Imdur (Isosorbide Mononitrate) Is Not Recommended for Primary Treatment of Hypertension
Nitrates, including Imdur (isosorbide mononitrate), have not been shown to be effective for the management of hypertension and are not recommended as antihypertensive agents. 1
Guideline-Based Evidence
The most authoritative guidance comes from the American Heart Association, American College of Cardiology, and American Society of Hypertension, which explicitly state that "nitrates have generally not been shown to be of use in the management of hypertension." 1 This represents the consensus position from 2015 guidelines specifically addressing hypertension in patients with coronary artery disease.
When Nitrates Are Appropriate
Nitrates serve specific roles that do not include primary hypertension treatment:
- Long-acting nitrates are indicated for angina relief when β-blockers and calcium channel blockers fail to control symptoms in hypertensive patients with coronary artery disease 1
- Hypertension does not impact the use of nitrates for angina prevention or sublingual preparations for acute anginal attacks 1
- The combination of isosorbide dinitrate plus hydralazine is recommended specifically for African American patients with advanced heart failure (NYHA class III or IV) requiring additional blood pressure control, but this is a specialized indication, not general hypertension management 1
Critical Limitation: Nitrate Tolerance
Nitrate tolerance significantly limits the ability of long-term nitrates to function as antihypertensive agents. 1 While the addition of hydralazine can reduce this tolerance, this combination is reserved for the specific heart failure population mentioned above, not for routine hypertension treatment.
Research Evidence Context
While some research studies have explored nitrates for systolic hypertension, these represent investigational approaches rather than established practice:
- One study in hemodialysis patients showed blood pressure reduction with isosorbide mononitrate, but this was in a highly specialized population with unique pathophysiology 2
- Studies examining extended-release isosorbide mononitrate for isolated systolic hypertension showed some efficacy 3, 4, 5, but these findings have not translated into guideline recommendations for general practice
The absence of guideline endorsement despite available research indicates insufficient evidence for morbidity and mortality benefit in routine hypertension management.
Recommended Antihypertensive Approach Instead
For patients requiring hypertension treatment, guidelines recommend:
- First-line agents include thiazide diuretics, ACE inhibitors, ARBs, and calcium channel blockers 1
- For patients with hypertension and coronary artery disease, the regimen should include a β-blocker (if prior MI), an ACE inhibitor or ARB (if prior MI, LV dysfunction, diabetes, or CKD), and a thiazide diuretic 1
- Target blood pressure is <130/80 mmHg in most patients with coronary disease 1
Clinical Pitfall to Avoid
Do not prescribe Imdur or other long-acting nitrates with the expectation of blood pressure control. If a patient is on nitrates for angina and happens to have hypertension, manage the hypertension with evidence-based antihypertensive medications (thiazides, ACE inhibitors, ARBs, calcium channel blockers, β-blockers) rather than relying on the nitrate for blood pressure reduction. 1