What blood pressure (BP) medication supports heart rate?

Blood Pressure Medications That Support Heart Rate

Beta-blockers are the primary blood pressure medications that actively lower heart rate, with carvedilol, metoprolol succinate, and bisoprolol being the preferred agents as they have proven mortality benefits in heart failure and effectively control both blood pressure and heart rate. 1

Beta-Blockers: First-Line for Heart Rate Control

When you need a BP medication that also controls heart rate, beta-blockers are your answer. The specific beta-blockers with the strongest evidence base are:

• Carvedilol, metoprolol succinate, and bisoprolol have demonstrated improved outcomes in heart failure and are effective in lowering both BP and heart rate 1
• Atenolol produces the greatest overall heart rate reduction (-12.2 beats/min from baseline) and is the only agent that further reduces heart rate even when baseline is ≤65 bpm 2
• Beta-blockers are specifically recommended when there are compelling indications such as angina, post-myocardial infarction, heart failure with reduced ejection fraction, or need for heart rate control 1

Non-Dihydropyridine Calcium Channel Blockers: Alternative Option

Diltiazem and verapamil also lower heart rate through their effects on cardiac conduction, but they come with important caveats:

• These agents reduce heart rate but are contraindicated in heart failure with reduced ejection fraction due to myocardial depressant activity 1
• They can be used for rate control in patients without heart failure who need both BP and heart rate management 1

Medications That Do NOT Lower Heart Rate

Understanding what doesn't work is equally important:

• Dihydropyridine calcium channel blockers (amlodipine, felodipine) do not significantly affect heart rate 2, 3
• ACE inhibitors and ARBs have minimal to no effect on heart rate 2
• Thiazide diuretics produce only small, clinically insignificant heart rate reductions 2
• Prazosin (alpha-blocker) actually increases heart rate (+3.8 beats/min) 2

Clinical Algorithm for Selection

When choosing a BP medication for heart rate support:

1. If the patient has heart failure with reduced ejection fraction: Use carvedilol, metoprolol succinate, or bisoprolol as guideline-directed medical therapy 1

2. If the patient has coronary artery disease or post-MI: Beta-blockers are indicated for both BP control and cardioprotection 1

3. If the patient has atrial fibrillation needing rate control: Consider beta-blockers or non-dihydropyridine CCBs (if no heart failure) 1

4. If beta-blockers are not tolerated and patient is in sinus rhythm with heart rate >70 bpm: Ivabradine may be used as an alternative, though it doesn't lower BP 1

Important Caveats

• Avoid non-dihydropyridine CCBs (verapamil, diltiazem) in patients with heart failure with reduced ejection fraction as they worsen outcomes 1
• Clonidine reduces heart rate but should be used with caution in heart failure as it may worsen symptoms 4
• Beta-blockers should be started at low doses and up-titrated slowly, especially in patients with low blood pressure or heart failure 1
• The heart rate reduction effect of beta-blockers is sustained over time, while clonidine's effect may attenuate with chronic use 2