Calcium antagonists in the elderly. A risk-benefit analysis.

Calcium antagonists are effective in lowering blood pressure, relieving anginal symptoms and improving exercise tolerance in older and younger patients with coronary artery disease. Verapamil and diltiazem are effective in slowing ventricular response rates to supraventricular arrhythmias in both older and younger patients. Although they belong to at least 3 distinct chemical classes, a moderate decrease in the clearance of all calcium antagonists occurs with aging. Most clinical trials of these drugs have used the same dosages in older and younger patients, confounding analyses of sensitivity in older compared with younger patients. Greater reductions in blood pressure usually occur in older compared with younger patients receiving the same dosages of calcium antagonists; similarly, the dosage required to reduce blood pressure to a certain level is usually lower in older compared with younger patients. Drug acquisition costs are generally higher for calcium antagonists than for beta-blockers or diuretics. Compared with younger patients, greater heart rate suppression may be seen in older patients treated with verapamil and diltiazem; conversely, heart rate increases are usually seen with dihydropyridines. Calcium antagonists have not been shown to provide long-term benefits or decreased morbidity or mortality in elderly patients with hypertension. Verapamil, but not dihydropyridines, decreases mortality after myocardial infarction in patients without congestive heart failure. Calcium antagonists have not been shown to be beneficial in the treatment of acute stroke. Adverse effects, such as a postural hypotension, may be more frequent in elderly compared with younger patients. In addition, the elderly are at greater risk for drug interactions with calcium antagonists due to the higher likelihood that they are receiving other drugs.