Hydralazine for Hypertension

Primary Role and Positioning

• The American College of Cardiology recommends hydralazine as an add-on agent in specific clinical contexts, such as combined with isosorbide dinitrate in Black patients with heart failure, or as a late-line agent in resistant hypertension after optimizing other drug classes 1, 2, 3

Clinical Context and Appropriate Use

Heart Failure with Reduced Ejection Fraction

• The American Heart Association recommends the combination of hydralazine plus isosorbide dinitrate for Black patients with NYHA class III-IV heart failure who remain symptomatic despite optimal therapy with ACE inhibitors/ARBs, beta-blockers, and aldosterone antagonists, with a Class I, Level A recommendation 2, 4
• This combination reduced mortality by 43% in the A-HeFT trial 2

Resistant Hypertension

• The American College of Cardiology recommends hydralazine as a fifth-line agent after maximizing a three-drug regimen and adding a mineralocorticoid receptor antagonist 3
• The 2017 ACC/AHA guidelines note that hydralazine can be effective in achieving blood pressure control in patients resistant to usual combination therapy, but it is reserved for refractory cases 3

Appropriate Combination Therapy When Hydralazine Is Used

Essential Concurrent Medications

• Beta-blockers must be added to control reflex tachycardia when using hydralazine 5, 6
• Thiazide or thiazide-like diuretics should be included to counteract sodium retention and fluid accumulation when using hydralazine 5, 6

Serious Adverse Effects

• Total daily doses of hydralazine should be kept below 150 mg to avoid drug-induced systemic lupus erythematosus 6