Clinical Effectiveness of Hydralazine–Isosorbide Dinitrate in African-American Patients With Heart Failure

Abstract

Objectives To evaluate the effectiveness of hydralazine and isosorbide dinitrate (H-ISDN) in African Americans (AA) with heart failure (HF) with reduced ejection fraction (HFrEF) Background Among AA patients with HFrEF, H-ISDN was found to improve quality of life, lower HF hospitalization and mortality rates in the A-HEFT trial. Few studies have evaluated the effectiveness in clinical practice. Methods VA patients with a HF admission between 2007 to 2013 were screened. Inclusion criteria included AA race, left ventricular ejection fraction (LVEF) <40%, and receipt of VA medications. Exclusions were documented contraindications to H-ISDN, creatinine > 2.0, or intolerance to ACE inhibitors or ARB. Adjusted hazard ratios (HR) were calculated for patients who received H-ISDN 6-months prior to admission compared to those that did not receive H-ISDN using inverse probability weighting of propensity scores and a time to death analysis for 18 months of follow-up. Propensity scores were generated using patient characteristics, LVEF, lab values, and hospital characteristics. Results The final cohort included 5,168 AA HF patients (mean age 65.2) with 15.2% treated with H-ISDN prior to index admission. After 18 months, there were 1,275 reported deaths (24.7%). The adjusted mortality rate at 18 months was 22.1% for H-ISDN treatment and 25.2% for untreated (p=0.009); adjusted HR 0.85 (95% CI: 0.73–1.00, p=0.057). Conclusions H-ISDN remains underutilized in AA patients with HFrEF. In this cohort, we find H-ISDN use was associated with lower mortality in AA HFrEF patients when controlling for patient selection using an inverse probability weighting of propensity scores.

Association between long-term adherence to class-I recommended medications and risk for potentially preventable heart failure hospitalizations among younger adults

“…The lowest rates of utilization and adherence among the five medication categories where for hydralazine (2.7% of all medication preparations; mean PDC = 62.0%) and isosorbide dinitrate (0.6% of all medication preparations; mean PDC = 60.7%). The low utilization rates may be because class-I guidelines for hydralazine and isosorbide dinitrate use in combination are specifically for African Americans [7, 35], but we were unable to examine utilization by race/ethnicity because the information is not captured in MarketScan data. A previous study found that more than half of HF patients prescribed hydralazine and isosorbide dinitrate at discharge did not fill these prescriptions within 90 days [36].…”

Cardiac resynchronization therapy: A comparative analysis of mortality in African Americans and Caucasians

“…Underutilization of hydralazine and nitrate therapy in African Americans was also documented in the Improve HF Registry, which included 719 African Americans, among a cohort of 7,748 patients with heart failure. Those data revealed that only 15% of African Americans received treatment with the hydralazine and nitrate combination despite the mortality lowering benefit …”

Rethinking Heart Failure: Patient Classification and Treatment

“…As with women, treatment modalities are different for Black patients. 27 For example, hydralazine-isosorbide dinitrate (H-ISDN) therapy is recommended to treat those with moderate to severe HFrEF. 16 Despite guideline recommendations, very few contemporary studies have examined the real-world use of H-ISDN.…”