View source for Unstable angina non ST elevation myocardial infarction calcium channel blockers

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{{Unstable angina / NSTEMI}}
{{CMG}}; '''Associate Editors-In-Chief:''' {{CZ}}; [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.; Smita Kohli, M.D.; {{NMG}}

==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==
*[[CCB]]s 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 [[CCB]]s 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 [[CCB]]s 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 [[CCB]]s are preferred.<ref name="pmid17692738">{{cite journal |author=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 |title=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=[[Journal of the American College of Cardiology]] |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi=10.1016/j.jacc.2007.02.013 |url=http://linkinghub.elsevier.com/retrieve/pii/S0735-1097(07)00511-6 |accessdate=2011-04-09}}</ref>

==2014 AHA/ACC Guideline for the Management of Patients With Non–ST-Elevation Acute Coronary Syndromes (DO NOT EDIT) <ref name=Guidelines> 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) </ref>==

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' In patients with NSTE-ACS, continuing or frequently recurring [[ischemia]], and a contraindication to [[beta blocker]]s, 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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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 blocker]]s and [[nitrate]]s. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' [[CCB]]s are recommended for ischemic symptoms when [[beta blocker]]s are not successful, are contraindicated, or cause unacceptable side effects. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''4.''' Long-acting [[CCB]]s and nitrates are recommended in patients with [[coronary artery spasm]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Immediate-release [[nifedipine]] should not be administered to patients with NSTE-ACS in the absence of [[beta-blocker]] therapy. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|}

==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)<ref name="pmid21545940">{{cite journal| author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM et al.| title=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. | journal=J Am Coll Cardiol | year= 2011 | volume= 57 | issue= 19 | pages= e215-367 | pmid=21545940 | doi=10.1016/j.jacc.2011.02.011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21545940  }} </ref><ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>==
===Calcium Channel Blockers (DO NOT EDIT)<ref name="pmid21545940">{{cite journal| author=Wright RS, Anderson JL, Adams CD, Bridges CR, Casey DE, Ettinger SM et al.| title=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. | journal=J Am Coll Cardiol | year= 2011 | volume= 57 | issue= 19 | pages= e215-367 | pmid=21545940 | doi=10.1016/j.jacc.2011.02.011 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21545940  }} </ref><ref name="pmid17692738">{{cite journal |author=Anderson JL, Adams CD, Antman EM, ''et al'' |title=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=JACC |volume=50 |issue=7 |pages=e1–e157 |year=2007 |month=August |pmid=17692738 |doi:10.1016/j.jacc.2007.02.013 |url=}}</ref>===

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Immediate-release dihydropyridine [[calcium antagonists]] should not be administered to patients with [[Unstable angina]] / [[NSTEMI]] in the absence of a [[beta blocker]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])<nowiki>"</nowiki>
|}

{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''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]]. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])<nowiki>"</nowiki>
|}

==References==
{{reflist|2}}

[[Category:Ischemic heart diseases]]
[[Category:Intensive care medicine]]
[[Category:Disease]]
[[Category:Cardiology]]
[[Category:Emergency medicine]]
[[Category:Mature chapter]]
[[Category:Up-To-Date]]
[[Category:Up-To-Date cardiology]]
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