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

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.