Thread by @SatyaPatelMD

1/8 A patient with compensated HFrEF (EF 35%) has positive orthostatics. He is not hypovolemic. What medication is reasonable to prescribe?
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2/8
💥Fludrocortisone will increase ⬆️ RAAS and can cause volume overload, so you should avoid it here
💥 Caffeine and ibuprofen are last-line agents to manage orthostatic hypotension
💥 Midodrine is probably your best bet here

3/8 You prescribe midodrine 2.5 mg PO q8h and end up titrating it up to 5 mg PO q8h over the course of a few weeks. The patient shows you their BP log and you notice that their nighttime supine BPs are elevated. What do you do next?

4/8 It is reasonable to change the timing of the nighttime dose! To avoid nighttime supine hypertension with midodrine use, administer it 3-4 hours before the patient goes to bed.

5/8
💥 Supine hypertension can increase this patient's afterload and worsen heart failure.
💥 There are even case reports of caudate hemorrhage being implicated in this type of hypertension. mayoclinicproceedings.org/article/S0025-…

6/8 The patient shows up a month later and continues to have nighttime supine hypertension. You decide to stop the midodrine. What might you consider giving?

7/8 Consider pyridostigmine! AChEIs are better at preventing supine hypertension because post-ganglionic sympathetic nerves are thought to be activated during orthostatic stress and NOT when supine.
🧠 I would ask my neurologist colleagues if this is reasonable.

8/8 To review management of orthostatic hypotension, take a look at this!

https://twitter.com/SatyaPatelMD/status/1417493742768902144?s=20