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Hypotension Management in HFrEF — EECC MCQ

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ModerateHeart FailureHypotension Management in HFrEFEECC

A 68-year-old woman with HFrEF (LVEF 32%) on optimal GDMT develops symptomatic hypotension (SBP 88 mmHg, dizziness on standing). Her medications include sacubitril/valsartan 97/103 mg bd, bisoprolol 10 mg, eplerenone 50 mg, dapagliflozin 10 mg, and furosemide 80 mg daily. She is euvolaemic. Which medication adjustment is most appropriate?

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Correct answer: D — Reduce furosemide dose first, as she is euvolaemic and diuretics are the only component without mortality benefit that can be dose-adjusted freely

When symptomatic hypotension develops in HFrEF patients on optimal GDMT, the first step is to identify and remove non-essential contributors. Diuretics should be reduced first when the patient is euvolaemic — they are the only HF medication without proven mortality benefit (they treat congestion symptoms only). If hypotension persists after diuretic optimisation, consider: timing adjustments (taking medications at different times), reducing non-cardiac medications that lower BP, and if necessary, cautious dose reduction of GDMT agents. The priority is to maintain all four pillars of GDMT at the highest tolerated doses, as dose-response relationships for mortality benefit have been demonstrated.

Reference: ESC (2023): Focused Update on Heart Failure