A 55-year-old with chronic stable angina is on a calcium channel blocker. The drug causes significant reflex tachycardia due to its strong peripheral vasodilation. Which drug is most likely?

• A Verapamil
• B Diltiazem
• C Amlodipine
• D Nifedipine ✓

Explanation

Nifedipine (a dihydropyridine) has the greatest vasodilatory action with minimal direct cardiac effects, causing significant baroreceptor-mediated reflex tachycardia which can worsen angina. This is why immediate-release nifedipine is no longer recommended as monotherapy for stable angina. Verapamil and diltiazem (non-dihydropyridines) have significant direct negative chronotropic and inotropic effects that counteract reflex tachycardia. Amlodipine (long-acting dihydropyridine) causes less reflex tachycardia due to its slow onset.

Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.

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