Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
ESC Heart Fail. 2019 Aug;6(4):878-883. doi: 10.1002/ehf2.12459. Epub 2019 May 22.
Hydralazine and nitrate combination was the first treatment that showed improved survival of patients with heart failure with reduced left ventricular ejection fraction (HFREF) in the Vasodilator Heart Failure Trial (V-HeFT trial) in 1986. This showed a 34% reduction of mortality at 2 years of follow-up in patients with advanced heart failure (New York Heart Association Class IV). The angiotensin-converting enzyme inhibitor (ACEi), beta-blockers, mineralocorticoid receptor antagonists, and most recently sacubitril-valsartan have superseded the combination of hydralazine and nitrates. However, the latter combination does have a place bridging the survival gap of Black patients with HFREF when added to their standard therapy. This was demonstrated in the African-American Heart Failure Trial (A-HeFT trial) in 2004 when the risk reduction in the Black patients was 43% compared with that in the placebo. This combination may have a potential use in patients with contraindications to the use of ACEi, angiotensin receptor blockers, and sacubitril-valsartan. This is suggested by both the European Society of Cardiology (ESC) Guidelines and the guidelines of the National Institute for Health and Care Excellence (NICE). In this perspective, the role of the combination of hydralazine and nitrates in the treatment of HFREF is reviewed through a synopsis of the evidence base consisting of three randomized controlled studies, several further analyses of subgroups within those trials, a systemic review, and two large observational studies of registry cohorts. The place of the combination in the treatment cascades proposed by heart failure guidelines of the ESC and NICE is explored. This perspective is to remind us of their appropriate roles, particularly given the findings of underuse of this combination in people of African ancestry in Europe.
肼屈嗪和硝酸盐的联合治疗在 1986 年的血管扩张剂心力衰竭试验（V-HeFT 试验）中首次显示出改善左心室射血分数降低的心力衰竭（HFREF）患者的生存率。这表明在 2 年的随访中，晚期心力衰竭（纽约心脏协会心功能分级 IV 级）患者的死亡率降低了 34%。血管紧张素转换酶抑制剂（ACEi）、β受体阻滞剂、盐皮质激素受体拮抗剂，以及最近的沙库巴曲缬沙坦已经取代了肼屈嗪和硝酸盐的联合治疗。然而，当联合用于标准治疗时，后者联合治疗确实为 HFREF 的黑人患者填补了生存差距。这在 2004 年的非裔美国人心力衰竭试验（A-HeFT 试验）中得到了证明，与安慰剂相比，黑人患者的风险降低了 43%。当患者存在使用 ACEi、血管紧张素受体阻滞剂和沙库巴曲缬沙坦的禁忌证时，这种联合治疗可能具有潜在的应用价值。这一点既得到了欧洲心脏病学会（ESC）指南的建议，也得到了英国国家卫生与保健优化研究所（NICE）指南的建议。从这个角度出发，通过对包含三项随机对照研究、这些试验中的几个亚组的进一步分析、系统评价以及两项大型观察性注册队列研究的证据基础进行综述，回顾了肼屈嗪和硝酸盐联合治疗 HFREF 的作用。探讨了该联合治疗在 ESC 和 NICE 心力衰竭指南提出的治疗级联中的地位。这一观点是为了提醒我们它们的适当作用，特别是考虑到在欧洲的非洲裔人群中，这种联合治疗的使用不足的发现。
