Heart Medications: Concerns About Verapamil and Stroke Risk

Q: Heart Medications: Concerns About Verapamil and Stroke Risk

Hello： 1, 2, 4. <br>Diltiazem and Verapamil are both classified as calcium channel blockers in pharmacology, commonly used to treat hypertension and alleviate tachycardia. <br>However, they are not recommended for use in cases of bradycardia or in patients with atrioventricular (

Xinsuping and Katie Heart

Hello Dr.
Hong,
This article continues from the previous question #153145.
I will list my questions for easier reading, and I kindly ask for your clarification.
Thank you.
1.
I often experience occasional missed heartbeats.
After my recent echocardiogram and 24-hour Holter monitor examination, the doctor said it was fine...
less than one percent.
However, he switched my medication from "Kadyshyn 90mg" to "Sotalol 240mg" (split in half).
2.
I recently searched online for the "Sotalol" package insert and noticed that it mentioned "use with caution in patients with cerebrovascular disease."
3.
Due to my dizziness issues, I had a neck ultrasound done in the neurology department.
The doctor mentioned that there was a narrowing in one area of the intracranial vessels but could not determine if it was congenital or acquired.
He advised me to continue taking the cardiology medications, and I have been asking my doctor every six months or annually whether I need follow-up examinations, but he said it was unnecessary.
4.
Regarding the cautionary note in the Sotalol package insert about "use with caution in patients with cerebrovascular disease," what does "cerebrovascular disease" refer to? I am a bit concerned whether Sotalol (Verapamil) is suitable for me.
P.S.
Given the severe recent pandemic situation, I really prefer not to visit the hospital frequently or occupy appointment slots.
I hope Dr.
Hong can help clarify these concerns.
Thank you.

Mr. Zhang, 50~59 year old female. Ask Date: 2020/03/11

Dr. Hong Weibin reply Neurology

Hello: 1, 2, 4.
Diltiazem and Verapamil are both classified as calcium channel blockers in pharmacology, commonly used to treat hypertension and alleviate tachycardia.
However, they are not recommended for use in cases of bradycardia or in patients with atrioventricular (AV) block.
It is also advisable not to use them concurrently with beta-adrenergic blockers.
I did not find specific information indicating that a history of cerebrovascular disease contraindicates their use.
Below are the contraindications and precautions regarding Verapamil from Medscape.
Warnings
Contraindications:
- Hypersensitivity to Verapamil or other calcium channel blockers
- Cardiogenic shock
- Congestive heart failure
- Symptomatic hypotension
- Sick sinus syndrome (unless a permanent pacemaker is in place)
- 2°/3° AV block (unless a permanent pacemaker is in place)
Cautions:
- Aortic stenosis
- Atrial fibrillation/flutter with accessory bypass tract
- 1° AV block
- Hypertrophic cardiomyopathy (e.g., idiopathic hypertrophic subaortic stenosis)
- Hypotension (initially or after dose increases)
- Exacerbation of angina (during initiation of treatment, after dose increase, or after withdrawal of beta blockers)
- Neuromuscular transmission defects; may exacerbate myasthenia gravis
- Hepatic or renal impairment
- Persistent progressive dermatologic reactions
- Generic products may not be bioequivalent
- Do not prescribe Covera-HS or Verelan PM for shift workers
- Concurrent beta-blocker therapy
- Concurrent ivabradine therapy; slows AV conduction; use cautiously with beta blockers
- Hypotension and bradyarrhythmias observed with concurrent use of other CYP3A4 substrates (e.g., cyclosporine, telithromycin) due to competitive metabolism
- Coadministration with CYP3A4 inhibitors (e.g., erythromycin, itraconazole) may decrease metabolism and thus increase toxicity
- Sinus bradycardia resulting in hospitalization and pacemaker insertion has been reported with concurrent use of clonidine and Verapamil; monitor heart rate if coadministered
- Verapamil is no longer part of the Pediatric Advanced Life Support tachyarrhythmia algorithm
- Potential toxic dose in patients <6 years old: 15 mg/kg
3.
Intracranial vascular stenosis typically requires evaluation of the severity of the stenosis.
If the stenosis is severe, one may inquire about the need for vascular stenting or artificial vessel replacement surgery.
However, the benefits and risks of such invasive treatment methods are still not definitively established.
Therefore, it is currently recommended to routinely use antiplatelet medications (or other anticoagulants) and to manage risk factors for stroke (such as weight, hypertension, diabetes, hyperlipidemia, smoking cessation, etc.) to slow the progression of atherosclerosis and plaque formation.
As for the need for follow-up, you can discuss this with your attending physician.

Reply Date: 2020/03/11

More Info

When considering the use of heart medications such as Verapamil, especially in the context of existing health conditions, it is essential to understand both the benefits and potential risks associated with their use. Verapamil is a calcium channel blocker commonly prescribed for conditions like hypertension, angina, and certain types of arrhythmias. However, it is crucial to evaluate its appropriateness in patients with a history of cerebrovascular issues.

1. Understanding Cerebrovascular Disease: The term "cerebrovascular disease" encompasses a range of conditions that affect blood flow to the brain, including stroke, transient ischemic attacks (TIAs), and other vascular abnormalities. The warning regarding the use of Verapamil in patients with cerebrovascular disease is primarily due to the potential for these medications to affect blood pressure and cerebral perfusion. In patients with existing vascular narrowing or other cerebrovascular conditions, the use of medications that can alter blood flow dynamics may pose a risk of exacerbating these issues.

2. Your Specific Situation: Based on your description, you have experienced occasional palpitations and have undergone evaluations that have not indicated significant concerns. The switch from Diltiazem (Kaidixin) to Verapamil (Xinsuping) may have been made to better manage your symptoms. However, the mention of a narrowing in your intracranial vessels raises valid concerns. While your neurologist has indicated that no immediate follow-up is necessary, it is essential to remain vigilant about any new symptoms or changes in your condition.

3. Verapamil and Stroke Risk: The concern regarding Verapamil in patients with cerebrovascular disease stems from its potential to lower blood pressure. In individuals with compromised cerebral circulation, this could theoretically lead to insufficient blood flow to the brain, increasing the risk of ischemic events. However, if your blood pressure is well-controlled and you are monitored regularly, the risk may be mitigated. It is essential to have open communication with both your cardiologist and neurologist regarding your treatment plan.

4. Monitoring and Follow-Up: Given your history of dizziness and the findings from your neck ultrasound, it would be prudent to maintain regular follow-ups with your healthcare providers. If you experience any new symptoms, such as increased dizziness, visual changes, or weakness, it is vital to seek medical attention promptly. Additionally, if you have concerns about the use of Verapamil, discussing these with your cardiologist can provide clarity and reassurance.

5. Lifestyle Considerations: Alongside medication management, lifestyle factors play a significant role in cardiovascular health. Maintaining a healthy diet, engaging in regular physical activity, managing stress, and avoiding smoking can all contribute to better outcomes. If anxiety about your health is affecting your quality of life, consider discussing this with your healthcare provider, as they may recommend strategies or therapies to help manage these feelings.

In conclusion, while Verapamil can be an effective medication for managing certain heart conditions, its use in patients with a history of cerebrovascular issues requires careful consideration and monitoring. Regular communication with your healthcare team is essential to ensure that your treatment plan is safe and effective. If you have any further questions or concerns, do not hesitate to reach out to your healthcare provider for personalized advice.

Similar Q&A

Does Cardiovascular Medication Increase Heat Stroke Risk?

Hello Dr. Lin, in 2015, I was diagnosed with left coronary artery atherosclerosis. In 2020, due to atrial fibrillation, I underwent two catheter ablation procedures. Since then, I have been taking five medications: (1) Isosorbide dinitrate (Esmolol), (2) Apixaban (Eliquis), (3) M...

Dr. Lin Zhebin reply Family Medicine
Hello: 1. The medications you are taking that are more likely to cause discomfort in your body include: - Isosorbide Dinitrate: Its primary function is vasodilation, and it may cause side effects such as dizziness, palpitations, and hypotension, among others. - Propafeno...

Managing Atrial Fibrillation and Stroke Risk in Elderly Patients

My grandmother at home is 96 years old and has symptoms of hypertension, for which she is taking antihypertensive medication. In early June, she suddenly experienced slurred speech and weakness in one side of her limbs. Unfortunately, she was not taken to the hospital within the ...

Dr. Chen Jili reply Cardiology
I suggest that you discuss the above situation with your grandmother's attending physician to see if further examinations are necessary. Thank you, and wish you good health!

Concerns About Heart Disease Medications: A Patient's Inquiry

[A]. Condition: There is severe ischemia or infarction and vascular calcification in the anterior wall of the apex (currently experiencing persistent shortness of breath, but the physician has not yet decided on a treatment plan). [B]. Medications prescribed by the physician: [1]...

Dr. Liao Lingmei reply Pharmacology
Dear Wayne: As I am not a physician, I would like to address your questions regarding the relationship between medication components and their effects. 1. Is there a risk of renal failure when combining antihypertensive medications with aspirin? There may be reports suggesting ...

Understanding the Medications for Tachycardia: Irbesartan, Glimepiride, and Diltiazem

Hello Doctor: Thank you very much for your detailed response regarding my mother's "pulse frequency syndrome" medication during our last inquiry. On July 15, my mother had a follow-up appointment, and the doctor prescribed "IRBESARTAN (APROVEL) 150MG/TA" ...

Dr. Zhong Yuxun reply Cardiology
Hello, Ms. Qiu: Glimepiride is marketed under the brand name Amaryl and is classified as an antidiabetic medication. Diltiazem 120 is a type of calcium channel blocker that can be used for treating arrhythmias, lowering blood pressure, and managing myocardial ischemia. Its side e...