[Comparison of the effects of nifedipine and diltiazem in patients with stable angina pectoris of various severity and pathomorphology of the coronary arteries].
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In a double blind 7-week randomized study the authors compared in 29 patients with stable angina the action of placebo, nifedipine and diltiazem. Nifedipine was administered in amounts of 60 mg/day for three weeks, diltiazem 270 mg/day also for three weeks. Nifedipine and diltiazem exerted a significant antianginous action in patients with occluded but collateralized coronary arteries (group A), as well as in patients without collaterals (group B). In both these groups diltiazem improved the load tolerance significantly more than nifedipine. Nifedipine and diltiazem were useful also in patients with mild (group E), medium (group D) and severe (group C) affections of the coronary arteries. Groups C and E differed significantly as to the different effect of nifedipine and diltiazem on load S-T depressions (in group C diltiazem was significantly more effective, in group E nifedipine was insignificantly better), and it was not possible to explain these differences by a different effect on Robinson's index. The authors conclude that neither nifedipine nor diltiazem led in the amounts used to the "steal phenomenon" with clinical impact. In patients with mild affections of the coronary arteries their antiischaemic and antianginous action was similar, in patients with severe affection of the coronary arteries diltiazem was more effective.Keywords:
Coronary arteries
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Cardioprotection
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An epidemiological and clinical study was carried out on 31 patients with spasm of normal coronary arteries. The series comprised 24 males and 7 females aged 30 to 68 years (mean age: 48 years) with isolated resting chest pain (61 p. 100) or with resting and effort chest pains (39 p. 100). Their cardiovascular risk factors were compared to 735 unselected patients with coronary insufficiency undergoing coronary coronary angiography. Abnormalities of lipid metabolism (45 p. 100) and obesity (14 p. 100) were less common but there was a higher incidence of smoking (74 p. 100 compared to 48 p. 100). Sixteen patients had a psychological test: repressed aggressivity and severe anxiety were found in all patients, a state of separation coincided wtih the onset of the illness in 10 of the 16 patients. On admission, 13 patients presented with attacks of Prinzmetal variant angina, with myocardial infarction in 2 cases. Eighteen patients had non-invalidating angina with sporadic attacks. Coronary angiography was normal in 8 patients and showed lesions with less than 50 p. 100 narrowing in the other 23 patients. Mitral valve prolapse was found on left ventriculography in four patients. Exercise electrocardiography was positive in 7 out of 20 patients, and notably in those who had not had effort angina. All patients were treated with calcium antagonist drugs (25 Nifedipine, 6 Diltiazem), the efficacity of which was tested in 20 patients with a control ergometrine test. Thirty patients were followed up for 6 to 46 months (mean: 15 months). The exercise stress tests were repeated in the 7 patients with positive results before treatment and the results were negative in all cases. Twenty three patients were completely pain free or significantly improved, although 25 p. 100 of control tests remained positive (4/16). Six patients continued to have as much chest pain, and three had positive control tests. One patient with a negative control test developed acute myocardial infarction six months later in the territory of the spasm: during hospitalisation the ergometrine test became positive again.
Mitral valve prolapse
Coronary arteries
Ergometrine
ST depression
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We present a case of a 68-year-old male inflicted with a rare anomaly of the coronary artery. He had been suspected to have worsening effort angina and underwent urgent cardiac catheterization. The coronary angiography revealed 75% stenosis in the first diagonal branch. The left anterior descending artery was terminated in the mid portion and did not reach the apex. Instead, an anomalous coronary artery from the portion just proximal to the right coronary artery reached the apex. After cardiac catheterization, nocturnal chest pain at rest started to occur frequently. We suspected that vasospasm may have occurred because ST segment elevations in leads II, III, aVF were recorded on the electrocardiogram. Administration of diltiazem (120 mg per day) suppressed angina. Exercise stress electrocardiogram and thallium-201 myocardial scintigram did not show apparent ischemia. This case suggests that we must consider the presence of coronary vasospasm even in patients with clinically-supposed effort angina, to be possibly due to vasospasm occurring in anomalous coronary arteries.
Coronary vasospasm
Left coronary artery
Cardiac catheterization
Coronary arteries
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A 60-year-old patient with variant angina was shown to have myocardial ischemia in two different regions supplied by separate major coronary arteries. Neither artery had significant coronary atherosclerotic obstruction. Ventricular fibrillation was noted during ST-segment elevation in anteroseptal leads. The attacks of pain and arrhythmias disappeared during nifedipine therapy.
Coronary arteries
ST elevation
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Calcium antagonistic activity of MCI-176, a new calcium antagonist, was compared with those of diltiazem and nifedipine in isolated depolarized porcine coronary arteries. MCI-176, diltiazem and nifedipine competitively inhibited calcium contraction of the large coronary arteries, and their pA2 values were 7.49, 6.89 and 9.55, respectively. Similar competitive inhibition by MCI-176, diltiazem and nifedipine of calcium contraction was also observed in the small coronary arteries, and their pA2 values were 7.38, 6.83 and 9.91, respectively. Although calcium antagonistic activity of nifedipine was several hundreds times more potent than MCI-176 and diltiazem, the action of nifedipine, unlike MCI-176 and diltiazem, favored the small coronary arteries rather than the large coronary arteries.
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The efficacy and safety of oral nifedipine and diltiazem were compared in 20 patients with stable angina pectoris with use of a placebo run-in, randomized, double-blind titration to maximal effect crossover protocol. The effects of treatment withdrawal were also analyzed. All patients received placebo for 2 weeks and were then randomly assigned to receive either diltiazem or nifedipine. A 2 week drug titration phase in which patients received either diltiazem (180 to 360 mg/day) or nifedipine (30 to 120 mg/day) in three divided doses was followed by a 1 week maintenance phase. Patients then received placebo for 1 to 2 weeks, followed by crossover to the other treatment regimen and a second placebo washout period of 1 week. Patients (n = 13) who remained symptomatic on both diltiazem and nifedipine during the monotherapy periods entered a 3 week combination treatment phase, followed by a final 1 week placebo washout period. Frequency of angina, nitroglycerin consumption, exercise tolerance (Naughton protocol), and frequency of daily episodes of ST segment deviations on the electrocardiogram (1 mm of ST segment depression persisting for at least 1 min with and without chest pain) on an ambulatory electrocardiographic monitor were assessed during the baseline placebo, active monotherapy, placebo withdrawal, and combination treatment phases. Plasma drug levels were also measured. Compared with initial placebo values, the frequency of angina and the amount of nitroglycerin treatment were reduced by both diltiazem (p less than .001) and nifedipine (p less than .02). Diltiazem was more effective than nifedipine in reducing angina (p less than .02). Exercise duration increased with both drugs (p less than .0001). Diltiazem was significantly better than nifedipine in reducing the episodes of ST segment depression on the ambulatory monitor (p less than .01). Diltiazem reduced the resting heart rate (p less than .01); both drugs reduced the resting blood pressure and rate-pressure product. Overall, combination therapy was more effective in patients who did not maximally respond to diltiazem or nifedipine alone with respect to anginal and exercise variables and in reducing blood pressure at rest and during exercise. Plasma drug levels could not predict an individual patient's treatment response. Diltiazem may increase nifedipine drug levels when the drugs are combined. Fewer side effects were observed with diltiazem than nifedipine; the most side effects were seen with combination treatment. There were no apparent withdrawal effects observed with either treatment regimen.(ABSTRACT TRUNCATED AT 400 WORDS)
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The efficacy and safety of oral nifedipine and diltiazem were compared in 20 patients with stable angina pectoris with use of a placebo run-in, randomized, double-blind titration to maximal effect crossover protocol. The effects of treatment withdrawal were also analyzed. All patients received placebo for 2 weeks and were then randomly assigned to receive either diltiazem or nifedipine. A 2 week drug titration phase in which patients received either diltiazem (180 to 360 mg/day) or nifedipine (30 to 120 mg/day) in three divided doses was followed by a 1 week maintenance phase. Patients then received placebo for 1 to 2 weeks, followed by crossover to the other treatment regimen and a second placebo washout period of 1 week. Patients (n = 13) who remained symptomatic on both diltiazem and nifedipine during the monotherapy periods entered a 3 week combination treatment phase, followed by a final 1 week placebo washout period. Frequency of angina, nitroglycerin consumption, exercise tolerance (Naughton protoc...
Crossover study
Regimen
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Nifedipine, diltiazem and verapamil are three effective calcium-antagonists in the treatment of angina pectoris. We compared their effects on effort angina to evaluate whether one of them is more efficacious. The data were collected from 42 patients (37 males, 5 females; mean age 51 +/- 4) entering one of 3 different trials; the beginning of all trials comprised a two-week, single blind, placebo run-in phase. An exercise stress test was performed at the end of this period and it was considered as basal test for the statistical analysis. Then the 42 patients were divided in 3 groups of 14 and entered a double-blind, randomized phase of drug treatment. The 3 groups started 3 parallel trials: 1) placebo/nifedipine 60 mg/day; 2) placebo/verapamil 360 mg/day; 3) placebo/diltiazem 240 mg/day. The duration of each trial was of 6 weeks (3 weeks of treatment with placebo and 3 weeks with active substance). Exercise stress tests were performed at the end of each phase of the trials, and the resulting data were compared with the data of the test performed at the end of run-in period. Parameters evaluated were: heart rate, blood pressure and rate pressure product at basal conditions, at submaximal and peak exercise; moreover we considered workload, maximal ST segment depression, total exercise duration and frequency of exercise-induced angina. Verapamil reduced rate pressure product at basal condition; all three drugs reduced rate pressure product at submaximal exercise, but a significant statistical difference was found only for verapamil and diltiazem.(ABSTRACT TRUNCATED AT 250 WORDS)
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A 60-year-old patient with variant angina was shown to have myocardial ischemia in two different regions supplied by separate major coronary arteries. Neither artery had significant coronary atherosclerotic obstruction. Ventricular fibrillation was noted during ST-segment elevation in anteroseptal leads. The attacks of pain and arrhythmias disappeared during nifedipine therapy.
Coronary arteries
ST elevation
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