From the Guidelines
Midodrine is generally not recommended for blood pressure control in patients with heart failure and reduced ejection fraction (HFrEF). This alpha-1 adrenergic agonist increases peripheral vascular resistance, which can worsen cardiac function in HFrEF patients by increasing afterload on an already struggling heart. Instead, the cornerstone of blood pressure management in HFrEF involves medications that reduce cardiac workload and improve outcomes, such as ACE inhibitors (like lisinopril 5-40 mg daily), ARBs (such as losartan 25-100 mg daily), or the combination drug sacubitril/valsartan (24/26 mg to 97/103 mg twice daily) 1. Beta-blockers (metoprolol succinate 12.5-200 mg daily, carvedilol 3.125-25 mg twice daily, or bisoprolol 1.25-10 mg daily) are also essential. For patients with persistent hypertension despite these therapies, hydralazine (25-100 mg three times daily) with isosorbide dinitrate (20-40 mg three times daily) or amlodipine (2.5-10 mg daily) may be added. Some key points to consider when managing HFrEF include:
- The use of guideline-directed medical therapy (GDMT) which includes four medication classes: renin-angiotensin-aldosterone system (RAS) inhibitors or angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid-receptor antagonists (MRAs), and sodium-glucose cotransporter-2 (SGLT2) inhibitors 1.
- The importance of optimizing medical therapy to improve patient outcomes, with a focus on reducing hospitalization and mortality 1.
- The need for careful consideration of the potential risks and benefits of different medications, including the potential for adverse events and interactions 1. Midodrine might only be considered in very specific situations where a patient has symptomatic hypotension that limits optimal HFrEF therapy, and even then, it should be used cautiously with close monitoring for worsening heart failure symptoms.
From the Research
Use of Midodrine for Blood Pressure Control
- Midodrine is a medication that has been used to maintain blood pressure in patients with heart failure and reduced ejection fraction (HFrEF) 2.
- However, the safety of midodrine in HFrEF patients has been a concern, with a study finding that midodrine use was associated with increased risks of respiratory failure, ICU admissions, hospitalizations, and mortality 2.
- The same study found that midodrine use reduced emergency room visits, but the overall risk-benefit profile of midodrine in HFrEF patients is still unclear 2.
Management of Low Blood Pressure in HFrEF
- Low blood pressure is common in HFrEF patients and can be a barrier to implementing guideline-directed medical therapy (GDMT) 3, 4.
- European and US guidelines recommend maintaining the same drug dosage in cases of non-severe and asymptomatic hypotension, while decreasing blood pressure-reducing drugs not indicated in HFrEF in cases of symptomatic or severe persistent hypotension 3.
- A clinical consensus statement from the Heart Failure Association (HFA) of the ESC provides management pathways to optimize HFrEF treatment in the context of low blood pressure, aiming to improve patient outcomes 4.
Pharmacological Management of HFrEF
- Guideline recommendations for the treatment of HFrEF include the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, and aldosterone antagonists 5.
- The use of renin-angiotensin system inhibitors/angiotensin receptor neprilysin inhibitors (RASI/ARNI) and beta blockers has been associated with lower mortality and morbidity in HFrEF patients 6.
- Diuretics and digoxin can be used as needed for symptom control, while statins are not recommended solely for the treatment of heart failure 5.