From the Guidelines
Midodrine should be avoided in patients with congestive heart failure (CHF) due to its potential to worsen cardiac workload and exacerbate the condition. This medication is a vasoconstrictor that increases blood pressure by stimulating alpha-1 adrenergic receptors, causing blood vessels to constrict and raising blood pressure 1. For CHF patients, this increased afterload can strain the already compromised heart, potentially leading to worsening heart failure symptoms or decompensation.
Some key points to consider when managing CHF patients include:
- Monitoring for changes in serum potassium and preventing hypokalemia or hyperkalemia, as both can adversely affect cardiac excitability and conduction 1
- Using diuretics to improve symptoms and exercise capacity in patients with signs and/or symptoms of congestion 1
- Considering alternative treatments for hypotension, such as careful fluid management, adjustment of heart failure medications, or other agents depending on the specific clinical situation
The most recent and highest quality study, from 2016, provides guidelines for the diagnosis and treatment of acute and chronic heart failure, but does not specifically address the use of midodrine in CHF patients 1. However, based on the available evidence, it is recommended that midodrine be used cautiously, if at all, in patients with CHF, and that alternative treatments be considered to minimize the risk of worsening cardiac workload and exacerbating the condition. If a patient with CHF is currently taking midodrine, they should consult their healthcare provider immediately about appropriate alternatives rather than discontinuing the medication abruptly.
From the FDA Drug Label
Midodrine hydrochloride tablets are contraindicated in patients with severe organic heart disease, acute renal disease, urinary retention, pheochromocytoma or thyrotoxicosis. Midodrine should not be used in patients with persistent and excessive supine hypertension.
The patient should not take midodrine when they have Congestive Heart Failure (CHF), as it can be considered a form of severe organic heart disease. 2
From the Research
Midodrine Use in Congestive Heart Failure (CHF)
- Midodrine is a peripheral alpha-1 agonist and a vasopressor anti-hypotensive agent approved for the treatment of orthostatic hypotension 3.
- It may be used off-label in patients with heart failure with reduced ejection fraction (HFrEF) and symptomatic hypotension to allow optimization of medical therapy 3.
- A study found that midodrine users had a lower incidence rate of all-cause hospitalizations compared to fludrocortisone users, especially among patients with congestive heart failure 4.
Safety and Efficacy of Midodrine in CHF
- Midodrine has been shown to improve blood pressure, reduce the need for vasopressor support, and enable the prescription of guideline-directed medical therapy (GDMT) in patients who are intolerant to it due to hypotension 5.
- However, there are concerns over increased all-cause mortality in some studies, small sample sizes, and nonrandomized study designs in others 5.
- A case report found that combination therapy of midodrine and droxidopa may contribute to the maintenance of blood pressure and diuretic activity in HFpEF patients with refractory hypotension 6.
Considerations for Midodrine Use in CHF
- Clinicians should consider the potential advantages of midodrine against the limited evidence and potential risks before incorporating it into their clinical practice for heart failure treatment 5.
- Further research, including large-scale randomized controlled trials and long-term follow-up studies, is needed to better understand the risks and benefits of midodrine use in heart failure patients, particularly in relation to GDMT 5.
- Midodrine is well tolerated, with the most commonly reported adverse events being piloerection, pruritus, paraesthesias, urinary retention, and chills 7.