What medication adjustments can be made to counter hypotension in a patient with Heart Failure with Reduced Ejection Fraction (HFrEF)?

Managing Hypotension in HFrEF Patient Taking Multiple Medications

Temporarily reduce or discontinue the furosemide (40mg daily) as the first step to counter hypotension in this 70-year-old patient with HFrEF experiencing dizziness and hypotension (BP 89/52) following introduction of Duodart. 1

Assessment of the Current Medication Regimen

The patient is currently on:

• Bisoprolol 5mg daily (beta-blocker)
• Entresto 24/26 BD (ARNI - sacubitril/valsartan)
• Furosemide 40mg daily (loop diuretic)
• Jardiance 10mg daily (SGLT2 inhibitor)
• Duodart (recently introduced - tamsulosin/dutasteride for BPH)

Medication Adjustment Algorithm

Step 1: Address Diuretic Therapy

• Reduce or temporarily discontinue furosemide since the patient shows signs of hypotension without evidence of fluid overload 1
• Diuretics should be adjusted first in patients with hypotension who don't have signs of congestion 1
• Monitor for signs of fluid retention after reduction

Step 2: If Hypotension Persists After Diuretic Adjustment

• Consider reducing the dose of Duodart or switching to an alternative BPH medication with less hypotensive effect
• Duodart contains tamsulosin (alpha-1 blocker) which can cause significant hypotension, especially when combined with other antihypertensive medications 1

Step 3: If Further Adjustment Needed

• Consider administering Entresto and bisoprolol at different times of day to minimize peak hypotensive effects 1
• Temporarily reduce Entresto dose if hypotension remains symptomatic 2
• Maintain bisoprolol if possible, as it's a cornerstone of HFrEF therapy 1

Step 4: If Severe Symptomatic Hypotension Persists

• Consider switching from bisoprolol to an alternative beta-blocker
• Evidence suggests that switching from carvedilol to bisoprolol can ameliorate hypotension in HF patients 3, but the patient is already on bisoprolol

Rationale for Recommendations

1. Diuretics First: Guidelines recommend adjusting diuretics first in patients with hypotension without congestion 1

   • Furosemide can be safely reduced or temporarily discontinued in euvolemic patients 1

2. Preserve GDMT: Maintain guideline-directed medical therapy (GDMT) whenever possible 1, 4

   • Beta-blockers (bisoprolol)
   • ARNI (Entresto)
   • SGLT2 inhibitors (Jardiance)
   • These medications have proven mortality benefits in HFrEF

3. Address Alpha-Blockers: Alpha-1 blockers like tamsulosin (in Duodart) are associated with orthostatic hypotension, especially in older adults 1

Monitoring and Follow-up

• Reassess blood pressure within 48-72 hours after medication adjustments
• Monitor for signs of fluid retention after diuretic reduction
• Check renal function and electrolytes, particularly if ARNI dose is adjusted 2
• Schedule close follow-up to ensure hypotension is resolving without worsening HF symptoms

Common Pitfalls to Avoid

• Don't discontinue GDMT medications hastily: Beta-blockers, ARNI, and SGLT2 inhibitors provide mortality benefits and should be maintained if possible 1
• Don't ignore the impact of newly introduced medications: The temporal relationship with Duodart introduction suggests it may be contributing significantly to hypotension
• Don't overlook volume status: Ensure the patient is not volume depleted before reintroducing or increasing diuretic dose 1
• Don't miss the opportunity to optimize medication timing: Administering hypotension-inducing medications at different times can minimize adverse effects 1

By following this stepwise approach, you can effectively manage hypotension while maintaining the core medications that provide mortality benefit in HFrEF.