In an adult with chronic heart failure and hypotension (blood pressure 90/60 mm Hg), which heart‑failure medications can be safely prescribed?

Heart Failure Medications Safe in Hypotension (BP 90/60)

In a patient with heart failure and blood pressure 90/60 mmHg, you can safely initiate or continue SGLT2 inhibitors and mineralocorticoid receptor antagonists (MRAs) first, as these do not lower blood pressure, followed by cautious low-dose beta-blockers or ACE inhibitors/ARNi/ARBs, while diuretics should be minimized to the lowest dose needed to prevent congestion. 1

Immediate Assessment Required

Before prescribing any medication, determine whether the hypotension is symptomatic or asymptomatic:

• Asymptomatic hypotension (BP 90/60 without dizziness, fatigue, or altered mental status) does not require treatment modification and guideline-directed medical therapy (GDMT) should be continued or initiated. 1, 2

• Symptomatic hypotension requires a stepwise approach: first reduce diuretics if no congestion is present, then eliminate non-essential vasodilators (nitrates, calcium channel blockers, alpha-blockers), and only as a last resort reduce life-saving medications like ACE inhibitors or beta-blockers. 1, 2

• Signs of shock or severe hypoperfusion (cool extremities, altered mental status, urine output <0.5 mL/kg/hr) require immediate hospitalization and intravenous inotropic support (dobutamine 2.5-10 μg/kg/min) before any oral medication adjustments. 3, 4

Medications You CAN Give (Priority Order)

First-Line: Blood Pressure-Neutral Agents

• SGLT2 inhibitors (dapagliflozin, empagliflozin) should be started first because they do not lower blood pressure and reduce mortality and hospitalization regardless of baseline BP. 1, 5

• Mineralocorticoid receptor antagonists (spironolactone 12.5-25 mg daily, eplerenone) can be initiated safely as they have minimal hypotensive effects, provided serum creatinine is <2.0-2.5 mg/dL and potassium is <5.0 mEq/L. 3, 1

Second-Line: Low-Dose Neurohormonal Blockade

• Beta-blockers can be initiated at very low doses even with BP 90/60 if the patient is asymptomatic:

  • Carvedilol 3.125 mg twice daily 3, 1
  • Metoprolol succinate 12.5 mg once daily 3, 1
  • Bisoprolol 1.25 mg once daily 1, 6

  Critical: Only bisoprolol, carvedilol, and metoprolol succinate (not tartrate) reduce mortality in heart failure. 6, 7

• ACE inhibitors/ARBs/ARNI should be started at the lowest possible doses:

  • Captopril 6.25 mg three times daily 1
  • Enalapril 2.5 mg twice daily 1
  • Lisinopril 2.5 mg once daily 1
  • Sacubitril/valsartan 24/26 mg twice daily (but expect more symptomatic hypotension) 8

• Titrate one drug at a time with small increments every 1-2 weeks under close observation, accepting BP as low as systolic 80s if asymptomatic. 1, 2

Third-Line: Diuretics (Minimize Dose)

• Loop diuretics should be reduced to the minimum dose needed to prevent congestion, as excessive diuresis worsens hypotension without improving outcomes. 3, 1

• If the patient has no signs of fluid overload (no edema, clear lungs, stable weight), consider holding or significantly reducing the diuretic dose. 1, 2

Medications to AVOID or Use With Extreme Caution

• Avoid nondihydropyridine calcium channel blockers (diltiazem, verapamil) entirely—they worsen heart failure and lower BP. 3, 1

• Avoid hydralazine/isosorbide dinitrate unless the patient cannot tolerate ACE inhibitors/ARBs/ARNI due to renal dysfunction or angioedema, as these are potent vasodilators. 3, 7

• Avoid alpha-blockers (doxazosin, prazosin) for benign prostatic hyperplasia—switch to alternative therapies. 1

• Digoxin can be used safely as it does not lower blood pressure, but it only improves symptoms without mortality benefit. 3

Practical Titration Algorithm for BP 90/60

Week 0-2:

• Start SGLT2 inhibitor (full dose immediately—no titration needed) 1
• Start spironolactone 12.5 mg daily 3, 1
• Reduce loop diuretic by 50% if no congestion 1

Week 2-4:

• Add beta-blocker at lowest dose (e.g., carvedilol 3.125 mg twice daily) 1, 6
• Monitor for symptomatic hypotension, bradycardia <50 bpm 6

Week 4-6:

• Add ACE inhibitor at lowest dose (e.g., lisinopril 2.5 mg daily) OR consider ARNI if patient can tolerate more hypotension 1, 8

Week 6 onward:

• Up-titrate one drug at a time every 1-2 weeks, prioritizing beta-blocker and ACE inhibitor/ARNI to target doses 1, 6
• Accept systolic BP 80-90 mmHg if asymptomatic 1, 2

Monitoring Requirements

• Check BP and heart rate at every visit during titration. 1, 6

• Monitor serum creatinine and potassium 1-2 weeks after starting or increasing ACE inhibitors/ARBs/MRAs—accept creatinine increases up to 50% above baseline or up to 3.0 mg/dL, and potassium up to 6.0 mEq/L. 1

• Daily weights: Instruct the patient to increase diuretic dose if weight increases by 1.5-2.0 kg over 2 consecutive days. 1, 6

• Seek specialist advice before stopping or significantly reducing beta-blockers or ACE inhibitors/ARBs/ARNI, as premature discontinuation increases mortality. 1, 2

Common Pitfalls to Avoid

• Do not stop life-saving medications (beta-blockers, ACE inhibitors, MRAs) for asymptomatic low BP—this is the most common error in clinical practice. 1, 2

• Do not use metoprolol tartrate for heart failure—only metoprolol succinate reduces mortality. 6, 7

• Do not combine ACE inhibitor + ARB + MRA—this triple combination increases hyperkalemia risk without proven benefit. 3

• Do not abruptly stop beta-blockers—this causes rebound ischemia, infarction, and arrhythmias. 1, 6

• Do not over-diurese—excessive diuresis worsens hypotension and renal function without improving outcomes in the absence of congestion. 3, 1