Measure blood pressure in a lying and standing position. A blood pressure < 90-100 mmHg or a drop in blood pressure > 20 mmHg systolic after standing suggests a causal relationship between complaints and hypotension.

Possible symptoms:

• Dizziness when standing up (orthostatism)
• Syncope with prodromes
• Unexplained falling

If hypotension is not symptomatic and blood pressure is > 90 mmHg systolic, heart failure therapy in patients with HFrEF is preferably continued unchanged, without dose reduction.

Target values for blood pressure:

• In HFrEF, therapy is increased to the lowest blood pressure at which the patient feels well, without symptoms of hypotension and preferably with a systolic blood pressure > 90 mmHg. If the systolic blood pressure is > 95 mmHg, without orthostatism, the heart failure therapy is continued and there is no reason to reduce or interrupt it. These patients should be advised to always rise carefully and slowly from a lying position.
• In HFpEF, on the other hand, normotension is simply aimed for (blood pressure around 120/80 mmHg). For example, with lower blood pressure, an ACE inhibitor, ARB or beta blocker can be reduced more quickly, because these treatments are less important in improving the prognosis in these patients with HFpEF.

In that case, the patient must be urgently referred to the emergency department for admission to an intensive care unit.

For example, an infection, diarrhea, vomiting, bleeding,...

• If possible, stop other medications that lower blood pressure and are not heart failure therapy, such as:
  • Calcium blockers (amlodipine, lercanidipine, etc.).
  • Centrally acting antihypertensives (e.g. moxonidine).
  • Alpha-blockers (for example tamsulosin as a treatment for prostatism complaints).
• These therapies are preferably first reduced or stopped before the heart failure therapy is reduced.

• Note: Some psychotropic drugs can also induce orthostatism and hypotension. Evaluate whether a reduction and possibly a complete stop in the long term is feasible.

• Diuretics should certainly be reduced or interrupted if there are signs of dehydration.
  • If the patient is also taking a thiazide diuretic (sometimes also hydrochlorothiazide or indapamide in a combination pill), this is preferably stopped first.
  • If necessary, a dose reduction of the loop diuretic is also indicated.
• In case of hypotension, always consider a dose reduction or discontinuation of the loop diuretic if there are no longer signs of fluid retention. If the weight quickly increases again by more than 1 or 2 kilograms with more dyspnea or signs of fluid retention, the loop diuretic must be restarted at a lower dose or the dose must be increased again.
• In HFmrEF and HFrEF the SGLT-2 inhibitor and the MRA should be continued if
• Check for possible too excessively strict fluid restriction, with less than 1 liter per day consumed (especially on hot days). In that case, advice should be given to increase the fluid intake up to 1 or even 2 liters per day.

• Be sure to consider this in the event of a suddenly faster heart rate > 100/min or a clear increase in heart rate (> 15-20/min), a new irregular heart rhythm or a new bradycardia.
• If possible, it is always best to take an ECG.
• In the event of abnormal ECG or if ECG collection is impossible in a general practice, if in doubt, the patient should be urgently evaluated by a cardiologist or at the emergency department to rule out underlying arrhythmias as a cause for the hypotension.

These can cause cardiac arrhythmias or cardiac decompensation.

If there are mainly orthostatic complaints or if there are clinical signs of venous insufficiency (varices, edema), it is best to start with compression therapy of the lower limbs (support stockings).

• Depending on the LVEF, heart rate, renal function and kalemia, it is best to reduce or stop another drug.
• SGLT2 inhibitors cause virtually no drop in blood pressure and can therefore always be continued. In case of illness and inability to eat, they are interrupted briefly until recovery.
• Remember to attempt to restart heart failure therapies at a lower dose and re-titrate as soon as possible after resolution of hypotension.

When heart failure therapy is reduced due to hypotension, preferably a lower dose of each of the 4 basic treatments is continued (beta-blocker, ACE inhibitor/ARB, ARNI, MRA, SGLT2 inhibitor).

Goal: the lowest blood pressure at which the patient feels well, without symptoms, and preferably > 90 mmHg systolic. If the blood pressure is > 95 mmHg systolic, without orthostatism, the heart failure therapy is continued and there is no reason to reduce or interrupt it.

Depending on the patient profile, treatment is preferably reduced according to these rules:

• Renal insufficiency with eGFR < 30 mL/min/1.73 m2: preferably dose reduction of ACE inhibitor/ ARB /ARNI and/or MRA , rather than dose reduction of the beta-blocker.
• In case of hyperkalemia > 5.0 – 5.5 mmol/l: MRA dose reduction is preferred.
• In case of bradycardia with heart rate < 55/min:
  • If these are taken: stop digitalis or ivabradine first.
  • Only then reduce the beta-blocker.
• If there is a history of cardiac arrhythmia, and especially if there is a history of ventricular arrhythmias (VT/VF), the beta-blocker should always be continued at the highest tolerated dose. In these patients, it is therefore preferable to first reduce or stop the ACE inhibitor/ ARB/ ARNI and/or the MRA.

A clinical re-evaluation must always be scheduled a few days up to a maximum of one week after adjustments to the treatments. If possible, after recovery of blood pressure and reduction of diuretics, it should be re-evaluated whether one of the HFrEF treatments can be cautiously slightly increased again.

Goal: normotension (120/80 mmHg).

This group of patients is more sensitive to changes in preload (filling status) and afterload.

A too high a dose of diuretics will promote hypotension.

An ACE inhibitor, ARB and beta blockade can be reduced more quickly with lower blood pressure.

• These treatments do not provide significant prognostic benefits in these patients.
• Exercise limitation in these patients is often partly caused by chronotropic incompetence. The heart rate and therefore the cardiac output therefore increase less during exercise. The patient may then feel better after tapering off the beta-blocker.
• In the case of permanent AF or a history of AF with a rapid ventricular response, the beta-blocker should not be reduced too much and should preferably not be stopped in order to maintain good rate control. After all, a relapse of AF with a rapid ventricular response can trigger another episode of cardiac decompensation.

SGLT2 inhibitors may contribute to underfilling and hypotension due to their additive diuretic effect. After initiation, it may be necessary to reduce the maintenance dose of the loop diuretic.

Patients with diabetes mellitus and Parkinson's disease are often more susceptible to symptomatic hypotension due to autonomic dysfunction and/or therapy for Parkinson's disease. This can cause falls. These patients must rise carefully and slowly from a lying position. Wearing support stockings can help. Antihypertensive medications must be reduced if necessary, although mild arterial hypertension (140-150 mmHg systolic) is sometimes best accepted.