What to prescribe for an adult patient with hypertension and bradycardia (heart rate 50) and no significant medical history?

Management of Hypertension with Bradycardia (HR 50)

In an adult with hypertension and bradycardia (heart rate 50), initiate combination antihypertensive therapy with agents that do not worsen bradycardia—specifically, start with an ACE inhibitor or ARB combined with a dihydropyridine calcium channel blocker (such as amlodipine), avoiding beta-blockers and non-dihydropyridine calcium channel blockers (diltiazem, verapamil). 1, 2

Initial Assessment Required

Before prescribing, you must:

• Rule out secondary causes of hypertension, particularly those associated with bradycardia, including increased intracranial pressure, high-grade atrioventricular block, sick sinus syndrome, and medication-induced bradycardia 1, 3
• Obtain a complete medication history to identify drugs that may cause both hypertension and bradycardia, including over-the-counter medications, herbals, and illicit substances 1
• Perform an ECG to evaluate for conduction abnormalities, particularly 2:1 AV block or other high-grade blocks that can cause bradycardia-induced hypertension through the Frank-Starling mechanism 3
• Screen for primary aldosteronism if there is resistant hypertension, hypokalemia, or family history of early-onset hypertension 1

First-Line Pharmacological Treatment

Start with combination therapy using a single-pill combination containing: 1, 2

• ACE inhibitor (e.g., lisinopril 10 mg) or ARB (e.g., losartan 50 mg) PLUS
• Dihydropyridine calcium channel blocker (e.g., amlodipine 5 mg) 1

Rationale for This Combination:

• Dihydropyridine CCBs (amlodipine, nifedipine) do NOT slow heart rate, unlike non-dihydropyridines (diltiazem, verapamil), making them safe in bradycardia 1
• ACE inhibitors and ARBs are first-line agents with proven cardiovascular outcomes benefit and no negative chronotropic effects 1
• Combination therapy achieves target BP faster and with fewer side effects than monotherapy 1, 2

Medications to AVOID

Absolutely Contraindicated:

• Beta-blockers (metoprolol, atenolol, carvedilol)—will worsen bradycardia 1
• Non-dihydropyridine calcium channel blockers (diltiazem, verapamil)—cause severe bradycardia and can precipitate cardiogenic shock when combined with beta-blockers or in patients with baseline bradycardia 4
• Combination of two RAS blockers (ACE inhibitor + ARB)—potentially harmful and not recommended 1

Use with Extreme Caution:

• Thiazide diuretics can be added as third-line therapy but monitor for electrolyte abnormalities that may worsen conduction abnormalities 1

Treatment Escalation Algorithm

If BP remains ≥130/80 mmHg after 2-4 weeks on dual therapy: 1, 2

1. Increase doses of the initial two-drug combination to maximum tolerated doses
2. Add a thiazide-type diuretic (chlorthalidone 12.5-25 mg or indapamide 1.25-2.5 mg) to create a triple-drug combination: RAS blocker + dihydropyridine CCB + thiazide diuretic 1
3. If still uncontrolled on triple therapy, add spironolactone 25-50 mg (after checking potassium and renal function) 1

Blood Pressure Targets

• Target systolic BP: 120-129 mmHg for most adults if well tolerated 1, 2
• Target diastolic BP: <80 mmHg 1
• Achieve target within 3 months of initiating therapy 2

Critical Pitfalls to Avoid

• Do NOT use beta-blockers or non-dihydropyridine CCBs in patients with baseline bradycardia—this can cause severe bradycardia, cardiogenic shock, and death 4
• Do NOT aggressively lower BP in the first 24 hours unless there is evidence of acute target-organ damage (hypertensive emergency) 5, 6
• Do NOT ignore the bradycardia—if heart rate is persistently <50 bpm, consider cardiology referral to evaluate for pacemaker need, especially if there is evidence of bradycardia-induced hypertension 3
• Do NOT start monotherapy—combination therapy is superior for achieving BP control and should be first-line in confirmed hypertension ≥140/90 mmHg 1, 2

Special Consideration: Bradycardia-Induced Hypertension

If the patient has severe bradycardia with wide pulse pressure (high systolic, low diastolic BP), this may represent bradycardia-induced hypertension via the Frank-Starling mechanism 3. In such cases:

• Treating the bradycardia (with pacing if indicated) may resolve the hypertension 3
• Cardiology consultation is essential before initiating antihypertensive therapy 3

Monitoring Plan

• Recheck BP and heart rate in 2-4 weeks after initiating therapy 2
• Monitor for orthostatic hypotension before and after treatment intensification 2
• Check electrolytes and renal function if using diuretics or RAS blockers 1
• Home BP monitoring improves control and patient engagement 2