Colucci W S, Fifer M A, Lorell B H, Wynne J
Am J Med. 1985 Feb 22;78(2B):9-17. doi: 10.1016/0002-9343(85)90164-0.
Although it has been suggested that calcium channel blocking agents may be utilized as vasodilators in patients with congestive heart failure, these agents also have the potential to cause a deterioration in cardiac function because of their negative inotropic actions. There is considerable variation among the available agents with regard to their relative effects on the vasculature, myocardial inotropy, and myocardial chronotropy. Thus, at clinically relevant dosages, nifedipine is a potent systemic and coronary vasodilator, but it has little or no direct effect on inotropy and chronotropy. In contrast, verapamil exerts significant negative inotropic and chronotropic effects at vasodilatory dosages, whereas diltiazem is a potent vasodilator with a negative chronotropic action at dosages that do not affect inotropy. In patients with heart failure, the largest experience so far has been with nifedipine. Data derived from over 100 patients with moderate to severe congestive heart failure indicate a generally beneficial net hemodynamic response to nifedipine, with substantial improvements in cardiac index (+24 percent) and left ventricular filling pressure (-15 percent). The major effect seems to be on arteriolar resistance vessels, resulting in a reduction in afterload, with relatively little effect on venous pressures. Limited data suggest that the initial effect is sustained during long-term therapy. The clinical experience with verapamil and diltiazem in patients with heart failure is at present limited. In patients with normal or mildly impaired left ventricular function, verapamil's vasodilator and negative inotropic effects are counterbalanced. With severe left ventricular dysfunction, however, treatment with verapamil can result in abrupt decompensation and development of overt pulmonary edema and hypotension. Diltiazem's relative lack of negative inotropic effects may allow it to be used safely in patients with congestive heart failure, particularly when control of supraventricular tachyarrhythmia is required.
尽管有人提出钙通道阻滞剂可作为充血性心力衰竭患者的血管扩张剂，但由于其负性肌力作用，这些药物也有可能导致心功能恶化。现有药物在对血管系统、心肌收缩力和心肌变时性的相对影响方面存在很大差异。因此，在临床相关剂量下，硝苯地平是一种强效的全身和冠状动脉血管扩张剂，但对心肌收缩力和变时性几乎没有直接影响。相比之下，维拉帕米在血管扩张剂量下会产生显著的负性肌力和负性变时性作用，而地尔硫䓬是一种强效血管扩张剂，在不影响心肌收缩力的剂量下具有负性变时性作用。在心力衰竭患者中，迄今为止经验最多的是硝苯地平。来自100多名中重度充血性心力衰竭患者的数据表明，硝苯地平通常会产生有益的净血流动力学反应，心脏指数显著改善（+24%），左心室充盈压显著降低（-15%）。主要作用似乎是对小动脉阻力血管，导致后负荷降低，对静脉压的影响相对较小。有限的数据表明，长期治疗期间初始效应可持续。目前，维拉帕米和地尔硫䓬在心力衰竭患者中的临床经验有限。在左心室功能正常或轻度受损的患者中，维拉帕米的血管扩张和负性肌力作用相互抵消。然而，在严重左心室功能不全的情况下，使用维拉帕米治疗可能会导致突然失代偿，并出现明显的肺水肿和低血压。地尔硫䓬相对缺乏负性肌力作用，这可能使其能够安全地用于充血性心力衰竭患者，尤其是在需要控制室上性快速心律失常时。
