Use of Midodrine in Heart Failure: Two Case Reports and a Review of the Literature

Adnan Hajjiah 1, Ossama Maadarani 2, Zouheir Bitar 2, Boutros Hanna 2, Ragab Elshabasy 2, Mohammad Abdelfatah 2, Mohammad Gohar 2

Affiliations

18 March 2022

-

doi: 10.12890/2022_003246

Abstract

Hypotension in patients with heart failure is much more frequent in daily clinical practice than the 10-15% reported in clinical trials. In patients with heart failure with reduced ejection fraction (HFrEF), hypotension frequently limits the initiation and up-titration of guideline-directed medical therapy (GDMT). Midodrine is a peripheral alpha-1 agonist and a vasopressor anti-hypotensive agent approved for the treatment of orthostatic hypotension. We describe two cases where midodrine was prescribed in patients with HFrEF and hypotension.

Learning points: Hypotension in patients with systolic heart failure is a frequent presentation and can limit the initiation and optimization of guideline-directed medical therapy.Midodrine is a peripheral alpha-1 agonist and anti-hypotensive agent approved for the treatment of orthostatic hypotension.Midodrine may be used off-label in patients with heart failure with reduced ejection fraction (HFrEF) and symptomatic hypotension to allow optimization of medical therapy.

Keywords: Midodrine; heart failure; noradrenaline.

Conflict of interest statement

Conflicts of Interests: The authors declare there are no competing interests.

Figures

Figure 1 The impact of titration of midodrine dose on noradrenaline requirement in a patient with heart failure and refractory hypotension. DBP, diastolic blood pressure; HR, heart rate; SBP, systolic blood pressure

Figure 1 The impact of titration of midodrine dose on noradrenaline requirement in a patient with heart failure and refractory hypotension. DBP, diastolic blood pressure; HR, heart rate; SBP, systolic blood pressure

Similar articles

Midodrine to optimize heart failure therapy in patients with concurrent hypotension.

Shiu P, Grewal GS, Kozik TM.SAGE Open Med Case Rep. 2022 May 18;10:2050313X221100400. doi: 10.1177/2050313X221100400. eCollection 2022.PMID: 35601610 Free PMC article.

Combination therapy of midodrine and droxidopa for refractory hypotension in heart failure with preserved ejection fraction per a pharmacist's proposal: a case report.

Asai Y, Sato T, Kito D, Yamamoto T, Hioki I, Urata Y, Abe Y.J Pharm Health Care Sci. 2021 Mar 3;7(1):10. doi: 10.1186/s40780-021-00193-z.PMID: 33653416 Free PMC article.

Preliminary experience with midodrine in kidney/pancreas transplant patients with orthostatic hypotension.

Hurst GC, Somerville KT, Alloway RR, Gaber AO, Stratta RJ.Clin Transplant. 2000 Feb;14(1):42-7. doi: 10.1034/j.1399-0012.2000.140108.x.PMID: 10693634

Midodrine. A review of its pharmacological properties and therapeutic use in orthostatic hypotension and secondary hypotensive disorders.

McTavish D, Goa KL.Drugs. 1989 Nov;38(5):757-77. doi: 10.2165/00003495-198938050-00004.PMID: 2480881 Review.

Midodrine: a selective alpha-adrenergic agonist for orthostatic hypotension and dialysis hypotension.

Cruz DN.Expert Opin Pharmacother. 2000 May;1(4):835-40. doi: 10.1517/14656566.1.4.835.PMID: 11249519 Review.

KMEL References

https://pubmed.ncbi.nlm.nih.gov/

References

  1.  
    1. CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS) N Engl J Med. 1987;316:1429–1435. - PubMed
  2.  
    1. Komajda M, Schope J, Wagenpfeil S, Tavazzi L, Bohm M, Ponikowski P, et al. QUALIFY Investigators. Physicians’ guideline adherence is associated with long-term heart failure mortality in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail. 2019;21:921–929. - PubMed
  3.  
    1. Ambrosy AP, Vaduganathan M, Mentz RJ, Greene SJ, Subacius H, Konstam MA, et al. Clinical profile and prognostic value of low systolic blood pressure in patients hospitalized for heart failure with reduced ejection fraction: insights from the Efficacy of Vasopressin Antagonism in Heart Failure: Outcome Study with Tolvaptan (EVEREST) trial. Am Heart J. 2013;165:216–225. - PubMed
  4.  
    1. Tartiere JM, Logeart D, Safar ME, Cohen-Solal A. Interaction between pulse wave velocity, augmentation index, pulse pressure and left ventricular function in chronic heart failure. J Hum Hypertens. 2006;20:213–219. - PubMed
  5.  
    1. National Library of Medicine- PubChem. Midodrine hydrochloride. Available from https://pubchem.ncbi.nlm.nih.gov/compound/Midodrine-hydrochloride.
  6.  
    1. Prakash S, Garg AX, Heidenheim AP, House AA. Midodrine appears to be safe and effective for dialysis-induced hypotension: a systematic review. Nephrol Dial Transplant. 2004 Oct;19(10):2553–2558. doi: 10.1093/ndt/gfh420. - DOI - PubMed
  7.  
    1. Brunelli SM, Cohen DE, Marlowe G, Van Wyck D. The impact of midodrine on outcomes in patients with intradialytic hypotension. Am J Nephrol. 2018;48(5):381–388. doi: 10.1159/000494806. - DOI - PubMed
  8.  
    1. Scoma C, Dae-Hyun L, Cohen A, Fernandez J. Prevalence of midodrine use in patients admitted with systolic congestive heart. J Am Coll Cardiol. 2021;77(18):678. doi: 10.1016/S0735-1097(21)02037-4.. - DOI
  9.  
    1. Zakir RM, Folefack A, Saric M, Berkowitz RL. The use of midodrine in patients with advanced heart failure. Congest Heart Fail. 2009 May–Jun;15(3):108–111. doi: 10.1111/j.1751-7133.2008.00042.x. - DOI - PubMed
  10.  
    1. Folefack A, Zakir RM, Saric M, Berkowitz RL. Midodrine increases blood pressure in hypotensive heart failure patients facilitating optimization of heart failure therapy leading to improved outcomes. J Cardiac Fail. 2006;12(6):S129. doi: 10.1016/j.cardfail.2006.06.448. doi: - DOI
  11.  
    1. Vijayaraghavan K, Little D, Mercer T, Querrey T, Wilmowski S, Win A, et al. Midodrine as a bridge to enable use of life enhancing therapies in chronic heart failure. J Cardiac Fail. 2020;26(10):S59. doi: 10.1016/j.cardfail.2020.09.175. - DOI
  12.  
    1. Bergman SM. Hemodialysis in hypotensive heart failure using midodrine. Am J Med Sci. 2009 Dec;338(6):470–473. doi: 10.1097/MAJ.0b013e3181b7efa7. - DOI - PubMed

Page Navigation