In patients with dilated cardiomyopathy who cannot tolerate ACE inhibitors or ARBs, which combination can be used?

• A. Hydralazine and nitrates
• B. Digoxin and diuretics
• C. Aldosterone antagonists only
• D. Calcium channel blockers

Answer: (A)

When a patient with dilated cardiomyopathy and reduced ejection fraction cannot tolerate ACE inhibitors or ARBs, using a combination of hydralazine and nitrates provides a proven alternative that can improve survival and symptoms. Hydralazine lowers arterial afterload, making it easier for the failing heart to eject blood, while nitrates reduce venous return (preload), which lowers filling pressures and wall stress. Together, they optimize cardiac output in a way that helps compensate for the lack of ACEi/ARB therapy. This combination has demonstrated mortality and morbidity benefits in heart failure patients who cannot take ACE inhibitors or ARBs, which is why it’s the best choice here.

Digoxin and diuretics mainly alleviate symptoms but don’t replace the mortality benefit of ACE inhibitors/ARBs and aren’t a substitute for disease-modifying vasodilators. Aldosterone antagonists do reduce mortality as add‑on therapy but aren’t used alone as a replacement for ACE inhibitors/ARBs. Calcium channel blockers are generally avoided in systolic heart failure because they can worsen contractility and outcomes.