Nifedipine-induced hypotension and myocardial ischemia in refractory angina pectoris

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Abstract
Combined nitrate/.beta.-blocker/nifedipine therapy is commonly used to treat refractory angina pectoris. Paradoxical myocardial ischemia was observed in 10 patients with refractory angina (7 receiving combined .beta.-blocker and nitrate therapy, and 3 receiving nitrate treatment alone) in whom nifedipine (mean dosage, 92 mg/day; range, 60-120 mg/day) induced a decrease in blood pressure, angina pectoris (10/10 patients), and ischemic ECG changes (7/10 patients). These 10 patients, all of whom regularly reported angina within 20-30 min of nifedipine ingestion, were prospectively studied before and after usual nifedipine dose administration, while blood pressures, heart rate, and ECG were recorded. Mean systolic BP [blood pressure] fell from 109 to 94 mm Hg after nifedipine (P < 0.001, paired t test); mean heart rate increased from 64 to 68 beats/min (P < 0.05); 7 patients developed transient ECG changes (5 with ST-T wave depression and 2 with ST-T wave elevation) during the hypotensive period. Nifedipine may provoke angina and myocardial ischemia in certain patients with refractory angina pectoris receiving concomitant .beta.-blocker and nitrate therapy.

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