What are the contraindications for Nifedipine (calcium channel blocker)?

Contraindications for Nifedipine

Immediate-release nifedipine is contraindicated in patients with acute coronary syndromes, ST-elevation myocardial infarction, and hypertrophic cardiomyopathy with outflow tract obstruction due to increased risk of mortality and adverse cardiovascular events. 1

Absolute Contraindications

• Cardiogenic shock 2
• Concomitant use with strong P450 inducers (e.g., rifampin) 2
• Known hypersensitivity to any component of the medication 2
• Absence of beta-blocker therapy in patients with acute coronary syndromes 1
• ST-elevation myocardial infarction (STEMI) - immediate-release nifedipine causes reflex sympathetic activation, tachycardia, and hypotension 1
• Hypertrophic cardiomyopathy (HCM) with resting or provocable left ventricular outflow tract obstruction 1

Relative Contraindications/Use with Caution

• Systolic left ventricular dysfunction and congestive heart failure - diltiazem and verapamil are absolutely contraindicated in this setting, while dihydropyridines like nifedipine should be used with extreme caution 1
• Unstable angina - may increase risk of coronary events 3
• Recent myocardial infarction - may worsen outcomes 3
• Severe aortic stenosis - can worsen hemodynamics due to peripheral vasodilation
• Severe hypotension (systolic BP <90 mmHg)
• Advanced heart block (without pacemaker)

Clinical Context-Specific Contraindications

1. Hypertensive emergencies:

   • While nifedipine has historically been used for hypertensive emergencies, immediate-release formulations are no longer recommended due to risk of unpredictable hypotension, reflex tachycardia, and potential for cerebrovascular and cardiac events 3, 4
   • Other agents like clevidipine, nicardipine, or labetalol are preferred for hypertensive emergencies 1

2. Coronary artery disease:

   • Immediate-release nifedipine should not be used in acute coronary syndromes 1
   • If calcium channel blockers are needed in patients with coronary disease, longer-acting formulations are preferred, and ideally combined with beta-blockers 3

3. Perioperative setting:

   • Use with caution in perioperative hypertension management
   • Other agents like clevidipine or nicardipine are preferred 1

Special Populations Considerations

• Pregnancy: Category C - use only if benefits outweigh risks
• Hepatic impairment: Requires dose adjustment due to decreased metabolism
• Elderly patients: Start with lower doses due to increased risk of hypotension
• Patients on multiple antihypertensives: Increased risk of hypotension

Monitoring When Using Nifedipine

• Blood pressure and heart rate
• Signs of peripheral edema
• Symptoms of hypotension (dizziness, lightheadedness)
• ECG in patients with conduction disorders

Alternative Medications When Nifedipine is Contraindicated

• For hypertension: ACE inhibitors, ARBs, beta-blockers, or other calcium channel blockers
• For angina: Beta-blockers, long-acting nitrates, or other calcium channel blockers
• For vasospastic angina: Long-acting calcium channel blockers (e.g., amlodipine)

Remember that while immediate-release nifedipine has significant contraindications and safety concerns, extended-release formulations have better safety profiles when used appropriately for chronic conditions.