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Nisoldipine

Editor: Muhammad F. Hashmi Updated: 2/28/2024 6:01:53 PM

Indications

FDA-Approved Indications

Nisoldipine is an FDA-approved 1,4-dihydropyridine calcium-channel blocker for the management of hypertension. The drug may be used alone or with other antihypertensive agents (eg, angiotensin-converting enzyme inhibitors, diuretics, or beta-blockers). The American College of Cardiology/American Heart Association guidelines for hypertension recommend calcium channel blockers, including nisoldipine, as one of the first-line therapies for hypertension.[1][2] The medication is also safe and effective for use in older patients.[3]

Off-Label Uses

Nisoldipine may be used off-label for treating ischemic heart conditions such as stable angina and Prinzmetal angina.[4]

Mechanism of Action

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Mechanism of Action

Nisoldipine falls under the class of dihydropyridine calcium channel blockers. The drug acts on the systemic smooth muscle cells by inhibiting the influx of calcium and blocking the voltage-gated calcium channels located in the cells; the reduction in the calcium results in the dilation of coronary and systemic arteries. Nisoldipine exhibits antihypertensive and anti-anginal activity due to its ability to reduce systemic blood pressure and the myocardial oxygen demand (thereby increasing myocardial oxygen delivery to cells).[5] This action ultimately results in vasodilation and decreases peripheral vascular resistance. Nisoldipine is comparatively more potent vasodilator than nifedipine.[6]

Pharmacokinetics

Absorption: The bioavailability of nisoldipine is low (5%) due to extensive first-pass (pre-systemic) metabolism.[7] Administration with high-fat meals significantly increases the peak plasma concentration and reduces nisoldipine's exposure/AUC (area under the curve).

Distribution: Plasma protein binding of nisoldipine is high. Nisoldipine can penetrate the blood-brain barrier.[8]

Metabolism: Nisoldipine is metabolized in the liver CYP3A4 pathway and excreted through the renal pathway.[9]

Elimination: Nisoldipine and its metabolites are excreted predominantly by the kidney. The elimination half-life is 13.7 ± 4.3 hours.[10]

Administration

Available Dosage Forms and Strengths

Nisoldipine is available in an oral formulation, as an extended-release tablet (20 mg, 30 mg, and 40 mg) or as an extended-release hydrogel (8.5 mg, 17 mg, and 34 mg). The patient should take the medication on an empty stomach or an hour after meals. The drug must be swallowed whole with water and not crushed or divided.[11] The dosing adjustment recommendations are on weekly intervals based on patient response. Avoid grapefruit juice and high-fat meals with medication administration because they affect drug bioavailability.[12]

Adult Dosing

Hypertension

  • Extended-release hydrogel is started at 17 mg by mouth daily, and the maximum daily dose is 34 mg by mouth daily.[1] The dosage is increased by 8.5 mg weekly or at longer intervals to achieve optimum blood pressure. The maintenance dose for nisoldipine ranges between 17 to 34 mg daily. In comparison, the original extended-release formulation is started at 20 mg/d and goes up to a maximum dosage of 40 mg daily. The dose is increased every 2 to 4 weeks for optimum blood pressure control. These formulations can be combined with ACE inhibitors, ARBs, beta-blockers, or thiazide diuretics if monotherapy is insufficient to attain the blood pressure goal.

Ischemic Heart Conditions

  • For ischemic heart disease, nisoldipine can be initiated at 8.5 mg once daily; the dose can be gradually titrated to 34 mg once daily.

Specific Patient Populations

Hepatic impairment: The concentration of nisoldipine is approximately 4 to 5-fold higher in patients with cirrhosis.[13] Starting with the lowest dose is recommended. The recommended dose is 8.5 to 10 mg orally daily (do not exceed 30 mg daily).

Renal impairment: Because nisoldipine's pharmacokinetics are not significantly different in patients with various degrees of renal impairment, dose adjustments are not required in patients with mild to moderate renal impairment.

Pregnancy considerations: No clinical data regarding nisoldipine in pregnancy exists. According to ACOG guidelines, chronic hypertension may result in substantial maternal, fetal, and neonatal morbidity and mortality. Patients may be treated with calcium channel blockers; however, nifedipine is preferred.[14]

Breastfeeding considerations: There is inadequate clinical data regarding the use of nisoldipine during lactation. Breastfeeding women should avoid this drug due to the risk of excretion into breast milk.[15]

Pediatric patients: The safety and efficacy of nisoldipine in the pediatric patient population have not been established.

Older patients: Caution is necessary for older patients due to higher drug plasma concentrations; recommendations are to start at a lower dose for safety. The recommended starting dose for hypertension is 8.5 mg once daily.

The equivalency of the nisoldipine dose is as follows:

Original Extended-Release Formulation 10 mg 20 mg 30 mg 40 mg
Extended-Release Hydrogel (newer) Formulation 8.5 mg 17 mg 25.5 mg 34 mg

Adverse Effects

Though nisoldipine is well-tolerated among patients, the drug does have some side effects mainly associated with its vasodilating property. Common adverse effects associated with nisoldipine include flushing, vasodilation (4%), hypotension, syncope, peripheral edema (7% to 29%,dose-related), headache (22%), dizziness (3% to 10%), and nausea (2%).[16]

Additionally, adverse reactions such as chest pain (2%), palpitations (3%), dermatitis (2%), pharyngitis (5%), and sinusitis (3%) are reported in patients taking nisoldipine. Occasional adverse effects (less than 1% of the population) include anemia, anxiety, alopecia, dysphagia, and gingival hyperplasia.[17]

In less than 1% of the population taking nisoldipine, the following adverse reactions are reported in postmarketing surveillance.

Increased blood urea nitrogen, increased creatine phosphokinase, abnormal hepatic function, increased serum creatinine, anorexia, hepatomegaly, abnormal dreams, amnesia, ataxia, cerebral ischemia,  cerebrovascular accident, depression, drowsiness,  insomnia, abnormal T waves on ECG, ejection murmur (systolic), first-degree atrioventricular block, atrial fibrillation, supraventricular tachycardia, amblyopia, blepharitis, diaphoresis, glaucoma, keratoconjunctivitis, exfoliative dermatitis, facial edema, dermal ulcer, hypersensitivity reaction, maculopapular rash, increased appetite, oral mucosa ulcer, hematuria, colitis, diarrhea, dysgeusia, dyspepsia, dysuria, epistaxis, gastritis, gastrointestinal bleeding, glossitis, leukopenia, malaise, melena, fever, flu-like symptoms, arthralgia, arthritis, gout, bruise, herpes simplex infection, herpes zoster, cellulitis, dyspnea, decreased libido, and gynecomastia is reported by manufacturer's product label.

In patients receiving peritoneal dialysis, there is a risk of nisoldipine-associated chyloperitoneum.[18]

Withdrawal Effects: Studies have shown that the abrupt withdrawal of nisoldipine may result in chest palpitations, chest pain, or increased severity of angina or hypertension. Thus, the medication must be slowly tapered over time.[18]

Drug-Drug Interactions

  • Nisoldipine is a substrate of the CYP3A4 enzyme. Avoid concurrent use of nisoldipine with cytochrome P450 inducers such as phenytoin.[19] Rifamycins are inducers of cytochrome P450; avoid concurrent use with nisoldipine.[20]
  • Avoid the concurrent use of nisoldipine with cytochrome P450 inhibitors such as itraconazole, as it can increase the serum concentration of nisoldipine and increase the risk of toxicity.[21][22]
  • Concurrent administration of calcium channel blockers with dantrolene increases the risk of hyperkalemia.[23]
  • Nisoldipine has the potential to interact with garlic and turmeric. Nisoldipine acts upon UGT (UDP-glucuronosyltransferase). Garlic and turmeric inhibit UGT, which can increase the serum concentration of nisoldipine. Avoid concurrent administration.[24]

Contraindications

Nisoldipine is contraindicated in individuals with hypersensitivity to the drug or other dihydropyridine calcium channel blockers. Nisoldipine-induced small bowel angioedema has been reported.[25]

Due to the lack of well-controlled studies, pregnant/breastfeeding women should avoid drug use to prevent teratogenicity. Nisoldipine is also contraindicated with grapefruit products and high-fat meals due to its effect on absorption.[26][27] Patients diagnosed with GERD or a hiatal hernia should exercise caution when using nisoldipine due to its action on the esophageal sphincter.[28] 

Warnings/Precautions

Hypotension/syncope: Hypotension with or without syncope is rarely reported, and target blood pressure should be attained at a rate appropriate for the patient's clinical condition. Clinicians should closely monitor patients during initial dosing and at dosage titrations.

Peripheral edema: The most common adverse reaction of nisoldipine is peripheral edema, which occurs within 2 to 3 weeks of therapy initiation. A prescribing cascade occurs when the edema is diagnosed as a new medical condition, and a diuretic is administered to manage the edema.[29]

Angina/myocardial infarction: Extreme caution is necessary for patients with aortic stenosis, myocardial infarction, or hypotension due to the risk of reflex tachycardia resulting in the possible exacerbation of angina or worsening of myocardial infarction (MI), especially in the absence of concomitant beta-blockade. Though rare, patients with coronary artery disease may have increased frequency or severity of angina after starting nisoldipine. Safety measures are advised in patients with heart failure or left ventricular dysfunction and severe bradycardia due to the drug's hypotensive effect.

Heart Failure: According to ACC/AHA heart failure guidelines, calcium channel blockers should be avoided in patients with heart failure due to lack of benefit and worsening of outcomes.[30]

Hepatic Impairment: Use nisoldipine with caution in patients with severe hepatic impairment.[9]

Monitoring

Individuals taking nisoldipine should be monitored for symptoms and any adverse effects of the medication. The medication should be stored in a cool place, away from heat and moisture.[3] 

The patient's blood pressure should be carefully observed during each clinic visit and at home. Monitoring cardiac function (eg, heart rate) for any abnormalities at each physician visit is essential, with dose adjustments made accordingly. It is also crucial to taper the dose slowly and adjust it at weekly intervals. Liver function test (LFT) monitoring is required in individuals with hepatic impairment. No dose adjustments are necessary for renal impairment.[16] According to ACC/AHA guidelines, ASCVD risk should be estimated for the primary prevention of cardiovascular diseases for patients with hypertension.[31]

Toxicity

Toxicity due to nisoldipine is diagnosed based on clinical status and history. As described above, hypotension with reflex tachycardia can occur when patients take excessive doses of dihydropyridine calcium channel blockers such as nisoldipine. In some severe cases of nisoldipine toxicity, the clinician will note hypotension with bradycardia. Secondary findings of confusion, heart failure, and abnormal ECG changes such as PR prolongation can indicate toxicity. Additionally, hyperglycemia in patients without diabetes can suggest calcium channel blockers poisoning.[32]

If toxicity is suspected, resuscitation is a priority. IV fluids and atropine for bradycardia are necessary alongside frequent reassessments by clinical staff. If a patient presents with severe symptoms, maintaining the airway, IV isotonic crystalloid, calcium salts, glucagon, insulin, and vasopressor therapy are all viable options. Activated charcoal should be administered to all patients suspected of nisoldipine overdose. Due to high plasma protein binding, dialysis is usually ineffective in nisoldipine overdose. Extracorporeal life support is associated with improved survival in patients with severe CCB poisoning related to cardiac arrest.[28]

Enhancing Healthcare Team Outcomes

In the United States, hypertension is one of the most common reasons for atherosclerotic cardiovascular disease (ASCVD)-related deaths.[33] Calcium channel blockers are widely used in the management of hypertension. An interprofessional healthcare team is the optimal means to successfully manage patients treated with dihydropyridine calcium channel blockers such as nisoldipine to address indicated pathologies.

Providers must be knowledgeable regarding the symptoms of toxicity. A team of physicians, advanced practice practitioners, nurses, laboratory technicians, pharmacists, and other healthcare professionals is necessary to optimize care to improve clinical outcomes in overdose cases. Pharmacists should provide accurate information regarding administering glucagon, insulin, and vasopressor therapy. A toxicologist consult should also take place when indicated. Cardiologists, intensivists, and the emergency team may be involved in managing a patient further, as many of these cases require further interventional management during the hospital course, including maintenance of an airway. By coordinating care, a patient on nisoldipine experiencing toxicity or adverse symptoms can be successfully managed.

Interprofessional team dynamics will also serve to prevent adverse reactions to nisoldipine. The prescriber can consult a pharmacist to verify dosing and check the medication record for potential drug interactions. Nurses can perform the necessary monitoring at follow-up visits and help determine patient compliance and treatment effectiveness, informing the prescriber and making recommendations as appropriate. The pharmacist and nursing should promptly alert the prescriber to any concerns so medication adjustments (dosing or agent selection) can improve patient outcomes.

References


[1]

Whelton PK, Carey RM, Aronow WS, Casey DE Jr, Collins KJ, Dennison Himmelfarb C, DePalma SM, Gidding S, Jamerson KA, Jones DW, MacLaughlin EJ, Muntner P, Ovbiagele B, Smith SC Jr, Spencer CC, Stafford RS, Taler SJ, Thomas RJ, Williams KA Sr, Williamson JD, Wright JT Jr. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension (Dallas, Tex. : 1979). 2018 Jun:71(6):e13-e115. doi: 10.1161/HYP.0000000000000065. Epub 2017 Nov 13     [PubMed PMID: 29133356]

Level 1 (high-level) evidence

[2]

Langan J, Rodríguez-Mañas L, Sareli P, Heinig R. Nisoldipine CC: clinical experience in hypertension. Cardiology. 1997:88 Suppl 1():56-62; discussion 63-5     [PubMed PMID: 9118169]


[3]

Lenz TL, Wurdeman RL, Hilleman DE. Comparison of 24-hour blood pressure profiles in patients with hypertension who were switched from amlodipine to nisoldipine. Pharmacotherapy. 2001 Aug:21(8):898-903     [PubMed PMID: 11718496]


[4]

Thadani U, Zellner SR, Glasser S, Bittar N, Montoro R, Miller AB, Chaitman B, Schulman P, Stahl A, DiBianco R. Double-blind, dose-response, placebo-controlled multicenter study of nisoldipine. A new second-generation calcium channel blocker in angina pectoris. Circulation. 1991 Dec:84(6):2398-408     [PubMed PMID: 1959195]

Level 1 (high-level) evidence

[5]

Chen YH, Liu RC, Wang SP. Antianginal and anti-ischemic efficacy of nisoldipine in stable angina pectoris: a randomized, double-blind, placebo-controlled trial. Zhonghua yi xue za zhi = Chinese medical journal; Free China ed. 1996 Nov:58(5):323-8     [PubMed PMID: 9037847]

Level 1 (high-level) evidence

[6]

Cacabelos R, Naidoo V, Corzo L, Cacabelos N, Carril JC. Genophenotypic Factors and Pharmacogenomics in Adverse Drug Reactions. International journal of molecular sciences. 2021 Dec 10:22(24):. doi: 10.3390/ijms222413302. Epub 2021 Dec 10     [PubMed PMID: 34948113]


[7]

El Maghraby GM, Elsergany RN. Fast disintegrating tablets of nisoldipine for intra-oral administration. Pharmaceutical development and technology. 2014 Sep:19(6):641-50. doi: 10.3109/10837450.2013.813543. Epub 2013 Jul 10     [PubMed PMID: 23841582]


[8]

Colbourne L, Harrison PJ. Brain-penetrant calcium channel blockers are associated with a reduced incidence of neuropsychiatric disorders. Molecular psychiatry. 2022 Sep:27(9):3904-3912. doi: 10.1038/s41380-022-01615-6. Epub 2022 May 26     [PubMed PMID: 35618884]


[9]

. Nisoldipine. LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. 2012:():     [PubMed PMID: 31643685]


[10]

Dudhipala N, Veerabrahma K. Pharmacokinetic and pharmacodynamic studies of nisoldipine-loaded solid lipid nanoparticles developed by central composite design. Drug development and industrial pharmacy. 2015:41(12):1968-77. doi: 10.3109/03639045.2015.1024685. Epub 2015 Apr 1     [PubMed PMID: 25830370]


[11]

Dudhipala N, Janga KY, Gorre T. Comparative study of nisoldipine-loaded nanostructured lipid carriers and solid lipid nanoparticles for oral delivery: preparation, characterization, permeation and pharmacokinetic evaluation. Artificial cells, nanomedicine, and biotechnology. 2018:46(sup2):616-625. doi: 10.1080/21691401.2018.1465068. Epub 2018 Apr 24     [PubMed PMID: 29688077]

Level 2 (mid-level) evidence

[12]

Rameis H. [Principles of the pharmacokinetics and pharmacodynamics of calcium antagonists]. Wiener medizinische Wochenschrift (1946). 1993:143(19-20):490-500     [PubMed PMID: 8135031]


[13]

Shah A, Krol G, Sundaresan P, Lettieri J, Falk R, Lasseter K, Heller AH. Pharmacokinetics of Nisoldipine Coat--Core Formulation in Subjects with Liver Cirrhosis. American journal of therapeutics. 1995 Jan:2(1):15-19     [PubMed PMID: 11850642]


[14]

American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin No. 203: Chronic Hypertension in Pregnancy. Obstetrics and gynecology. 2019 Jan:133(1):e26-e50. doi: 10.1097/AOG.0000000000003020. Epub     [PubMed PMID: 30575676]


[15]

. Nisoldipine. Drugs and Lactation Database (LactMed®). 2006:():     [PubMed PMID: 30000110]


[16]

White WB, Saunders E, Noveck RJ, Ferdinand K. Comparative efficacy and safety of nisoldipine extended-release (ER) and amlodipine (CESNA-III study) in African American patients with hypertension. American journal of hypertension. 2003 Sep:16(9 Pt 1):739-45     [PubMed PMID: 12944032]

Level 1 (high-level) evidence

[17]

Tajani AH, Nesbitt SD. Gingival hyperplasia in a patient with hypertension. Journal of clinical hypertension (Greenwich, Conn.). 2008 Nov:10(11):863-5. doi: 10.1111/j.1751-7176.2008.00036.x. Epub     [PubMed PMID: 19128276]

Level 3 (low-level) evidence

[18]

Kim S, Yu YM, Kwon J, Yoo H, Jung SH, Lee E. Calcium Channel Blocker-Associated Chyloperitoneum in Patients Receiving Peritoneal Dialysis: A Systematic Review. International journal of environmental research and public health. 2019 Apr 13:16(8):. doi: 10.3390/ijerph16081333. Epub 2019 Apr 13     [PubMed PMID: 31013922]

Level 1 (high-level) evidence

[19]

Perucca E. Clinically relevant drug interactions with antiepileptic drugs. British journal of clinical pharmacology. 2006 Mar:61(3):246-55     [PubMed PMID: 16487217]


[20]

Nahid P, Dorman SE, Alipanah N, Barry PM, Brozek JL, Cattamanchi A, Chaisson LH, Chaisson RE, Daley CL, Grzemska M, Higashi JM, Ho CS, Hopewell PC, Keshavjee SA, Lienhardt C, Menzies R, Merrifield C, Narita M, O'Brien R, Peloquin CA, Raftery A, Saukkonen J, Schaaf HS, Sotgiu G, Starke JR, Migliori GB, Vernon A. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2016 Oct 1:63(7):e147-e195. doi: 10.1093/cid/ciw376. Epub 2016 Aug 10     [PubMed PMID: 27516382]

Level 1 (high-level) evidence

[21]

Ikemura N, Yamaori S, Kobayashi C, Kamijo S, Murayama N, Yamazaki H, Ohmori S. Inhibitory effects of antihypertensive drugs on human cytochrome P450 2J2 activity: Potent inhibition by azelnidipine and manidipine. Chemico-biological interactions. 2019 Jun 1:306():1-9. doi: 10.1016/j.cbi.2019.04.005. Epub 2019 Apr 6     [PubMed PMID: 30965050]


[22]

Guengerich FP. Inhibition of Cytochrome P450 Enzymes by Drugs-Molecular Basis and Practical Applications. Biomolecules & therapeutics. 2022 Jan 1:30(1):1-18. doi: 10.4062/biomolther.2021.102. Epub     [PubMed PMID: 34475272]


[23]

Schneiderbanger D, Johannsen S, Roewer N, Schuster F. Management of malignant hyperthermia: diagnosis and treatment. Therapeutics and clinical risk management. 2014:10():355-62. doi: 10.2147/TCRM.S47632. Epub 2014 May 14     [PubMed PMID: 24868161]


[24]

Prieto-Garcia JM, Graham L, Alkhabbaz O, Mazzari ALDA. Potential Pharmacokinetic Interactions of Common Cardiovascular Drugs and Selected European and Latin American Herbal Medicines: A Scoping Review. Plants (Basel, Switzerland). 2023 Jan 31:12(3):. doi: 10.3390/plants12030623. Epub 2023 Jan 31     [PubMed PMID: 36771707]

Level 2 (mid-level) evidence

[25]

Turcu AF, White JA, Kulaga ME, Skluth M, Gruss CB. Calcium channel blocker-associated small bowel angioedema. Journal of clinical gastroenterology. 2009 Apr:43(4):338-41. doi: 10.1097/MCG.0b013e31815cf6b9. Epub     [PubMed PMID: 19077729]

Level 3 (low-level) evidence

[26]

Bailey DG, Dresser GK. Interactions between grapefruit juice and cardiovascular drugs. American journal of cardiovascular drugs : drugs, devices, and other interventions. 2004:4(5):281-97     [PubMed PMID: 15449971]


[27]

Stouras I, Papaioannou TG, Tsioufis K, Eliopoulos AG, Sanoudou D. The Challenge and Importance of Integrating Drug-Nutrient-Genome Interactions in Personalized Cardiovascular Healthcare. Journal of personalized medicine. 2022 Mar 22:12(4):. doi: 10.3390/jpm12040513. Epub 2022 Mar 22     [PubMed PMID: 35455629]


[28]

St-Onge M, Dubé PA, Gosselin S, Guimont C, Godwin J, Archambault PM, Chauny JM, Frenette AJ, Darveau M, Le Sage N, Poitras J, Provencher J, Juurlink DN, Blais R. Treatment for calcium channel blocker poisoning: a systematic review. Clinical toxicology (Philadelphia, Pa.). 2014 Nov:52(9):926-44. doi: 10.3109/15563650.2014.965827. Epub 2014 Oct 6     [PubMed PMID: 25283255]

Level 3 (low-level) evidence

[29]

Savage RD, Visentin JD, Bronskill SE, Wang X, Gruneir A, Giannakeas V, Guan J, Lam K, Luke MJ, Read SH, Stall NM, Wu W, Zhu L, Rochon PA, McCarthy LM. Evaluation of a Common Prescribing Cascade of Calcium Channel Blockers and Diuretics in Older Adults With Hypertension. JAMA internal medicine. 2020 May 1:180(5):643-651. doi: 10.1001/jamainternmed.2019.7087. Epub     [PubMed PMID: 32091538]


[30]

WRITING COMMITTEE MEMBERS, Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL, American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation. 2013 Oct 15:128(16):e240-327. doi: 10.1161/CIR.0b013e31829e8776. Epub 2013 Jun 5     [PubMed PMID: 23741058]

Level 1 (high-level) evidence

[31]

Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2019 Sep 10:74(10):e177-e232. doi: 10.1016/j.jacc.2019.03.010. Epub 2019 Mar 17     [PubMed PMID: 30894318]

Level 1 (high-level) evidence

[32]

Wachowiak R, Strach B, Lopatka P. [Toxicological analysis of selected 1,4-dihydropyridine calcium channel blockers in the diagnosis of intoxications]. Archiwum medycyny sadowej i kryminologii. 2005 Jan-Mar:55(1):47-54     [PubMed PMID: 15984121]


[33]

Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, Himmelfarb CD, Khera A, Lloyd-Jones D, McEvoy JW, Michos ED, Miedema MD, Muñoz D, Smith SC Jr, Virani SS, Williams KA Sr, Yeboah J, Ziaeian B. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. 2019 Sep 10:74(10):1376-1414. doi: 10.1016/j.jacc.2019.03.009. Epub 2019 Mar 17     [PubMed PMID: 30894319]

Level 1 (high-level) evidence