Should I Hold or Administer Trazodone?
Direct Answer
Hold the trazodone. The patient's presentation of symptomatic bradycardia (HR 64) combined with a wide pulse pressure (BP 128/54, indicating diastolic hypotension) creates significant risk for further cardiovascular compromise, as trazodone is specifically contraindicated in patients with symptomatic bradycardia and causes orthostatic hypotension 1.
Critical Safety Concerns with Trazodone in This Clinical Context
Cardiovascular Contraindications
Trazodone should be avoided in patients with symptomatic bradycardia, as this increases the risk of torsade de pointes and sudden death 1.
The FDA label explicitly states that trazodone should be avoided "in patients with a history of cardiac arrhythmias, as well as other circumstances that may increase the risk of the occurrence of torsade de pointes and/or sudden death, including symptomatic bradycardia" 1.
Hypotension, including orthostatic hypotension and syncope, has been reported in patients receiving trazodone, and concomitant use with antihypertensive medications may require dose reduction 1.
Evidence of Hypotensive Effects
In a 2025 study of hypertensive older adults (≥75 years), trazodone users showed significantly lower office diastolic BP (71.8 versus 80.1 mmHg, p = 0.042) and greater systolic BP reduction immediately after standing (23.8 versus 14.3 mmHg, p = 0.037) 2.
Trazodone users had a 58.3% incidence of syncope and falls versus 21.2% in non-users (p = 0.001), demonstrating substantial clinical risk in older adults with cardiovascular vulnerability 2.
The patient's diastolic BP of 54 mmHg already indicates compromised diastolic perfusion, and trazodone would likely worsen this further 2.
Clinical Decision Algorithm
Step 1: Assess Current Hemodynamic Status
HR 64 with BP 128/54 indicates borderline bradycardia with significant diastolic hypotension (pulse pressure of 74 mmHg suggests reduced diastolic filling) 3.
Evaluate for symptoms: dizziness, lightheadedness, fatigue, or syncope 3.
If the patient is symptomatic, this represents a contraindication to trazodone administration 1.
Step 2: Evaluate Cardiac Risk Factors
Check for pre-existing cardiac disease: trazodone may be arrhythmogenic in patients with preexisting cardiac disease, with reported arrhythmias including ventricular tachycardia and torsade de pointes 1.
Post-marketing events of torsade de pointes have been reported at doses of 100 mg or less 1.
Trazodone prolongs the QT/QTc interval, creating additional risk in patients with bradycardia 1.
Step 3: Consider Alternative Medications
If the patient is on other medications that lower heart rate or blood pressure (beta-blockers, calcium channel blockers, antihypertensives), trazodone creates additive risk 1.
The American College of Cardiology guidelines note that beta-blockers cause hypotension and bradycardia as potential adverse effects, and drugs with SA and/or AV nodal-blocking properties should be used with caution together 3.
What to Do Instead
Immediate Management
Hold the trazodone dose and reassess the patient's cardiovascular status 1.
Monitor vital signs, particularly for symptomatic hypotension or worsening bradycardia 3.
If the patient is symptomatic with bradycardia and hypotension, consider atropine 0.5 mg IV as first-line treatment 4.
Longer-Term Considerations
If trazodone is being used for insomnia or anxiety, consider alternative agents that do not cause cardiovascular depression 1.
If trazodone must be continued, it should only be restarted after cardiovascular stabilization and with close monitoring 1.
Concomitant use with antihypertensive medications may require dose reduction of the antihypertensive 1.
Common Pitfalls to Avoid
Do not assume trazodone is "cardiac-safe" simply because it has fewer anticholinergic effects than tricyclic antidepressants—it still carries significant cardiovascular risks including arrhythmias, QT prolongation, and hypotension 1, 5.
Do not administer trazodone in patients with symptomatic bradycardia or significant hypotension, as this violates FDA safety warnings 1.
Do not overlook the wide pulse pressure (74 mmHg), which suggests reduced diastolic perfusion and increased cardiovascular vulnerability 2.
In older adults with cardiovascular disease, trazodone at lower doses (100-300 mg) may be better tolerated, but the current hemodynamic parameters suggest even this would be inappropriate 6.
Key Monitoring Parameters If Trazodone Is Eventually Restarted
Baseline and serial ECGs to monitor QTc interval 1.
Regular vital sign monitoring, particularly orthostatic blood pressure measurements 2.
Assessment for symptoms of hypotension (dizziness, lightheadedness, syncope) 1, 2.
Close monitoring in patients with cardiac disease, as antidepressant drugs including trazodone may cause cardiac arrhythmias 1.