What is the best treatment approach for a patient with hypotension and congestive heart failure (CHF)?

Treatment for Low Blood Pressure and Congestive Heart Failure

Continue and optimize guideline-directed medical therapy (GDMT) for heart failure even in the presence of low blood pressure, as asymptomatic or mildly symptomatic hypotension should not be a barrier to life-saving medications. 1

Initial Assessment: Distinguish Symptomatic from Asymptomatic Hypotension

The critical first step is determining whether the low blood pressure is causing significant symptoms or end-organ hypoperfusion. 2

• Check mental status, urine output, extremity temperature, and renal function to assess end-organ perfusion rather than treating numbers alone 2
• Verify blood pressure accuracy by repeating measurements in both supine and standing positions if the patient is ambulatory 2
• Correlate symptoms with BP measurements to determine if the patient has true symptomatic hypotension 3

The 2025 European Heart Failure Association consensus explicitly states that asymptomatic or mildly symptomatic low BP should not trigger medication changes or cessation of GDMT. 1, 2

When to Maintain Current GDMT Without Changes

For systolic BP 90-110 mmHg without major symptoms: Continue all guideline-directed medications at current doses. 1

The evidence strongly supports this approach:

• GDMT medications remain effective and safe across all baseline systolic BP levels, including those with SBP 95-110 mmHg 1
• In PARADIGM-HF, benefits of sacubitril/valsartan were consistent across all baseline SBP categories (<110-120-130-140, >140 mmHg) 1
• Patients with lower baseline BP (95-110 mmHg) often experience BP increases over time when treated with GDMT, likely reflecting improved cardiac function 1
• In DAPA-HF, patients with baseline SBP 95-110 mmHg had minimal BP decrease with dapagliflozin (−1.50 mmHg), which diminished to <1 mmHg after 4 months 1
• In EMPHASIS-HF, patients with baseline SBP 95-105 mmHg on eplerenone showed an average increase of 2.8 mmHg compared to placebo 1

The hypotensive effect of HF medications diminishes as baseline SBP decreases, making continuation safer than clinicians typically assume. 1

Critical Threshold Requiring Immediate Action

Systolic BP <80 mmHg or symptomatic hypotension with severe symptoms (profound fatigue, disabling dizziness, severe orthostatic hypotension) requires intervention. 2

For these patients:

1. Hospitalize if signs of shock or severe congestion are present 4
2. Identify and discontinue non-essential BP-lowering drugs first: alpha-blockers, antidepressants, non-HF antihypertensives 1, 2
3. Evaluate for cardiac causes: valvular disease, myocardial ischemia, arrhythmias that may impair cardiac output 2
4. Reduce loop diuretic dose if no signs of congestion 4
5. Consult HF specialist before stopping or decreasing drugs with class I indication 4

Medication Prioritization in Heart Failure with Low BP

When adjustments are absolutely necessary, follow this hierarchy:

Medications to Continue (Highest Priority):

• SGLT2 inhibitors (empagliflozin, dapagliflozin) have the least impact on BP and should be continued 3
• Mineralocorticoid receptor antagonists (MRAs) have minimal BP effect and should be maintained 3
• Beta-blockers should be continued; in COPERNICUS, patients with SBP 85-95 mmHg treated with carvedilol showed BP increases 1

Medications That May Require Dose Adjustment:

• Sacubitril/valsartan (ARNI) causes the most significant BP decreases but maintains efficacy and safety even with hypotension 1
• ACE inhibitors/ARBs if ARNI not being used 4
• Loop diuretics should be reduced first if no congestion present 4

Medications to Discontinue First:

• Alpha-blockers (e.g., doxazosin) 2
• Non-HF antihypertensives 2
• Antidepressants that lower BP 2

Special Considerations for Acute vs. Chronic Settings

Acute decompensated heart failure has higher prevalence of hypotension (9-25% depending on definition) compared to chronic outpatient settings (3-4%). 1

In the acute setting:

• Maintain SBP >100 mmHg for 6 hours before initiating GDMT 1
• Ensure clinical stability (no escalating diuretic or inotropic therapy in last 24 hours) 1
• Initiate treatment at low doses for patients with lower SBP 1
• In STRONG-HF, hypotension occurred in 5% of high-intensity implementation vs. 1% in usual care, but rapid optimization was still beneficial 1

Device-Based Interventions That Improve Blood Pressure

Cardiac resynchronization therapy (CRT) results in an average BP increase of 5% due to enhanced myocardial synchrony and improved ejection fraction. 1

• CRT should be considered in selected patients with HFrEF and left ventricular electrical dyssynchrony 1
• This therapy may enable up-titration of beta-blockers in patients with symptomatic bradycardia 1

Transcatheter valve interventions for aortic stenosis or mitral/tricuspid regurgitation significantly increase BP after the procedure by improving forward stroke volume and cardiac output. 1

Common Pitfalls to Avoid

1. Do not discontinue HF medications prematurely in stable patients with low BP; investigate other causes first 2
2. Do not treat asymptomatic low diastolic numbers alone; assess organ perfusion and symptoms first 2
3. Do not assume all hypotension is medication-related; evaluate for valvular disease, ischemia, arrhythmias 2
4. Do not reduce GDMT when systolic BP is 90-110 mmHg without symptoms 1, 2
5. Do not forget that low BP on GDMT has diminished prognostic impact compared to low BP without treatment 1

Prognostic Context

While low BP is a prognostic marker in HFrEF (included in PROMPT-HF, LIFE-HF, and Seattle Heart Failure Model), the association between low BP and increased mortality is attenuated in patients on optimized GDMT. 1

• In the Swedish Heart Failure Registry, composite risk of cardiovascular death or HF hospitalization increased 2.5-fold at SBP <80 mmHg and 1.5-fold at SBP <100 mmHg compared to 120 mmHg 1
• However, this association was weakened in patients on optimized GDMT, suggesting higher mortality relates partly to fewer patients reaching target medication doses 1

The key principle: Continue GDMT to realize large clinical benefits, as treatment weakens the negative prognostic association of low BP. 1