This reduces peripheral vascular resistance and leads to a compensatory baroreceptor-mediated release of epinephrine and norepinephrine, which, as a result, increases venous return and cardiac output. Specifically, it acts to inhibit inositol trisphosphate (IP3)-induced release of calcium from the smooth muscle cells sarcoplasmic reticulum and inhibits myosin phosphorylation within the arterial smooth muscle. Although the mechanism is not completely understood, it is theorized to be associated with intracellular calcium homeostasis. Hydralazine is a direct arteriole vasodilator. Per the 2019 American College of Cardiology expert consensus guidelines, fixed-dose long-acting nitrates and hydralazine can be added to African American people already receiving an ACE inhibitor, ARB, or ARNI plus a beta-blocker. Within this population, the use of hydralazine in combination with isosorbide dinitrate has demonstrated a mortality benefit, although more recent studies have shown less robust efficacy. įor African-American patients with severe heart failure (New York Heart Association Class III and IV) with reduced ejection fraction (HFrEF), the American Heart Association recommends ACE inhibitors and beta-blockers as first-line therapy. Either of these medications should be administered during the intrapartum or postpartum period if severe blood pressure persists greater than 15 minutes. IV hydralazine along with IV labetalol are considered first-line therapy for the treatment of acute-onset, severe hypertension in pregnancy and during the postpartum period. Reasons for this include highly variable blood pressure changes and adverse hypotensive episodes. It is often given to hospitalized patients but has little evidence of improved outcomes. ![]() IV hydralazine has had increased off-label use in the setting of hypertensive emergencies. In these guidelines, hydralazine is categorized with other medications, including beta-blockers and aldosterone antagonists, that have more compelling additional indications when compared to hydralazine, such as their use in heart failure and pregnancy. Per the JNC 8 guideline algorithm, hydralazine can be considered if initiation of first-line therapy titrated to its maximum dose and/or the addition of a second first-line agent does not meet blood pressure reduction goals. Studies comparing its effects as an add-on medication to multidrug treatment for hypertension have proved effective but not as efficacious as other multi-modal first-line therapies (calcium channel blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, thiazides). In current practice, oral hydralazine is used in essential hypertension refractory to other therapeutic agents. It has also been utilized in the treatment of eclampsia along with heart failure with reduced ejection fraction (HFrEF) when in combination with isosorbide dinitrate. ![]() Hydralazine is primarily used to treat hypertension and hypertensive urgency/emergency.
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