High BP but Low HR... Which med will you give/hold?

EllaBella1, BSN · Nov 5, 2016

Neither. I would call the MD and get an order for hydralazine.

SmilingBluEyes · Nov 5, 2016

I would also ask for very clear parameters for all these medications, when to give, hold. If in doubt, like Ella said, always call the doctor. Let them make that decision. They may get annoyed, but that is not our call.

gelman · Nov 5, 2016

I'm orienting in the CCU (night shift)!as a new grad and my preceptor has 30 years of experience. She asked me to give Coreg and hold Cardizem. She provided an explanation but I'' still skeptical. It wasn't meant to be a scope of practice question, more of an academic one. Thanks for the replies though. If I were on my own and working days, I'd probably call the doctor like you said.

KatieMI, BSN, MSN, RN · Nov 5, 2016

Theoretically, it must be opposite. Coreg is b-blocker, causes brady, so it should be hold. Cardizem is CCB and at least doesn't cause brady, although it is less "tachycardic" than hydralazine. And I would like to see what the baseline is and how the patient looks like in general.

Till you do not feel comfortable enough, call provider and let them deal with this headache.

VANurse2010 · Nov 6, 2016

Theoretically, it must be opposite. Coreg is b-blocker, causes brady, so it should be hold. Cardizem is CCB and at least doesn't cause brady, although it is less "tachycardic" than hydralazine. And I would like to see what the baseline is and how the patient looks like in general.
Till you do not feel comfortable enough, call provider and let them deal with this headache.

Cardizem can definitely slow heart - it will have have far more effect on HR than BP.

GM2RN · Nov 6, 2016

You need more information. Cardizem is also given for rapid afib, so definitely can slow the heart rate. BUT, does the patient have a history of afib? What is the cardizem prescribed for? Is this a home med that he is used to taking and what has his HR been trending? You also definitely need parameters because if he is on a maintenance dose for an arrhythmia then it might be ok to give. Call the doc, day or night for clarification. That's his job and I never feel bad waking a doc when necessary.

Wile E Coyote, ASN, RN · Nov 6, 2016

If pt primarily had heart failure symptoms and I had to choose one, I'd give the Coreg. If pt's primary concern was unstable angina, then I'd choose Cardizem.

Having said that, as a newby I'd call for clarification and ask for parameters.

If this is a reoccurring issue, consider asking about pts vagal tone and if the mild bradycardia is contributing to his HTN (relatively long diastole's effects on vagal tone and/or baroreseptors can contribute to further bradycardia and hypertension outside of drug effects).

TheCommuter, BSN, RN · Nov 6, 2016

Moved to the Nursing & Patient Medications forum.

Amnesty · Nov 6, 2016

I've had this situation come up at work several times before. The answer is a bit complex.

If I've discussed it with the patient and he is well-informed about his health and says his heart rate is usually in that range and his primary doctor has okayed the use of those meds, I'll usually give them after running it by my charge nurse. He'll check over the other meds being given and tell me if there are any red flags.

If the patient doesn't know but both are home meds, hold Coreg (or whatever other BP med it is) and give Cardizem, then call the doc to see if they want any kind of coverage on it like hydralazine. On the couple of occasions where I'd ask my charge nurses's advice on this, he told me that cardizem is one that we try to always give because it controls how the heart beats and keeps patients out of afib or unstable angina, as mentioned in different posts above.

If the Cardizem is newly prescribed, I'll look up what's happened with it and why it was prescribed and call whichever hospitalist is on for us that night to get their take on it. In my experience, they usually say to give it anyway. It's 50/50 on whether they want hydralazine administered with it. Almost always, they'll say to hold the Coreg if it's a new med and the HR is in the 50's.

SummitRN, BSN, RN · Nov 6, 2016

I'd like to know why this patient has a HR in the 50s and SBP 170 before I can try to reason pharmacological interventions. I don't know their history or treatment goals. How can I possibly answer this "academic" question?

CCU BSN RN · Nov 6, 2016

What's their rhythm? HR in the 50's with a high degree AVB is different than sinus brady. What is their baseline HR? If they're in complete heart block and their HR normally runs in the 80's-90's, the hypertension is likely compensatory, and I wouldn't necessarily even treat it. And would also hold both dilt and coreg

If they're NSR or rate controlled a fib, have already been receiving the above meds without incident, HR is this low (or close to it) at baseline, not symptomatic bradycardia I'd give both meds without a second thought.

Also, is this guy just bradycardic when he sleeps? You say you're in CCU, so we definitely need more info about the clinical picture to offer you helpful advice.

If not compensatory HTN to deal with new bradycardia, why is he hypertensive? Just history of HTN and these are his home meds? Pain? CVA? I want so much more intel here!