Treatment of Heart Failure with Hypotension, CKD, and IHD

1. Overall Framework: What Type of HF?

• HFrEF (LVEF ≤40%) - more guideline-directed medical therapy (GDMT) options, particularly relevant with IHD
• HFpEF (LVEF ≥50%) - primarily diuretics, SGLT2i; fewer proven mortality-reducing drugs

2. The Four Pillars of GDMT (and how hypotension/CKD modify them)

A. ARNI / ACEi / ARB

• Asymptomatic low BP does NOT usually require stopping therapy
• Symptomatic hypotension (dizziness, confusion, SBP <90 mmHg): first review and stop concurrent nitrates, calcium channel blockers, other vasodilators; reduce diuretic dose if no congestion
• If still not tolerated, seek specialist advice
• Do not start if SBP <90 mmHg

• Some rise in creatinine is expected and acceptable
• Creatinine rise up to 50% above baseline or 266 µmol/L (3 mg/dL), whichever is smaller - acceptable
• Potassium rise up to 5.5 mmol/L - acceptable, monitor closely
• If K+ >5.5 mmol/L or creatinine rises >100% or >310 µmol/L (3.5 mg/dL): stop and seek specialist advice
• K+ binders (e.g., patiromer) can allow continuation in hyperkalemia
• Stop concurrent nephrotoxic drugs (NSAIDs)

B. Beta-blockers

• Do not start if: SBP <90 mmHg, current congestion, recent (<4 weeks) decompensation, HR <60 bpm
• Once stable/euvolemic: start at very low dose, double no sooner than every 2 weeks
• Preferred agents: bisoprolol (start 1.25 mg OD), carvedilol (start 3.125 mg BD), metoprolol CR/XL (12.5-25 mg OD), nebivolol (1.25 mg OD)
• Nebivolol has vasodilatory properties (via NO release) and may be better tolerated in borderline BP
• "Some beta-blocker is better than no beta-blocker" - even partial doses confer benefit
• Carvedilol is substantially more effective than short-acting metoprolol

C. Mineralocorticoid Receptor Antagonists (MRA: spironolactone/eplerenone)

• Do NOT use if:
  • Serum creatinine >2.5 mg/dL (>221 µmol/L)
  • K+ >5.0 mmol/L
  • eGFR severely impaired
• Monitoring: check electrolytes and renal function at 1, 4, 8, 12 weeks; then 6, 9, 12 months; 6-monthly thereafter
• Reduce dose if K+ >5.5 mmol/L or creatinine rises to 221 µmol/L
• STOP immediately if K+ >6.0 mmol/L or creatinine >310 µmol/L (3.5 mg/dL)
• Patiromer (K+ binder) may allow continuation when hyperkalemia develops
• Eplerenone preferred over spironolactone in males (less gynecomastia)

D. SGLT2 Inhibitors (dapagliflozin or empagliflozin)

• eGFR <20 mL/min/1.73 m²: contraindicated
• eGFR <30 mL/min/1.73 m²: use with caution, specialist advice
• eGFR 30-60: can be used; glycemic effect attenuated but CV/renal benefits preserved
• Monitor for volume depletion (may worsen hypotension)

3. ARNI vs. ACEi: Which to Choose?

• Starting dose (switching from ACEi/ARB): 49/51 mg BD; if starting de novo: 24/26 mg BD; target: 97/103 mg BD
• Must stop ACEi for 36 hours before starting (angioedema risk)
• Same renal/potassium monitoring as ACEi
• More potent BP-lowering effect - may be harder to tolerate in hypotensive patients
• If SBP is already <100 mmHg, start with ACEi/ARB first; switch to ARNI once BP is stable

4. Additional Therapies in IHD + HF

5. Approach to Hypotension - Priority Management

1. First, treat the cause - is this acute decompensation? Cardiogenic shock? Or is it chronic low BP due to medications?
2. Reduce/stop vasodilators: nitrates, calcium channel blockers (especially dihydropyridines)
3. Reassess diuretic dose: if no overt congestion, reduce or hold diuretics
4. Avoid new vasodilating agents (amlodipine, hydralazine) until BP is stabilized
5. Do NOT stop beta-blockers abruptly in IHD - reduce dose instead
6. Hold MRA and ACEi/ARB temporarily if BP is very low and symptomatic, especially if also hyperkalemic or creatinine is rising
7. If true cardiogenic shock: IV inotropes (dobutamine) ± vasopressors (norepinephrine); these are bridge therapies, not chronic agents

6. Drugs to Avoid

• NSAIDs: worsen renal function, raise BP, cause fluid retention and worsen HF
• Non-dihydropyridine CCBs (verapamil, diltiazem): contraindicated with beta-blockers in HF (negative inotropy); can also worsen HF
• Dihydropyridine CCBs (amlodipine): generally avoided in HFrEF unless refractory angina; worsens hypotension
• PDE5 inhibitors (sildenafil): contraindicated with vericiguat; dangerous hypotension with nitrates
• Salt substitutes (high K+): dangerous in CKD + MRA/ACEi combination

7. Summary Algorithm

HFrEF + IHD + CKD + Hypotension
        |
        v
Is patient euvolemic and SBP ≥90 mmHg?
        |
       YES                              NO (decompensated/shock)
        |                                       |
Start GDMT at ultra-low doses          IV diuretics if congested
  1. Beta-blocker (bisoprolol 1.25 mg)  IV inotropes if low CO
  2. ACEi (if SBP allows)              Stabilize before adding GDMT
  3. SGLT2i (if eGFR ≥20)
  4. MRA (if K+ <5.0, Cr <2.5)
  5. ARNI when BP/renal stable
        |
  Uptitrate every 2 weeks
  Monitor: K+, Cr, BP, HR
        |
  Add ivabradine if HR ≥70 and symptoms persist
  Revascularization (PCI/CABG) if ischemia drives HF

Recent Evidence