Hydralazine Hold Parameters and Clinical Considerations

Blood Pressure Thresholds for Holding

The American Heart Association recommends holding hydralazine when systolic blood pressure is <100 mmHg or diastolic blood pressure is <60 mmHg, due to the risk of hypotension and compromised coronary perfusion 1, 2
Hydralazine preferentially lowers diastolic more than systolic pressure, and excessive diastolic lowering can compromise coronary perfusion, especially in patients with coronary artery disease 1

The American College of Cardiology recommends holding hydralazine in patients with heart rate >110 bpm, as it can precipitate anginal attacks and myocardial ischemia through reflex tachycardia 2
Bradycardia (<60 bpm) can create unpredictable cardiovascular responses when combined with hydralazine, due to reflex tachycardia 2

The American Heart Association recommends that hydralazine should not be given in acute hypertensive situations, due to its unpredictable response and prolonged duration of action 1, 2, 3
Hydralazine must be combined with a beta-blocker and diuretic to counteract reflex tachycardia and sodium retention when used for chronic hypertension 3
The American College of Cardiology recommends that hydralazine without isosorbide dinitrate is contraindicated (Class III Harm) in heart failure with reduced ejection fraction 3, 4

The American Heart Association recommends scheduled therapy with nitrate, combining hydralazine with isosorbide dinitrate for African American patients with NYHA class III-IV heart failure 3, 4
Hydralazine can be used as fifth-line therapy for resistant hypertension at 25mg TID, titrated upward, with concurrent beta-blocker and diuretic 3, 5

The American College of Rheumatology recommends holding hydralazine if patient develops signs of drug-induced lupus, such as arthralgia, fever, chest pain, or unexplained malaise 3
Advanced aortic stenosis is an absolute contraindication for hydralazine due to unpredictable hemodynamic effects 3