This review evaluates the current position of
calcium channel blockers (CCB) in
antihypertensive treatment in the light of three major comparative studies and two extensive meta-analyses. The latter both show that CCB are equivalent to conventional (initial beta-blocker or
diuretic therapy) when total and cardiovascular mortality are the end points. Divergent points between the meta-analyses include
stroke and
myocardial infarction (MI). One meta-analysis compared CCB with conventional
therapy, to find a small 13% reduction in
stroke and a small, nonsignificant 12% increase in MI. The other meta-analysis found a 26% increase in MI when CCB were compared with all other
therapies including the
angiotensin converting enzyme (
ACE) inhibitors. This increase was most robust (P < .001) when comparing CCB with
ACE inhibitors, consonant with proposed protective effects of
ACE inhibitors on cardiovascular risk. At present, only the comparison of CCB with conventional
therapy, and not that with
ACE inhibitors, rests on secure comparative data. When cost is compelling, conventional
therapy is less expensive. For the individual patient, issues of quality of life (for example,
impotence with
diuretics and beta-blockers) might be decisive. Nonetheless, beta-blockers are preferred in postinfarct patients or in those with
heart failure or
unstable angina (a
contraindication to
dihydropyridines in the absence of beta-blockade). In others, the benefits of only a borderline
stroke reduction with CCB versus an equally borderline increase in MI should be evaluated for each individual patient, taking into account the age group and the patient's preferences. In conclusion, overall CCB are neither better nor worse than conventional
therapy, allowing for possible small differences in
stroke and MI. The
ACE inhibitors may protect better, although data are incomplete.