From the Guidelines
Combining ARNIs with hydralazine is not recommended without medical supervision due to the potential increased risk of hypotension. When considering the combination of ARNIs (Angiotensin Receptor-Neprilysin Inhibitors) with hydralazine, it's crucial to weigh the benefits against the risks, particularly the risk of hypotension, as both medications lower blood pressure through different mechanisms 1. The 2017 ACC/AHA/HFSA guideline update suggests that ARNIs, such as sacubitril/valsartan, are recommended for patients with chronic symptomatic HFrEF NYHA class II or III who tolerate an ACE inhibitor or ARB, to further reduce morbidity and mortality 1. However, the guideline also warns against administering ARNIs concomitantly with ACE inhibitors or within 36 hours of the last dose of an ACE inhibitor due to the risk of angioedema 1. While hydralazine is a direct vasodilator used for hypertension and can be used in heart failure, particularly in patients who cannot tolerate ACE inhibitors or ARBs, its combination with ARNIs requires careful consideration and monitoring 1. The 2021 update to the ACC expert consensus decision pathway for optimization of heart failure treatment provides guidance on starting and target doses of select GDMT and novel therapies for HF, including ARNIs and hydralazine, emphasizing the need for individualized dosing and careful titration 1. Key points to consider when combining ARNIs with hydralazine include:
- Monitoring for symptoms of hypotension, such as dizziness, lightheadedness, or fainting, especially when starting therapy or adjusting doses.
- Individualizing dosing based on blood pressure response and tolerance.
- Regular monitoring of blood pressure, kidney function, and electrolytes by a healthcare provider. Given the potential risks and the need for careful management, combining ARNIs with hydralazine should only be done under the guidance of a healthcare provider.
From the Research
Combination of ARNI with Hydralazine
- There is no direct evidence in the provided studies that discusses the combination of ARNI with hydralazine.
- However, the studies suggest that ARNI, such as sacubitril/valsartan, can be used in combination with other antihypertensive agents, including calcium channel blockers and diuretics, to treat resistant hypertension 2, 3, 4.
- The use of ARNI in patients with heart failure and preserved ejection fraction has been shown to be effective in reducing blood pressure and improving clinical outcomes 4.
- The safety and efficacy of sacubitril/valsartan have been established in various clinical trials, including the PARADIGM-HF and PARAGON-HF trials 5, 4, 6.
- While there is no specific evidence on the combination of ARNI with hydralazine, the provided studies suggest that ARNI can be used in combination with other antihypertensive agents to achieve better blood pressure control and improve clinical outcomes in patients with hypertension and heart failure.