Should I stop one of the blood pressure medications in a patient with bradycardia and hypotension who is taking amlodipine, lisinopril-hctz, and hydralazine?

Medication Management in Bradycardia with Hypotension

Yes, you should discontinue hydralazine immediately and consider reducing or holding the amlodipine temporarily given this patient's symptomatic bradycardia and borderline hypotension (BP 114/58 mmHg). 1, 2

Immediate Action Required

Stop hydralazine now. This is your primary culprit and should be discontinued permanently in this clinical scenario. 1, 2

Why Hydralazine Must Go:

• Diastolic BP of 58 mmHg is critically low - The American Heart Association specifically recommends holding hydralazine when DBP falls below 60 mmHg, particularly in patients over 60 years of age. 2
• Hydralazine causes reflex tachycardia - While this might seem beneficial in bradycardia, it's unpredictable and can worsen hemodynamic instability. 2, 3
• Hydralazine is a poor choice for chronic hypertension - It causes sodium/water retention and has an unpredictable, prolonged duration of action (2-4 hours), making it less desirable as a maintenance agent. 2
• The patient is already on superior alternatives - ACE inhibitors (lisinopril) and dihydropyridine calcium channel blockers (amlodipine) are evidence-based first-line agents. 1

Secondary Consideration: Amlodipine

Temporarily hold or reduce amlodipine dose while awaiting cardiology evaluation. 1

Rationale:

• Amlodipine is generally safe in bradycardia - Dihydropyridine calcium channel blockers have minimal effects on heart rate and are considered safe alternatives. 1
• However, the BP is too low - With a BP of 114/58 mmHg and symptomatic bradycardia, you're dealing with potential hypoperfusion. 4, 2
• Amlodipine can be restarted - Once the patient is stable and cardiology has evaluated the bradycardia etiology, amlodipine can likely be resumed at a lower dose. 1

Keep Lisinopril-HCTZ (For Now)

Continue lisinopril-HCTZ 20-25 mg unless the patient develops symptoms of hypoperfusion. 1

Why This Should Stay:

• ACE inhibitors don't affect heart rate - They are suitable alternatives for patients with bradycardia and don't contribute to the rate problem. 1
• Mortality benefit - ACE inhibitors reduce mortality in patients with cardiovascular disease and should be maintained when possible. 4
• Diuretics are safe in bradycardia - Hydrochlorothiazide does not directly affect heart rate. 1

Critical Caveat:

• Monitor for hypoperfusion symptoms - If the patient develops dizziness, syncope, chest pain, altered mental status, or oliguria, hold all antihypertensives immediately. 2
• The diastolic BP of 58 mmHg is concerning - In patients over 60 with coronary artery disease risk factors, DBP below 60 mmHg can compromise coronary perfusion. 4, 2

What You're Missing: Evaluate the Bradycardia

Before cardiology sees this patient, you need to:

• Rule out medication causes - Is the patient on any other rate-slowing agents? Beta-blockers, non-dihydropyridine calcium channel blockers (diltiazem/verapamil), or central alpha-2 agonists (clonidine) would be absolute contraindications. 1
• Check electrolytes - Hyperkalemia from the ACE inhibitor/HCTZ combination can worsen bradycardia. 4
• Assess volume status - Overdiuresis can cause hypotension and reflex bradycardia. 4
• Get an ECG - Rule out heart block, sick sinus syndrome, or other conduction abnormalities. 4

Target Blood Pressure After Adjustment

Aim for BP <130/80 mmHg, but NOT at the expense of symptomatic hypotension. 4

Important Nuances:

• Systolic BP of 114 mmHg is acceptable - Some guidelines suggest targets as low as 120 mmHg in high-risk patients. 4
• Diastolic BP of 58 mmHg is NOT acceptable - This is below the safety threshold, especially in a 61-year-old male. 4, 2
• Wide pulse pressure is a red flag - A pulse pressure of 56 mmHg (114-58) suggests arterial stiffness and increases risk of end-organ hypoperfusion. 4

Common Pitfall to Avoid

Do NOT assume hydralazine is helping the bradycardia. While one old study from 1981 suggested hydralazine might increase heart rate in symptomatic sinus bradycardia 3, this is vastly outweighed by:

• The current hypotension (BP 114/58 mmHg) which is a contraindication. 2
• Modern guidelines recommending against hydralazine as a first-line agent. 2
• The availability of safer, more effective alternatives already in this patient's regimen. 1

Monitoring Plan Until Cardiology Evaluation

• Check orthostatic vital signs - Assess for symptomatic orthostatic hypotension. 2
• Monitor heart rate and BP daily - Document any correlation between medication timing and symptoms. 1
• Recheck electrolytes and renal function - Especially potassium and creatinine given the ACE inhibitor/diuretic combination. 4
• Assess for symptoms of hypoperfusion - Dizziness, lightheadedness, chest pain, confusion, or decreased urine output. 4, 2