What is the target blood pressure for a patient with wet beriberi and an ejection fraction (EF) of 29-40 percent?

Target Blood Pressure for Wet Beriberi with EF 29-40%

In a patient with wet beriberi and ejection fraction of 29-40%, the primary goal is immediate thiamine replacement rather than aggressive blood pressure lowering, as the hemodynamic instability will resolve dramatically with thiamine administration; however, once stabilized, target a blood pressure <130/80 mmHg using guideline-directed medical therapy for heart failure with reduced ejection fraction.

Acute Management Priority

The critical first step is recognizing that wet beriberi presents as high-output heart failure (or paradoxically low-output in severe cases) that is rapidly reversible with thiamine administration 1, 2. The hemodynamic profile typically shows:

• High cardiac output with low systemic vascular resistance in most cases 3
• Severe cases may present with extremely low cardiac output refractory to standard support 2
• Right-sided heart failure predominance with lactic acidosis 4
• Dramatic improvement within 6 hours of thiamine administration 3

During the acute phase, avoid aggressive blood pressure lowering that could compromise organ perfusion. The hypotension in wet beriberi stems from the underlying metabolic derangement, not from pump failure alone 3, 2.

Blood Pressure Management After Thiamine Replacement

Once thiamine deficiency is corrected and hemodynamics stabilize, manage the patient according to heart failure with reduced ejection fraction (HFrEF) guidelines, as the EF of 29-40% places them in this category:

Target Blood Pressure

• <130/80 mmHg is the recommended target for patients with heart failure and reduced ejection fraction 5, 6
• This target reduces cardiovascular morbidity and mortality in high-risk patients 7

Medication Approach for HFrEF

Initiate guideline-directed medical therapy (GDMT) sequentially 7:

1. ACE inhibitor or ARB (or ARNI when stable):

   • Start at low doses and uptitrate gradually 7
   • Monitor renal function and potassium 1-2 weeks after initiation 7
   • These agents reduce mortality even when lowering BP from already low baseline values 7

2. Beta-blocker:

   • Essential for mortality reduction in HFrEF 7
   • Initiate after acute decompensation resolves 7

3. Mineralocorticoid receptor antagonist (MRA):

   • Add if potassium <5.0 mmol/L and eGFR adequate 7
   • Has minimal BP-lowering effect, making it valuable in low BP scenarios 7

4. SGLT2 inhibitor:

   • Recommended for all HFrEF patients 7
   • Minimal impact on blood pressure 7
   • Continue even if BP is low, as benefits outweigh risks 7

Critical Considerations for Low Blood Pressure

If systolic BP falls below 90 mmHg during GDMT optimization 7:

• Do not discontinue GDMT prematurely - outcomes worsen with discontinuation more than from the low BP itself 7
• Prioritize continuing SGLT2 inhibitors and MRAs as they have least BP impact 7
• Space out medication timing to reduce synergistic hypotensive effects 7
• Implement compression stockings and exercise training to improve orthostatic tolerance 7
• Only reduce or discontinue ACE inhibitors/ARBs or beta-blockers if symptomatic hypotension with major symptoms persists despite these measures 7

Special Pitfall: Diuretic-Induced Thiamine Deficiency

Be aware that long-term diuretic therapy can precipitate thiamine deficiency through increased urinary thiamine excretion 3. In patients with HFrEF requiring chronic diuretics:

• Consider thiamine supplementation prophylactically 3
• Maintain high index of suspicion for recurrent thiamine deficiency 3
• Monitor for signs of high-output failure despite adequate diuresis 3

Monitoring Strategy

• Confirm thiamine deficiency with serum levels (though treatment should not be delayed for results) 3
• Reassess hemodynamics 6-24 hours after thiamine administration 3, 2
• Once stable, uptitrate GDMT with BP and renal function checks every 1-2 weeks 7
• Target achievement of <130/80 mmHg over weeks to months, not acutely 5, 6

The key distinction is that wet beriberi requires metabolic correction first, then standard HFrEF blood pressure management second - attempting aggressive BP control before thiamine replacement will fail and may worsen outcomes 3, 2.