Do patients with Congestive Heart Failure (CHF) typically have hypotension?

Blood Pressure in Congestive Heart Failure Patients

Patients with congestive heart failure (CHF) typically do not have hypotension, and the majority of patients with clinical evidence of volume overload do not exhibit hypoperfusion, even though cardiac performance may be severely depressed. 1

Blood Pressure Patterns in CHF

• Most CHF patients maintain normal blood pressure despite having compromised cardiac function, with only 3-4% of the HFrEF population having low blood pressure (defined as SBP <90-95 mmHg) in the outpatient setting 1
• The prevalence of hypotension increases with the severity of heart failure, ranging from 9% in acute decompensation to 25% in hospitalized patients 1
• Low blood pressure in CHF is an important prognostic marker, with a 2.5-fold increase in the composite risk of cardiovascular death or HF hospitalization at SBP <80 mmHg compared to an SBP of 120 mmHg 1
• Clinical signs of hypoperfusion become most apparent only when cardiac output declines markedly or abruptly 1

When Hypotension Does Occur in CHF

Clinical Indicators of Reduced Cardiac Output:

• Narrow pulse pressure 1
• Cool extremities 1
• Altered mentation 1
• Cheyne-Stokes respiration 1
• Resting tachycardia 1
• Disproportionate elevation of blood urea nitrogen relative to serum creatinine 1

Management Considerations for CHF Patients with Low BP:

• Symptomatic or severe asymptomatic hypotension (systolic BP <90 mmHg) is a caution that requires specialist advice when using ACE inhibitors 1
• In cases of non-severe and asymptomatic hypotension in patients on guideline-directed medical therapy (GDMT), European and US guidelines recommend maintaining the same drug dosage 2
• For symptomatic or severe persistent hypotension, it is recommended to first decrease blood pressure-reducing drugs not indicated for HFrEF and reduce loop diuretic doses in the absence of congestion 2

Diurnal Blood Pressure Patterns in CHF

• CHF patients have lower overall blood pressure compared to controls (day-time: 105±10 vs 130±11 mmHg; night-time: 97±10 vs 112±10 mmHg) 3
• CHF patients can be divided into "dippers" and "non-dippers" based on whether they show a normal nocturnal blood pressure decrease 3
• There are significantly more non-dipping CHF patients (64%) compared to controls (20%), indicating altered blood pressure regulation 3

Clinical Implications

• When assessing CHF patients, blood pressure should be measured both sitting and standing to detect orthostatic changes 1
• The combination of elevated resting heart rate and lower systolic blood pressure identifies patients at highest risk for cardiovascular events 1, 4
• Asymptomatic low blood pressure does not usually require any change in therapy 1
• When patients with CHF are on optimized GDMT, the prognostic impact of low SBP is diminished 1

Common Pitfalls and Caveats

• Relying solely on blood pressure to assess volume status in CHF patients is inadequate; jugular venous distention is the most reliable sign of volume overload 1
• Many patients with chronic heart failure have elevated intravascular volume without peripheral edema or rales 1
• Symptoms of CHF do not reliably predict hemodynamic profiles (wet vs. dry, cold vs. warm) despite significant differences in actual hemodynamics 5
• The presence of rales generally reflects the rapidity of onset of HF rather than the degree of volume overload 1
• When initiating ACE inhibitors in CHF patients, monitor for hypotension, especially in those with systolic blood pressure below 90 mmHg, ischemic heart disease, or high-dose diuretic therapy 6