Initiating Hydralazine in Heart Failure with Reduced Ejection Fraction
Introduction to Hydralazine Therapy
- The European Society of Cardiology recommends hydralazine when hypertension persists despite treatment with an ACE inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and diuretic in patients with heart failure with reduced ejection fraction (HFrEF) 1, 2
- The American College of Cardiology recommends ensuring the patient is on maximally tolerated doses of ACE inhibitor, beta-blocker, and mineralocorticoid receptor antagonist before considering hydralazine 1, 3, 4
Stepwise Approach to Initiating Hydralazine
- The European Society of Cardiology suggests verifying adequate diuretic therapy, with loop diuretics preferred over thiazides in patients with chronic kidney disease stage 3B or worse 1, 2, 4
- Amlodipine is recommended as the preferred third-line agent for blood pressure control, with a Class I, Level A recommendation 1, 2
- Felodipine is an alternative dihydropyridine calcium channel blocker, with a Class IIa, Level B recommendation 1, 2
Special Considerations for Hydralazine Use
- The American College of Cardiology recommends hydralazine combined with isosorbide dinitrate for self-described African American patients with HFrEF and persistent symptoms, with a Class I, Level A recommendation 3, 7, 5, 6
- The American Heart Association suggests referral to a heart failure specialist before using hydralazine in patients who cannot tolerate ACE inhibitors or ARBs 3, 7, 8, 9, 10
Contraindications and Precautions
- The European Society of Cardiology advises against using moxonidine, due to increased mortality, with a Class III recommendation 1, 2, 5, 6
- The American College of Cardiology recommends avoiding alpha-adrenergic blockers like doxazosin, as they can cause neurohumoral activation, fluid retention, and worsening heart failure, with a Class III recommendation 1, 2, 5, 6
- The American Heart Association suggests never using non-dihydropyridine calcium channel blockers in HFrEF, with a Class III recommendation 1, 2, 5, 6