Can calcium‑channel blockers be used in a patient with systolic heart failure (reduced ejection fraction)?

Calcium Channel Blockers in Heart Failure with Reduced Ejection Fraction

Non-dihydropyridine calcium channel blockers (diltiazem and verapamil) are contraindicated in heart failure with reduced ejection fraction (HFrEF) and should not be used, as they worsen heart failure outcomes and increase hospitalizations. 1

Non-Dihydropyridine CCBs: Contraindicated in HFrEF

Diltiazem and verapamil are explicitly not recommended in patients with HFrEF due to their negative inotropic effects, which increase the risk of heart failure worsening and hospitalization. 1

• The 2016 ESC guidelines give diltiazem and verapamil a Class III recommendation (harm) in HFrEF, stating they "increase the risk of HF worsening and HF hospitalization." 1
• The 2013 ACC/AHA guidelines similarly classify non-dihydropyridine CCBs as Class III (No Benefit) with Level A evidence, stating they are "not recommended as routine treatment in HFrEF." 1
• Verapamil's FDA label explicitly warns it "has a negative inotropic effect" and "should be avoided in patients with severe left ventricular dysfunction (e.g., ejection fraction less than 30%) or moderate to severe symptoms of cardiac failure." 2

Exception: Acute Atrial Fibrillation with Rapid Ventricular Response

• In the specific scenario of acute AF with RVR in HFrEF patients who are hemodynamically stable, diltiazem may be cautiously considered as a second-line option when beta-blockers are insufficient or contraindicated, though data is limited. 3, 4
• Beta-blockers remain first-line for acute rate control in this setting due to their additional neurohormonal blockade benefits. 3
• Verapamil should be avoided even in this acute setting until more safety data are available. 3

Amlodipine: Safe but Not Beneficial in HFrEF

Amlodipine is the only calcium channel blocker that can be safely used in HFrEF, but only for treating concomitant hypertension or angina that is inadequately controlled by other medications—it provides no heart failure benefit itself. 5, 6

• The ACC/AHA guidelines classify amlodipine as Class III (No Benefit) for treating heart failure itself, but acknowledge it can be used safely for other indications. 1, 5
• Amlodipine has neutral effects on morbidity and mortality in HFrEF, unlike first-generation CCBs which caused worse outcomes. 5, 7
• The PRAISE trial demonstrated that amlodipine "had no effect on the primary endpoint of the study which was the combined endpoint of all-cause mortality and cardiac morbidity" in 1,153 patients with NYHA Class III/IV heart failure. 6
• Amlodipine must always be used in combination with guideline-directed medical therapy (ACE inhibitors/ARBs, beta-blockers, diuretics, mineralocorticoid receptor antagonists)—never as monotherapy or primary treatment for heart failure. 5

Clinical Use of Amlodipine in HFrEF

• Primary indications: concomitant hypertension or angina not adequately controlled by nitrates and beta-blockers. 5
• Monitor blood pressure closely during the first 3 months when blood pressure-lowering effects are most potent. 5
• Amlodipine offers no functional or survival benefit in heart failure, showing only no worsening of the condition. 5

Heart Failure with Preserved Ejection Fraction (HFpEF)

For HFpEF patients, non-dihydropyridine CCBs may be considered for rate control in atrial fibrillation, though beta-blockers are preferred first-line. 1

• The 2014 AHA/ACC/HRS AF guidelines recommend beta-blockers or non-dihydropyridine CCBs as Class I for rate control in HFpEF with AF. 1
• Non-dihydropyridine CCBs received a Class IIb recommendation (may be considered) for rate control in HFpEF. 1
• Recent observational data from 16,954 patients showed CCB use in HFpEF/HFmrEF was not associated with worse heart failure outcomes and was associated with lower pump failure death (HR 0.76), though stroke risk was higher (HR 1.26). 8

Common Pitfalls to Avoid

• Do not prescribe diltiazem or verapamil to any patient with reduced ejection fraction (<40%) outside of the acute AF with RVR scenario. 1
• Do not use amlodipine as primary heart failure therapy—it has no mortality or morbidity benefit for heart failure itself. 1, 5
• Avoid combining non-dihydropyridine CCBs with beta-blockers in HFrEF, as this increases the risk of heart failure decompensation. 2
• Approximately 7% of HFrEF patients with atrial fibrillation are inappropriately discharged on contraindicated CCBs, often on multiple AV nodal blockers simultaneously—this practice should be avoided. 9
• Ensure all HFrEF patients are on optimal guideline-directed medical therapy (ACE-I/ARB/ARNI, beta-blocker, MRA) before considering any CCB for comorbid conditions. 1