How to manage an 89-year-old female with heart failure, ejection fraction of 32%, postural hypotension, and on metoprolol, betahistine, sertraline, and olanzapine?

Management of Heart Failure with Reduced Ejection Fraction in an 89-Year-Old Female with Postural Hypotension

The metoprolol dose should be reduced to a lower dose (12.5mg once daily in the morning only) and olanzapine should be discontinued or significantly reduced due to their contribution to postural hypotension in this elderly heart failure patient. 1, 2

Assessment of Current Medication Regimen

• The patient has heart failure with reduced ejection fraction (HFrEF) with an EF of 32%, which requires guideline-directed medical therapy including beta-blockers 1
• Current medications contributing to postural hypotension include:
  • Metoprolol 12.5mg morning and 25mg night (total 37.5mg daily) 3
  • Olanzapine 2.5mg twice daily, which can cause significant orthostatic hypotension due to α1-adrenergic antagonism 2, 4
  • Sertraline 50mg daily may also contribute to hypotension, though to a lesser extent 5

Medication Adjustments for Postural Hypotension

Beta-Blocker Management

• Reduce metoprolol to a single daily morning dose of 12.5mg to minimize postural hypotension while maintaining some cardioprotective effect 1
• Do not abruptly discontinue metoprolol as this can worsen heart failure and cause rebound tachycardia 3
• Beta-blockers remain essential in HFrEF management as they reduce mortality by approximately 30% and hospitalizations by 40% 1
• For elderly patients, especially those with postural hypotension, lower doses (25-50% of target dose) may be reasonable 1

Antipsychotic Management

• Olanzapine should be discontinued or significantly reduced (to 1.25mg daily if needed) due to its strong association with orthostatic hypotension 2, 4
• FDA labeling specifically warns about olanzapine causing orthostatic hypotension, especially in patients with cardiovascular disease 2
• Consider psychiatric consultation for alternative management of the indication for olanzapine 1

Other Medication Considerations

• Evaluate the necessity of betahistine for vertigo, as it may be contributing to cardiovascular effects 5
• Maintain sertraline if clinically indicated, but monitor for additive hypotensive effects 5

Heart Failure Management Strategy

• Consider adding low-dose ACE inhibitor (starting at 25-50% of target dose) once postural hypotension improves 1
• Consider low-dose spironolactone (12.5-25mg daily) for additional mortality benefit if renal function permits 1
• Assess volume status and consider low-dose diuretics if fluid retention is present 1
• Consider digoxin (0.125mg every other day) for symptom control given the patient's advanced age and heart failure 1

Monitoring and Follow-up Plan

• Monitor blood pressure in both sitting and standing positions before and after medication adjustments 5, 6
• Implement fall prevention strategies including home safety assessment 1, 2
• Schedule follow-up within 1-2 weeks to assess response to medication changes 1
• Monitor renal function and electrolytes, particularly if adding ACE inhibitors or spironolactone 1

Common Pitfalls to Avoid

• Avoid abrupt discontinuation of beta-blockers, which can worsen heart failure 3
• Avoid excessive diuresis which can worsen postural hypotension 6
• Avoid high-dose beta-blockers in elderly patients with postural hypotension 1
• Recognize that olanzapine poses significant risk for orthostatic hypotension in elderly patients with heart disease 2, 4
• Avoid assuming that all medications need to be at target doses in elderly patients; lower doses may provide benefit while minimizing adverse effects 1