How to manage a patient with hypotension and bradycardia on lisinopril (ACE inhibitor) and Norvasc (amlodipine)?

Immediate Management of Severe Bradycardia and Hypotension in Patient on Lisinopril and Amlodipine

Stop both lisinopril and amlodipine immediately and administer atropine 0.5 mg IV every 3-5 minutes up to a maximum of 3 mg as first-line treatment for this patient's symptomatic bradycardia (HR 34) with wide pulse pressure hypotension (BP 130/45). 1

Critical Assessment

This patient presents with:

• Severe bradycardia (HR 34 bpm) - significantly below normal
• Wide pulse pressure (85 mmHg) - suggesting possible aortic regurgitation or severe arterial stiffness
• Relative hypotension - diastolic BP of 45 mmHg indicates inadequate organ perfusion
• Medication-induced etiology - both ACE inhibitor and calcium channel blocker can cause bradycardia and hypotension 2, 3

The combination of lisinopril and amlodipine is known to cause additive hypotensive effects, and case reports document severe bradycardia and hypotension with ACE inhibitor therapy, particularly in elderly patients 4.

Immediate Interventions

First-Line Treatment

• Administer atropine 0.5 mg IV bolus immediately, repeat every 3-5 minutes to maximum total dose of 3 mg 1, 2
• Do NOT use doses less than 0.5 mg as this may paradoxically worsen bradycardia 2, 1
• Target heart rate of approximately 60 bpm, not necessarily normal range 2

Medication Management

• Discontinue lisinopril immediately - ACE inhibitors can cause hypotension and bradycardia, especially when combined with calcium channel blockers 3, 4
• Discontinue amlodipine (Norvasc) immediately - calcium channel blockers are specifically contraindicated in hypotension and can worsen bradycardia 2
• Avoid restarting these medications until hemodynamic stability is achieved and alternative regimens are considered 2

Supportive Care

• Establish IV access and initiate normal saline bolus to address potential volume depletion 2
• Apply continuous cardiac monitoring with frequent blood pressure checks 2
• Assess for signs of end-organ hypoperfusion including altered mental status, decreased urine output, or cool extremities 1

Second-Line Treatments (If Atropine Fails)

Vasopressor Support

• Epinephrine infusion 2-10 mcg/min IV if no response to atropine 1
• Dopamine infusion 5-20 mcg/kg/min IV particularly useful for hypotension with bradycardia 1
• Start with lower doses (5-10 mcg/kg/min) given potential medication toxicity 1

Transcutaneous Pacing

• Prepare transcutaneous pacing immediately - do not delay if patient shows signs of poor perfusion 1
• Apply pacing patches as standby even if atropine is being administered 2
• Activate pacing if heart rate remains <50 bpm with symptoms despite atropine 2

Special Considerations for Calcium Channel Blocker Toxicity

Given the patient is on amlodipine, consider specific antidotes if standard measures fail:

• Calcium chloride 10-20 mL of 10% solution IV may reverse calcium channel blocker effects 2
• Glucagon 3-10 mg IV bolus followed by infusion of 3-5 mg/h for refractory cases 1
• High-dose insulin therapy (1 unit/kg bolus, then 0.5 units/kg/h infusion with dextrose supplementation) for severe calcium channel blocker toxicity 1

Monitoring Parameters

• Continuous ECG monitoring for heart rate and rhythm 2
• Blood pressure every 5-15 minutes until stable 2
• Assess for second or third-degree heart block which would require immediate pacing 2
• Monitor serum potassium - lisinopril can cause hyperkalemia which may worsen bradycardia 3
• Check renal function - both medications are renally cleared and accumulation may occur 3

Common Pitfalls to Avoid

• Do NOT restart beta-blockers or additional calcium channel blockers - these will worsen bradycardia and hypotension 1, 2
• Do NOT give metoprolol or other beta-blockers despite hypertension history - contraindicated with bradycardia and hypotension 2, 5
• Do NOT delay transcutaneous pacing if atropine fails and patient remains unstable 1
• Do NOT assume this is benign - rule out acute coronary syndrome, especially with wide pulse pressure 2
• Do NOT use verapamil or diltiazem - these calcium channel blockers are absolutely contraindicated 2

Long-Term Management

Once hemodynamically stable:

• Reassess blood pressure control regimen - the 2024 ESC guidelines recommend combination therapy but this patient clearly cannot tolerate this specific combination 2
• Consider alternative antihypertensive classes such as thiazide diuretics alone initially 2
• Target systolic BP 120-129 mmHg when restarting therapy, but only after resolution of acute episode 2
• Monitor closely for recurrence if any ACE inhibitor or calcium channel blocker is reintroduced 2