Hemodynamic action of captopril in coronary patients with heart failure tolerant to nitroglycerin

Current perspectives on hydralazine and nitrate therapies in heart failure

The origins of the hydralazine/isosorbide dinitrate (H+ISDN) combination therapy are rooted in the first large-scale clinical trial in heart failure: V-HeFT I. Initially utilized for the balanced vasodilatory properties of each drug, we now know there is "more to the story." In fact, the maintenance of the nitroso-redox balance may be the true mechanism of benefit. Since the publication of V-HeFT I 30 years ago, H+ISDN has been the subject of much discussion and debate. Regardless of the many controversies surrounding H+ISDN, one thing is clear: therapy is underutilized and many patients who could benefit never receive the drugs. Ongoing physician and patient education are mandatory to improve the rates of H+ISDN use.

Nitrate therapy for heart failure: benefits and strategies to overcome tolerance

Combination therapy with hydralazine and nitrates can improve outcomes in patients with heart failure and low ejection fraction. However, this combination is underused in clinical practice for several reasons, including side effects related to hydralazine and polypharmacy. Some of the benefits seen with hydralazine, including afterload reduction and attenuation of nitrate tolerance, have also been observed with angiotensin-converting enzyme inhibitors. Demonstrating similar clinical benefits with nitrates plus angiotensin-converting enzyme inhibitor therapy alone, in the absence of hydralazine, may represent an opportunity to improve heart failure care by increasing the use of nitrates. In this paper, we summarize data that support studying such an approach.

Systolic Hypertension in the Elderly: Pushing the Frontiers of Therapy—A Suggested New Approach

In elderly patients with systolic hypertension resistant to treatment with conventional therapy, increased aortic pulse wave reflection and a high augmentation index are often present. These findings are indicative of endothelial dysfunction and deficient generation of nitric oxide, a potent vasodilator in the arterial tree. In such patients, treatment with the nitric oxide donor extended-release isosorbide mononitrate characteristically produces prompt and sustained falls in both pulse wave reflection and systolic blood pressure. The adjunct use of this nitrate produces useful additional decreases in systolic blood pressure ranging from 10 to 45 mm Hg, often achieving target blood pressure goals in isolated systolic hypertension. By combining this endothelium-independent nitric oxide donor with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, the potential exists to address both the nitric oxide deficiency and endothelial dysfunction of the vascular endothelium in these patients. Other possibilities for synergism with this combination include complementary hemodynamic, circadian, and metabolic actions together with prevention of nitrate tolerance. Isosorbide mononitrate may also be used successfully with calcium channel blockers, beta blockers, and diuretics.