WHAT, IF ANYTHING, IS CONTROVERSIAL ABOUT CALCIUM-ANTAGONISTS

Recent publications purporting to show that calcium antagonists, when used for the treatment of hypertension or in the post myocardial infar ction patient, would paradoxically increase the rate of heart attack a nd mortality have cast doubts on the safety and efficacy of this drug class. All three studies are retrospective, and have various drawbacks . Specifically, the metaanalysis of Furberg et al is fraught with mist akes, of borderline significance, and based on old data pertaining to short-acting nifedipine only (which should not be given in patients wh o have suffered an acute heart attack). The case control study of Psat y et al suggested that hypertensive patients who were treated with sho rt-acting verapamil, diltiazem, and nifedipine had an excessive rate o f myocardial infarction when compared with patients who were treated w ith diuretics. Two out of the three calcium antagonists that were used in this study were not approved for the treatment of hypertension by the US Food and Drug Administration. Some patients were taking these d rugs only once a day whereas, because of their short duration of actio n, at least a three or four times daily regimen would be required to a chieve an acceptable blood pressure control throughout a 24-h period. The cohort study of Pahor et al suggested distinct differences among v arious calcium antagonists with regard to survival. Blood pressure was controlled in <40% of all patients, and in some patients blood pressu re was never even measured. Recent studies, such as the Prospective Ra ndomized Amlodipine Survival Evaluation (PRAISE), the third Vasodilato r-Heart Failure Trial (VHeFT-III), the second Doppler Flow and Echocar diography in Functional Cardiac Insufficiency Assessment of Nisoldipin e Therapy (DEFIANT II), the Angina Prognosis Study in Stockholm (APSIS ), and the Shanghai Trial of Nifedipine in the Elderly (STONE), attest to the safety and efficacy of the newer long-acting calcium antagonis ts in patients with a wide spectrum of heart disease. Several ongoing trials including the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) with amlodipine, the International Nifedipine-GITS Study: Intervention as a Goal in Hypertension Treatme nt (INSIGHT) with nifedipine, the Hypertension Optimal Treatment study (HOT) with felodipine, the Systolic Hypertension in the Elderly in Eu rope Trial (SYST-EUR) with nicardipine, the Second Swedish Trial in Ol d Patients with Hypertension (STOP II) with felodipine, and Nordic Dil tiazem Study (NORDIL) with diltiazem, will give us morbidity and morta lity data in patients with high blood pressure within the next few yea rs. Until these results are available, we can be confident that the lo wering of blood pressure and providing relief of patients with symptom atic angina can be achieved safely and efficiently with the presently available long-acting calcium antagonists. (C) 1996 American Journal o f Hypertension, Ltd.