Hydralazine Dosing for Hypertension

Standard Maintenance Dosing

The American College of Cardiology recommends a total daily dose of 100-200 mg divided into 2-3 doses per day for hydralazine maintenance dosing 1, 2
Three times daily dosing may be necessary in rapid acetylators or those requiring higher doses, according to the American College of Cardiology guidelines 1, 2

The American College of Cardiology suggests always combining hydralazine with a diuretic and beta-blocker to counteract sodium/water retention and reflex tachycardia 1, 2, 3
Hydralazine monotherapy is inappropriate due to compensatory mechanisms that limit efficacy, as stated by the American College of Cardiology 4, 3

The American Heart Association recommends considering hydralazine as an alternative when ACE inhibitors/ARBs are contraindicated due to renal insufficiency, but use with caution 5

For heart failure with reduced ejection fraction, the American College of Cardiology recommends combining hydralazine with isosorbide dinitrate, not using it alone 4

The American College of Cardiology recommends holding hydralazine if systolic BP <100 mmHg or diastolic BP <60 mmHg due to hypotension risk and compromised coronary perfusion 4, 6
The American College of Cardiology suggests holding hydralazine if heart rate >110 bpm as reflex tachycardia can precipitate anginal attacks and myocardial ischemia 4
The American College of Cardiology recommends holding hydralazine if signs of drug-induced lupus develop, such as arthralgia, fever, chest pain, or unexplained malaise 4

The American College of Cardiology advises against using hydralazine for acute hypertensive emergencies due to unpredictable response and prolonged duration of action (2-4 hours) 4, 6
The American College of Cardiology recommends avoiding hydralazine in advanced aortic stenosis (absolute contraindication) due to unpredictable hemodynamic effects 4
The American College of Cardiology suggests monitoring for lupus-like syndrome, especially at doses ≥150 mg daily in elderly patients 1
The American College of Cardiology notes that hydralazine preferentially lowers diastolic more than systolic pressure, which can compromise coronary perfusion in CAD patients 4