CHF and arrhythmias:

Indications for: BIDIL

Heart failure (HF) in black patients, as adjunct to standard treatment, to improve survival, prolong time to hospitalization for HF, and improve patient-reported functional status.

Limitations of Use:

There is little experience in patients with NYHA class IV heart failure.

Clinical Trials:

BiDil or a combination of isosorbide dinitrate and hydralazine hydrochloride was studied in two placebo-controlled clinical trials in 1,692 patients with mild to severe heart failure (mostly NYHA class II and III) and one active control trial (vs. enalapril) in 804 patients. 

Placebo-controlled Study:

  • In the multicenter trial V-HeFT I, the combination of hydralazine and isosorbide dinitrate 75 mg/40 mg 4 times daily (n=186) was compared to placebo (n=273) in men with impaired cardiac function and reduced exercise tolerance (primarily NYHA class II and III) and on therapy with digitalis glycosides and diuretics. There was no overall significant difference in mortality between the two treatment groups. There was, however, a trend favoring hydralazine and isosorbide dinitrate, which on retrospective analysis, was attributable to an effect in blacks (n=128). Survival in white patients (n=324) was similar on placebo and the combination treatment.

Active-controlled Study:

  • In a second study of mortality, V-HeFT II, the combination of hydralazine and isosorbide dinitrate 75 mg/40 mg 4 times daily was compared to enalapril in 804 men with impaired cardiac function and reduced exercise tolerance (NYHA class II and III), and on therapy with digitalis glycosides and diuretics. The combination of hydralazine and isosorbide dinitrate was inferior to enalapril overall, but retrospective analysis showed that the difference was observed in the white population (n=574); there was essentially no difference in the black population (n=215).
    Based on these retrospective analyses suggesting an effect on survival in black patients, but showing little evidence of an effect in the white population, a third study was conducted among black patients with heart failure.

Placebo-controlled Study:

  • The A-HeFT trial evaluated BiDil vs. placebo among 1,050 self-identified black patients (over 95% NYHA class III) at 169 centers in the United States. All patients had stable symptomatic heart failure. Patients were required to have LVEF ≤35% or left ventricular internal diastolic dimension >2.9 cm/m2 plus LVEF <45%. Patients were maintained on stable background therapy and randomized to BiDil (n=518) or placebo (n=532). BiDil was initiated at 20 mg isosorbide dinitrate/37.5 mg hydralazine hydrochloride three times daily and titrated to a target dose of 40/75 mg three times daily or to the maximum tolerated dose. Patients were treated for up to 18 months.
  • The primary endpoint was a composite score consisting of all-cause mortality, first hospitalization for heart failure, and responses to the Minnesota Living with Heart Failure questionnaire.
  • The trial was terminated early, at a mean follow-up of 12 months, primarily because of a statistically significant 43% reduction in all-cause mortality in the BiDil-treated group (HR: 0.57 [95% CI, 0.37-0.89]; P =0.012). The primary endpoint was also statistically in favor of BiDil (P ≤ 0.021). The BiDil-treated group also showed a 39% reduction in the risk of a first hospitalization for heart failure (HR: 0.61 [95% CI, 0.46-0.80]; P <0.001) and had statistically significant improvement in response to the Minnesota Living with Heart Failure questionnaire, a self-report of the patient's functional status, at most time points (see full labeling). Patients in both treatment groups had mean baseline questionnaire scores of 51 (out of a possible 105).

Adult Dosage:

Initially 1 tab 3 times daily, may reduce to ½ tab 3 times daily if not tolerated; titrate as tolerated after 3–5 days. Max 2 tabs 3 times daily.

Children Dosage:

Not established.

BIDIL Contraindications:

Allergy to organic nitrates. Concomitant PDE5 inhibitors (eg, avanafil, sildenafil, tadalafil, vardenafil), or riociguat.

BIDIL Warnings/Precautions:

Correct volume/salt depletion prior to initiation. Hypotension. Hypertrophic cardiomyopathy. Discontinue if syncope occurs. Give pyridoxine if peripheral neuritis occurs. Elderly. Pregnancy. Nursing mothers.

BIDIL Classification:

Vasodilators (nitrate + direct-acting).

BIDIL Interactions:

See Contraindications. Severe hypotension with PDE5 inhibitors or riociguat.

Adverse Reactions:

Headache, dizziness, asthenia, nausea, vomiting, hypotension, sinusitis, tachycardia, paresthesia, amblyopia; SLE.


Hydralazine is metabolized by acetylation, ring oxidation and conjugation with endogenous compounds including pyruvic acid. 

Isosorbide dinitrate undergoes extensive first-pass metabolism in the liver and is cleared at a rate of 2 to 4 L/minute.

Drug Elimination:

Hydralazine: Metabolism is the main route for the elimination of hydralazine. Negligible amounts of unchanged hydralazine are excreted in urine.

Isosorbide dinitrate: Most isosorbide dinitrate is eliminated renally as conjugated metabolites.

Generic Drug Availability:


How Supplied: