Hydralazine and Beta Blocker Combination Therapy in Heart Failure

Combination Therapy Recommendations

The American College of Cardiology recommends the combination of hydralazine and isosorbide dinitrate to reduce morbidity and mortality for patients self-described as African Americans with NYHA class III-IV HFrEF who are already receiving optimal therapy with ACE inhibitors and beta blockers (Class I, Level of Evidence: A) 1, 2
For patients with reduced ejection fraction who are already taking an ACE inhibitor and a beta-blocker for symptomatic heart failure and who have persistent symptoms, the addition of hydralazine and isosorbide dinitrate is reasonable (Class IIa, Level of Evidence: B) 3
The combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of HF and reduced LVEF who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufficiency (Class IIb, Level of Evidence: C) 3

Beta blockers help counteract the reflex tachycardia that commonly occurs with hydralazine therapy, making this combination pharmacologically complementary 4

When monitoring patients on hydralazine and beta blocker combination therapy, it is essential to monitor for blood pressure response, heart rate, and signs of fluid retention 4

Hydralazine begins to decrease blood pressure within 10-30 minutes, with effects lasting 2-4 hours, so dosing frequency is important 5
The unpredictability of response and prolonged duration of action may make hydralazine less desirable as a first-line agent for acute treatment in most patients 5