The Impact of Midodrine On Guideline-Directed Medical Therapy in Patients Admitted with Systolic Heart Failure

Background Midodrine is occasionally used off-label to treat hypotension associated with advanced heart failure. Its association with changes in prescription of guideline-directed medical therapy (GDMT) has not previously been evaluated. Objectives We sought to evaluate the clinical characteristics and GDMT prescriptions of heart failure patients who were prescribed midodrine. Methods We performed a retrospective cohort study identifying all patients admitted to our hospital in 2020 with decompensated systolic heart failure who were prescribed midodrine upon discharge. They were compared to decompensated systolic heart failure patients who were not prescribed midodrine. Baseline characteristics, GDMT adjustments, and clinical outcomes were collected. Results 114 patients met inclusion criteria in the midodrine group and were compared to 358 patients in the control group. At baseline, the midodrine group had worse left ventricular function, more right ventricular dysfunction, and more severe heart failure symptoms. At 6-months, the midodrine group had more initiation or up-titration of beta blockers (24.6% vs.15.4%; p=0.035), renin-angiotensin-aldosterone system (RAAS) inhibitors (34.2% vs. 24.0%; p=0.043) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) (19.3% vs.10.6%; p=0.024) compared to the non-midodrine group, with a similar pattern for MRA (mineralocorticoid receptor antagonists) prescriptions (17.5% vs. 11.5%; p=0.126). Mortality was not statistically different between the two groups, but the midodrine group had more frequent re-hospitalization for heart failure (39.5% vs. 25.4%; p=0.006). Conclusions Midodrine is frequently prescribed to patients presenting with systolic heart failure; the patients given midodrine tended to have more advanced heart failure and worse 6-month clinical outcomes. However, the patients who were prescribed midodrine achieved better initiation and up-titration of GDMT at 6 months compared to those who were not prescribed midodrine. Future prospective clinical trials are warranted to confirm these findings and determine if this translates to improved clinical outcomes.