From the Guidelines
Nifedipine should be avoided in patients with heart failure because it can worsen the condition, as stated in the 2013 ACCF/AHA guideline for the management of heart failure 1.
Reasons to Avoid Nifedipine in Heart Failure
- As a dihydropyridine calcium channel blocker, nifedipine causes peripheral vasodilation and reflex sympathetic activation, which increases heart rate and myocardial oxygen demand, further straining an already compromised heart.
- In heart failure patients, nifedipine may lead to increased fluid retention, worsening of symptoms, and potentially precipitate acute decompensation.
- The negative inotropic effects of calcium channel blockers can further reduce contractility in an already weakened heart.
Alternative Treatment Options
- Standard heart failure medications like ACE inhibitors, beta-blockers, aldosterone antagonists, and diuretics are preferred as they have proven mortality benefits.
- If a calcium channel blocker is absolutely necessary for a heart failure patient with hypertension, amlodipine is generally considered safer as it has less negative inotropic effects and has been studied in heart failure populations 1.
Clinical Considerations
- Patients with heart failure should be monitored carefully for changes in serum potassium, and every effort should be made to prevent the occurrence of either hypokalemia or hyperkalemia, both of which may adversely affect cardiac excitability and conduction and may lead to sudden death 1.
- Close observation and follow-up are crucial in managing heart failure patients, and nonadherence with diet and medications can rapidly and profoundly affect the clinical status of patients 1.
From the FDA Drug Label
Congestive Heart Failure Rarely, patients (usually while receiving a beta-blocker) have developed heart failure after beginning nifedipine Patients with tight aortic stenosis may be at greater risk for such an event, as the unloading effect of nifedipine would be expected to be of less benefit to these patients, owing to their fixed impedance to flow across the aortic valve. Nifedipine can not be used in patients with heart failure because it may worsen heart failure in some cases, particularly in patients with tight aortic stenosis or those receiving beta-blockers 2.
- Key points:
- Nifedipine may cause excessive hypotension
- Increased angina and/or myocardial infarction may occur
- Congestive heart failure may develop after beginning nifedipine, especially in patients with tight aortic stenosis or those receiving beta-blockers.
From the Research
Nifedipine in Heart Failure
- Nifedipine, a calcium channel blocker, is not recommended for use in patients with heart failure due to its potential to worsen the condition 3, 4.
- The drug can cause hemodynamic and clinical deterioration, and may increase the frequency of cardiac events in post-myocardial infarction patients with heart failure 3.
- Nifedipine can depress left ventricular contractility in the short term, and can activate neurohormonal systems due to its hypotensive effects 3.
Mechanism of Action
- Calcium channel blockers, including nifedipine, can theoretically be effective in treating chronic systolic heart failure due to their actions as arteriolar dilators, anti-ischemic agents, and relaxants of diastolic left ventricular function 3, 4.
- However, the first-generation calcium channel blockers, such as nifedipine, verapamil, and diltiazem, have direct negative inotropic effects and can worsen heart failure 4.
Clinical Evidence
- Studies have shown that nifedipine can improve symptoms and reduce blood pressure in patients with severe hypertension and congestive heart failure, but these effects may not be beneficial in patients with heart failure due to systolic dysfunction 5.
- Larger trials have found that calcium channel blockers, including nifedipine, may have detrimental effects on survival and cardiovascular events in patients with heart failure 4.
- The use of nifedipine in patients with heart failure is not recommended, except in specific cases where the benefits outweigh the risks, such as in the management of hypertension or coronary artery disease in patients with heart failure 4.