Hydralazine plus nitrate therapy in patients with heart failure with reduced ejection fraction
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
Hydralazine plus nitrate therapy provides symptomatic and mortality benefit in selected patients with heart failure with reduced ejection fraction (HFrEF; also known as HF due to systolic dysfunction or systolic HF) .
Recommendations for use of hydralazine plus nitrates in patients with HFrEF and data supporting the efficacy of this drug combination will be presented here. An overview of the treatment of HFrEF is presented separately (figure 1). (See "Overview of the therapy of heart failure with reduced ejection fraction".)
A hemodynamic rationale for the combined use of hydralazine and nitrate therapy is to reduce cardiac preload and afterload by achieving both venous and arterial vasodilation. Hydralazine is an arterial vasodilator and nitrates are predominantly venodilators. These vasodilatory effects can reduce intracardiac filling pressures, which may reduce adverse cardiac remodeling. (See "Cardiac remodeling: Basic aspects".)
It has also been hypothesized that combined hydralazine and nitrate therapy enhances nitric oxide bioavailability since nitrates serve as nitric oxide donors and hydralazine is an antioxidant that reduces consumption of nitric oxide [1-3]. It has been postulated that this protective mechanism can be recruited even in the presence of neurohormonal blockade (eg, use of angiotensin converting enzyme inhibitors).
Indications — For select patients with heart failure with reduced ejection fraction (HFrEF), we recommend hydralazine plus oral nitrate as a component of therapy. Our recommendations are similar to major society guidelines (figure 1) and are based on the clinical trial evidence discussed below. The strength of the evidence for benefit is somewhat stronger in black patients than in other patient groups, as reflected in our recommendations. (See 'Major society guidelines and regulations' below and 'Evidence of benefit' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- Our approach
- - Indications
- - Contraindications
- - Evaluation prior to initiation of therapy
- - Administration
- - Management of adverse effects
- Major society guidelines and regulations
- EVIDENCE OF BENEFIT
- In addition to standard therapy
- Earlier trials
- Unresolved issues
- - Racial subgroups
- - NYHA class II or IV heart failure
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS