Written by SMH Heart Failure Nurse Specialist Stacey Daggett
Heart failure is a life-threatening, chronic condition affecting millions in the US. For these patients, proper management is vital and often requires taking multiple medications daily. It can be hard to get into a routine of taking these medications and figuring out what to take when.
If you or a loved one is managing heart failure, it’s important to know what the medications do and how they affect the body. Below is a medication primer for those dealing with heart failure. Use it as a guide to understand the medications, how they work and their common side effects.
Note: If you are not tolerating a medication well, notify your healthcare provider so that he/she can determine whether there is another medication that may work better for you.
Heart Failure Medications 101
There are several types of diuretic medication, but all are designed to remove excess fluid and reduce pressure on your heart. These include:
Loop Diuretics — usually used as a first choice
- Furosemide (Lasix) – edema and pulmonary edema (lasts 4 to 6 hours)
- Bumetanide (Bumex) – lasts 6 to 8 hours
- Torsemide (Demadex) – Better in right-sided heart failure and/or conditions that are resistant to other loop diuretics (lasts 12 to 16 hours)
Thiazide Diuretics — added to loop diuretics when a patient has persistent fluid retention
- Hydrochlorothiazide – lasts 6 to 12 hours
- Metolazone (zaroxolyn) – lasts 12 to 24 hours
- Indapamide – lasts 36 hours
K+ Sparing Diuretics — Contraindicated for elevated K+ or Creatinine
- Spironalactone — also an aldosterone antagonist (lasts 48 to 72 hours)
- Amiloride – lasts 24 hours
- Triamterene – lasts 7 to 9 hours
Angiotensin-converting enzyme inhibitors, often referred to as “ACE inhibitors,” are used to reduce the muscular contractions that cause blood vessels to narrow and to reduce sodium and fluid retention. ACE inhibitors commonly prescribed to heart-failure patients include:
- Lisinpril (Zestril) – considered the gold standard of ACE inhibitors
- Ramipril (Altace)
- Enalapril (Vasotec)
- Captopril (Capoten)
- Perindopril (Aceon)
- Fosinopril (Monopril)
- Quinapril (Accupril)
Possible side effects: cough, rash, dizziness, hyperkalemia (high potassium levels), hypotension (low blood pressure)
Like ACE inhibitors, Angiotensin II Receptor Blockers, or “ARBs,” also reduce muscular contractions that cause blood vessels to narrow (vascoconstriction) and reduce sodium and fluid retention. ARBs that are commonly prescribed to help manage heart failure include:
- Cozaar (Losartan)
- Diovan (Valsartan)
- Atacand (Candesartan)
- Avapro (Irbesartan)
- Benicar (Olmesartan)
Possible side effects: dizziness, hyperkalemia (high potassium levels), hypotension (low blood pressure)
Beta-blocker medications are designed to improve cardiac remodeling, reduce arrhythmias, improve exercise tolerance and lower the heart’s oxygen consumption. Users should never stop taking beta-blockers abrubtly. Commonly prescribed beta-blockers include:
- Coreg (Carvedilol) – considered the gold standard of beta-blockers for heart failure
- Toprol XL - Metoprolol – better for diastolic heart failure than for coreg as it doesn’t lower blood pressure as much
Possible side effects: bradycardia (abnormally slow heart rate), cold extremities, fatigue, weakness, dizziness
When ACE inhibitors aren’t effective, aldosterone antagonists might be prescribed, as they reduce the salt and fluid retention caused by aldosterone. However, these aren’t appropriate for all heart failure conditions and are actually contraindicated when K+ is more than 5.0 or Creatinine is more than 2.5. Aldosterone antagonist medications include:
- Spironolactone (Aldactone)
For patients who cannot tolerate ACE inhibitors or ARBs, Hydralazine and Imdur are often effective options for reducing vascoconstriction (muscular contractions that cause blood vessels to narrow).
Possible side effects: headache, dizziness, nausea/vomiting, hypotension (low blood pressure)
Inotropes combat heart failure by widening blood vessels and improving the heart’s ability to generate force (contractility), which in turn increases cardiac output. Common isotropes include:
- Dobutamine (Dobutrex)
- Dopamine (Intropin)
Calcium Channel Blockers in Diastolic HF
Calcium channel blockers are sometimes prescribed for managing diastolic heart failure. Designed to relax the myocardium (muscular heart tissue), calcium channel blockers also improve filling time. However, patients with systolic heart failure should only use these with caution. Calcium channel blockers for diastolic heart failure include:
- Verapamil (Calan)
- Cardizem (Diltiazem)
- Norvasc (Amlodipine)
HCN Channel Blocker
An HCN Channel Blocker, Corlanor lowers the heart rate by selectively blocking the HCN channel, part of the heart’s “electrical” system. It also helps lower patients’ risk of hospitalization with worsening heart failure. It is most often prescribed to patients with an ejection fraction (EF) of 35 percent or less.
Possible side effects: bradycardia (slowing of the heart rate), hypertension (high blood pressure), atrial fibrillation and temporary vision disturbance (flashes of light).
Angiotensin-Receptor Neprilysin Inhibitor (ARNI)
The most common angiotensin-receptor neprilysin inhibitor (ARNI) is Entresto (Sacubitril/Valsartan). Like Corlanor, Entresto lower patients’ risk of heart failure-related hospitalization or death, and it is used for patients with an ejection fraction (EF) of 35 percent or less. Note Entresto cannot be taken if you are on an ACE inhibitor or an ARB. User must be off ACE inhibitors for at least 36 hours before taking Entresto.
Possible side effects: hypotension (low blood pressure), kidney problems, hyperkalemia (elevated potassium levels)
NSAIDs & Heart Failure
Before taking any Nonsteroidal Anti-inflammatory Drugs (NSAIDs) like Aspirin or Advil, patients managing heart failure should discuss it with their physician. NSAIDs—which can be prescription and over the counter— can cause blood vessel constriction and sodium retention, and they can lead to increased edema and renal function declines. NSAIDs also can decrease the effectiveness of ACE inhibitors and diuretics. Common NSAIDs include:
- Ibuprofen (Motrin, Advil)
* IF YOU TAKE ANY NSAID REGULARLY, SPEAK TO YOUR DOCTOR ABOUT IT. *
Stacey Daggett, RN, BSN, PCCN, CHFN, is a heart failure nurse specialist at Sarasota Memorial Hospital. She provides in-depth education specific to each patient’s individual diagnosis and needs.