Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients

Abstract

Low blood pressure is common in patients with heart failure and reduced ejection fraction (HFrEF). While spontaneous hypotension predicts risk in HFrEF, there is only limited evidence regarding the relationship between hypotension observed during heart failure (HF) drug titration and outcome. Nevertheless, hypotension (especially orthostatic hypotension) is an important factor limiting the titration of HFrEF treatments in routine practice. In patients with signs of shock and/or severe congestion, hospitalization is advised. However, in the very frequent cases of non-severe and asymptomatic hypotension observed while taking drugs with a class I indication in HFrEF, European and US guidelines recommend maintaining the same drug dosage. In instances of symptomatic or severe persistent hypotension (systolic blood pressure < 90 mmHg), it is recommended to first decrease blood pressure reducing drugs not indicated in HFrEF as well as the loop diuretic dose in the absence of associated signs of congestion. Unless the management of hypotension appears urgent, a HF specialist should then be sought rather than stopping or decreasing drugs with a class I indication in HFrEF. If symptoms or severe hypotension persist, no recommendations exist. Our HF group reviewed available evidence and proposes certain steps to follow in such situations in order to improve the pharmacological management of these patients.

Combination of ivabradine and sacubitril/valsartan in patients with heart failure and reduced ejection fraction

“…Recently, an algorithm for the management of hypotension in patients with HFrEF had been proposed by European experts. If hypotensive factors unrelated to HF had been excluded, doses of diuretics and guideline‐recommended medical therapies for HF might need to be decreased in hypotensive patients with HFrEF 25 …”

“…If hypotensive factors unrelated to HF had been excluded, doses of diuretics and guideline-recommended medical therapies for HF might need to be decreased in hypotensive patients with HFrEF. 25 Instead of de-escalating disease-modifying medications, ivabradine was associated with an increase in directly measured central systolic pressure and may help counter the hypotension. 11 Previous studies demonstrated that ivabradine's introduction might allow the introduction of a beta-blocker secondarily and/or enable increasing the betablocker dose more easily compared with introducing a beta-blocker directly.…”

The Altmetric Attention Score: how science tries to meet social media

“…However, even within a niche field like HF, it is possible to analyse which issues gain more interest and are more requested, thus partially representing the ‘news value’ of a journal. Tables 2–5 report the top 10 articles published in 2019 and 2020 in the European Journal of Heart Failure and ESC Heart Failure , according to their Altmetric Attention Score 5–44 . 2020 was the year of…”

All rise! Orthostatic hypotension in heart failure. Letter regarding the article ‘Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients’

“…We read with great interest the article by Cautela et al, 1 which provides a useful stepwise algorithm for management of low blood pressure (BP) in heart failure (HF) with reduced ejection fraction (HFrEF). The authors need to be commended for emphasizing the need for not only supine BP but Figure 1 Considerations on orthostatic testing in heart failure (HF).…”