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

A Rare Case of Hydralazine-Induced Diffuse Alveolar Hemorrhage

Hydralazine-induced anti-neutrophil cytoplasmic antibody (ANCA) vasculitis may occur any time after hydralazine initiation. General internists should recognize diffuse alveolar hemorrhage (DAH) as a rare complication of this condition, as early treatment reduces the associated high risk of mortality. We describe the case of an 82-year-old female with diastolic heart failure who presented with a one-month history of worsening dyspnea on exertion and a one-week history of scant hemoptysis and fatigue. Her medications included aspirin and hydralazine. She was hypoxic with bilateral expiratory wheezes on exam. Labs showed new anemia, elevated creatinine, proteinuria, and hematuria. Chest computed tomography showed asymmetric bilateral upper lobe ground-glass attenuation superimposed on interlobular septal thickening and intralobular lines. Further testing showed anti-nuclear antibody, positive ANCA, perinuclear ANCA (p-ANCA), and anti-myeloperoxidase ANCA (anti-MPO-ANCA). Renal biopsy revealed MPO-ANCA, pauci-immune, necrotizing, and crescentic glomerulonephritis. She was diagnosed with DAH secondary to hydralazine-induced ANCA-associated vasculitis (AAV). Hydralazine is an anti-hypertensive medication with known potential for autoimmune reactions. Of these, AAV is a rare sequela mediated by anti-MPO and most commonly affects the kidneys. In rare circumstances, patients with AAV can develop pulmonary-renal syndrome, resulting in both glomerulonephritis and DAH with an associated high risk of mortality. Diagnosis requires a high index of suspicion in patients with acute kidney injury of unclear etiology. Early diagnosis through immune work-up and kidney biopsy should be pursued, as prompt recognition of the vasculitis, cessation of hydralazine, immunosuppression, and early plasma exchange are essential to an improved prognosis.

Combination Sodium Nitrite and Hydralazine Therapy Attenuates Heart Failure With Preserved Ejection Fraction Severity in a "2-Hit" Murine Model

Background Recent studies have suggested that cardiac nitrosative stress mediated by pathological overproduction of nitric oxide (NO) via inducible NO synthase (iNOS) contributes to the pathogenesis of heart failure with preserved ejection fraction (HFpEF). Other studies have suggested that endothelial NO synthase (eNOS) dysfunction and attenuated NO bioavailability contribute to HFpEF morbidity and mortality. We sought to further investigate dysregulated NO signaling and to examine the effects of a NO-based dual therapy (sodium nitrite+hydralazine) following the onset of HFpEF using a "2-hit" murine model. Methods and Results Nine-week-old male C57BL/6 N mice (n=15 per group) were treated concurrently with high-fat diet and N(ω)-nitro-L-arginine methyl ester (L-NAME) (0.5 g/L per day) via drinking water for 10 weeks. At week 5, mice were randomized into either vehicle (normal saline) or combination treatment with sodium nitrite (75 mg/L in the drinking water) and hydralazine (2.0 mg/kg IP, BID). Cardiac structure and function were monitored with echocardiography and invasive hemodynamic measurements. Cardiac mitochondrial respiration, aortic vascular function, and exercise performance were also evaluated. Circulating and myocardial nitrite were measured to determine the bioavailability of NO. Circulating markers of oxidative or nitrosative stress as well as systemic inflammation were also determined. Severe HFpEF was evident by significantly elevated E/E', LVEDP, and Tau in mice treated with L-NAME and HFD, which was associated with impaired NO bioavailability, mitochondrial respiration, aortic vascular function, and exercise capacity. Treatment with sodium nitrite and hydralazine restored NO bioavailability, reduced oxidative and nitrosative stress, preserved endothelial function and mitochondrial respiration, limited the fibrotic response, and improved exercise capacity, ultimately attenuating the severity of "two-hit" HFpEF. Conclusions Our data demonstrate that nitrite, a well-established biomarker of NO bioavailability and a physiological source of NO, is significantly reduced in the heart and circulation in the "2-hit" mouse HFpEF model. Furthermore, sodium nitrite+hydralazine combined therapy significantly attenuated the severity of HFpEF in the "2-hit" cardiometabolic HFpEF. These data suggest that supplementing NO-based therapeutics with a potent antioxidant and vasodilator agent may result in synergistic benefits for the treatment of HFpEF.

Utilization of Standard Therapy and Adjunctive Isosorbide Dinitrate Pump with Clinical Outcomes in Acute Heart Failure Patients

BACKGROUND: Acute heart failure is a life-threatening medical condition. Thus, effective therapy is very important for this case. Utilization of standard therapy and adjunctive isosorbide dinitrate (ISDN) pump play an important role in reducing mortality, length of hospitalization, and national early warning score – NEWS 2. However, the research on the utilization of the ISDN pump as adjunctive therapy is still limited. AIM: This study aimed to analyze the association between utilization of standard therapy and adjunctive ISDN pump with clinical outcomes (mortality, length of hospitalization, and NEWS 2) in patients with acute heart failure. METHODS: This was a cohort retrospective observational study. The purposive sampling technique was utilized to select the acute heart failure patients in UNS Sukoharjo Hospital. All the data were obtained from medical records. Logistic regression was used to analyze the data. RESULTS: A total of 94 patients were included as the samples. There was a significant association between the utilization of standard therapy (OR=7.9; CI 95%= 3.1–20.4; p < 0.001) or ISDN pump (OR=0.3; CI 95%= 0.1–0.7; p < 0.001) with the length of hospitalization. However, there was no significant association between the utilization of standard therapy (OR=1.1; CI 95%= 0.2–6.6; p = 0.9) and ISDN pump (OR=0.2; CI 95%= 0.02–1.6; p = 0.1) with NEWS 2 on patients with acute heart failure. CONCLUSION: There was a significant association between the utilization of standard therapy and ISDN pump with the length of hospitalization.

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

Background

Five guideline-recommended medication categories are available to treat patients who have heart failure (HF) with reduced ejection fraction. However, adherence to these medications is often suboptimal, which places patients at increased risk for poor health outcomes, including hospitalization. We aimed to examine the association between adherence to these medications and potentially preventable HF hospitalizations among younger insured adults with newly diagnosed HF.

Methods and results

Using the 2008–2012 IBM MarketScan Commercial database, we followed 26,439 individuals aged 18–64 years with newly diagnosed HF and calculated their adherence (using the proportion of days covered (PDC) algorithm) to the five guideline-recommended medication categories: angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers; beta blockers; aldosterone receptor antagonists; hydralazine; and isosorbide dinitrate. We determined the association between PDC and long-term preventable HF hospitalizations (observation years 3–5) as defined by the United States (U.S.) Agency for Healthcare Research and Quality. Overall, 49.0% of enrollees had good adherence (PDC≥80%), which was more common among enrollees who were older, male, residing in higher income counties, initially diagnosed with HF in an outpatient setting, and who filled prescriptions for fewer medication categories assessed. Adherence differed by medication category and was lowest for isosorbide dinitrate (PDC = 60.7%). In total, 7.6% of enrollees had preventable HF hospitalizations. Good adherers, compared to poor adherers (PDC<40%), were 15% less likely to have a preventable hospitalization (HR 0.85, 95% confidence interval, 0.75–0.96).

Conclusion

We found that approximately half of insured U.S. adults aged 18–64 years with newly diagnosed HF had good adherence to their HF medications. Patients with good adherence, compared to those with poor adherence, were less likely to have a potentially preventable HF hospitalization 3–5 years after their initial diagnosis. Because HF is a chronic condition that requires long-term management, future studies may want to assess the effectiveness of interventions in sustaining adherence.

Hydralazine and nitrates in the treatment of heart failure with reduced ejection fraction

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.

Science-based Ethnic Bridging in Drug Development; Review of Recent Precedence and Suggested Steps Forward

BACKGROUND

Exposure, safety and/or efficacy of drugs are subject to potential differences between human races or ethnicities, as acknowledged by regulatory guidance and by label texts of various, but not all approved drugs.

OBJECTIVE

The objective of the present review was to assess recent regulatory precedence on drug use and race or ethnicity, with the goal of identifying opportunities for increasing the informative value of clinical ethnic or racial bridging in drug development.

METHODS

Recently, (January 2014-July 2018) FDA approved drug product label texts and approval packages were reviewed for claims, comments and underlying data on use of the product in specific ethnic or racial groups.

RESULTS

Among the 266 FDA-approved products, no product with unambiguous race- or ethnicity specific dosing instructions was retrieved. A small majority (55%) was approved with a claim or comment on race or ethnicity, and of these, a large majority (87%) was based on population pharmacokinetic data analysis. Statements were often related to incidence of a genotype for drug metabolizing enzyme or for other risk factors, or were related to body weight. Absence of clinically relevant exposure differences were often justified in terms of exposure ratios that notably exceeded the typical 0.80-1.25 no-effect boundary.

CONCLUSIONS

Recent precedence reflected a pragmatic, descriptive approach of racial or ethnic bridging, apparently meeting current regulatory expectations, whilst not resulting in strict guidance to prescribers. We recommend further work on defining the objectives of bridging studies, as well as criteria for their design and data analysis. Regarding the latter, we recommend investigating the value of prospectively defined tests for similarity with appropriate follow-up analysis in the case where the test has failed.

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

BACKGROUND

Cardiac resynchronization therapy (CRT) is recommended in patients with heart failure, reduced left ventricular ejection fraction, and a prolonged QRS duration. African Americans are underrepresented in clinical trials and CRT is underutilized; consequently, the benefits and outcomes of CRT are not well-defined.

METHODS

We evaluated 294 patients, determined survival using Kaplan-Meier analysis, and used Cox proportional hazards regression model to determine predictors of mortality. Propensity score-match analysis was applied to balance covariates in African Americans and Caucasians.

RESULTS

The mean age for African Americans (n  =  131) and Caucasians (n  =  163) was 65 ± 12 and 70 ± 13 years (P  =  0.0003). Mortality in African Americans was 28% compared to 37% in Caucasians (P  =  0.14) over a median follow-up of 8.1 ± 0.6 years. Survival was significantly reduced in African Americans and Caucasians with a glomerular filtration rate (GFR) < 60 (6.7 ± 0.4, 95% confidence interval [CI]: 5.9-7.5 vs 8.6 ± 0.5 CI: 7.7-9.5 years, P  =  0.005), and those not treated with an aldosterone antagonist (7.1 ± 0.4, 95% CI: 6.5-7.9 vs 8.7 ± 0.6, 7.6-9.9 years, P  =  0.04), respectively. Independent predictors of mortality were a GFR <60 and low left ventricular ejection fraction. In African Americans, ischemic cardiomyopathy (ICM) and lack of therapy with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) were associated with increased mortality.

CONCLUSIONS

Long-term survival benefit from CRT was similar in African Americans and Caucasians. A GFR < 60 and lack of therapy with an aldosterone antagonist were associated with decreased survival. Survival also was inversely related to the number of comorbidities. In African Americans, underutilization of an ACEI or ARB, and ICM were additional factors associated with increased mortality.

Heart Failure and Kidney Disease

Kidney disease is commonly found in heart failure (HF) patients. They share many risk factors and common pathophysiological pathways which often lead to mutual dysfunction. Both haemodynamic and non-haemodynamic mechanisms are involved in the development of renal impairment in heart failure patients. Moreover, the presence of a chronic kidney disease is a significant independent predictor of worse outcome in chronic as well as in acute decompensated HF. As a consequence, an accurate evaluation of renal function plays a key role in the management of HF patients. Serum creatinine levels and glomerular filtration rate (GFR) estimates are the corner stones of renal function evaluation in clinical practice. However, to overcome their limits, several emerging glomerular and tubular biomarkers have been proposed over the last years. Alongside the renal biomarkers, imaging techniques could complement the laboratory data exploring different pathophysiological pathways. In particular, Doppler evaluation of renal circulation is a highly feasible technique that can effectively identify HF patients prone to develop renal dysfunction and with a worse outcome. Finally, some classes of drugs currently used in heart failure treatment can affect renal function and their use can be influenced by the presence of chronic kidney disease.