From the Guidelines
For a patient with heart failure with reduced ejection fraction (EF 30%) who is hypotensive while on guideline-directed medical therapy (GDMT), careful medication adjustment is necessary, prioritizing the maintenance of beta-blockers and mineralocorticoid receptor antagonists, as these have been shown to have a significant impact on reducing mortality and improving quality of life 1. The management of such patients requires a delicate balance between maintaining life-saving GDMT and addressing hypotension, which can lead to organ hypoperfusion and prevent optimal heart failure therapy.
Key Considerations
- Temporarily reducing or holding medications that lower blood pressure, particularly vasodilators like ACE inhibitors, ARBs, or ARNIs, while maintaining beta-blockers at the lowest tolerated dose, is a crucial step in managing hypotension in these patients 1.
- Adding midodrine 2.5-10 mg three times daily during waking hours to support blood pressure may be considered, as it can help alleviate hypotension without significantly impacting the patient's overall heart failure management.
- Ensuring adequate fluid status by checking for signs of hypovolemia or congestion and adjusting diuretics accordingly is essential to prevent further complications.
- Once blood pressure stabilizes, gradually reintroducing GDMT medications at lower doses, prioritizing beta-blockers (such as carvedilol, metoprolol succinate, or bisoprolol) and mineralocorticoid receptor antagonists (spironolactone or eplerenone), which may have less impact on blood pressure, is recommended.
Advanced Therapies
For persistent hypotension despite these measures, considering referral for advanced heart failure therapies like mechanical circulatory support or transplant evaluation may be necessary, as these options can provide significant benefits in terms of morbidity, mortality, and quality of life for patients with refractory heart failure 1.
Medication Tolerability
It is essential to note that guideline-directed medical therapies for heart failure with reduced ejection fraction are generally well-tolerated, and adverse events occur at similar rates in the placebo and intervention arms of clinical trials 1. Therefore, providers should consider whether their patients' symptoms may not be related to GDMT therapies and, if medications are stopped for symptoms, consider re-trialing them in the future.
From the FDA Drug Label
The main reasons for not receiving the target beta-blocker doses at baseline were hypotension (45% of patients not at target), fatigue (32%), dyspnea (14%), dizziness (12%), history of cardiac decompensation (9%), and bradycardia (6%). Most patients (89%) were taking beta-blockers, with 26% on guideline-defined target daily doses SHIFT demonstrated that ivabradine reduced the risk of the combined endpoint of hospitalization for worsening heart failure or cardiovascular death based on a time-to-event analysis (hazard ratio: 0.82,95% confidence interval [CI]: 0.75,0.90, p < 0. 0001)
The management of heart failure with an ejection fraction (EF) of 30% and hypotension on guideline-directed medical therapy (GDMT) may include the use of ivabradine in addition to optimized beta-blocker therapy, as the SHIFT trial demonstrated a reduction in the risk of hospitalization for worsening heart failure or cardiovascular death in patients with heart failure and a left ventricular ejection fraction ≤ 35% 2.
- Key considerations:
- Hypotension is a common reason for not achieving target beta-blocker doses
- Ivabradine may be beneficial in reducing the risk of hospitalization for worsening heart failure or cardiovascular death in patients with heart failure and a left ventricular ejection fraction ≤ 35%
- Patients should be initiated on ivabradine 5 mg (or matching placebo) twice daily and the dose should be increased to 7.5 mg twice daily or decreased to 2.5 mg twice daily to maintain the resting heart rate between 50 and 60 bpm, as tolerated.
From the Research
Management of Heart Failure with Reduced Ejection Fraction
The management of heart failure with an ejection fraction (EF) of 30% and hypotension on guideline-directed medical therapy (GDMT) involves the use of multiple medications proven to improve clinical outcomes, as tolerated.
- Guideline-directed medical therapy (GDMT) is the cornerstone of pharmacological therapy for patients with heart failure with reduced ejection fraction (HFrEF) and consists of the four main drug classes: renin-angiotensin system inhibitors, evidence-based β-blockers, mineralocorticoid inhibitors, and sodium glucose cotransporter 2 inhibitors 3.
- The recommendation for use of GDMT is based on the results of multiple major randomized controlled trials demonstrating improved clinical outcomes in patients with HFrEF who are maintained on this therapy 3.
- Despite the evidence, there is an underutilization of GDMT, partially due to lack of awareness of how to safely and effectively initiate and titrate these medications 3, 4.
Clinical Benefits of GDMT
The use of GDMT has been shown to have several clinical benefits, including:
- Improved ejection fraction 4
- Reduced heart failure hospitalizations 4, 5
- Lower mortality risk 6, 7
- Improved renal function 4
Factors Associated with GDMT Use
Several factors are associated with the use and dose of GDMT, including:
- Older age 6
- Lower blood pressure 6
- More severe functional class 6
- Renal insufficiency 6
- Recent HF hospitalization 6
Dosing of GDMT
The dosing of GDMT is critical to achieving optimal clinical outcomes.