From the Guidelines
Given the patient's current hypotension (BP 86/59), I recommend temporarily holding all antihypertensive medications until her blood pressure normalizes. The patient should stop taking amlodipine 5mg, atacand 32mg, and metoprolol 25mg immediately. She should monitor her blood pressure at home twice daily (morning and evening) and document the readings. Once her systolic blood pressure consistently reaches 110-120 mmHg, she should restart her medications one at a time, beginning with metoprolol 25mg twice daily due to her history of LBBB, as beta blockers like metoprolol are preferred in patients with heart failure or ischemic heart disease 1. After 3-5 days, if blood pressure remains stable, she can add atacand at a reduced dose of 16mg daily, followed by amlodipine 2.5mg daily after another 3-5 days of stable readings.
The patient should also be advised on non-pharmacologic measures to manage orthostatic hypotension, such as ensuring adequate salt intake, avoiding medications that aggravate hypotension, and using compressive garments over the legs and abdomen 1. Physical activity and exercise should be encouraged to avoid deconditioning, which is known to exacerbate orthostatic intolerance. Volume repletion with fluids and salt is critical, and the patient should be instructed to drink plenty of water and consider increasing her salt intake.
The patient should contact her healthcare provider immediately if she experiences dizziness, fainting, chest pain, or if her systolic blood pressure drops below 90 mmHg or rises above 160 mmHg. This approach is necessary because continuing antihypertensives during hypotension can worsen organ perfusion and lead to falls, syncope, or end-organ damage. The gradual reintroduction allows for careful titration while maintaining cardiac protection, particularly important with her LBBB history which requires continued beta-blockade when possible.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient's Current Medications and Condition
- The patient is a 70-year-old female with current hypotension, BP 86/59.
- She is taking amlodipine 5mg, atacand 32 mg daily, and metoprolol 25mg BD.
- She has a history of LBBB.
Management of Hypotension
- Considering the patient's current hypotension, it may be necessary to adjust her antihypertensive medications.
- However, there is no direct evidence from the provided studies to support a specific plan for adjusting her antihypertensive medications while at home given her current BP.
Use of Midodrine in Hypotension
- Midodrine, an alpha-adrenergic agonist, has been shown to be effective in increasing standing blood pressure and improving symptoms of orthostatic hypotension 2, 3.
- However, a study found that midodrine did not accelerate liberation from intravenous vasopressors and was not effective for the treatment of hypotension in critically ill patients 4.
- Midodrine has been used as bridge therapy for the initiation or continuation of Guideline-Directed Medical Therapy (GDMT) in patients with heart failure and concurrent hypotension 5.
Treatment of Primary Orthostatic Hypotension
- Nonpharmacological strategies are the primary treatment for primary orthostatic hypotension, but if these fail, pharmacotherapy can help ameliorate symptoms 6.
- Midodrine and droxidopa possess the most evidence with respect to increasing blood pressure and alleviating symptoms of primary orthostatic hypotension 6.