Should the dose of carvedilol (Coreg) be held for a patient with Peripheral Vascular Disease (PVD) presenting with hypotension and a heart rate of 88 beats per minute?

From the Guidelines

I would recommend holding the carvedilol 3.125 mg dose tonight due to the patient's low blood pressure of 104/58. For patients with PVD (peripheral vascular disease) on beta-blockers like carvedilol, it would be reasonable to hold the medication for systolic blood pressure (SBP) less than 100 mmHg or heart rate (HR) less than 55 beats per minute, as suggested by the potential for hypotension and associated symptoms like dizziness or falls 1. The current BP is borderline low, and you mentioned previous BPs have been "soft" as well, suggesting a pattern of lower blood pressure. While the current HR of 88 is acceptable, administering carvedilol could further lower the blood pressure, potentially causing hypotension and associated symptoms like dizziness or falls, as beta-blockers that also block alpha-1-receptors, such as carvedilol, can produce hypotension, which is usually asymptomatic but may produce dizziness, lightheadedness, or blurred vision 1. Please document the held dose and continue to monitor vital signs. If this pattern of lower blood pressure continues, Dr. Patel should consider reassessing the carvedilol dosing regimen or schedule. Be sure to notify the physician of this decision during handoff or in your documentation. Key parameters to monitor include SBP and HR, with a focus on avoiding SBP less than 100 mmHg and HR less than 55 beats per minute.

From the FDA Drug Label

5.2 Bradycardia In clinical trials, Carvedilol Tablet caused bradycardia in about 2% of hypertensive patients, 9% of heart failure patients and 6.5% of myocardial infarction patients with left ventricular dysfunction. If pulse rate drops below 55 beats/minute, the dosage should be reduced. 5.3 Hypotension Postural hypotension occurred in 1.8% and syncope in 0. 1% of hypertensive patients, primarily following the initial dose or at the time of dose increase and was a cause for discontinuation of therapy in 1% of patients.

The patient's current blood pressure is 104/58 and heart rate is 88. Given that the patient's last few blood pressures have been soft, it would be prudent to exercise caution.

• The patient's heart rate is above 55 beats/minute, so reducing the dosage is not necessary based on heart rate alone 2.
• However, the patient's blood pressure is on the lower side, and considering the risk of hypotension and postural hypotension associated with carvedilol, it may be wise to hold this dose and monitor the patient's blood pressure and heart rate closely 2. Systolic blood pressure to consider holding the dose would be below 90 mmHg, but this value is not explicitly stated in the label. Heart rate to consider holding the dose would be below 55 beats/minute, which is not the case here. Given the patient's current blood pressure and heart rate, and considering the potential risks, it would be reasonable to hold the dose and monitor the patient closely 2.

From the Research

Patient Assessment

• The patient has been diagnosed with Peripheral Vascular Disease (PVD) and is scheduled to take 3.125 mg of carvedilol tonight.
• The patient's current blood pressure is 104/58 mmHg, with a heart rate of 88 beats per minute.
• The patient's last few blood pressure readings have been low, with no parameters provided.

Carvedilol Mechanism of Action

• Carvedilol is a beta-adrenoceptor antagonist and a vasodilator, which reduces blood pressure by decreasing peripheral vascular resistance 3.
• The reduction in blood pressure produced by carvedilol is not associated with reflex tachycardia due to its beta-adrenoceptor blocking activity 3.
• Carvedilol has been shown to have antioxidant properties, which may provide additional benefits in patients with cardiovascular disease 4.

Considerations for Holding the Dose

• Given the patient's low blood pressure readings, it may be necessary to hold the dose of carvedilol to avoid further reducing blood pressure 5.
• However, carvedilol has been shown to be effective in patients with hypertension and peripheral vascular disease, and its use may be beneficial in this patient population 5.
• The patient's heart rate is within normal limits, but it is essential to monitor blood pressure and heart rate closely when administering carvedilol 6.

Systolic Blood Pressure and Heart Rate Targets

• The ideal systolic blood pressure target for patients with PVD is not explicitly stated in the provided evidence, but it is generally recommended to aim for a systolic blood pressure below 140 mmHg 7.
• The ideal heart rate target for patients with PVD is also not explicitly stated, but it is generally recommended to aim for a heart rate between 60-100 beats per minute 7.