Discontinuation of Isosorbide Mononitrate in Hypotensive Patients

Introduction to Discontinuation Guidelines

• The American College of Cardiology, American Heart Association, and Heart Failure Society of America recommend against routine use of nitrates in heart failure with preserved ejection fraction (HFpEF), as the NEAT-HFpEF trial found no beneficial effects on activity levels, quality of life, exercise tolerance, or NT-proBNP levels 1

Patient Evaluation and Discontinuation Criteria

• For patients who were taking isosorbide for angina and are now chest pain-free with hypotension, discontinuation is appropriate, considering the original indication for isosorbide 2
• In patients with heart failure, particularly African Americans on the hydralazine-isosorbide combination for HFrEF, the decision to discontinue should be made more cautiously as this combination has shown mortality benefits in this specific population 2

Special Considerations

• The American College of Cardiology recommends considering the original indication for isosorbide and evaluating chest pain status before discontinuation, as absence of anginal symptoms suggests the potential benefit no longer outweighs the risk of hypotension 1
• For African American patients with heart failure who were on hydralazine-isosorbide combination, consider consulting cardiology before discontinuation, as stated by the American Heart Association 2