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Hydralazine/isosorbide-dinitrate/milrinone/nitroglycerin Lack of efficacy: 4 case reports

A case report described four patients [1 woman and 3 men] aged 26–57 years, who experienced lack of efficacy following treatment with hydralazine/isosorbide dinitrate, milrinone or nitroglycerin for pulmonary hypertension. A 26-year-old woman (patient 1), who had advanced heart failure, familial cardiomyopathy and a decreased ejection fraction, was hospitalised for heart transplant evaluation. She was scheduled for pulmonary artery catheter placement for monitoring of pulmonary artery pressure. She received IV milrinone 0.5 µg/kg/minute, dobutamine and an unspecified diuretic therapy. Her diuretic therapy was titrated. At the time of catheter placement, she had a high pulmonary artery diastolic pressure than the pulmonary capillary wedge pressure, indicative of pulmonary hypertension. Therefore, she received IV nitroglycerin 150 µg/minute. Milrinone was continued. Despite vasodilatory treatment with nitroglycerin and milrinone, pulmonary hypertension persisted. Therefore, her heart transplant status became inactive and she received treatment with sacubitril/valsartan. Additionally, nitroglycerin and milrinone were stopped. After the treatment with sacubitril/valsartan, her pulmonary hypertension resolved and she was re-scheduled for the heart transplant. A 57-year-old man (patient 3), who had advanced heart failure, non-ischaemic cardiomyopathy and a decreased ejection fraction, was hospitalised for heart transplant evaluation. He was scheduled for pulmonary artery catheter placement for monitoring of pulmonary artery pressure. He received IV milrinone 0.5 µg/kg/minute, dobutamine and an unspecified diuretic therapy. His diuretic therapy was titrated. At the time of catheter placement, he had a high pulmonary artery diastolic pressure than the pulmonary capillary wedge pressure, indicative of pulmonary hypertension. Despite vasodilatory treatment with milrinone, pulmonary hypertension persisted. Therefore, his heart transplant status became inactive and he received treatment with sacubitril/ valsartan. Additionally, milrinone was stopped. After the treatment with sacubitril/valsartan, his pulmonary hypertension resolved and he was re-scheduled for the heart transplant. A 53-year-old man (patient 4), who had advanced heart failure, non-ischaemic cardiomyopathy and a decreased ejection fraction, was hospitalised for heart transplant evaluation. He was scheduled for pulmonary artery catheter placement for monitoring of pulmonary artery pressure. He received IV milrinone 0.25 µg/kg/minute, dobutamine and an unspecified diuretic therapy. His diuretic therapy was titrated. At the time of catheter placement, he had a high pulmonary artery diastolic pressure than the pulmonary capillary wedge pressure, indicative of pulmonary hypertension. Therefore, he received oral hydralazine/isosorbide dinitrate 35/30mg three times a day. Treatment with milrinone was continued. Despite vasodilatory treatment with milrinone and hydralazine/is