Beta-blocker Dose Adjustment for Hypotension — EECC MCQ

Correct answer: A — Symptomatic orthostatic hypotension on beta-blocker should prompt assessment: check for dehydration, reduce diuretic if euvolaemic, adjust timing of medications, and if necessary reduce bisoprolol cautiously — maintaining SOME beta-blocker is important for mortality benefit even if target dose cannot be achieved

Beta-blocker management in HFrEF with symptomatic hypotension requires a balanced approach: (1) FIRST: address reversible causes of hypotension — reduce diuretic dose if euvolaemic (over-diuresis is a common cause), review other BP-lowering agents (nitrates, alpha-blockers), timing adjustments (take at bedtime); (2) THEN: if symptomatic hypotension persists, cautiously reduce beta-blocker dose (e.g. bisoprolol 10 → 7.5 → 5 mg); (3) KEY PRINCIPLE: maintaining SOME beta-blocker provides mortality benefit — even sub-target doses confer significant mortality reduction (the dose-response is steep at lower doses); complete withdrawal should be avoided if possible; (4) carvedilol has alpha-blocking properties and may cause MORE orthostatic hypotension than bisoprolol (a beta-1 selective agent); (5) resting HR 58 bpm is at the lower acceptable limit — asymptomatic bradycardia <50 bpm should prompt dose reduction.

Reference: ESC (2023): HF Guidelines