A 74-year-old man with heart failure with reduced ejection fraction (EF; left ventricular EF 25-30%) is taking a combination of spironolactone 25 mg, metoprolol succinate 100 mg, lisinopril 40 mg, and empagliflozin 10 mg. He has no symptoms with his activities of daily living, but his blood pressure (BP) on two outpatient visits, measured correctly, has been 94/62 mm Hg (92/61 mm Hg after standing 3 min).
His spouse has said his BP is "too low." He asks about stopping one or more of his medications.
The correct answer is: C. He has nonsevere, asymptomatic low BP, which should not deter his present regimen.
Low BP without symptoms is not an indication for the need to limit maximally tolerated GDMT. Patients with low BP taking GDMT do better, and limiting medications will decrease the benefits of evidence-based medicine. OH may even improve with continued medications.
The 2025 multisociety Guideline for the Prevention, Detection, Evaluation, and Management of High BP in Adults confirms the continuation of antihypertensive medications for patients with OH. This patient did not have orthostasis; even if it were present, it would not defer the need for GDMT.
This patient case quiz is part of the larger Managing HF Across the Spectrum: From Recognizing Symptoms to Implementing Appropriate Treatment initiative, supported by Bayer. To visit the Managing HF Across the Spectrum page and access additional educational activities on this topic, click here.
References
- Cautela J, Tartiere JM, Cohen-Solal A, et al. Management of low blood pressure in ambulatory heart failure with reduced ejection fraction patients. Eur J Heart Fail. 2020;22(8):1357-1365. doi:10.1002/ejhf.1835
- Jones DW, Ferdinand KC, Taler SJ, et al. 2025 AHA/ACC/AANP/AAPA/ABC/ACCP/ACPM/AGS/AMA/ASPC/NMA/PCNA/SGIM guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. Published online August 8, 2025. doi:10.1016/j.jacc.2025.05.007
- Girerd N, Coiro S, Benson L, et al. Hypotension in heart failure is less harmful if associated with high or increasing doses of heart failure medication: insights from the Swedish Heart Failure Registry. Eur J Heart Fail. 2024;26(2):359-369. doi:10.1002/ejhf.3066
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