Midodrine to optimize heart failure therapy in patients with concurrent hypotension

Abstract

According to the Centers for Disease Control and Prevention statistics, about 6.2 million adults in the United States have heart failure. Guideline-Directed Medical Therapy (GDMT) involving the use of renin-angiotensin-aldosterone system inhibitors with or without a neprilysin inhibitor, β-blockers, mineralocorticoid-receptor-antagonists, and sodium-glucose cotransporter-2 inhibitors serve as the backbone for heart failure with reduced ejection fraction (HFrEF) therapy. However, in patients with refractory hypotension, the initiation of GDMT may not be possible. We present four cases where the use of midodrine, an alpha adrenergic agonist, serves as bridge therapy for the initiation or continuation of GDMT with marked clinical improvement. These cases illustrate how exacerbations of HFrEF may be ameliorated with outpatient midodrine titration among patients with baseline, persistent hypotension such that GDMT may be better tolerated.

Safety of midodrine in patients with heart failure with reduced ejection fraction: a retrospective cohort study

“…However, a poster presentation ( Scoma et al, 2021 ) indicated significantly higher all-cause mortality at 6 months following hospitalization in the midodrine group compared to the non-midodrine group (HR:6.7, 95% CI:5.2%–8.5%). There have been some recent case reports showing potential benefits (at least in terms of blood pressure improvement and a higher likelihood of GDMT) ( Hajjiah et al, 2022 ; Shiu et al, 2022 ). However, these studies were only case series with small sample sizes, lacking matched controls, and limited to short-term follow-ups.…”

Might midodrine be useful in patients with decompensated and worsening chronic heart failure? Author's reply

“…However we agree that hypotension could be the Achilles' heel for up titration of GDMT and differently from the real word practice, most trials have included patients without significant hypotension at baseline. In the last years, some Authors have described, in small case series, the off-label use of Midodrine in hypotensive HFrHF patients [9,10]. However from these small reports the role of Midodrine administration to allow initiation and optimization of GDMT remains unfortunately unproven as well as its safety.…”