What medication should be discontinued in a 72-year-old female with a past medical history of heart failure with reduced ejection fraction (HFrEF) and severe hypotension, currently on lisinopril (Angiotensin-Converting Enzyme inhibitor), bisoprolol (beta-blocker), spironolactone (aldosterone antagonist), furosemide (loop diuretic), and empagliflozin (Sodium-Glucose Cotransporter 2 inhibitor), presenting with acute decompensated heart failure and impaired renal function?

Beta-Blocker (Bisoprolol) Should Be Discontinued

In this patient with NYHA Class IV acute decompensated heart failure requiring intravenous inotropic support (dobutamine), bisoprolol should be discontinued or at minimum reduced in dose. 1

Rationale for Beta-Blocker Discontinuation

Guideline-Directed Management in Acute Decompensation

• Beta-blockers should be used cautiously in patients with overt acute heart failure and more than basal pulmonary rales, and this patient has significant rales on examination 1
• As a general rule, patients admitted with worsening heart failure on beta-blockers should continue therapy unless inotropic support is needed, at which point the dose should be reduced or the medication discontinued 1
• This patient is already receiving IV dobutamine 1 mcg/kg/min, which represents inotropic support and is a clear indication to stop or reduce beta-blocker therapy 1

Clinical Presentation Supports Discontinuation

• The patient demonstrates cardiogenic shock physiology with cold extremities, severe hypotension (BP 89/52 mmHg), and altered consciousness—all contraindications to continued beta-blockade 1, 2
• Beta-blockers should not be initiated or continued when patients are unstable and require intravenous inotropic therapy 1
• If phosphodiesterase inhibitors are needed for inotropic support in beta-blocked patients, they should be preferred because their effects are not antagonized by beta-blockers, but dobutamine's effects ARE partially antagonized 1

Why Other Medications Should Be Continued

Furosemide (Loop Diuretic)

• Diuretics are recommended to improve symptoms in patients with signs and symptoms of congestion (Class I, Level B recommendation) 1
• This patient has 3+ pitting edema, rales, and 8 kg weight gain—clear volume overload requiring aggressive diuresis 1
• The current dose of 20 mg twice daily is actually suboptimal and will likely need to be increased to IV administration 1

Spironolactone (MRA)

• While the patient's potassium is 4.3 mEq/L (acceptable range) and eGFR is 39 mL/min (borderline but not prohibitive), spironolactone should be continued as it reduces mortality in NYHA Class III-IV heart failure 1
• Spironolactone discontinuation is recommended when potassium rises to ≥6.0 mEq/L or eGFR falls below 30 mL/min, neither of which applies here 3
• The mortality benefit of MRA therapy outweighs risks at this potassium and renal function level 1

Empagliflozin (SGLT2 Inhibitor)

• SGLT2 inhibitors provide cardiac and renal protection and reduce hyperkalemia risk in HFrEF patients 3
• There is no contraindication to continuing empagliflozin in acute decompensation unless the patient develops severe hypotension requiring multiple vasopressors 3
• The current blood pressure (89/52 mmHg), while low, is not an absolute contraindication with inotropic support already initiated 4

Lisinopril (ACE Inhibitor)

• ACE inhibitors should be maintained whenever possible as they provide mortality benefit (Class I, Level A recommendation) 1, 3
• In cases of symptomatic hypotension, other vasodilators should be reduced first before stopping ACE inhibitors 1, 4
• The dose may need temporary reduction but should not be discontinued 4

Management Algorithm for Beta-Blocker in This Setting

1. Immediately discontinue or reduce bisoprolol dose by 50% given the need for inotropic support 1
2. Monitor for hemodynamic improvement with dobutamine therapy and aggressive diuresis 1
3. Once the patient stabilizes (typically after 4 days), euvolemia is achieved, and inotropic support is weaned, reinitiate beta-blocker at a very low dose (bisoprolol 1.25 mg daily) 1
4. Uptitrate slowly over weeks to months once the patient is discharged and stable as an outpatient 1

Critical Pitfalls to Avoid

• Never abruptly stop beta-blockers in stable patients, as this risks rebound myocardial ischemia and arrhythmias, but this patient requiring inotropes is an exception 1
• Do not discontinue ACE inhibitors or MRAs first, as these provide greater mortality benefit and the hypotension is better managed by stopping the beta-blocker in this acute setting 3, 4
• Do not continue beta-blocker at full dose when inotropic support is required, as this antagonizes the therapeutic effect and worsens outcomes 1