Do you hold ACE inhibitors and Calcium Channel blockers for compensated bradycardia?


For example, patient’s heart rate and rhythm sinus brady mid 50’s but BP is compensated around 110s-120s systolic. Would you administer the medications or hold in the presence of patient have hx of htn?


ACE inhibitors prevent hypertension through the following pathways:

  • Decreased aldosterone (sodium and water absorption).
  • Prevention of vasoconstriction by stopping conversion to angiotensin II
  • Prevention of vasopressin (ADH-water retention) release

The only thing that might concern me with an ACEi on BP (in the short term) is the effect on the arterioles. Assuming the patient is not vasoconstricted before administering the ACEi, the effect on BP should be minimal, as it does not cause vasodilation, but simply prevents vasoconstriction.

As for the Ca channel blocker, this may have effects on both heart rate as well as blood pressure depending on the type:

Dihydropyridines. These will have mostly vascular effects. They’re good for angina due to the vasodilation properties but may cause rebound tachycardia. An example is Amlodipine/Norvasc.

Non-dihydropyridines. These types will have more of an effect on cardiac tissue and will have minimal vasodilatory effects compared with dihydropyridines, so expect less rebound tachycardia. Examples are verapamil & diltiazem.

You should probably avoid these in brady patients unless you are actively suppressing a rhythm such as a fib and the brady is well compensated.

So to answer your specific situation… I would feel comfortable giving the ACEi, but probably not the CCB since they’re already brady. The ACEi would maintain a non-hypertensive state, and the CCB is likely not needed.