A patient with heart failure who develops a persistent dry cough on an ACE inhibitor and cannot tolerate ARBs should start which combination as first-line therapy?

A patient with heart failure who develops a persistent dry cough on an ACE inhibitor and cannot tolerate ARBs should start which combination as first-line therapy?

• A. Amlodipine
• B. Furosemide
• C. Hydralazine + nitrates
• D. Spironolactone

Answer: (C)

When heart failure with reduced ejection fraction patients can’t tolerate ACE inhibitors (due to cough) or ARBs, you need an alternative that replaces the neurohormonal blockade provided by those drugs. Hydralazine plus a nitrate fits this role because hydralazine lowers afterload (arterial dilation) and the nitrate lowers preload (venous dilation). Together they reduce the heart’s workload and improve cardiac output, with evidence showing mortality and symptom benefits for patients who cannot use ACE inhibitors or ARBs. The other options don’t replace the renin–angiotensin system in this setting: a diuretic like furosemide helps symptoms but doesn’t improve survival; amlodipine isn’t shown to improve outcomes in HFrEF; spironolactone is beneficial as an add-on in many patients but does not substitute for ACE inhibitors/ARBs.

When heart failure with reduced ejection fraction patients can’t tolerate ACE inhibitors (due to cough) or ARBs, you need an alternative that replaces the neurohormonal blockade provided by those drugs. Hydralazine plus a nitrate fits this role because hydralazine lowers afterload (arterial dilation) and the nitrate lowers preload (venous dilation). Together they reduce the heart’s workload and improve cardiac output, with evidence showing mortality and symptom benefits for patients who cannot use ACE inhibitors or ARBs.

The other options don’t replace the renin–angiotensin system in this setting: a diuretic like furosemide helps symptoms but doesn’t improve survival; amlodipine isn’t shown to improve outcomes in HFrEF; spironolactone is beneficial as an add-on in many patients but does not substitute for ACE inhibitors/ARBs.