From the Guidelines
Hydralazine is not recommended for patients with atrial fibrillation due to its potential to worsen the condition by causing reflex tachycardia. While hydralazine is an effective vasodilator used to treat hypertension and heart failure, as noted in the 2013 ACCF/AHA guideline for the management of heart failure 1, its use in patients with atrial fibrillation is not supported by recent evidence. The relationship between heart failure and atrial fibrillation is complex, with atrial fibrillation being a risk factor for developing heart failure and vice versa, as discussed in the 2019 ACC/AHA versus ESC guidelines on heart failure 1.
For patients with hypertension who also have atrial fibrillation, alternative antihypertensive medications such as beta-blockers (like metoprolol 25-100 mg twice daily), calcium channel blockers (like diltiazem 120-360 mg daily), or ACE inhibitors/ARBs would typically be preferred. These alternatives provide blood pressure control while either helping to control heart rate (beta-blockers, non-dihydropyridine calcium channel blockers) or offering cardiovascular protection without the reflex tachycardia seen with hydralazine.
Key considerations in managing atrial fibrillation in the context of heart failure include:
- Identification and correction of reversible causes of atrial fibrillation
- Assessment of thromboembolic risk and anticoagulation need
- Rate control, with beta-blockade as the first-line rate-control medication and digoxin as an adjunctive medication, as recommended by ACCG 1
- Symptom management, which may involve rhythm control in specific cases, such as when there is a reversible secondary cause of atrial fibrillation or refractory symptoms despite adequate rate control and heart failure management.
If hydralazine must be used in a patient with atrial fibrillation due to specific circumstances, it should be administered with close monitoring and typically in combination with medications that can control heart rate, such as beta-blockers or non-dihydropyridine calcium channel blockers, to mitigate the risk of worsening atrial fibrillation.
From the Research
Hydralazine and Atrial Fibrillation
- Hydralazine is a vasodilator that is used to treat high blood pressure and heart failure 2, 3, 4.
- Atrial fibrillation is a type of irregular heartbeat that can increase the risk of stroke and other heart-related problems 5, 2.
- The use of hydralazine in patients with atrial fibrillation is not well established, but it may be used in certain situations, such as in patients with heart failure who are not responding to other treatments 2, 3, 4.
- One study found that patients with atrial fibrillation and advanced heart failure who were treated with hydralazine and other vasodilators had improved survival rates compared to those who were treated with other medications 2.
- However, another study found that angiotensin receptor blockers (ARBs) were more effective than calcium channel blockers (CCBs) in preventing atrial fibrillation recurrence in patients with hypertension and atrial fibrillation, and there was no mention of hydralazine as a treatment option 5.
- The current guidelines for the treatment of systolic heart failure include the use of beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, nitrate-hydralazine, diuretics, aldosterone antagonists, ivabradine, devices, and digoxin, but the role of hydralazine in the treatment of atrial fibrillation is not clearly established 4.
Treatment Options
- The treatment of atrial fibrillation typically involves the use of medications such as beta-blockers, anti-arrhythmic drugs, and anticoagulants to control the heart rate and prevent stroke 5, 2.
- Hydralazine may be used in certain situations, such as in patients with heart failure who are not responding to other treatments, but its use is not well established 2, 3, 4.
- The choice of treatment for atrial fibrillation depends on the individual patient's needs and medical history, and should be made in consultation with a healthcare provider 5, 2, 4.