Drug Comparisons

The Calcium Channel Blockers (CCBs) are one of several classes of medications used in the treatment of various types of coronary heart disease (CHD) including chronic stable angina (chest pain with activity), unstable angina (chest pain at rest), and myocardial infarction (heart attack). The CCBs work by blocking calcium's entry into the heart muscle and blood vessels, thus, causing blood vessels to dilate (improves blood flow) and contraction of the heart to slow.

Because of slight differences in how various CCBs work in the body, the CCBs can be further categorized into one of two subclasses--the Dihydropyridine (pronounced "die-hi-dro-pie-rih-deen") CCBs and the Non-dihydropyridine CCBs.

The dihydropyridine CCB subclass includes amlodipine, felodipine, isradipine, nicardipine, nifedipine, and nisoldipine.

The non-dihydropyridine CCB subclass includes verapamil and diltiazem.

Drugs in this Class
Nifedipine ER (Adalat CC, Afeditab CR, Nifediac CC, Procardia XL)
Nisoldipine (Sular)
Diltiazem Hydrochloride Extended-Release Tablets (Cardizem LA)
Amlodipine (Norvasc)
Isradipine Capsules ()
Verapamil Extended-Release Capsules (Verapamil Sustained-Release Capsule, Verelan Sustained-Release Capsule)
Felodipine Extended-Release Tablets (Plendil Extended-Release Tablets)
Nicardipine (Cardene)
Verapamil Tablets (Calan Tablets)
Nicardipine SR (Cardene SR)

Summarizing the Evidence

There are many different drug classes that may be used to treat coronary heart disease. Clinical studies have been performed to compare CCBs to other drugs used for coronary heart disease. In general, CCBs are not used first-line in the treatment of coronary heart disease (CHD).

The choice of a drug for CHD depends on numerous factors such as other diseases or conditions you may have, other medications you may be taking, your doctor's preference and your prescription benefits formulary. Your doctor is in the best position to decide if a CCB is an appropriate treatment for your type of CHD.

Chronic stable angina (chest pain during activity)

• Studies comparing efficacy of the different CCBs have shown that they are similar in effectiveness in reducing angina frequency in patients with CHD. The most extensively studied CCBs are diltiazem and verapamil.

• CCBs are considered second-line therapy in treating the various types of CHD. In some types of angina, however, CCBs can be used first-line (eg. cocaine-induced angina or variant, spastic or Prinzmetal's angina which occur at rest due to a sudden spasm in one of the heart's blood vessels.)

• The Food and Drug Administration has approved extended-release nifedipine, immediate release nifedipine, amlodipine, nicardipine, verapamil and diltiazem for treatment of angina (chest pain) caused by coronary heart disease.

Unstable angina (chest pain at rest)

• Verapamil and diltiazem are two CCBs that should not be used first-line to treat unstable angina. Verapamil and diltiazem may be used in individuals who cannot tolerate, or have contraindications to first-line beta-blocker therapy. CCBs can also be added to beta-blocker therapy if angina symptoms are not adequately controlled on beta-blocker therapy. CCBs can also be substituted for a beta-blocker in individuals having unacceptable side effects with beta-blocker therapy.

Myocardial Infarction (heart attack)

• The American College of Cardiology and American Heart Association guidelines for treatment of an acute heart attack recommend that verapamil or diltiazem be used only in patients who cannot tolerate or have contraindications to first-line beta blocker therapy. CCBs can also be added to beta blocker therapy if the symptoms of angina are not controlled.

• CCBs are generally well tolerated with mild side effects. Several of the CCBs are associated with a higher incidence of side effects than the others. For example, verapamil is associated with more constipation than the other CCBs. Swelling of the ankles and feet has been associated with higher doses of CCBs, with the exception of diltiazem and verapamil. Excessive growth of the gums (gingival hyperplasia) has been most commonly documented with diltiazem and nifedipine but may occur with any of the CCBs.

Dosing and Administration

• Some products [nifedipine, verapamil, diltiazem, nicardipine] can typically be dosed up to three or four times daily. Sustained release formulations [nicardipine SR, isradipine, verapamil SR] are dosed twice daily, while extended-release nifedipine, nisolidipine, amlodipine, felodipine, isradipine, verapamil can often be dosed once daily. Once daily dosing is especially important when CCBs are used to treat angina because abrupt changes in blood pressure and heart rate may occur if a dose is missed of a drug taken two or three times daily.

Generic Availability

• Many formulations and strengths of amlodipine, diltiazem, verapamil, felodipine, nicardipine and nifedipine immediate release and extended-release formulations have generic equivalents that are available for a lower cost than the brand name formulations. Formulations that do not have generic equivalents available are isradipine (Dynacirc CR), nicardipine (Cardene SR), and nisoldipine (Sular).

Drug Interactions

Some interactions between medications can be more severe than others. The best way for you to avoid harmful interactions is to tell your doctor and/or pharmacist what medications you are currently taking, including any over-the-counter products, vitamins, and herbals. For specific information on how the drugs interact and the severity of the interaction, please use our Drug Interactions Checker.

Side Effects

To view specific side effect information, please use our Side Effect Checker.

Additional Information

1. Silvestry FE, St John Sutton MG. Sustained-release calcium channel antagonists in cardiovascular disease: pharmacology and current therapeutic use. Eur Heart J. 1998;19 (Suppl I):I8-I14.
2. Vascor. Raritan, NJ. Ortho-McNeil Pharmaceuticals, Inc: March 2000.
3. Verelan. Milwaukee, WI: Schwarz Pharma. May 2004.
4. Covera-HS [package insert]. Chicago, IL: G.D. Searle & Co.; May 2004.
5. Verelan PM [package insert]. Milwaukee, WI: Schwarz Pharma; May 2004.
6. Cardizem SR, Cardizem. Physicians Desk Reference. 53rd Ed. Montvale, NJ: Medical Economics Company, Inc. 1999:1314-1316, 1316-1318.
7. Cardizem CD [package insert]. Morrisville, NC: Biovail Pharmaceuticals, Inc.; August 2001.
8. Dilacor XR. Physicians Desk Reference. 54th Ed. Montvale, NJ: Medical Economics Company, Inc. 2000:3172-3174.
9. Tiazac [package insert]. St. Louis, MO: Forest Pharmaceuticals; April 2006.
10. Calan [package insert]. Chicago, IL: G.D. Searle LLC, A subsidiary of Pharmacia Corporation; July 2003.
11. Calan SR [package insert]. Chicago, IL: G.D. Searle LLC, A subsidiary of Pharmacia Corporation; July 2003.
12. Cardizem LA [package insert]. Bridgewater, NJ; April 2004.
13. Isoptin SR. Physicians Desk Reference. 55th Ed. Montvale, NJ: Medical Economics Company, Inc. 2001:1623-1625.
14. Adalat CC [package insert]. West Haven, CT: Bayer Corporation; August 2005.
15. Procardia [package insert]. New York, NY: Pfizer Labs; September 2000.
16. Procardia XL [package insert]. New York, NY: Pfizer Labs; August 2003.
17. Norvasc [package insert]. New York, NY: Pfizer Labs; September 2005.
18. Plendil[package insert]. Wilmington, DE: AstraZeneca LP; November 2003.
19. DynaCirc [package insert]. East Hanover, NJ: Sandoz Pharmaceuticals; March 1996.
20. DynaCirc CR [package insert]. East Hanover, NJ: Sandoz Pharmaceuticals; August 2005.
21. Cardene [package insert]. Nutley, NJ: Roche Laboratories; August 2000.
22. Cardene SR [package insert]. Nutley, NJ: Roche Laboratories; August 2000.
23. Sular [package insert]. Wilmington, DE: Zeneca Pharmaceuticals; January 2001.
24. Smolensky MH, Portaluppi F. Chronopharmacology and chronotherapy of cardiovascular medications: relevance to prevention and treatment of coronary heart disease. Am Heart J. 1999;137:S14-S24.
25. Black HR, Elliott WJ, Neaton JD, et al. Rationale and design for the Controlled Onset Verapamil Investigation of Cardiovascular Endpoints (CONVINCE) trial. Control Clin Trials. 1998;19(4):370-390.
26. Abernathy DR, Schwartz JB. Calcium-antagonist drugs. N Engl J Med. 1999;341:1447-1457.
27. Freher M, Challapalli S, Pinto JV, et al. Current status of calcium channel blockers in patients with cardiovascular disease. Curr Probl Cardiol. 1999;24;236-340.
28. Parker JD. Clinical outcome studies of anti-anginal drug therapy for patients with stable coronary disease: an indication for clinical trials. Eur Heart J. 1998;19(Suppl I):I15-I19.
29. Gibbons RJ, Chatterjee K, Daley J, et al. ACC/AHA/ACP-ASIM guidelines for the management of patients with chronic stable angina: executive summary and recommendations: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Chronic Stable Angina). Circulation. 1999;99:2829-2848.
30. Braunwald et al. ACC/AHA 2002 Guideline update for the management of patients with unstable angina and non-ST segment elevation MI. Available at: http://www.acc.org/clinical/guidelines/unstable/update_index.htm. Accessed May 20, 2004.
31. Silvestry FE, St John Sutton MG. Sustained-release calcium channel antagonists in cardiovascular disease: pharmacology and current therapeutic use. Eur Heart J. 1998;19 Suppl I:I8-I14.
32. Opie LH, Messerli FH. Nifedipine and mortality. Circulation. 1995;92:1068-1073.
33. Sleight P. Calcium antagonists during and after myocardial infarction. Drugs. 1996;51:216-225.
34. Koenig W, Lowel H, Lewis M, et al. Long-term survival after myocardial infarction: relationship with thrombolysis and discharge medication. Results of the Augsburg Myocardial Infarction Follow-up Study 1985 to 1993. Eur Heart J. 1996;17:1199-1206.
35. Zuanetti G, Latini R, Avanzini F, et al. Trends and determinants of calcium antagonist usage after acute myocardial infarction (the GISSI experience). Am J Cardiol. 1996;78:153-157.
36. Freher M, Challapalli S, Pinto JV, et al. Current status of calcium channel blockers in patients with cardiovascular disease. Curr Probl Cardiol. 1999;24;236-340.
37. Straka RJ, Swanson AL. Calcium channel antagonists: morbidity and mortality--what's the evidence? Am Fam Physician. 1998;57:1551-1560.
38. Koenig W, Hoher M. Felodipine and amlodipine in stable angina pectoris: results of a randomized double-blind crossover trial. J Cardiovasc Pharmacol. 1997;29:520-524.
39. Frishman WH, Glasser S, Stone P, et al. Comparison of controlled-onset, extended-release verapamil with amlodipine and amlodipine plus atenolol on exercise performance and ambulatory ischemia in patients with chronic stable angina pectoris. Am J Cardiol. 1999;83:507-514.
40. Knight CJ, Fox KM. Amlodipine versus diltiazem as additional antianginal treatment to atenolol. Am J Cardiol. 1998;81:133-136.
41. Psaty BM, Heckbert SR, Koepsell TD, et al. The risk of myocardial infarction associated with antihypertensive drug therapies. JAMA. 1995;274:620-625.
42. Braunwald E, Antman EM, Beasley JW, et al. ACC/AHA guidelines for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina). J Am Coll Cardiol. 2002.
43. Ellis JS, Seymour RA, Steele JG, et al. Prevalence of gingival overgrowth induced by calcium channel blockers: a community-based study. J Periodontol. 1999;70:63-67.
44. Tavassoli S, Yamalik N, Cagalyan F, et al. The clinical effects of nifedipine on periodontal status. J Periodontol. 1998;69:108-112.
45. Leenen FHH, Nwachuku CE, Black HR, et al. Clinical Events in High-Risk Hypertensive Patients Randomly Assigned to Calcium Channel Blocker Versus Angiotensin-Converting Enzyme Inhibitor in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Hypertension 2006; 48: 374-84.

Last Updated: April 2008
This content was created by members of the DrugDigest team of experts and is solely under DrugDigest's editorial control.

Note: The above information is intended to supplement, not substitute for, the expertise and judgment of your physician, pharmacist, or other healthcare professional. It should not be construed to indicate that the use of the product is safe, appropriate, or effective for you. Consult your healthcare professional before taking any medication.