How to manage a patient with orthostatic hypotension and COVID-19 (Coronavirus Disease 2019) positivity with congestive heart failure?

From the Guidelines

Managing a patient with postural blood pressure drop, COVID-19 infection, and heart failure requires continuation of traditional cardiovascular therapies, including ACE inhibitors and angiotensin receptor blockers (ARBs), as they do not appear to confer an increased risk of acquiring SARS-CoV-2 infection or mortality 1. To approach this patient, consider the following key points:

• Ensure adequate hydration while avoiding fluid overload that could worsen heart failure, considering IV fluids cautiously if the patient is significantly dehydrated.
• Temporarily reduce or discontinue medications that can worsen orthostatic hypotension, such as diuretics, vasodilators, and beta-blockers, while monitoring for worsening heart failure symptoms.
• For COVID-19 management, provide supportive care including oxygen supplementation if needed, and consider antiviral therapy.
• Monitor oxygen saturation closely, as heart failure patients are at higher risk for respiratory deterioration.
• Encourage non-pharmacological measures for orthostatic hypotension, including slow position changes, compression stockings, and small frequent meals.
• If orthostatic symptoms persist despite these measures, consider pharmacological interventions while monitoring for potential complications. Given the prothrombotic state associated with COVID-19, prophylactic anticoagulation against venous thromboembolism is recommended, with therapeutic anticoagulation individualized based on patient risk factors and clinical status 1. It's crucial to balance the management of orthostatic hypotension with the treatment of both COVID-19 infection and heart failure, recognizing the potential interactions and complications between these conditions.

From the FDA Drug Label

Midodrine hydrochloride tablets are indicated for the treatment of symptomatic orthostatic hypotension (OH) Because midodrine hydrochloride tablets can cause marked elevation of supine blood pressure (BP>200 mmHg systolic), it should be used in patients whose lives are considerably impaired despite standard clinical care, including non-pharmacologic treatment (such as support stockings), fluid expansion, and lifestyle alterations

The patient has postural BP drop (orthostatic hypotension) and is positive for Covid with heart failure.

• Midodrine may be considered for the treatment of symptomatic orthostatic hypotension.
• However, caution is advised as midodrine can cause marked elevation of supine blood pressure, which may be a concern in patients with heart failure.
• The FDA label does not provide specific guidance on the use of midodrine in patients with Covid-19 or heart failure.
• Therefore, the use of midodrine in this patient should be approached with caution and careful monitoring of blood pressure and clinical status is recommended 2.

From the Research

Managing Postural BP Drop and COVID-19 with Heart Failure

• Patients with heart failure and COVID-19 require careful management, as the infection can exacerbate heart failure symptoms and worsen prognosis 3.
• Postural orthostatic tachycardia syndrome (POTS) and orthostatic hypotension (OH) are common in patients recovering from COVID-19, with 48.3% and 16.7% of patients experiencing OH and POTS, respectively, at the time of hospital discharge 4.
• The management of POTS after COVID-19 is challenging, and nonpharmacologic treatments such as fluids, sodium intake, and compression stockings are often ineffective 5.
• Pharmacological interventions, including beta-adrenergic blockers, mineral corticosteroids, midodrine, and ivabradine, may be necessary to manage POTS symptoms 5.
• Patients with post-COVID-19 POTS demonstrate disruptions in circadian blood pressure regulation, with higher mean 24-hour and nighttime systolic blood pressure, and more daytime hypotensive episodes 6.
• The trajectory of vital signs in patients with COVID-19 can be unpredictable, with rapid deterioration in respiratory function and minor abnormalities in other vital signs 7.
• Guideline-directed medical therapy for heart failure should not be interrupted in patients with COVID-19, unless there are concerns about tolerance or clinical presentation 3.
• Advanced heart failure team members should be involved in the management of heart failure patients with COVID-19, particularly those on advanced therapies or with heart transplantation 3.