What is the optimal management plan for a patient with HFrEF, EF 37%, on low dose ARNI, Furosemide, low dose Bisoprolol, and MRA, presenting with hypotension and normal heart rate?

Optimal Management Plan for HFrEF with Low Blood Pressure

Your patient requires aggressive uptitration of ARNI and beta-blocker toward target doses, with the addition of an SGLT2 inhibitor immediately—the blood pressure of 100/80 mmHg is NOT a contraindication to therapy optimization and should not delay treatment escalation. 1, 2

Critical First Step: Add SGLT2 Inhibitor Immediately

• Start dapagliflozin 10 mg once daily or empagliflozin 10 mg once daily without delay, as SGLT2 inhibitors cause the smallest average BP decrease (only -1.50 mmHg in patients with baseline SBP 95-110 mmHg, diminishing to <1 mmHg after 4 months) and provide substantial mortality benefit regardless of blood pressure. 1, 2
• SGLT2 inhibitors reduce cardiovascular death and HF hospitalization with minimal blood pressure effect, making them ideal for patients with borderline BP. 2, 3
• No dose titration is required—10 mg daily is the evidence-based dose from clinical trials that provides maximal benefit. 2

Aggressive Uptitration Strategy for Existing Medications

The current low-dose ARNI and bisoprolol represent a critical missed opportunity—your patient is receiving only a fraction of the proven mortality benefit from these medications. 1, 2

ARNI Uptitration Protocol

• Increase ARNI (sacubitril/valsartan) from current low dose to 97/103 mg twice daily over 4-8 weeks using the following schedule: 1, 4
  • If currently on 24/26 mg twice daily → increase to 49/51 mg twice daily after 2-4 weeks
  • Then increase to 97/103 mg twice daily after another 2-4 weeks (target dose)
• The target dose of 97/103 mg twice daily was used in PARADIGM-HF and provides at least 20% mortality reduction superior to ACE inhibitors. 1, 2
• Do not delay uptitration due to the BP of 100/80 mmHg—ARNI maintains efficacy and safety even in patients with baseline SBP <110 mmHg. 1

Beta-Blocker Uptitration Protocol

• Increase bisoprolol toward target dose of 10 mg daily using 2-week intervals if heart rate remains ≥70 bpm: 2, 5
  • Current low dose → increase by 1.25-2.5 mg increments every 2 weeks
  • Target dose: bisoprolol 10 mg once daily
• Beta-blockers provide 34% mortality reduction (the highest relative risk reduction among the four medication classes) and must be uptitrated to target doses used in clinical trials. 5, 6
• With current heart rate of 70 bpm, there is room for beta-blocker uptitration without causing excessive bradycardia. 1

Sequencing Strategy for Low Blood Pressure

The European Society of Cardiology provides explicit guidance for patients with borderline BP like yours (SBP 100 mmHg): 1

1. First priority: Start SGLT2 inhibitor and ensure MRA is optimized (both have minimal BP effects) 1, 2
2. Second priority: Uptitrate beta-blocker if heart rate >70 bpm (your patient qualifies with HR 70) 1
3. Third priority: Uptitrate ARNI dose using small increments every 2-4 weeks 1, 4

Diuretic Management

• Reassess furosemide dose based on volume status—if patient has no signs of congestion (no edema, no orthopnea, no jugular venous distension), consider cautiously decreasing diuretic dose to minimize BP-lowering effects. 1
• A recent randomized controlled trial demonstrated that diuretic reduction is feasible in stable patients without congestive signs. 1
• Serial monitoring of natriuretic peptide levels can be useful during diuretic titration to ensure congestion does not worsen. 1

Critical Pitfalls to Avoid

Never discontinue or down-titrate GDMT for asymptomatic hypotension with adequate perfusion—adverse events occur in 75-85% of HFrEF patients regardless of treatment, with no substantial difference between GDMT and placebo arms in clinical trials. 1, 2

Common Mistakes That Kill Patients:

• Accepting suboptimal doses of ARNI and beta-blocker due to unfounded BP concerns—clinical trials demonstrated benefits at target doses, not low doses. 2, 5
• Delaying SGLT2 inhibitor initiation—this medication should have been started simultaneously with other GDMT at diagnosis. 2, 6
• Stopping medications for asymptomatic low BP—discontinuing RAAS inhibitors after hypotension is associated with two to fourfold higher risk of subsequent adverse events. 1, 2

Monitoring Protocol

• Assess blood pressure, heart rate, renal function, and electrolytes 1-2 weeks after each dose increment. 2, 7
• Modest increases in creatinine (up to 30% above baseline) are acceptable and should not prompt discontinuation. 2
• Potassium levels require close monitoring with MRA—if hyperkalemia develops, consider potassium binders like patiromer rather than discontinuing life-saving medications. 2

Expected Outcomes with Optimal Therapy

Comprehensive disease-modifying therapy (ARNI + beta-blocker + MRA + SGLT2i at target doses) provides approximately 5.3 additional life-years compared to no treatment, with the combination reducing all-cause mortality by 61% (HR 0.39,95% CI: 0.32-0.49) over 2 years. 2, 3, 8

When to Refer to Heart Failure Specialist

Refer if any of the following occur: 7

• Persistent hypotension with major symptoms (not your patient—BP 100/80 is acceptable)
• Recurrent HF hospitalizations despite attempted GDMT optimization
• Persistent NYHA class III-IV symptoms despite maximal tolerated GDMT
• Need for continuous or intermittent inotropic support

Your patient does NOT meet referral criteria—this is a straightforward case requiring medication optimization in the outpatient setting. 1, 7