Question: What are the benefits of the combination of a long-acting nitrate and hydralazine, and who would be a good candidate for that combination therapy?
Answer: Some years ago, we learned that by combining long-acting nitrates with hydralazine -- these are both drugs that dilate blood vessels; hydralazine tends to dilate more the arteries, and long-acting nitrates more the veins -- we can improve heart function, we can increase exercise tolerance and we can prolong survival.
And we tended to abandon the combination in the years that followed because we found out that ace inhibitors had those same benefits, and in fact the benefits were greater for ace inhibitors than they were for hydralazine and long-acting nitrates.
Then some years later, we reanalyzed the study that compared these two therapies and found out that in African-Americans, long-acting nitrates and hydralazine seem to have very favorable survival effects.
Therefore, a study was done that added long-acting nitrates and hydralazine to background therapy with ace inhibitors and beta blockers. And in fact, in this study called the African-American Heart Failure Trial, the risk of dying or being hospitalized were each reduced by about 40 percent.
We don't know whether adding long-acting nitrates and hydralazine to the medical regimen in white Americans will prolong survival or not, but we do do this in patients who continue to have refractory symptoms on standard therapy.