appropriate use of beta blockers and nitrates. (Level of Evidence: C)" |
| "3. CCBs are recommended for ischemic symptoms when beta blockers are not successful, are contraindicated, or cause unacceptable side effects. (Level of Evidence: C)" |
| "4. Long-acting CCBs and nitrates are recommended in patients with coronary artery spasm. (Level of Evidence: C)" |
| Class III |
| "1. Immediate-release nifedipine should not be administered to patients with NSTE-ACS in the absence of beta-blocker therapy. (Level of Evidence: B)" |
2011 ACCF/AHA Focused Update Incorporated Into the ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non -ST-Elevation Myocardial Infarction (DO NOT EDIT)[3][1]
Calcium Channel Blockers (DO NOT EDIT)[3][1]
| Class I |
| "1. In unstable angina / NSTEMI patients with continuing or frequently recurring ischemia and in whom beta blockers are contraindicated, a non dihydropyridine calcium channel blocker (e.g., verapamil or diltiazem) should be given as initial therapy in the absence of clinically significant left ventricular dysfunction or other contraindications. (Level of Evidence: B)" |
| Class III |
| "1. Immediate-release dihydropyridine calcium antagonists should not be administered to patients with Unstable angina / NSTEMI in the absence of a beta blocker. (Level of Evidence: A)" |
| Class IIa |
| "1. Oral long acting non dihydropyridine calcium antagonists are reasonable for use in Unstable angina / NSTEMI patients for recurrent ischemia in the absence of contraindications after beta blockers and NTG have been fully used. (Level of Evidence: C)" |
| Class IIb |
| "1. The use of extended-release forms of non dihydropyridine calcium antagonists instead of a beta blocker may be considered in patients with Unstable angina / NSTEMI. (Level of Evidence: B)" |
| "2. Immediate-release dihydropyridine calcium antagonists in the presence of adequate beta blocker may be considered in patients with Unstable angina / NSTEMI with ongoing ischemic symptoms or hypertension. (Level of Evidence: B)" |
References
- ↑ 1.0 1.1 1.2 Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Chavey WE, Fesmire FM, Hochman JS, Levin TN, Lincoff AM, Peterson ED, Theroux P, Wenger NK, Wright RS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Halperin JL, Hunt SA, Krumholz HM, Kushner FG, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B (2007). "ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-Elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine". Journal of the American College of Cardiology. 50 (7): e1–e157. doi:10.1016/j.jacc.2007.02.013. PMID 17692738. Retrieved 2011-04-09. Unknown parameter
|month=ignored (help) - ↑ Ezra A. Amsterdam, MD, FACC; Nanette K. Wenger, MD et al.2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. JACC. September 2014 (ahead of print)
- ↑ 3.0 3.1 Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM; et al. (2011). "2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 Guidelines for the Management of Patients with Unstable Angina/Non-ST-Elevation Myocardial Infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines developed in collaboration with the American Academy of Family Physicians, Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons". J Am Coll Cardiol. 57 (19): e215–367. doi:10.1016/j.jacc.2011.02.011. PMID 21545940.