What is the best approach to manage a patient with heart failure with reduced ejection fraction (HFrEF) and hypotension, who has a history of hypertension and is currently taking amlodipine (calcium channel blocker)?

Management of HFrEF with Hypotension in a Patient on Amlodipine

Discontinue amlodipine immediately and initiate guideline-directed medical therapy (GDMT) starting with SGLT2 inhibitors and mineralocorticoid receptor antagonists, as calcium channel blockers like amlodipine are contraindicated in HFrEF and worsen outcomes. 1

Immediate Medication Changes

Discontinue Harmful Medications

• Stop amlodipine immediately as calcium channel blockers (except amlodipine and felodipine for refractory hypertension only) are Class III: Harm recommendations in HFrEF, increasing risk of heart failure worsening and hospitalization 1
• Specifically, diltiazem and verapamil (non-dihydropyridines) are absolutely contraindicated, while even dihydropyridines like amlodipine neither improve nor worsen survival and should only be used after all other options are exhausted 1
• Review and discontinue other non-essential blood pressure medications that lack mortality benefit in HFrEF 1

Assess Congestion Status First

• Evaluate for clinical signs of congestion including jugular venous distension, peripheral edema, pulmonary rales, and hepatomegaly 1
• Check for biological markers (natriuretic peptides) and consider lung/cardiac ultrasound to assess volume status 1
• If no signs of congestion are present, cautiously reduce diuretic dose to help mitigate hypotension while initiating GDMT 1

Initiate GDMT Despite Low Blood Pressure

Start with BP-Neutral Medications First

• Begin SGLT2 inhibitor immediately (dapagliflozin 10mg daily if eGFR ≥20 mL/min/1.73m² or empagliflozin 10mg daily if eGFR ≥30 mL/min/1.73m²) as these have minimal blood pressure effects, require no titration, and provide rapid mortality benefits within weeks 1, 2
• Initiate mineralocorticoid receptor antagonist (spironolactone 12.5-25mg daily or eplerenone 25mg daily) concurrently, as these also rarely cause hypotension 1, 2
• Monitor potassium and renal function closely: potassium must be <5.0 mEq/L and creatinine ≤2.5 mg/dL (men) or ≤2.0 mg/dL (women) before starting 1

Add Beta-Blocker with Caution

• If heart rate >70 bpm, initiate low-dose beta-blocker using bisoprolol 1.25mg daily, metoprolol succinate 12.5-25mg daily, or carvedilol 3.125mg twice daily 1, 2
• Selective β₁ receptor blockers (bisoprolol, metoprolol) have lesser BP-lowering effects than carvedilol and may be preferred in borderline hypotension 1
• If heart rate <60 bpm or symptomatic hypotension persists, consider ivabradine as an alternative to beta-blocker for rate control 1, 2

Initiate RAAS Inhibition Strategically

• For NYHA class II-III symptoms, prefer sacubitril/valsartan (ARNI) starting at 24/26mg or 49/51mg twice daily over ACE inhibitors, as it provides superior mortality reduction 1, 2
• If systolic BP <100 mmHg but patient is asymptomatic or mildly symptomatic, use very low starting doses of ARNI (24/26mg twice daily) or ACE inhibitor (enalapril 2.5mg twice daily, lisinopril 2.5mg daily) 1, 2
• If ARNI causes symptomatic hypotension, switch to ACE inhibitor at low dose as the alternative 1, 2
• ARBs are reserved for ACE inhibitor-intolerant patients (angioedema, intractable cough) 1

Managing Persistent Hypotension

Algorithmic Approach Based on Symptoms

For asymptomatic or mildly symptomatic low BP (SBP 85-100 mmHg):

• Do NOT reduce or discontinue GDMT 1, 2
• Continue all four medication classes at current doses 1
• Monitor closely for signs of organ hypoperfusion (confusion, oliguria, cool extremities) 1

For symptomatic hypotension with major symptoms (dizziness, syncope, fatigue):

• First: Reduce diuretic dose if no signs of congestion present 1, 3
• Second: Review and stop non-HF blood pressure medications (alpha-blockers, additional antihypertensives) 1, 3
• Third: If heart rate >70 bpm, reduce ACE inhibitor/ARNI dose first while maintaining SGLT2i, MRA, and beta-blocker 1
• Fourth: If heart rate <60 bpm, reduce beta-blocker dose first while maintaining SGLT2i, MRA, and ARNI/ACE inhibitor 1
• Always maintain SGLT2 inhibitors and MRAs as these have the least BP effect 1

Refer to Specialist if Needed

• If symptomatic hypotension persists despite above measures, refer to heart failure specialist or advanced HF program before further down-titration of GDMT 1, 3
• Do NOT independently stop or significantly reduce Class I medications without specialist input 1, 3

Titration Strategy Over 4-6 Weeks

• Uptitrate one medication at a time using small increments every 1-2 weeks 2
• Target doses: sacubitril/valsartan 97/103mg twice daily, carvedilol 25mg twice daily, bisoprolol 10mg daily, metoprolol succinate 200mg daily, spironolactone 25-50mg daily 1, 2
• Monitor BP (supine and standing), heart rate, renal function (eGFR, creatinine), and potassium at each titration visit 2
• Serial natriuretic peptide monitoring can guide diuretic adjustments to ensure congestion doesn't worsen 1

Critical Contraindications and Pitfalls

Absolute Contraindications

• Never combine ACE inhibitor with ARB and MRA (triple RAAS blockade) due to hyperkalemia and renal dysfunction risk 1
• Never use diltiazem or verapamil in HFrEF patients 1
• Never use moxonidine as it increases mortality 1
• Avoid NSAIDs as they cause sodium retention, peripheral vasoconstriction, and attenuate efficacy of diuretics and ACE inhibitors 1

Common Pitfalls to Avoid

• Do not use traditional step-by-step approach that delays one drug class until another is optimized; all four classes should be started within 4-6 weeks 2
• Do not discontinue GDMT for asymptomatic hypotension (SBP 85-100 mmHg without organ hypoperfusion), as mortality benefit far outweighs theoretical risks 1, 2, 3
• Do not over-diurese patients, as this worsens hypotension and limits GDMT optimization 2
• Do not use amlodipine for blood pressure control unless all other HF medications at maximum tolerated doses fail to control hypertension 1

Monitoring Requirements

• Check BP (supine and standing), heart rate, weight daily during initial titration phase 2
• Assess renal function and electrolytes within 1-2 weeks of starting MRA or RAAS inhibitor, then every 4 weeks during titration 2
• Evaluate volume status clinically at each visit to guide diuretic adjustments 1
• If SBP drops below 85 mmHg with symptoms or signs of hypoperfusion, hospitalization may be required to exclude cardiogenic shock 1