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

Fro Ve Un Pa Sci ha rel Ma OBJECTIVES This study sought to evaluate the effectiveness of hydralazine–isosorbide dinitrate (H-ISDN) in African Americans with heart failure (HF) with reduced ejection fraction (HFrEF). BACKGROUND Among African-American patients with HFrEF, H-ISDN was found to improve quality of life and lower HF-related hospitalization and mortality rates in the A-HEFT (African-American Heart Failure Trial). Few studies have evaluated the effectiveness of this therapy in clinical practice. METHODS Veterans Affairs patients with a hospital admission for HF between 2007 and 2013 were screened. Inclusion criteria included African-American race, left ventricular ejection fraction<40%, and receipt of Veterans Affairs medications. Exclusions were documented contraindications to H-ISDN, creatinine>2.0 mg/dl, or intolerance to angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Adjusted hazard ratios were calculated for patientswho received H-ISDN 6-months before admission compared with patients who did not receive H-ISDN, by using inverse probability weighting of propensity scores and a time to death analysis for 18 months of follow-up. Propensity scores were generated using patients’ characteristics, left ventricular ejection fraction, laboratory values, and hospital characteristics. RESULTS The final cohort included 5,168 African-American patients with HF (mean age 65.2 years), with 15.2% treated with H-ISDN before index admission. After 18 months, there were 1,275 reported deaths (24.7%). The adjusted mortality rate at 18 months was 22.1% for patients receiving H-ISDN treatment and 25.2% for untreated patients (p 1⁄4 0.009); adjusted hazard ratio: 0.85 (95% confidence interval: 0.73 to 1.00; p 1⁄4 0.057). CONCLUSIONS H-ISDN remains underused in African-American patients with HFrEF. In this cohort, the study found that H-ISDN use was associated with lower mortality rates in African-American patients with HFrEF when controlling for patient selection by using an inverse probability weighting of propensity scores. (J Am Coll Cardiol HF 2017;-:-–-) Published by Elsevier on behalf of the American College of Cardiology Foundation. T he efficacy of hydralazine–isosorbide dinitrate (H-ISDN) therapy for heart failure (HF) was established in the first V-HeFT I (Vasodilator-Heart Failure Trial), regarded as the first major randomized controlled in cardiovascular m the Division of Cardiology, David Geffen School of Medicine at UCL teran Affairs Greater Los Angeles Healthcare System, Los Angeles, Cal iversity of California, Los Angeles Medical Center, Los Angeles, Californi lo Alto Healthcare System, Palo Alto, California. Dr. Ziaeian was supported entist Training Program (T32 HL007895). Dr. Fonarow has received researc s done consulting for Amgen, Janssen, Medtronic, Novartis, and St. Jude M ationships relevant to the contents of this paper to disclose. nuscript received November 21, 2016; revised manuscript received April medicine (1,2). Subsequent trials established angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and angiotensin receptor-neprilysin inhibitors (ARNIs) as preferred agents in patients with HF with reduced A, Los Angeles, California; Division of Cardiology, ifornia; Ahmanson-UCLA Cardiomyopathy Center, a; and the Division of Cardiology, Veterans Affairs by the National Institutes of Health Cardiovascular h support from the National Institutes of Health; and edical. Dr. Heidenreich has reported that he has no 24, 2017, accepted April 25, 2017. ABBR EV I A T I ON S