Boden W E, Korr K S, Bough E W
JAMA. 1985 Feb 22;253(8):1131-5.
Combined nitrate/beta-blocker/nifedipine therapy is commonly used to treat refractory angina pectoris. We have observed "paradoxical" myocardial ischemia in ten patients with refractory angina (seven receiving combined beta-blocker and nitrate therapy, and three receiving nitrate treatment alone) in whom nifedipine (mean dosage, 92 mg/day; range, 60 to 120 mg/day) induced a decrease in blood pressure, angina pectoris (10/10 patients), and ischemic ECG changes (7/10 patients). These ten patients, all of whom regularly reported angina within 20 to 30 minutes of nifedipine ingestion, were prospectively studied before and after usual nifedipine dose administration, while blood pressures, heart rate, and ECGs were recorded. Mean systolic BP fell from 109 to 94 mm Hg after nifedipine (P less than .001, paired t test); mean heart rate increased from 64 to 68 beats per minute (P less than .05); seven patients developed transient ECG changes (five with ST-T wave depression and two 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.
硝酸酯类/β受体阻滞剂/硝苯地平联合疗法常用于治疗难治性心绞痛。我们观察到10例难治性心绞痛患者（7例接受β受体阻滞剂和硝酸酯类联合治疗，3例仅接受硝酸酯类治疗）出现“矛盾性”心肌缺血，这些患者服用硝苯地平（平均剂量92毫克/天；范围60至120毫克/天）后血压下降、心绞痛发作（10/10例患者）以及缺血性心电图改变（7/10例患者）。这10例患者在服用硝苯地平后20至30分钟内均规律出现心绞痛，在常规剂量硝苯地平给药前后进行了前瞻性研究，同时记录血压、心率和心电图。服用硝苯地平后平均收缩压从109毫米汞柱降至94毫米汞柱（配对t检验，P<0.001）；平均心率从每分钟64次增加至68次（P<0.05）；7例患者在血压降低期间出现短暂性心电图改变（5例ST-T段压低，2例ST-T段抬高）。硝苯地平可能会使某些接受β受体阻滞剂和硝酸酯类联合治疗的难治性心绞痛患者诱发心绞痛和心肌缺血。
