If a patient has bradycardia or severe COPD, which should be used instead of a beta-blocker?

• A. Verapamil or Diltiazem
• B. Metoprolol
• C. Amlodipine
• D. Nifedipine

Answer: (A)

When beta-blockers are risky because of bradycardia or severe COPD, you want a drug that slows the heart’s conduction without triggering airway constriction. Verapamil or diltiazem, which are non-dihydropyridine calcium channel blockers, fit this need. They slow AV nodal conduction, reducing the ventricular rate in tachyarrhythmias like atrial fibrillation, and they do so without the bronchospastic potential associated with beta-blockers in COPD.

Be mindful that these agents can themselves cause bradycardia, hypotension, and, in some patients, reduced cardiac contractility, so they require careful monitoring, especially if there’s existing conduction disease or heart failure. In contrast, dihydropyridine calcium channel blockers such as amlodipine or nifedipine mainly dilate vessels and have little effect on AV node conduction, so they aren’t used for rate control. Metoprolol is a beta-blocker and would still be avoided in this scenario.