What are the recommended antihypertensive medications for patients with Atrioventricular (AV) block and hypertension?

Antihypertensive Medications for Patients with AV Block and Hypertension

For patients with AV block and hypertension, non-dihydropyridine calcium channel blockers and beta blockers should be avoided, while ARBs are the preferred first-line agents, followed by dihydropyridine calcium channel blockers and diuretics as needed for combination therapy. 1

First-Line Therapy

• Angiotensin Receptor Blockers (ARBs) are recommended as first-line therapy for hypertensive patients with AV block due to their favorable cardiovascular profile and lack of effect on cardiac conduction 1
• ARBs have been shown to be beneficial in patients with hypertension and cardiac conduction disorders as they do not slow heart rate or affect AV nodal conduction 1
• ACE inhibitors can also be considered as first-line therapy with similar benefits to ARBs in terms of not affecting cardiac conduction 1

Medications to Avoid

• Beta blockers (including atenolol, metoprolol, nadolol, and propranolol) should be avoided in patients with AV block as they can worsen conduction abnormalities by slowing heart rate and prolonging AV conduction 1, 2
• Non-dihydropyridine calcium channel blockers (diltiazem and verapamil) are contraindicated in patients with AV block greater than first degree due to their direct negative effects on AV nodal conduction 1, 2
• The combination of beta blockers with non-dihydropyridine calcium channel blockers is particularly dangerous in patients with AV block and should be strictly avoided 1, 2

Second-Line and Combination Therapy

• Dihydropyridine calcium channel blockers (such as amlodipine) can be used as second-line agents as they have minimal effects on cardiac conduction 1
• Diuretics (particularly thiazide or thiazide-like diuretics) can be added as part of combination therapy when blood pressure remains uncontrolled on monotherapy 1
• When using diuretics, electrolyte balance should be carefully monitored as electrolyte abnormalities can potentially worsen cardiac conduction disorders 1

Special Considerations

• In patients with chronic aortic insufficiency and AV block, treatment of systolic hypertension should focus on agents that do not slow heart rate (avoid beta blockers) 1
• For patients with resistant hypertension and AV block, adding a low-dose aldosterone antagonist may be considered after ensuring the patient is not at risk for hyperkalemia 1
• Regular monitoring of ECG is recommended when initiating or adjusting antihypertensive therapy in patients with pre-existing AV block 2

Treatment Algorithm

1. Start with an ARB (e.g., losartan 50 mg daily) as first-line therapy 1
2. If blood pressure remains uncontrolled after maximizing ARB dose, add a dihydropyridine calcium channel blocker (e.g., amlodipine) 1
3. If further blood pressure control is needed, add a thiazide-like diuretic as a third agent 1
4. For resistant hypertension, consider referral to a hypertension specialist or cardiologist for advanced management 1

Monitoring

• Baseline ECG should be obtained before initiating therapy to document the degree of AV block 1
• Follow-up ECG is recommended after initiation or dose adjustment of antihypertensive medications 2
• Regular monitoring of electrolytes is essential, particularly if diuretics are used 1
• Blood pressure should be assessed within 4-6 weeks after initiating or adjusting therapy 1