Congestive heart failure vasodilators

Overview
Nitrates reduce both preload and afterload in the setting of congestive heart failure and thereby relieve symptoms.

Background

 * A nitrate may be added to ACE inhibitors to relieve symptoms of pulmonary edema
 * The addition of a nitrate to an ACE inhibitor may improve exercised tolerance.
 * The combination of hydralazine and nitrates is useful in patients with advanced heart failure and in particularly, when ACE inhibitors are not well tolerated.
 * Hydralazine by itself is only an arterial vasodilator and does not reduce left ventricular filling pressures to the same extent as nitrates and ACE inhibitors do. In fact when used alone it can stimulate sympathetic tone reflexively. The combination of hydralazine and nitrates has been shown to decrease mortality as well as improve the left ventricular ejection fraction and exercise capacity in patients with heart failure. However the combination of hydralazine and nitrates has been found to be less effective than ACE inhibitors.
 * The major of use of this combination is in those patients who are intolerant of ACE inhibitors.

==ACC/AHA Guidelines- Combination of Hydralazine and Nitrates Recommendation == {{cquote|

Class I
1. The combination of hydralazine and nitrates is recommended to improve outcomes for patients self described as African-Americans, with moderate-severe symptoms on optimal therapy with ACE inhibitors, beta blockers, and diuretics. (Level of Evidence: B)

Class IIa
1. The addition of a combination of hydralazine and a nitrate is reasonable for patients with reduced left ventricular ejection fraction (LVEF) who are already taking an ACE inhibitor and beta blocker for symptomatic heart failure and who have persistent symptoms. (Level of Evidence: B)

Class IIb
1. A combination of hydralazine and a nitrate might be reasonable in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF) who cannot be given an ACE inhibitor or ARB because of drug intolerance, hypotension, or renal insufﬁciency. (Level of Evidence: C)}}

Vote on and Suggest Revisions to the Current Guidelines

 * The CHF Living Guidelines: Vote on current recommendations and suggest revisions to the guidelines

Guidelines Resources

 * The ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult


 * 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation