In African-American patients with heart failure with reduced ejection fraction, which therapy provides mortality reduction when added to standard therapy?

In African-American patients with heart failure with reduced ejection fraction, which therapy provides mortality reduction when added to standard therapy?

• A. Digoxin
• B. Hydralazine plus isosorbide dinitrate
• C. Calcium channel blocker
• D. Thiazolidinedione

Answer: (B)

In African-American patients with heart failure with reduced ejection fraction, adding a vasodilator combination that targets both arteries and veins reduces mortality when added to standard therapy. This benefit comes from the hydralazine plus isosorbide dinitrate regimen, demonstrated in the A-HeFT trial, where African-American patients already on typical HF therapy showed lower mortality and fewer hospitalizations with this add-on treatment. Mechanistically, hydralazine relaxes arterial vessels, decreasing afterload, while isosorbide dinitrate relaxes veins, decreasing preload. Together, they improve cardiac workload and perfusion, and they seem to enhance nitric oxide signaling, which can positively affect remodeling and survival in this population. Other options do not carry the same mortality benefit in this setting. Digoxin can help symptoms and reduce hospitalizations but has not been shown to decrease mortality in modern trials. Calcium channel blockers, particularly ones like amlodipine, have not demonstrated a mortality benefit in heart failure with reduced ejection fraction and are not used to improve survival in this context. Thiazolidinediones worsen fluid retention and heart failure symptoms and are not appropriate for HF management.

In African-American patients with heart failure with reduced ejection fraction, adding a vasodilator combination that targets both arteries and veins reduces mortality when added to standard therapy. This benefit comes from the hydralazine plus isosorbide dinitrate regimen, demonstrated in the A-HeFT trial, where African-American patients already on typical HF therapy showed lower mortality and fewer hospitalizations with this add-on treatment.

Mechanistically, hydralazine relaxes arterial vessels, decreasing afterload, while isosorbide dinitrate relaxes veins, decreasing preload. Together, they improve cardiac workload and perfusion, and they seem to enhance nitric oxide signaling, which can positively affect remodeling and survival in this population.

Other options do not carry the same mortality benefit in this setting. Digoxin can help symptoms and reduce hospitalizations but has not been shown to decrease mortality in modern trials. Calcium channel blockers, particularly ones like amlodipine, have not demonstrated a mortality benefit in heart failure with reduced ejection fraction and are not used to improve survival in this context. Thiazolidinediones worsen fluid retention and heart failure symptoms and are not appropriate for HF management.