Next generation agents include lercanidipine, lacidipine, and manidipine. These dihydropyridines have important and subtle differences when compared with second and third generation dihydropyridine calcium antagonists. Lercanidipine has been shown to have major advantages over amlodipine. Because the drug dilates both afferent and efferent arterioles, the high incidence of peripheral edema caused by older calcium antagonists is reduced more than 50%. The balanced effect of lercanidipine and manidipine on efferent and afferent arterioles is important in renal protection. The older calcium antagonists listed above dilate only afferent arterioles. The COHORT study of elderly hypertensive patients concluded that lercanidip-ine and lacidipine are much better tolerated than amlodipine.
Recent investigations indicate that lercanidipine admin¬istered to hypertensive diabetic patients is more effective than the angiotensin receptor blocker, losartan, in reducing left ventricular hypertrophy and left ventricular mass.
These third generation dihydropyridines represent an important addition to the therapeutic armamentarium.
Their place in clinical practice will increase further if they are shown to be devoid of the major adverse effect of all calcium antagonists — the precipitation of heart failure in patients with significant left ventricular dysfunction.

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