What antihypertensive medications, such as beta blockers (BB), calcium channel blockers (CCB), and angiotensin-converting enzyme inhibitors (ACEi), should be held or adjusted in patients with hypotension (blood pressure < 110/60 mmHg) or bradycardia (heart rate < 60 beats per minute)?

Blood Pressure Medications to Hold When BP <110/60 or HR <60

Hold beta-blockers and non-dihydropyridine calcium channel blockers (diltiazem, verapamil) when heart rate is below 60 bpm, and consider holding all antihypertensives when systolic BP drops below 110 mmHg, with beta-blockers and calcium channel blockers being the highest priority to withhold. 1

Medications to Hold Based on Heart Rate <60 bpm

Beta-Blockers (Highest Priority)

• Beta-blockers (carvedilol, metoprolol, bisoprolol, atenolol, propranolol) should be held when heart rate falls below 60 bpm, as these agents directly slow heart rate through negative chronotropic effects and can precipitate symptomatic bradycardia. 1, 2
• Beta-blockers have compelling indications (post-MI, heart failure with reduced ejection fraction, angina) that may warrant continuation despite bradycardia, but this requires careful assessment of symptoms and hemodynamic stability. 1, 2

Non-Dihydropyridine Calcium Channel Blockers

• Diltiazem and verapamil should be held when heart rate is below 60 bpm, as these non-dihydropyridine CCBs have significant negative chronotropic effects and can worsen bradycardia. 1, 2
• These agents are particularly problematic in patients with heart failure, where they are explicitly contraindicated due to negative inotropic effects. 1

Dihydropyridine Calcium Channel Blockers (Lower Priority for HR)

• Amlodipine and other dihydropyridine CCBs have minimal direct effect on heart rate and generally do not need to be held for bradycardia alone, though they should be held for hypotension. 2, 3

Medications to Hold Based on BP <110/60 mmHg

All Antihypertensives Require Consideration

• When systolic BP drops below 110 mmHg, prioritize holding medications in this order: beta-blockers first, then non-dihydropyridine CCBs, then dihydropyridine CCBs, then ACE inhibitors/ARBs, and finally thiazide diuretics. 1

Beta-Blockers (Hold First)

• Beta-blockers lower BP through multiple mechanisms (decreased cardiac output, reduced renin release) and should be the first class held when BP is low, unless there are compelling indications like recent MI or decompensated heart failure. 1, 2

Calcium Channel Blockers (Hold Second)

• Both dihydropyridine (amlodipine) and non-dihydropyridine (diltiazem, verapamil) CCBs cause vasodilation and should be held when BP falls below 110/60 mmHg. 2, 3
• Amlodipine has a long half-life (30-50 hours), so effects will persist for days after discontinuation. 4

ACE Inhibitors and ARBs (Hold Third)

• ACE inhibitors (lisinopril, enalapril, benazepril) and ARBs (losartan, valsartan, olmesartan) cause vasodilation through renin-angiotensin system blockade and should be held when BP is below 110/60 mmHg. 1, 2
• Exercise caution when holding these agents in patients with heart failure, as they improve outcomes even at lower BP levels, but symptomatic hypotension takes precedence. 1

Thiazide Diuretics (Hold Last)

• Thiazide and thiazide-like diuretics (hydrochlorothiazide, chlorthalidone, indapamide) reduce BP through volume depletion and should be held when BP is below 110/60 mmHg, particularly if the patient shows signs of volume depletion. 1, 2

Critical Clinical Considerations

Assess for Symptoms First

• Asymptomatic hypotension (BP 100-110/60 mmHg) or bradycardia (HR 50-60 bpm) may not require medication adjustment, particularly in elderly patients or those with long-standing hypertension where lower BP may be well-tolerated. 1
• Symptomatic hypotension (dizziness, lightheadedness, syncope, fatigue) or symptomatic bradycardia mandates immediate medication review and withholding of offending agents. 1

Special Populations Requiring Caution

• In patients with coronary artery disease and heart failure, the guidelines specifically warn about lowering diastolic BP below 60 mmHg, as this can precipitate myocardial ischemia and worsening heart failure, particularly in patients over age 60 or with diabetes. 1
• Elderly patients with wide pulse pressures may develop very low diastolic values (<60 mmHg) when systolic BP is lowered, requiring careful assessment for ischemia or worsening heart failure. 1

Medications That Should NOT Be Held

• Aldosterone antagonists (spironolactone, eplerenone) do not directly lower heart rate and have minimal acute BP effects, so they generally should not be held for bradycardia or mild hypotension unless severe hypotension is present. 1
• Alpha-blockers (doxazosin) can cause hypotension but are rarely used as primary antihypertensives and should be held if BP is low. 1

Practical Algorithm for Medication Management

Step 1: Assess Hemodynamic Stability

• Check for symptoms: dizziness, syncope, chest pain, dyspnea, altered mental status. 1
• Confirm BP and HR with repeat measurements to rule out measurement error. 1

Step 2: Hold Medications in Priority Order

• For HR <60 bpm: Hold beta-blockers first, then non-dihydropyridine CCBs (diltiazem/verapamil). 1, 2
• For BP <110/60 mmHg: Hold beta-blockers first, then CCBs (both types), then ACE inhibitors/ARBs, then diuretics last. 1, 2

Step 3: Reassess in 24-48 Hours

• Monitor BP and HR after holding medications to determine if resumption at lower doses is appropriate. 1
• Target BP should be <140/90 mmHg minimum, ideally <130/80 mmHg for high-risk patients, but avoid diastolic BP <60 mmHg in elderly or those with coronary disease. 1, 2

Step 4: Resume Medications Strategically

• Restart medications at lower doses once BP stabilizes above 110/60 mmHg and HR above 60 bpm. 1
• Consider whether the patient was overmedicated and requires fewer agents or lower doses long-term. 1, 2

Common Pitfalls to Avoid

• Do not abruptly discontinue beta-blockers in patients with coronary artery disease or recent MI, as this can precipitate rebound ischemia or arrhythmias—taper if possible. 1, 2
• Do not hold all antihypertensives simultaneously in patients with heart failure, as ACE inhibitors/ARBs and beta-blockers improve outcomes even at lower BP levels—hold selectively based on symptoms. 1
• Do not assume white coat hypertension or measurement error without confirming with home BP monitoring or repeat measurements, as true hypotension requires medication adjustment. 1
• Do not restart medications at full doses after holding for hypotension or bradycardia—resume at 50% of previous dose and titrate slowly. 1, 4