Diltiazem Hold Parameters for Hypotension
Diltiazem should be held when systolic blood pressure is less than 90 mmHg, as this represents an absolute contraindication to administration. 1
FDA-Mandated Contraindication
The FDA drug label explicitly contraindicates diltiazem in patients with hypotension, defined as systolic blood pressure less than 90 mmHg 1. This is a hard stop—not a relative contraindication or a "use with caution" scenario, but an absolute prohibition based on safety data.
Clinical Context and Rationale
The 90 mmHg systolic threshold is non-negotiable because diltiazem causes vasodilation and negative inotropic effects that can precipitate further hemodynamic compromise 1.
In prehospital studies, hypotension (defined as final systolic BP <90 mmHg with a drop of at least 10 mmHg) occurred in only 2 of 278 patients receiving diltiazem, demonstrating the drug's relative safety when used appropriately—but these rare cases underscore why the contraindication exists 2.
Additional Hold Parameters Beyond Blood Pressure
While the question focuses on blood pressure, diltiazem should also be held for:
- Second- or third-degree AV block without a functioning pacemaker 1
- Sick sinus syndrome without a functioning pacemaker 1
- Acute myocardial infarction with pulmonary congestion documented on chest x-ray 1
Common Pitfall to Avoid
Do not confuse treatment targets with hold parameters. While guidelines recommend various blood pressure targets for chronic management (120-139 mmHg systolic depending on patient characteristics) 3, 4, these are goals for ongoing therapy, not thresholds for withholding medication. The hold parameter of <90 mmHg systolic is specifically about acute safety and preventing cardiovascular collapse.