From the Guidelines
Ranolazine is not typically associated with causing hypotension, making it a suitable option for patients with stable angina who are at risk of hypotension or cannot tolerate blood pressure-lowering medications. Unlike many other anti-anginal medications such as nitrates or calcium channel blockers, ranolazine does not significantly affect blood pressure or heart rate at therapeutic doses 1. Ranolazine works primarily by inhibiting the late sodium current in cardiac cells, which improves myocardial perfusion without the hemodynamic effects seen with other anti-anginal agents. This makes it particularly useful for patients with stable angina who cannot tolerate blood pressure-lowering medications or in whom hypotension would be concerning.
The standard dosing of ranolazine is typically 500 mg twice daily initially, which can be increased to 1000 mg twice daily as needed for symptom control. If a patient experiences hypotension while taking ranolazine, it's essential to consider other causes or medication interactions rather than assuming ranolazine is the culprit. Patients with severe renal impairment or moderate to severe hepatic impairment may require dose adjustments due to potential drug accumulation. Ranolazine should be used cautiously with other QT-prolonging medications but does not require blood pressure monitoring as a primary safety concern 1.
Some key points to consider when using ranolazine include:
- Ranolazine has a good safety profile, being devoid of any adverse haemodynamic effects when used as monotherapy or in combination 1
- The recommended initial dose is 500 mg orally twice daily, which can be uptitrated to a maximum of 1000 mg orally twice daily 1
- Ranolazine prolongs the QTc interval in a dose-related manner, but QTc prolongation requiring dose reduction was comparable with ranolazine and placebo in the MERLIN-TIMI 36 trial 1
- In patients with lower blood pressure, the use of ivabradine, ranolazine, or trimetazidine is preferable, considering a threshold of 130 mmHg systolic and 80 mmHg diastolic as a reasonable cutoff for high versus low blood pressure in patients with coronary artery disease 1
From the FDA Drug Label
Vascular Disorders – hypotension, orthostatic hypotension Ranolazine may cause hypotension and orthostatic hypotension.
- The FDA label reports hypotension as an adverse reaction.
- The clinical significance of this effect is uncertain, but it may be a concern in some patients, especially those with pre-existing hypotension or orthostatic hypotension.
- Monitoring of blood pressure is recommended, especially in patients with a history of hypotension or orthostatic hypotension 2.
- In cases of oral overdose of Ranolazine Extended-Release Tablets, hypotension has been seen 2 2.
From the Research
Ranolazine and Hypotension
- Ranolazine is a unique antianginal agent that does not lower blood pressure or heart rate, making it a suitable option for patients with hypotension 3.
- The mechanism of action of ranolazine involves inhibiting the late inward sodium current, which prevents pathologic intracellular calcium accumulation and leads to ischemia, myocardial dysfunction, and electrical instability 3, 4.
- Studies have shown that ranolazine can be effective in reducing symptoms of angina and improving exercise tolerance in patients with symptomatic coronary heart disease, without causing significant hypotension or bradycardia 3, 5.
- Ranolazine may be considered as an initial antianginal agent for patients with hypotension or bradycardia, as it does not exacerbate these conditions 3.
- The safety and efficacy of ranolazine have been demonstrated in various clinical trials, with a low incidence of adverse effects, including those related to hypotension 5, 4.
- Ranolazine's multifaceted role beyond coronary artery disease is being explored, including its potential use in conditions such as atrial fibrillation, pulmonary arterial hypertension, and diastolic dysfunction, where its effects on blood pressure may be beneficial 6.