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Hydralazine-Nitrate in HFrEF — EECC MCQ

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ModerateHeart FailureHydralazine-Nitrate in HFrEFEECC

A 60-year-old Black Caribbean man with HFrEF (LVEF 30%) is intolerant of both ACE inhibitors and ARBs due to severe angioedema. He is on bisoprolol 10 mg, dapagliflozin 10 mg, and eplerenone 50 mg. What additional agent should be started?

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Correct answer: A — Hydralazine and isosorbide dinitrate

The combination of hydralazine and isosorbide dinitrate (H-ISDN) is recommended in two scenarios: (1) as an alternative to ACEi/ARB/ARNI in patients who are intolerant (Class IIa), and (2) as add-on therapy in self-identified Black patients with HFrEF already on ACEi/ARB/ARNI who remain symptomatic, based on the A-HeFT trial (Class IIa). This patient has ACEi/ARB intolerance due to angioedema (which also contraindicates ARNI as it contains valsartan), making H-ISDN the appropriate next agent. Re-challenging with any RAAS inhibitor after angioedema is not recommended.

Reference: ESC (2023): Focused Update on Heart Failure