Should Concor (bisoprolol) and Dapa (possibly referring to a medication, but assuming it's a brand or abbreviation for a medication not clearly identified, however, considering the context it might refer to a medication like Dapagliflozin) be stopped in a patient with Dengue Hemorrhagic Fever (DHF) who has hypotension and a normal heart rate?

Management of Concor and Dapa in DHF with Hypotension

In a patient with Dengue Hemorrhagic Fever (DHF) presenting with hypotension (BP 89/60) and normal heart rate, Concor (bisoprolol) should be temporarily held or reduced, while Dapa (dapagliflozin) can generally be continued as it does not affect blood pressure. 1

Immediate Assessment Priorities

• Verify blood pressure readings in both supine and standing positions to confirm true hypotension and assess for orthostatic changes (drop of 20 mmHg systolic and/or 10 mmHg diastolic within 3 minutes of standing) 1
• Assess organ perfusion status - check for signs of cardiogenic shock including altered mental status, cool extremities, oliguria, and elevated lactate 1
• Evaluate volume status - DHF characteristically involves plasma leakage with hemoconcentration; monitor hematocrit levels which rise with plasma leakage 2, 3
• Check for bleeding manifestations - DHF patients may have thrombocytopenia and hemorrhagic complications requiring different fluid management 2, 3

Management of Beta-Blocker (Concor/Bisoprolol)

• Temporarily reduce dose or hold bisoprolol if systolic BP remains <90 mmHg with symptoms or evidence of hypoperfusion 1
• Beta-blockers should generally not be stopped completely unless the patient is clinically unstable with signs of low cardiac output 1
• Do not permanently discontinue - plan to restart at lower dose once BP stabilizes and acute DHF phase resolves 1
• In acute decompensated states, dose reduction is preferred over complete withdrawal to maintain some cardioprotective benefit 1

Management of SGLT2 Inhibitor (Dapa/Dapagliflozin)

• Continue dapagliflozin as SGLT2 inhibitors are unique among heart failure medications in having no effect on blood pressure or heart rate 1
• Dapagliflozin does not cause symptomatic hypotension and has a favorable safety profile even in vulnerable populations 1
• No dose adjustment required - SGLT2 inhibitors require no titration and maintain effectiveness regardless of blood pressure levels 1
• May actually facilitate management by reducing congestion without further lowering BP 1

DHF-Specific Fluid Management Considerations

• Primary treatment is adequate volume replacement with crystalloid solutions to address plasma leakage 2, 3
• Monitor hematocrit levels closely - rising hematocrit indicates ongoing plasma leakage requiring more aggressive fluid resuscitation 3
• Colloid solutions (10% Dextran-40 or 10% Haes-steril) may be needed if crystalloid alone is insufficient 4
• Avoid overdiuresis which could worsen hypotension in the setting of plasma leakage 2, 3

Monitoring Parameters During Acute Phase

• Check BP hourly along with heart rate, urine output, and mental status 1
• Monitor hematocrit every 6-12 hours - decreasing hematocrit after fluid resuscitation indicates recovery phase 3
• Platelet count monitoring - thrombocytopenia is characteristic of DHF and may worsen before improvement 2, 3
• Renal function surveillance - DHF can cause acute tubular necrosis even without hemorrhagic features; monitor creatinine and urine output 5

Medication Reintroduction Strategy

• Restart bisoprolol at low dose (e.g., 1.25-2.5 mg daily) once BP stabilizes above 100/60 mmHg and DHF enters recovery phase 1
• Continue dapagliflozin throughout unless acute kidney injury develops with eGFR <20 mL/min/1.73 m² 1
• Gradual up-titration of beta-blocker over weeks after hospital discharge as tolerated by BP 1

Critical Pitfalls to Avoid

• Do not permanently discontinue heart failure medications based solely on transient hypotension during acute illness - poor outcomes are often related to medication discontinuation rather than the side effects themselves 1
• Avoid NSAIDs for fever control in DHF as they can worsen bleeding risk; use acetaminophen instead 3
• Do not rely on BP alone - assess the complete clinical picture including perfusion status, as asymptomatic low BP does not require medication adjustment 1
• Recognize that DHF hypotension differs from cardiogenic shock - it results from plasma leakage requiring volume replacement, not necessarily cardiac dysfunction 2, 3