What is the role of calcium channel blockers (CCBs) in the treatment of heart failure?

Calcium Channel Blockers in Heart Failure

Calcium channel blockers (CCBs) are generally not recommended as routine treatment for patients with heart failure with reduced ejection fraction (HFrEF), but certain types may be considered in specific heart failure scenarios. 1

Role of CCBs in Different Types of Heart Failure

Heart Failure with Reduced Ejection Fraction (HFrEF)

• Non-dihydropyridine CCBs (verapamil, diltiazem):

  • Contraindicated in HFrEF due to negative inotropic effects 1
  • Can lead to worsening heart failure and have been associated with increased risk of cardiovascular events 1

• Dihydropyridine CCBs (amlodipine, felodipine):

  • May be considered for concomitant conditions in HFrEF patients:
    • For management of hypertension when other agents are insufficient 1
    • For treatment of angina when other therapies are inadequate 1
  • Have neutral effects on mortality and morbidity in HFrEF based on clinical trials 2
  • Do not improve heart failure outcomes compared to placebo 1

Heart Failure with Preserved Ejection Fraction (HFpEF)

• CCBs may have a more favorable role in HFpEF:
  • Can be used to control hypertension and ventricular rate in patients with atrial fibrillation 1
  • Small studies suggest verapamil may improve exercise capacity and symptoms in HFpEF patients 1
  • Recent research suggests possible mortality benefit with CCBs in HFpEF patients 3, 4
  • Rate-limiting CCBs may be useful for ventricular rate control in HFpEF patients with AF 1

Evidence from Clinical Trials

• In the PRAISE-2 trial, amlodipine showed no statistically significant difference compared to placebo in all-cause mortality in patients with non-ischemic cardiomyopathy 2

• Long-term placebo-controlled mortality/morbidity studies of amlodipine in NYHA Class III-IV heart failure patients showed no effect on the combined endpoint of all-cause mortality and cardiac morbidity 2

• Newer CCBs (felodipine, amlodipine) added to baseline therapy including ACE inhibitors and diuretics do not provide better effect on survival compared to placebo 1

Specific Recommendations by CCB Type

Dihydropyridine CCBs (amlodipine, felodipine)

• May be considered in HFrEF patients who require additional treatment for:

  • Hypertension not controlled by first-line agents 1
  • Angina not responding to optimal therapy 1

• Have shown neutral effects on heart failure outcomes in clinical trials 5

• May be safer than non-dihydropyridine CCBs in heart failure patients due to greater vascular selectivity 5

Non-dihydropyridine CCBs (verapamil, diltiazem)

• Contraindicated in HFrEF 1
• Particularly contraindicated when combined with beta-blockers due to risk of heart block 1
• May have a limited role in HFpEF for rate control in atrial fibrillation 1

Practical Considerations

• When treating hypertension in heart failure patients:

  • ACE inhibitors, ARBs, beta-blockers, and diuretics should be prioritized over CCBs 1
  • If CCBs are needed, use dihydropyridine agents (amlodipine, felodipine) 1

• For patients with heart failure and angina:

  • Optimize existing therapy (e.g., beta-blockers) first
  • Consider coronary revascularization
  • Add long-acting nitrates
  • Only consider adding second-generation dihydropyridine CCBs if other measures fail 1

Common Pitfalls to Avoid

• Using non-dihydropyridine CCBs (verapamil, diltiazem) in patients with HFrEF
• Combining non-dihydropyridine CCBs with beta-blockers in heart failure patients
• Using short-acting nifedipine, which can cause reflex sympathetic activation
• Relying on CCBs as primary therapy for heart failure when more effective options exist

In summary, while CCBs are not first-line agents for heart failure treatment, certain dihydropyridine CCBs may be used cautiously in specific situations, particularly for managing comorbid conditions in heart failure patients. The evidence supports a more favorable role for CCBs in HFpEF compared to HFrEF.