What if a patient with dilated cardiomyopathy and reduced ejection fraction is hypotensive?

Management of Hypotension in Dilated Cardiomyopathy with Reduced Ejection Fraction

Asymptomatic or mildly symptomatic low blood pressure should NOT prevent initiation or continuation of guideline-directed medical therapy (GDMT) in patients with dilated cardiomyopathy and reduced ejection fraction, as these medications improve mortality and quality of life regardless of baseline blood pressure. 1

Critical Assessment Framework

Determine Severity and Symptoms

First, confirm the blood pressure reading and assess for symptoms and organ perfusion. 1

• Systolic BP <80 mmHg or symptomatic hypotension (dizziness, syncope, significant fatigue, signs of shock or pre-shock) requires immediate intervention and possible medication adjustment 1, 2
• Systolic BP 80-100 mmHg without symptoms or with mild symptoms should NOT trigger GDMT reduction or cessation 1
• In acute heart failure settings, always assess organ perfusion (shock or pre-shock status) rather than focusing solely on blood pressure numbers 1

Identify Reversible Causes

Before adjusting heart failure medications, systematically eliminate other causes of hypotension: 1

• Stop non-essential blood pressure-lowering medications first: antihypertensives without Class I HFrEF indication, alpha-blockers for benign prostatic hypertrophy, certain antidepressants, antiarrhythmics 1
• Assess volume status carefully: overdiuresis is a common reversible cause—reduce loop diuretic dose if no signs of congestion present 1, 3
• Evaluate for transient causes: infection, dehydration, anemia, arrhythmias, medication interactions 1

Medication Management Strategy for Persistent Hypotension

If Patient is Treatment-Naïve or Undertreated

Start with SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs) as first-line therapy—these have minimal blood pressure effects and may actually increase BP in low BP groups. 1, 2

Sequential initiation approach: 1

1. Step 1: Initiate SGLT2 inhibitor and MRA simultaneously (neither significantly lowers BP) 1

2. Step 2: Add either:

   • Low-dose beta-blocker if heart rate >70 bpm (selective β₁ receptor blockers preferred as they have lesser BP-lowering effect than non-selective beta-blockers) 1
   • OR very low-dose sacubitril/valsartan (25 mg twice daily) or low-dose (50 mg twice daily) 1
   • OR low-dose ACE inhibitor if sacubitril/valsartan not tolerated 1

3. Step 3: Gradually up-titrate one drug at a time using small increments every 1-2 weeks until highest tolerated or target dose achieved 1

If beta-blockers are not tolerated hemodynamically: ivabradine is a viable alternative (either alone or with low-dose beta-blockers) as it facilitates beta-blocker titration without lowering blood pressure 1

If Patient Already on GDMT

For patients stable on optimal GDMT who develop hypotension, look for other etiologies rather than immediately attributing it to HF therapy. 1

If hypotension occurs after recent GDMT initiation or up-titration: 1

• Maintain current doses if asymptomatic or mildly symptomatic 1
• If symptomatic or SBP <80 mmHg persistently:
  • First decrease or stop non-Class I HFrEF medications 1
  • Adjust diuretics based on volume status 1
  • Only if symptoms persist: consider temporary dose reduction of the most recently initiated or up-titrated GDMT drug 1, 3
  • When discontinuation is necessary: start with the least tolerated medication 1

Special Considerations

Drug-Specific Blood Pressure Effects

Rank order from least to most BP-lowering effect: 1

1. SGLT2 inhibitors: No meaningful BP effect, may increase BP in low BP groups 1
2. MRAs: Minimal BP effect 1
3. Selective β₁ blockers: Less BP-lowering than non-selective beta-blockers 1
4. ACE inhibitors/ARBs: Moderate BP-lowering 1
5. Sacubitril/valsartan: Moderate to significant BP-lowering, especially at higher doses 1, 4

Monitoring and Follow-Up

• Close monitoring is essential: apply strategy to initiate or up-titrate one drug at a time 1
• Schedule follow-up every 1-2 weeks during titration phase 5
• When BP improves, always consider reinitiation or rechallenge of drugs based on better tolerated first 1
• Strive to achieve optimal therapy—target evidence-based doses from clinical trials 1, 5

Referral Indications

Refer early to heart failure specialist or advanced therapy programs if: 1

• Persistent hypotension with inability to initiate or titrate GDMT despite following above algorithm 1
• Uncertainty about medication management in complex cases 3
• Consideration needed for advanced therapies (inotropes, mechanical support, transplant evaluation) 1

Critical Pitfalls to Avoid

• Do NOT discontinue GDMT for mild asymptomatic hypotension or small creatinine elevations unless severe 5
• Do NOT delay GDMT initiation—hospitalization is a critical opportunity to start life-saving medications 5
• Do NOT use arbitrary "tolerated" doses—aim for evidence-based target doses 5
• Remember that blood pressure thresholds in clinical trials were primarily set to prevent dropouts, not because lower BP causes harm in asymptomatic patients 1
• Recognize "decapitated hypertension"—decreased BP resulting from reduced pump function in advanced HF, not medication effect 6