Many different medications are used in the treatment of heart failure. They include:
- Angiotensin-converting enzyme (ACE) inhibitors
- Angiotensin-receptor blockers (ARBs)
- Beta blockers
- Aldosterone blockers
- Hydralazine and nitrates
- Aspirin and warfarin
Angiotensin-converting enzyme (ACE) inhibitors are among the most important drugs for treating patients with heart failure. ACE inhibitors open blood vessels and decrease the workload of the heart. They are used to treat high blood pressure, but can also help improve heart and lung muscle function. ACE inhibitors are particularly important for patients with diabetes, because they also help slow progression of kidney disease.
Brands and Indications. ACE inhibitors are used to treat Stage A high-risk conditions such as high blood pressure, heart disease, and diabetic nerve disorders (neuropathy). They are also used to treat Stage B patients who have had a heart attack or who have left ventricular systolic disorder, and Stage C patients with heart failure. Specific brands of ACE inhibitors include:
- Captopril (Capoten, generic)
- Enalapril (Vasotec, generic)
- Fosinopril (Monopril, generic)
- Lisinopril (Prinivil, Zestril, generic)
- Perindopril (Aceon, generic)
- Quinapril (Accupril, generic)
- Ramipril (Altace, generic)
- Trandolapril (Mavik, generic)
Side Effects of ACE Inhibitors:
- Low blood pressure is the main side effect of ACE inhibitors. This can be severe in some patients, especially at the start of therapy.
- Irritating cough is a common side effect, which some people find intolerable. All ACE inhibitors can have this side effect. An angiotensin-receptor blocker (ARB) can be used in place of an ACE inhibitor if cough is a problem.
- Although ACE inhibitors can protect against kidney disease, they also increase potassium retention by the kidneys. This increases the risk for cardiac arrest (when the heart stops beating) if potassium levels become too high. Because of this action, they are not generally given with potassium-sparing diuretics or potassium supplements.
- Patients who have difficulty tolerating ACE inhibitor side effects are usually switched to an angiotensin-receptor blocker (ARB).
Angiotensin-Receptor Blockers (ARBs)
ARBs, also known as angiotensin II receptor antagonists, are similar to ACE inhibitors in their ability to open blood vessels and lower blood pressure. They may have fewer or less-severe side effects than ACE inhibitors, especially coughing, and are sometimes prescribed as an alternative to ACE inhibitors.
Brands and Indications. ARBs are used to treat Stage A high-risk conditions such as high blood pressure and diabetic nerve disorders (neuropathy). They are also used to treat Stage B patients who have had a heart attack or who have left ventricular systolic disorder, and Stage C patients with heart failure. Specific brands include:
- Candesartan (Atacand)
- Valsartan (Diovan)
- Losartan (Cozaar)
Common Side Effects
- Low blood pressure
- Dizziness and lightheadedness
- Raised potassium levels
Beta blockers are almost always used in combination with other drugs, such as ACE inhibitors and diuretics. They help slow heart rate and lower blood pressure. When used properly, beta blockers can reduce the risk of death or rehospitalization. Over time, an ejection fraction that is low may increase with beta blocker therapy.
Brands and Indications. Beta blockers treat Stage A high blood pressure. They also treat Stage B patients, both those who have had a heart attack and those who have not had a heart attack, but who have heart damage. A specialist should monitor patients with heart failure who take beta blockers. The three beta blockers that are best for treating Stage C patients with heart failure are:
- Carvedilol (Coreg, generic)
- Bisoprolol (Zebeta)
- Metoprolol succinate (Toprol XL, generic)
Beta Blocker Concerns
- Do not abruptly stop taking these drugs. The sudden withdrawal of beta blockers can increase the risk of angina and even a heart attack. If you need to stop your beta-blocker, your doctor may want you to slowly decrease the dose before stopping completely. In addition, when first starting on a beta blocker, your doctor may start at a very low dose and increase it slowly to avoid problems.
- Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol, can narrow bronchial airways. Patients with asthma, emphysema, or chronic bronchitis may need to avoid non-selective beta blockers.
- Beta blockers can lower HDL ("good") cholesterol, although the benefits they provide for coronary artery disease and heart failure outweigh any bad effects on cholesterol.
- These drugs can hide warning signs of low blood sugar (hypoglycemia) in patients with diabetes, especially those who take insulin.
Common Side Effects
- Fatigue and lethargy
- Vivid dreams and nightmares
- Memory loss
- Dizziness and lightheadedness
- Reduced ability to exercise
- Coldness in extremities (legs, toes, arms, or hands)
Check with your doctor about any side effects. Do not stop taking these drugs on your own.
Diuretics cause the kidneys to rid the body of excess salt and water. Fluid retention is a major symptom of heart failure. Aggressive use of diuretics can help eliminate excess body fluids, while reducing hospitalizations and improving exercise capacity. These drugs are also important to help prevent heart failure in patients with high blood pressure. In addition, certain diuretics, notably spironolactone (Aldactone, generic), block aldosterone, a hormone involved in heart failure. This drug class is beneficial for patients with more severe heart failure (Stages C and D).
Diuretics come in many brands and are generally inexpensive. Some need to be taken once a day, some more often a day. Diuretics are usually started at a low dose and gradually increased. Your doctor may advise you to adjust the amount and timing of the diuretic if you notice swelling or weight gain. Diuretics are virtually always used in combination with other drugs, especially ACE inhibitors and beta blockers.
There are three main types of diuretics:
Potassium-sparing diuretics include amiloride (Midamor, generic) and triamterene (Dyrenium, generic).
Thiazide diuretics include chlorothiazide (Diuril, generic), chlorthalidone (Clorpres, generic), indapamide (Lozol, generic), hydrochlorothiazide (Esidrix, generic), and metolazone (Zaroxolyn, generic).
Loop diuretics are considered the preferred diuretic type for most patients with heart failure. They include bumetanide (Bumex, generic), furosemide (Lasix, generic), and torsemide (Demadex, generic).
Side Effects. In addition to increased urination, all types of diuretics may cause dry mouth, dehydration, fatigue, muscle cramps, and dizziness and lightheadedness. Diuretics can increase the amount of uric acid in the blood, which can lead to gout.
Potassium imbalances are an important concern with diuretics:
- Potassium-sparing diuretics can cause abnormally high levels of potassium. This can be especially dangerous for people who have pre-existing elevated levels of potassium or those with damaged kidneys. It is very important not to take potassium supplements or eat foods high in potassium (like bananas) when taking this type of diuretic unless your doctor instructs you to do so.
- Loop and thiazide diuretics can cause too-low potassium levels, which increase the risk for life-threatening heart rhythm disturbances (arrhythmias). If this occurs, your doctor may prescribe a lower dose, recommend potassium supplements, or prescribe a potassium-sparing diuretic either alone or in combination with a thiazide or loop diuretic.
Aldosterone is a hormone that is critical in controlling the body's balance of salt and water. Excessive levels play important roles in high blood pressure and heart failure. Drugs that block aldosterone are prescribed for some patients with symptomatic heart failure. They reduce death rates for patients with heart failure and coronary artery disease, especially after a heart attack.
Aldosterone blocker brands include spironolactone (Aldactone, generic) and eplerenone (Inspra, generic).
Like loop and thiazide diuretics, aldosterone blockers can cause abnormally high levels of potassium in the blood. Patients should not take potassium supplements at the same time as this drug and may need to avoid foods with high potassium content.
Digitalis is derived from the foxglove plant. It has been used to treat heart disease since the 1700s. Digoxin (Lanoxin, generic) is the most commonly prescribed digitalis preparation. Digoxin decreases heart size and reduces certain heart rhythm disturbances (arrhythmias).
Although it was once a mainstay of heart failure treatment, it is now used less often than newer drugs and is generally reserved for select patients who have significant symptoms while on maximal medical therapy.
While digitalis is generally a safe drug, it can have severe adverse side effects. The most serious side effects are arrhythmias.
Hydralazine and Nitrates
Hydralazine and nitrates are two older drugs that help relax arteries and veins, thereby reducing the heart's workload and allowing more blood to reach the tissues. They are used primarily for patients who are unable to tolerate ACE inhibitors and angiotensin receptor blockers. BiDil is a drug that combines isosorbide dinitrate and hydralazine. BiDil is approved to specifically treat heart failure in African-American patients while on other standard medications (such as beta blockers and ACE inhibitors).
Statins are important drugs used to lower cholesterol. Statins can help prevent heart disease, which is a leading cause of heart failure. They can also help the progression to heart failure for patients who have had heart attack or acute coronary syndrome.
These drugs include lovastatin (Mevacor, generic), pravastatin (Pravachol, generic), simvastatin (Zocor, generic), fluvastatin (Lescol), atorvastatin (Lipitor, generic), rosuvastatin (Crestor), and pitavastatin (Livalo). Atorvastatin is specifically approved to reduce the risks for hospitalization for heart failure in patients with heart disease.
Anti-Platelet and Anticoagulant Drugs
Anti-platelet and anticoagulant drugs help thin the blood and prevent the formation of blood clots. It is not clear if these drugs are helpful for patients with heart failure who are not at risk for blood clots. These drugs increase the risk for bleeding.
Aspirin. Aspirin is an anti-platelet drug and a type of non-steroid anti-inflammatory (NSAID). Aspirin is recommended for protecting patients with (primarily atherosclerotic) heart disease, and can safely be used with ACE inhibitors, particularly when it is taken in lower dosages (75 to 81 mg).
Anticoagulants. Anticoagulants may be appropriate for patients with heart failure and atrial fibrillation to reduce the risk of stroke. Anticoagulants include warfarin (Coumadin, generic), dabigatran (Pradaxa), apixaban (Eliquis), and rivaroxaban (Xarelto).
Erythropoietin. Erythropoietin is used to treat anemia, which is a common complication of heart failure. This drug can increase the risk of blood clots and stroke. Due to these risks, recent guidelines recommend against the use of erythropoietin drugs for patients with heart failure and mild-to-moderate anemia.
Tolvaptan. Tolvaptan (Samsca) is a drug approved for treating hyponatremia (low sodium levels) associated with heart failure and other conditions.