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Hydralazine-ISDN in Black Patients — EECC MCQ

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ModerateHeart FailureHydralazine-ISDN in Black PatientsEECC

A 65-year-old man with HFrEF (LVEF 22%) is considered for hydralazine and isosorbide dinitrate (H-ISDN). In which specific patient population did the A-HeFT trial demonstrate a mortality benefit?

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Correct answer: A — Self-identified Black/African American patients with HFrEF in NYHA class III-IV already on standard GDMT — H-ISDN added to standard therapy reduced mortality by 43%

The A-HeFT (African-American Heart Failure Trial, 2004) demonstrated that adding fixed-dose hydralazine 37.5 mg / isosorbide dinitrate 20 mg (titrated to H 75 mg / ISDN 40 mg TDS) to standard neurohormonal therapy in self-identified Black patients with NYHA III-IV HFrEF reduced mortality by 43% and HF hospitalisations by 33%. The trial was stopped early for overwhelming benefit. The mechanism may relate to nitric oxide deficiency and oxidative stress differences. The ESC HF Guidelines recommend H-ISDN as an alternative to ACEi/ARB in patients who cannot tolerate either (Class IIb), and specifically in Black patients with HFrEF already on optimal GDMT (Class IIa, based on A-HeFT). H-ISDN is also used when ACEi/ARB/ARNI are contraindicated (e.g. bilateral renal artery stenosis, angioedema).

Reference: ESC (2023): HF Guidelines; A-HeFT Trial