What heart rate parameters indicate holding medication?

Heart Rate Parameters for Holding Medication

Medications should be held when heart rate falls below 45-50 beats per minute (bpm) or when systolic blood pressure drops below 100 mmHg to prevent adverse outcomes including increased mortality and stroke. 1

Heart Rate Thresholds by Medication Class

Beta Blockers

• Hold oral beta blockers if heart rate is consistently below 45 bpm 1
• For patients with heart rates between 45-49 bpm, delay next dose by 12 hours 1
• For intravenous beta blockers, hold if heart rate drops below 50 bpm 1
• Target resting heart rate for optimal outcomes is typically 50-60 bpm if well tolerated 2, 3

Calcium Channel Blockers (Non-dihydropyridine)

• Hold diltiazem or verapamil if heart rate is less than 50 bpm 1
• Avoid these medications completely in patients with decompensated heart failure 1
• For patients with atrial fibrillation, maintain heart rate between 60-100 bpm, with up to 110 bpm potentially acceptable in some cases 1

Digoxin

• Hold if heart rate falls below 50 bpm 1
• Use with caution in elderly patients who are more susceptible to bradycardia 1
• Target heart rate for digoxin in heart failure patients is typically 60-80 bpm 1

Amiodarone

• Hold if heart rate drops below 50 bpm 1
• Monitor closely in combination with other rate-controlling medications due to additive effects 1

Clinical Context Considerations

Atrial Fibrillation Management

• For rate control in atrial fibrillation, a heart rate <80 bpm at rest is reasonable for symptom management 1
• A more lenient rate control strategy (resting heart rate <110 bpm) may be reasonable in asymptomatic patients with preserved left ventricular function 1
• Heart rates between 60-100 bpm are generally targeted, with lower rates (60-70 bpm) associated with better outcomes 1

Perioperative Beta Blockade

• In perioperative settings, hold beta blockers if heart rate is consistently below 45 bpm 1
• Clinically significant bradycardia (heart rate <45 bpm) is associated with increased risk of death and stroke (adjusted OR 2.13,95% CI 1.37 to 3.12) 1
• An absolute mean perioperative heart rate lower than 70 bpm is associated with the best outcomes, but not if it causes symptomatic bradycardia 1

Hypertrophic Cardiomyopathy

• For HOCM patients, target resting heart rate is 50-60 bpm unless limited by side effects 4, 5
• Hold beta blockers if heart rate drops below 50 bpm 4

Important Pitfalls to Avoid

• Do not abruptly discontinue beta blockers in the perioperative period unless absolutely necessary, as this can increase mortality risk 1
• When bradycardia occurs, investigate for alternative causes beyond medication effects, such as sick sinus syndrome or heart block 1
• In patients with persistent tachycardia despite rate-controlling medications, search for underlying causes such as sepsis, hypovolemia, pulmonary embolism, or anemia before adjusting medications 1
• Remember that heart rate parameters should be interpreted alongside blood pressure measurements, as hypotension (systolic BP <100 mmHg) combined with bradycardia significantly increases mortality risk 1
• Recognize that different patient populations may require different heart rate targets (e.g., heart failure patients with reduced ejection fraction benefit from lower heart rates of 50-60 bpm) 3