From the Guidelines
For a patient with bradycardia requiring an alternative to intravenous losartan, I would recommend intravenous fenoldopam at a dose of 0.1 mg/kg/min i.v. infusion, which can be increased every 15 min until goal BP is reached with 0.05 to 0.1 mg/kg/min increments. Fenoldopam is a dopamine receptor agonist that can help control blood pressure without exacerbating bradycardia, as it does not have a significant negative effect on heart rate 1.
Key Considerations
- The patient's heart rate of 68 beats per minute is a consideration when choosing an alternative to losartan, as some medications may worsen bradycardia.
- Fenoldopam is a suitable alternative because it does not have significant adverse effects on heart rate, unlike esmolol, metoprolol, and labetalol, which are contraindicated in bradycardia 1.
- Other options like nicardipine, clevidipine, and nitroglycerine may cause reflex-tachycardia, which could be beneficial in this case, but fenoldopam is a more direct alternative that does not rely on this mechanism 1.
Mechanism and Dosage
- Fenoldopam works by agonizing dopamine receptors, leading to vasodilation and a decrease in blood pressure.
- The recommended dose is 0.1 mg/kg/min i.v. infusion, which can be increased every 15 min until goal BP is reached with 0.05 to 0.1 mg/kg/min increments 1.
- This medication can be used in patients with hypertensive emergencies, including those with bradycardia, as it provides a controlled reduction in blood pressure without significant adverse effects on heart rate.
From the Research
Alternative Intravenous Medications to Losartan
For a patient with bradycardia (heart rate of 68 beats per minute), alternative intravenous medications to losartan (Angiotensin II receptor antagonist) can be considered.
- Sodium nitroprusside is a popular agent for hypertensive emergencies and can be used to immediately reduce blood pressure 2.
- Nitroglycerin (glyceryl trinitrate) is preferred when there is acute coronary insufficiency and can be used to reduce blood pressure 2, 3.
- Esmolol is an ultra short-acting beta-adrenergic blocker that can be used to control heart rate and blood pressure, but it may not be suitable for patients with bradycardia due to its potential to decrease heart rate further 4.
- Urapidil or trimetaphan camsilate can be used as alternatives to beta-blockers if they are contraindicated 2.
- Hydralazine is the drug of choice for patients with eclampsia, but it can be used as an alternative in other cases 2.
- Labetalol can be used to control blood pressure, but it is contraindicated in patients with bradycardia or heart blocks 2.
Considerations for Patients with Bradycardia
When selecting an alternative medication, it is essential to consider the patient's heart rate and potential contraindications.