The patient is hypotensive:  Is the Heart Rate Appropriate?

Primary pathological processes of the heart can cause brady- or tachy- arrhythmias and hypotension as a secondary process.  Hypotension is failure of compensation. Sick sinus syndrome or complete heart block (for example following an inferior wall myocardial infarction) may cause bradycardia.

If the patient is hypotensive he should have a tachycardia. A slow or normal heart rate in the presence of hypotension is a pathological. You need to determine what the cause of this relative bradycardia is (often inappropriate beta blockade). Look for p wave on the ECG (absence suggests atrial fibrillation or an escape rhythm). Excessively slow heart rate may be accelerated using isoproteranol, epinephrine or dobutamine. The patient may require pacing, or pacemaker adjustment.

Tachycardia causing hypotension must be slowed. If the arrhythmia is acute, then cardioversion is the gold standard. If you are unsure of the origin, correction of magnesium and potassium deficits are indicated, followed by amiodarone intravenously. Alternatives for supraventricular arrhythmias are calcium channel blockers (verapamil and diltiazem) and beta-blockers.

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