2026 Southeastern Residency Conference

Abstract 
Background and Purpose 
Hypotension is a common barrier to optimization of guideline-directed medical therapy (GDMT) in patients with heart failure with reduced or mildly reduced ejection fraction (HFrEF/HFmrEF). Midodrine, an oral α₁-adrenergic agonist approved for orthostatic hypotension, has been used off-label to support blood pressure and facilitate GDMT initiation or titration in hypotensive heart failure patients. However, data evaluating its impact on clinical outcomes remains limited. This study aimed to evaluate the association between midodrine use at hospital discharge and 30-day all-cause readmission in hypotensive heart failure patients. 
 
Methods 
This retrospective cohort study included adult patients (≥18 years) admitted to the AdventHealth Central Florida Division between October 2024 and November 2025 with HFrEF or HFmrEF (EF <50%) and documented hypotension. Patients were grouped based on discharge with midodrine versus discharge without midodrine. Clinical data was extracted from the electronic health record, including baseline characteristics, use of GDMT at admission and discharge, length of stay (LOS), 30-day all-cause readmission, 30-day mortality, and adverse events such as hypertension and bradycardia. 
 
Results 
A total of 142 patients were included (65 intervention, 77 control). Baseline demographics and clinical characteristics were similar between groups. The 30-day all-cause readmission rate was identical between patients discharged on midodrine and those not discharged on midodrine (34% vs 34%, p=0.99). 30-day mortality was low and comparable between groups (2% vs 1%, p=0.49). Median length of stay did not differ significantly (11 vs 9 days, p=0.54). 
Hypertensive events occurred more frequently in those discharged with midodrine (31% vs 20%), though this difference was not statistically significant (p=0.11). Rates of bradycardia were similar (21% vs 17%, p=0.95). Changes in GDMT dosing from admission to discharge were comparable between groups, with no significant improvement in GDMT up-titration associated with midodrine use. 
 
Conclusions 
In this retrospective cohort of hypotensive HFrEF and HFmrEF patients, discharge on midodrine was not associated with reduced 30-day readmission, mortality, or length of stay compared to patients not discharged on midodrine. While midodrine was frequently used as a supportive agent, its use did not translate into meaningful GDMT optimization and was associated with a numerically higher incidence of hypertensive events.