What can be given intravenously (IV) for hypertension in a cancer patient with atrial fibrillation?

IV Medications for Hypertension in Cancer Patients with Atrial Fibrillation

For hypertension in cancer patients with atrial fibrillation, intravenous beta blockers (esmolol, metoprolol, or propranolol) are the first-line treatment, with intravenous amiodarone as an alternative when beta blockers are contraindicated or unsuccessful. 1

First-Line IV Medications

• IV Beta Blockers (esmolol, metoprolol, or propranolol) are recommended as first-line agents for acute management of hypertension in patients with AF, providing both blood pressure control and rate control benefits 1
• For cancer patients with preserved left ventricular function, IV non-dihydropyridine calcium channel blockers (diltiazem, verapamil) can be considered as alternatives to beta blockers 1
• IV nitroglycerin can be used as an adjunct therapy for blood pressure control, particularly when preload reduction is beneficial, as it dilates veins and arterioles to reduce both preload and afterload 2

Special Considerations for Cancer Patients

• Cancer patients may have increased risk of drug-drug interactions between antiarrhythmics and cancer therapies, requiring careful medication selection 1, 3
• Diltiazem may be preferred over verapamil in cancer patients due to lower risk of symptomatic hypotension 1
• Be cautious with calcium channel blockers as they inhibit CYP3A4, potentially causing interactions with anticancer drugs and anticoagulants 1

When First-Line Agents Are Contraindicated

• IV amiodarone is recommended when beta blockers or calcium channel blockers are unsuccessful or contraindicated, particularly in patients with heart failure 1
• For cancer patients with AF and heart failure, avoid non-dihydropyridine calcium channel antagonists as they may worsen hemodynamic compromise 1
• IV digoxin can be used in patients with AF and heart failure who don't have an accessory pathway, but use with caution in cancer patients as some anticancer drugs (e.g., ibrutinib) can increase serum digoxin levels 1

Dosing and Monitoring

• Target heart rate should be between 60-80 beats per minute at rest and 90-115 beats per minute during moderate exercise 4
• Monitor both resting and exercise heart rates to ensure adequate rate control before adding additional agents 4
• When combining rate-controlling agents, monitor closely for excessive bradycardia, especially in elderly patients 4

Common Pitfalls to Avoid

• Avoid non-dihydropyridine calcium channel antagonists in patients with decompensated heart failure as they may exacerbate hemodynamic compromise 1
• Do not use digitalis glycosides or non-dihydropyridine calcium channel antagonists in patients with AF and preexcitation syndrome as they may paradoxically accelerate ventricular response 1
• Avoid combining multiple negative chronotropic agents without careful dose adjustment and monitoring 4
• Cancer itself and certain cancer therapies (angiogenesis inhibitors, cisplatin, gemcitabine, fluorouracil) can increase thromboembolic risk, while others (ibrutinib, ponatinib, lenalidomide) can increase bleeding risk, complicating management 1, 5

Algorithm for IV Medication Selection in Cancer Patients with AF and Hypertension

1. Assess cardiac function:

   • If preserved LV function: Start with IV beta blockers (esmolol, metoprolol, propranolol) 1
   • If reduced LV function/HF: Use IV beta blockers or IV amiodarone 1

2. If first-line therapy inadequate or contraindicated:

   • For preserved LV function: Consider IV diltiazem (preferred over verapamil in cancer patients) 1
   • For reduced LV function: Use IV amiodarone 1
   • Consider IV digoxin for patients with heart failure (with caution regarding drug interactions) 1

3. For additional BP control if needed:

   • Add IV nitroglycerin for additional blood pressure reduction 2

4. Monitor for:

   • Drug-drug interactions with cancer therapies 1, 3
   • Adequate rate control (60-80 bpm at rest) 4
   • Signs of hemodynamic compromise 1