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

Abstract

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) is unknown. Objectives: We sought to evaluate the effect of midodrine upon the GDMT prescription pattern and clinical outcomes of patients with decompensated systolic heart failure. Methods: We retrospectively identified 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: A total of 114 patients met inclusion criteria in the midodrine group and were compared to 358 patients in the control group. At 6-months, the midodrine group had more initiation or up-titration of beta blockers (25.5% vs 15.0%; p=0.023), renin-angiotensin-aldosterone system (RAAS) inhibitors (35.8% vs 24.8%; p=0.041) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) (19.8% vs 11.2%; p=0.04) compared to the non-midodrine group, with a similar pattern for MRA (mineralocorticoid receptor antagonists)prescriptions (17.0% vs 11.6%; p=0.21). Survival at 6 months was similar between the two groups, but the midodrine group had more frequent re-hospitalization for heart failure. 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 uptitration of GDMT at 6 months compared to those who were not prescribed midodrine.