Target Blood Pressure for HFrEF (LVEF 26-40%) with Wet Beriberi
In patients with heart failure and reduced ejection fraction (LVEF 26-40%) complicated by wet beriberi, blood pressure management should target systolic BP <140/90 mmHg once hemodynamic stability is achieved after thiamine replacement, while tolerating lower pressures during the acute high-output phase. 1
Immediate Management Priority: Thiamine Replacement First
Wet beriberi presents as high-output heart failure with low systemic vascular resistance, elevated cardiac output, and often hypotension—this is a medical emergency requiring immediate thiamine administration before aggressive BP targets are pursued. 2, 3, 4
Administer thiamine 100-200 mg intravenously or intramuscularly immediately upon suspicion, as hemodynamic improvement occurs within 6-12 hours of thiamine replacement. 4, 5
The high-output state with low peripheral vascular resistance will spontaneously correct with thiamine, often normalizing BP without additional interventions. 4, 5
Blood Pressure Targets During Acute Phase
During the acute wet beriberi phase, tolerate systolic BP as low as 80-90 mmHg if the patient is asymptomatic and perfusing adequately, as aggressive BP elevation may worsen the underlying pathophysiology. 1
Low BP in the setting of high cardiac output and low systemic vascular resistance is expected and should not trigger vasopressor use unless there is evidence of end-organ hypoperfusion. 4, 5
Monitor for symptomatic hypotension (dizziness, syncope, altered mental status) rather than treating absolute BP numbers during the first 24-48 hours. 1
Blood Pressure Targets After Thiamine Correction
Once thiamine deficiency is corrected and the high-output state resolves (typically within days to weeks), standard HFrEF BP targets apply:
Target systolic BP <140/90 mmHg in all HFrEF patients as the general goal. 1
Target systolic BP <130/80 mmHg in patients with diabetes or other high-risk features (prior stroke, MI, renal dysfunction, proteinuria). 1
Importantly, when patients with HFrEF are on guideline-directed medical therapy (GDMT), the prognostic impact of low BP is diminished, and systolic BP as low as 90-100 mmHg is often well-tolerated. 1
Guideline-Directed Medical Therapy Initiation
After hemodynamic stabilization with thiamine:
Initiate ACE inhibitors (or ARBs if ACE inhibitor intolerant) as they are recommended in all patients with LVEF <40% to reduce mortality and morbidity. 1
Start beta-blockers (bisoprolol, carvedilol, or metoprolol succinate) as they are recommended in all patients with LVEF <40% to reduce mortality. 1
Add mineralocorticoid receptor antagonists (spironolactone or eplerenone) in patients with LVEF ≤35% who remain symptomatic despite ACE inhibitor and beta-blocker therapy. 1
These medications will lower BP, but their mortality benefit persists even when BP drops to 90-100 mmHg systolic, so do not withhold them solely due to low-normal BP. 1
Critical Pitfalls to Avoid
Never delay thiamine administration while waiting for laboratory confirmation—wet beriberi is a clinical diagnosis and thiamine is harmless, while delay can be fatal. 2, 3, 4
Do not aggressively treat low BP with vasopressors during the acute high-output phase, as this worsens cardiac afterload without addressing the underlying thiamine deficiency. 4, 5
Avoid excessive diuresis in wet beriberi despite edema, as these patients have high cardiac output and may become hypotensive; diuretics should be used cautiously only after thiamine replacement. 2, 4
Do not use calcium channel blockers (diltiazem, verapamil) in patients with LVEF ≤40%, as these are Class III (harm) recommendations. 6, 7
Recognize that long-term diuretic therapy (especially loop diuretics and thiazides) increases urinary thiamine excretion and may have precipitated the beriberi—consider thiamine supplementation during chronic diuretic therapy. 2
Monitoring Strategy
Reassess hemodynamics with echocardiography within 48-72 hours after thiamine administration to document improvement in cardiac output and normalization of systemic vascular resistance. 4
Measure serum thiamine pyrophosphate (TPP) levels and lactate at baseline and after treatment—elevated lactate with high venous oxygen saturation suggests wet beriberi. 5
Serial BP monitoring during GDMT titration is essential, but prioritize achieving target doses of life-saving medications (ACE inhibitors, beta-blockers, MRAs) over maintaining arbitrary BP thresholds above 100 mmHg. 1
Regular monitoring of renal function and electrolytes is mandatory during medication titration, especially with MRAs and ACE inhibitors. 1
Special Considerations for This Population
The LVEF range of 26-40% places this patient in the HFrEF category where all four pillars of GDMT (ACE inhibitor/ARB/ARNI, beta-blocker, MRA, SGLT2 inhibitor) should be initiated sequentially. 1
Wet beriberi can coexist with underlying structural heart disease, so do not assume all cardiac dysfunction will resolve with thiamine—continue HFrEF management even after thiamine correction. 2, 4
Consider ICD evaluation if LVEF remains ≤35% after 3 months of optimal medical therapy and thiamine repletion. 1