From the Guidelines
Patients with heart failure (HF) and hypotension should be treated with medications that improve outcomes for HF, such as diuretics, ACE inhibitors (or ARBs), β-blockers, and aldosterone receptor antagonists, rather than traditional vasopressors for hypotension. When managing hypotension in patients with HF, it is crucial to prioritize medications that not only address the low blood pressure but also consider the underlying heart failure condition. The use of diuretics, such as thiazide diuretics for BP control and loop diuretics for volume control in severe HF or renal impairment, is recommended 1. Additionally, ACE inhibitors (or ARBs), β-blockers, and aldosterone receptor antagonists have been shown to improve outcomes for patients with HF and are effective in lowering BP 1. Specific β-blockers like carvedilol, metoprolol succinate, and bisoprolol have been shown to improve outcomes in HF and lower BP 1. It is also important to consider the addition of hydralazine/isosorbide dinitrate in black patients with NYHA class III or IV heart failure 1. Medications to avoid in patients with HF and hypertension include nondihydropyridine CCBs, clonidine, and moxonidine 1. In the context of HF, the primary approach to managing hypotension should focus on optimizing heart failure medications and addressing underlying causes, with careful consideration and monitoring when initiating any new medications, especially those that may worsen heart failure symptoms or fluid retention 1. Key points to consider in managing hypotension in HF patients include:
- Optimizing HF medications
- Addressing underlying causes of hypotension
- Careful selection and monitoring of medications that may affect HF
- Avoiding certain medications that can worsen HF
- Close monitoring for worsening HF symptoms, fluid retention, or pulmonary edema 1.
From the Research
Medications for Hypotension
- Midodrine, a peripheral alpha1-adrenergic agonist, is used to treat hypotension in patients with heart failure (HF) 2, 3.
- Droxidopa is another medication used in combination with midodrine to treat refractory hypotension in HF patients 3.
- Fludrocortisone, a mineralocorticoid analog, is also used to treat orthostatic hypotension, but its use may be associated with a higher risk of all-cause hospitalizations compared to midodrine 4.
Suitability for Patients with Heart Failure
- Midodrine may be suitable for patients with HF, as it allows for up-titration of neurohormonal antagonist therapy, leading to improved outcomes 2.
- The combination of midodrine and droxidopa may contribute to the maintenance of blood pressure and diuretic activity in HF patients with refractory hypotension 3.
- Mineralocorticoid receptor antagonists (MRAs) are not typically associated with hypotension in patients with HF, and their use may not be limited by low systolic blood pressure 5.
- Fludrocortisone may be used to treat orthostatic hypotension in patients with HF, but its effects on blood pressure and orthostatic symptoms are uncertain, and it may be associated with a higher risk of hospitalizations 4, 6.
Comparison of Medications
- Midodrine and fludrocortisone have different mechanisms of action and may be used in different clinical contexts 2, 4, 6.
- The combination of midodrine and droxidopa may be more effective than midodrine alone in treating refractory hypotension in HF patients 3.
- MRAs may be a suitable alternative to midodrine or fludrocortisone in patients with HF, as they are not typically associated with hypotension 5.