Heart Failure Fact or Fiction: BP, How Low Is Too Low?

A 71-year-old man with heart failure with reduced ejection fraction (HFrEF; 30%) due to ischemic cardiomyopathy, hypertension, and hyperlipidemia is admitted for acute decompensated heart failure (HF). He received 3 days of intravenous furosemide and optimization of guideline-directed medical therapy (GDMT). He is now euvolemic. He reports dizziness with ambulation this morning during bedside rounds.

His blood pressure is 95/65 mm Hg and heart rate is 70 bpm. He has no elevation in jugular venous pressure (JVP) and his extremities are warm and without edema. There is no significant change in blood pressure with going from sitting to standing. Yesterday, his vital signs revealed blood pressure 105/70 mm Hg and heart rate 75 bpm; he was asymptomatic. His current medication regimen includes aspirin 81 mg daily, metoprolol succinate 100 mg daily, sacubitril/valsartan 49/51 mg BID, spironolactone 25 mg daily, dapagliflozin 10 mg daily, and furosemide 20 mg daily.

His renal function is stable (creatinine level 0.89 mg/dL) and electrolyte levels are within the reference ranges. N-terminal pro–B-type natriuretic peptide level has improved from 7,522 g/dL on admission to 3,406 g/dL.

The clinician decides to decrease the doses of sacubitril/valsartan and spironolactone, and to repeat vital sign readings tomorrow.

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