All Rise! Orthostatic Hypotension in Heart Failure: Reply

We have read with interest the letter from Fudim and Soloveva and we are pleased that they acknowledged the importance of low blood pressure management in the follow-up of patients with chronic heart failure with reduced ejection fraction (HFrEF). The step-by-step evaluation we previously proposed for the HFrEF patient with low blood pressure emphasizes the need to assess the link between a (low) blood pressure reading and signs and/or symptoms suggestive of hypotension rather than immediately change heart failure therapeutics.1 Only few tools are available to establish such a relationship. To that purpose, office orthostatic hypotension screening is highly available, simple, fast and remains crucial in routine practice, as it could explain many symptoms (i.e. falls) in frail populations. Fudim and Soloveva offered us a very useful figure to put this into perspective. However, office orthostatic hypotension screening can lack sensitivity. Additional evidence is probably needed on that topic, but in the meanwhile, we preferred suggesting in our algorithm a wider use of ambulatory blood pressure monitoring (ABPM). ABPM remains only scarcely used and studied in HFrEF until now,2, 3 but can be useful as it provides a larger number of blood pressure measurements in conditions that are more representative of daily life. The overall goal of our low blood pressure management algorithm1 is to protect most severe patients with low baseline blood pressure from a decrease/discontinuation of therapeutic classes that have demonstrated a benefit in morbidity and mortality. Old patients are at particular high risk of orthostatic hypotension, even if supine blood pressure seems to be adequate, with sometimes severe consequences (i.e. falls). However, our algorithm also improves the probability of maintaining life-saving HFrEF medication in patients with an actual low blood pressure intolerance by first favouring the suppression of antihypertensive drugs not indicated in HFrEF and by modulating diuretic doses according to the level of congestion. We agree with Fudim and Soloveva regarding the need to better understand the blood pressure profile of these hypotensive patients. Searching for office orthostatic hypotension and a more frequent use of ABPM should probably be part of the routine assessment of HFrEF patients. Whether implementing this blood pressure assessment and using the low blood pressure algorithm we proposed1 can improve outcome through an optimized use of heart failure medication should be nonetheless formally evaluated.