Hydralazine combined with isosorbide dinitrate is specifically indicated for heart failure in which patient population, and why is ACE inhibitor/ARB preferred over this combination in most patients?

• A Self-identified African Americans who have demonstrated greater mortality benefit from this combination; ACE inhibitors/ARBs are preferred in others because they also inhibit cardiac remodelling via RAAS suppression ✓
• B Patients with diabetes and nephropathy; hydralazine-isosorbide combination provides renoprotection equivalent to ACE inhibitors
• C Patients with acute decompensated heart failure; chronic RAAS blockade worsens acute decompensation
• D Elderly patients over 80 years; ACE inhibitors cause dangerous hyperkalaemia in this group

Explanation

The A-HeFT trial demonstrated that hydralazine-isosorbide dinitrate (H-ISDN) significantly reduced mortality specifically in self-identified African-American patients with heart failure already on standard therapy. This may relate to differences in NO bioavailability and RAAS responsiveness. ACE inhibitors/ARBs are first-line for most patients because they block RAAS-mediated adverse cardiac remodelling (fibrosis, hypertrophy) and provide proven mortality reduction across broader populations. H-ISDN is used when ACE-I/ARB/ARNi is contraindicated (severe renal impairment, hyperkalaemia).

Reference: KD Tripathi, Essentials of Medical Pharmacology, 8th ed.

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Written and medically reviewed by the StethoPrep medical team.