Should I hold irbesartan (Angiotensin II receptor antagonist) in patients with bradycardia (heart rate <60 beats per minute)?

Management of Irbesartan in Patients with Bradycardia

Irbesartan should be held in patients with bradycardia (HR <60 bpm) as ARBs can potentially worsen hypotension in the setting of bradycardia. 1

Rationale for Holding Irbesartan in Bradycardia

• In patients with heart failure and bradycardia, reducing or stopping RAS inhibitors (including ARBs like irbesartan) is recommended when heart rate is below 60 bpm 1
• When managing patients with low blood pressure and bradycardia, guidelines suggest reducing ARBs before other medications if the heart rate is below 60 bpm 1
• Bradycardia is defined as a heart rate <60 beats per minute, though clinical significance typically occurs at rates <50 bpm or when symptoms develop 2

Clinical Assessment for Bradycardia Management

• Assess for signs of symptomatic bradycardia, including:

  • Altered mental status
  • Ischemic chest discomfort
  • Acute heart failure
  • Hypotension 1, 2

• If symptomatic bradycardia is present:

  • Hold irbesartan immediately
  • Consider atropine for acute management
  • Evaluate for temporary pacing if needed 2, 1

• If asymptomatic bradycardia (HR <60 bpm):

  • Hold irbesartan 1
  • Monitor for development of symptoms 2

Medication Management Considerations

• Irbesartan does not typically affect heart rate in most patients with normal heart rates, as noted in clinical trials 3
• However, in the setting of pre-existing bradycardia, ARBs like irbesartan may exacerbate hypotension due to their vasodilatory effects 1
• The combination of bradycardia and hypotension can lead to decreased cardiac output and tissue perfusion 2

Monitoring Recommendations

• Continuous cardiac monitoring is essential when managing antihypertensives in patients with bradycardia 1
• Monitor for signs of hypoperfusion including altered mental status, dizziness, or worsening symptoms 1
• After holding irbesartan, reassess heart rate and blood pressure before considering restarting the medication 2

Special Considerations

• In patients with tachy-brady syndrome, management may be more complex and require evaluation for underlying causes 2
• Patients with chronic bradycardia may require permanent adjustment of their antihypertensive regimen 2
• If bradycardia persists despite holding medications, further evaluation for intrinsic conduction system disease may be warranted 2