Congestive heart failure vasodilators

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Chronic Pharmacotherapy in HFrEF

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ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
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Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2] Edzel Lorraine Co, DMD, MD[3]

## Overview

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Nitrates reduce both preload and afterload in the setting of congestive heart failure and thereby relieve symptoms.

## Vasodialators

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### Background

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* A nitrate may be added to ACE inhibitors to relieve symptoms of pulmonary edema
* The addition of a nitrate to an ACE inhibitor may improve exercised tolerance.
* The combination of hydralazine and nitrates is useful in patients with advanced heart failure.[1] and in particularly, when ACE inhibitors are not well tolerated.
* Hydralazine by itself is only an arterial vasodilator and does not reduce left ventricular filling pressures to the same extent as nitrates and ACE inhibitors do. In fact, when used alone it can stimulate sympathetic tone reflexively. The combination of hydralazine and nitrates has been shown to decrease mortality as well as improve the left ventricular ejection fraction and exercise capacity in patients with heart failure. However, the combination of hydralazine and nitrates have been found to be less effective than ACE inhibitors.
* The primary use of this combination is in those patients who are intolerant of ACE inhibitors.

## 2022 AHA/ACC/HFSA Heart Failure Guideline (DO NOT EDIT) [2]

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### Hydralazine and Isosorbide Dinitrate

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Class I

"1. For patients self-identified as African American with NYHA class III-IV HFrEF who are receiving optimal medical therapy, the combination of hydralazine and isosorbide dinitrate is recommended to improve symptoms and reduce morbidity and mortality. [3][1] (Level of Evidence: A) "
Value Statement: High Value

"2. For patients self-identified as African American with NYHA class III to IV HFrEF who are receiving optimal medical therapy with ACEi or ARB, beta blockers, and MRA, the combination of hydralazine and isosorbide dinitrate provides high economic value.[4] (Level of Evidence: A) "
Class IIb

"3. In patients with current or previous symptomatic HFrEF who cannot be given first-line agents, such as ARNi, ACEi, or ARB, because of drug intolerance or renal insufficiency, a combination of hydralazine and isosorbide dinitrate might be considered to reduce morbidity and mortality. [5][6] (Level of Evidence: C-LD) "

## Vote on and Suggest Revisions to the Current Guidelines

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* The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

## External Links

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* 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines[7]

* The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult [8]

* 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation [9]

## References

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1. ↑ 1.0 1.1 Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN (2004). "Combination of isosorbide dinitrate and hydralazine in blacks with heart failure". The New England Journal of Medicine. 351 (20): 2049–57. doi:10.1056/NEJMoa042934. PMID 15533851. Retrieved 2012-04-05. Unknown parameter `|month=` ignored (help)CS1 maint: Multiple names: authors list (link)
2. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM; et al. (2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e876–e894. doi:10.1161/CIR.0000000000001062. PMID 35363500 Check `|pmid=` value (help).CS1 maint: Multiple names: authors list (link)
3. ↑ Carson P, Ziesche S, Johnson G, Cohn JN (1999). "Racial differences in response to therapy for heart failure: analysis of the vasodilator-heart failure trials. Vasodilator-Heart Failure Trial Study Group". J Card Fail. 5 (3): 178–87. doi:10.1016/s1071-9164(99)90001-5. PMID 10496190.CS1 maint: Multiple names: authors list (link)
4. ↑ Angus DC, Linde-Zwirble WT, Tam SW, Ghali JK, Sabolinski ML, Villagra VG; et al. (2005). "Cost-effectiveness of fixed-dose combination of isosorbide dinitrate and hydralazine therapy for blacks with heart failure". Circulation. 112 (24): 3745–53. doi:10.1161/CIRCULATIONAHA.105.563882. PMID 16344404.CS1 maint: Multiple names: authors list (link)
5. ↑ Cohn JN, Archibald DG, Ziesche S, Franciosa JA, Harston WE, Tristani FE; et al. (1986). "Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study". N Engl J Med. 314 (24): 1547–52. doi:10.1056/NEJM198606123142404. PMID 3520315.CS1 maint: Multiple names: authors list (link)
6. ↑ Khazanie P, Liang L, Curtis LH, Butler J, Eapen ZJ, Heidenreich PA; et al. (2016). "Clinical Effectiveness of Hydralazine-Isosorbide Dinitrate Therapy in Patients With Heart Failure and Reduced Ejection Fraction: Findings From the Get With The Guidelines-Heart Failure Registry". Circ Heart Fail. 9 (2): e002444. doi:10.1161/CIRCHEARTFAILURE.115.002444. PMC 4755330. PMID 26867758.CS1 maint: Multiple names: authors list (link)
7. ↑ Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW (May 2022). "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines". Circulation. 145 (18): e895–e1032. doi:10.1161/CIR.0000000000001063. PMID 35363499 Check `|pmid=` value (help).
8. ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
9. ↑ Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967

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