Can a patient with hypotension and heart failure with preserved ejection fraction (HFpEF) on Levophed (norepinephrine) receive Lasix (furosemide)?

Managing Lasix in Hypotensive HFpEF Patients on Levophed

Furosemide (Lasix) should be avoided in patients with heart failure with preserved ejection fraction (HFpEF) who are hypotensive and on norepinephrine (Levophed) until adequate perfusion is restored. 1

Rationale for Avoiding Diuretics in Hypotensive Patients

The European Society of Cardiology guidelines clearly state that diuretics should be avoided in patients with signs of hypoperfusion until adequate perfusion is attained 1. This recommendation is particularly important for patients with HFpEF who are already on vasopressor support with norepinephrine (Levophed).

The primary concerns with administering Lasix in this scenario include:

1. Worsening hypotension: Furosemide can cause further reduction in blood pressure through volume depletion and vasodilation 2.

2. Impaired organ perfusion: Levophed is typically used in patients with hypotension to maintain coronary and cerebral artery perfusion 3. Adding Lasix could counteract this effect.

3. Risk of acute kidney injury: The combination of hypotension and diuretics significantly increases the risk of worsening renal function, particularly in HFpEF patients 4.

Management Algorithm for Hypotensive HFpEF Patients

Step 1: Address Hypotension First

• Focus on restoring adequate perfusion before considering diuretic therapy
• Continue vasopressor support with Levophed to maintain systolic BP > 90 mmHg
• Consider invasive hemodynamic monitoring to guide therapy in patients with clinical evidence of impaired perfusion 5

Step 2: Once Blood Pressure Stabilizes (SBP > 90 mmHg)

• Transition to low-dose furosemide therapy with careful monitoring
• Start with IV furosemide at a dose equal to or less than the pre-existing oral dose 1
• Consider continuous infusion at low doses (<160 mg/24 hours) rather than bolus dosing 6

Step 3: Close Monitoring

• Monitor blood pressure, urine output, renal function, and electrolytes daily 1
• Perform daily assessment of clinical signs of congestion and perfusion 1
• Track fluid balance with input/output measurements and daily weights

Special Considerations for HFpEF

Patients with HFpEF present unique challenges compared to those with reduced ejection fraction:

• HFpEF patients are more susceptible to developing worsening renal function when hospitalized with acute heart failure 4
• Research shows that continuous infusion diuretic strategies may be associated with greater renal impairment in HFpEF patients compared to intermittent bolus administration 4
• HFpEF patients with refractory hypotension may require alternative strategies to maintain blood pressure while allowing for necessary diuresis 7

Alternative Approaches if Diuresis is Urgently Needed

If the patient has severe fluid overload that must be addressed despite hypotension:

1. Consider low-dose inotropic support alongside Levophed to improve cardiac output while maintaining blood pressure 1

2. Ultrafiltration may be reasonable for patients with refractory congestion not responding to medical therapy 5

3. Sequential nephron blockade with the addition of thiazide-type diuretics can be considered once blood pressure is stabilized 1

Potential Complications and Monitoring

• Electrolyte abnormalities: Monitor for hypokalemia, hyponatremia, and metabolic alkalosis 1, 2
• Thiamine deficiency: Long-term furosemide therapy may cause thiamine deficiency in heart failure patients 8
• Drug interactions: Furosemide may decrease arterial responsiveness to norepinephrine, potentially reducing the effectiveness of Levophed 2

In conclusion, while diuretics are a cornerstone of heart failure management, they should be temporarily avoided in hypotensive HFpEF patients on Levophed until adequate perfusion is restored. Once blood pressure stabilizes, careful introduction of diuretics with close monitoring is appropriate.