How to stabilize blood pressure in a patient with heart failure and reduced ejection fraction?

Stabilizing Blood Pressure in Heart Failure with Reduced Ejection Fraction

Optimize guideline-directed medical therapy (GDMT) first—ACE inhibitors/ARNIs, beta-blockers, mineralocorticoid receptor antagonists, and SGLT2 inhibitors—as these medications simultaneously treat heart failure and control blood pressure, with additional agents added only if BP remains elevated after GDMT optimization. 1, 2

Primary Strategy: GDMT as First-Line Blood Pressure Control

The standard treatment of HFrEF typically lowers BP to a normal range of 110-130 mmHg in most successful trials, making GDMT optimization the cornerstone of BP management. 1

Core GDMT Components for BP Control:

• ACE inhibitors or ARNIs are the foundation—start low and uptitrate to target doses (enalapril 10-20 mg twice daily or sacubitril/valsartan 97/103 mg twice daily), as these provide both mortality benefit and BP reduction. 1, 2

• Beta-blockers should be initiated in all stable HFrEF patients—carvedilol is the preferred agent for refractory hypertension due to its combined α1-β1-β2-blocking properties, making it more effective at lowering BP than metoprolol succinate or bisoprolol. 1

• SGLT2 inhibitors (dapagliflozin or empagliflozin) should be started immediately in all patients with eGFR >20 mL/min/1.73 m², as they have minimal BP effects but provide mortality benefit—ideal for patients with borderline low BP. 2, 3

• Mineralocorticoid receptor antagonists at low doses (25-50 mg daily) provide survival benefit with minimal BP impact, making them safe even in patients with lower baseline BP. 2

Initiation Strategy for Patients with Different BP Profiles:

• For low baseline BP but adequate perfusion: Start SGLT2 inhibitor and MRA first (neither significantly lowers BP), then add low-dose beta-blocker if heart rate >70 bpm, followed by cautious ACE inhibitor/ARNI titration. 2

• For normal or elevated BP: Start all four GDMT classes simultaneously at low doses rather than sequentially, uptitrating one drug at a time every 1-2 weeks. 2, 3

Additional BP-Lowering Strategies After GDMT Optimization

If BP remains uncontrolled after maximizing GDMT, consider these evidence-based additions:

Hydralazine-Isosorbide Combination:

• In Black patients with persistent NYHA class III-IV symptoms: Adding hydralazine-isosorbide to ACE inhibitor/ARB and beta-blocker is beneficial to reduce morbidity and mortality AND lower BP (Class I, Level A). 1

• In non-Black patients with uncontrolled hypertension: This combination may be beneficial for BP control (Class IIa, Level C). 1

Diuretic Therapy:

• Thiazide or thiazide-like diuretics are useful for BP control and mild volume overload—more effective than loop diuretics for BP reduction (Class IIa, Level C). 1

• Loop diuretics are preferred for congestion management but less effective for BP control; however, they remain essential for symptomatic volume overload. 1, 4

• Triple-drug regimen of ACE inhibitor/ARB + calcium channel blocker + thiazide diuretic is effective and well-tolerated when other combinations fail. 1

Calcium Channel Blockers:

• Dihydropyridines (amlodipine or felodipine) can be used for BP control ONLY after other medications have failed, as they neither improve nor worsen HF survival. 1

Critical Medications to AVOID:

• Non-dihydropyridine calcium channel blockers (verapamil, diltiazem) are contraindicated—they worsen HF outcomes (Class III: Harm). 1

• Moxonidine should be avoided entirely in HFrEF patients (Class III: Harm). 1

• Alpha-adrenergic blockers (doxazosin) should be avoided; use only if all other options exhausted at maximum tolerated doses (Class III: Harm). 1

Managing Acute Decompensation with BP Instability:

• Start IV loop diuretics immediately without delay—initial dose should equal or exceed chronic oral daily dose, as early intervention improves outcomes. 4

• Continue GDMT (ACE inhibitors/ARBs and beta-blockers) during acute exacerbations unless hemodynamic instability or contraindications exist. 4

• Non-invasive ventilation plus IV furosemide for patients with respiratory distress and pulmonary congestion. 4

• Monitor closely: Fluid intake/output, vital signs, daily weight, electrolytes, BUN, and creatinine during IV diuretic therapy. 4

Common Pitfalls to Avoid:

• Never discontinue GDMT for asymptomatic or mildly symptomatic low BP—this compromises long-term outcomes; low BP alone (even <90 mmHg) without hypoperfusion is NOT a contraindication. 2, 3

• Don't use thiazides if GFR <30 mL/min unless combined synergistically with loop diuretics. 2

• Avoid NSAIDs—they interfere with ACE inhibitor efficacy and worsen renal function. 2

• Don't give IV fluids to patients with clear volume overload (orthopnea, dyspnea). 4

Monitoring Parameters:

• Check BP, heart rate, renal function, and electrolytes at 1-2 weeks after each medication increment. 2

• For potassium-sparing diuretics, check potassium and creatinine after 5-7 days and recheck every 5-7 days until stable. 2

• Serial assessment of urine output and congestion signs with diuretic dose titration accordingly. 4