What is the best management approach for a patient with heart failure, an ejection fraction (EF) of 25%, tachycardia, and hypotension?

Management of Heart Failure with EF 25%, Tachycardia, and Hypotension

For a patient with heart failure, EF 25%, tachycardia, and BP 101/67, initiate ivabradine to reduce heart rate and improve outcomes while maintaining blood pressure, as this medication has minimal impact on BP compared to other heart failure therapies.

Assessment of Current Status

• The patient presents with heart failure with reduced ejection fraction (HFrEF) at 25%, tachycardia, and borderline hypotension (BP 101/67) 1
• This clinical scenario represents a challenging situation as most guideline-directed medical therapies (GDMT) for HFrEF can further lower blood pressure 1
• Low blood pressure in HFrEF patients is associated with increased risk and limits medication titration in clinical practice 2

Initial Management Strategy

First-Line Approach

• Initiate SGLT2 inhibitor as it has minimal impact on blood pressure while providing mortality benefit in HFrEF patients 1
  • SGLT2 inhibitors can be started in patients with eGFR >20 ml/min/1.73 m² 1
  • Monitor for volume depletion, especially when combined with other HF medications 3

Heart Rate Control

• Add ivabradine for heart rate control as it does not significantly lower blood pressure 4
  • Indicated for stable NYHA class II-IV heart failure with LVEF ≤35% and resting heart rate ≥70 bpm 4
  • Start at 5 mg twice daily and titrate to maintain heart rate between 50-60 bpm 4
  • Ivabradine reduced hospitalization for worsening heart failure in the SHIFT trial (HR: 0.74,95% CI: 0.66-0.83) 4

Medication Adjustments

• Consider selective β₁ receptor blockers (metoprolol or bisoprolol) at low doses instead of non-selective beta-blockers with vasodilatory properties 1
  • These have less BP-lowering effect than carvedilol 1
  • If beta-blockers are not tolerated, ivabradine can be used alone or with low-dose beta-blockers 1

Optimizing Therapy Despite Low BP

• Use small increments when titrating medications, focusing on one drug at a time 1
• Space out medications throughout the day to reduce synergistic hypotensive effects 1
• Recommend compression stockings to minimize orthostatic drops in BP 1
• Encourage regular exercise which can improve orthostatic hypotension and low BP 1

Algorithm for Medication Prioritization

If HR remains elevated (>70 bpm):

1. Maintain or initiate SGLT2 inhibitor 1
2. Add ivabradine if in sinus rhythm or digoxin if in atrial fibrillation 1
3. Consider reducing ACEi/ARB/ARNi dose if symptomatic hypotension persists 1

If eGFR is adequate (>30 ml/min):

1. Add mineralocorticoid receptor antagonist (MRA) at low dose 1
2. Initiate or maintain low-dose ACEi/ARB or very low dose ARNi (sacubitril/valsartan 25 mg twice daily) 1

Special Considerations

• Monitor for dehydration when combining SGLT2 inhibitors with other HF medications, especially ARNi, as this combination may cause severe hypotension 3
• Adjust diuretics according to volume status, as overdiuresis can worsen hypotension 1
• For persistent symptomatic hypotension despite optimization, refer to advanced heart failure team 1

Common Pitfalls to Avoid

• Don't discontinue all GDMT due to borderline low BP; instead, prioritize medications with less impact on BP 1
• Avoid high-dose initiation of multiple medications simultaneously 1
• Don't overlook non-pharmacological interventions like compression stockings and exercise 1
• Avoid carvedilol in this setting due to its greater hypotensive effect; prefer metoprolol or bisoprolol 1

By following this approach, you can optimize heart failure therapy while minimizing the risk of symptomatic hypotension in this challenging clinical scenario.