From the Guidelines
Hydralazine should not be used as monotherapy in patients with coronary artery disease (CAD) due to concerns that it may provoke angina. When considering the use of hydralazine in CAD patients, it is crucial to prioritize combination therapy to mitigate potential risks. According to the American Heart Association, American College of Cardiology, and American Society of Hypertension 1, hydralazine can be beneficial when used in conjunction with other medications for specific patient groups, such as African Americans with advanced heart failure.
For patients with CAD, the focus should be on therapies that have proven benefits in reducing morbidity, mortality, and improving quality of life. The use of hydralazine in CAD requires careful consideration of its potential to cause reflex tachycardia, which could exacerbate angina or trigger cardiac events. Therefore, if hydralazine is to be used, it should be combined with a beta-blocker to counteract this effect. Key points to consider include:
- Initial dosing and gradual increase as needed and tolerated
- Combination with beta-blockers to prevent reflex tachycardia
- Monitoring for hypotension, especially at the initiation of therapy
- Regular assessment of blood pressure, heart rate, and symptoms of angina
The mechanism of hydralazine, which involves the direct relaxation of vascular smooth muscle, can be beneficial in reducing afterload without significant venous pooling, making it useful in the context of heart failure accompanying CAD. However, the primary concern in CAD patients is the potential for hydralazine to provoke angina, highlighting the need for cautious use and close monitoring 1.
From the FDA Drug Label
PRECAUTIONS General Myocardial stimulation produced by hydrALAZINE can cause anginal attacks and ECG changes of myocardial ischemia. The drug has been implicated in the production of myocardial infarction. It must, therefore, be used with caution in patients with suspected coronary artery disease The use of hydralazine in patients with coronary artery disease (CAD) should be done with caution, as it may cause anginal attacks, ECG changes of myocardial ischemia, and has been implicated in the production of myocardial infarction 2.
From the Research
Treatment of Hypertension in CAD Patients
- The American Heart Association recommends a blood pressure goal of <140/90 mm Hg for most adults with hypertension, and <130/80 mm Hg for patients with diabetes mellitus, chronic kidney disease, known coronary artery disease (CAD), or CAD equivalents 3.
- For primary CAD prevention, any effective antihypertensive drug or combination is indicated, but preference is given to angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), and thiazide diuretics 3.
- For the management of hypertension in patients with established CAD, beta-blockers and ACE inhibitors (or ARBs) are the basis of treatment, with the addition of a thiazide diuretic and/or a dihydropyridine CCB if further blood pressure lowering is needed 3, 4.
Role of Hydralazine in CAD Patients
- Hydralazine may provoke myocardial ischemic events in patients with severe chronic heart failure secondary to coronary artery disease, particularly in the absence of significant tachycardia and hypotension 5.
- The use of hydralazine in patients with heart failure may be associated with a higher risk of ischemic events compared to other vasodilator agents, such as nitroprusside 5.
- In patients with left ventricular dysfunction, hydralazine/isosorbide dinitrate may be considered as part of the recommended therapy, in addition to an ACE inhibitor or ARB, a beta-blocker, and either a thiazide or loop diuretic 3.
Blood Pressure Targets in CAD Patients
- The primary blood pressure goal in patients with established CAD is below 140/90 mm Hg, with recent studies suggesting that a lower systolic blood pressure may be appropriate 6.
- Caution is advised when lowering diastolic blood pressure below 60 mm Hg, as this may be associated with an increased risk of coronary events 6.
- The blood pressure target in patients with CAD may vary depending on age, with a recommended systolic blood pressure < 150 mm Hg for patients aged ≥ 80 years 4.