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Use of medications in heart failure

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Use of medications in heart failure

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Patients with heart failure need to take many different medicines. The most important are summarized in the table below.

General points of interest

  • The prescribed medication must be taken correctly every day and strictly according to your doctor's prescribed medication schedule.
  • If this is difficult for the patient, help should be sought from family or home care.
  • In case of doubt or discomfort (dizziness, low blood pressure, increasing or decreasing weight, etc.), the heart failure nurse and/or treating physician should be consulted.
  • Use a medication box for one week in which you can properly prepare the medication. These boxes are available at the pharmacy. This way you will forget your medication less quickly and take it more correctly.
  • If side effects are suspected, it is best to adjust the medication in consultation with the treating physician. Do not stop or change any medication without consulting your doctor.
  • Make sure there is always enough of the prescribed medicines at home. If a box is going to be empty soon, it is best to get a new box from the pharmacy in a timely manner.

Certain medicines should not be used!

  • Anti-inflammatories or NSAIDs such as Ibuprofen (Brufen, Nurofen, Spidifen), Naproxen (Apranax), Diclofenac (Voltaren, Cataflam, Motifene), Aceclofenac (Biofenac), Meloxicam (Mobic), Piroxicam (Brexine, Feldene), Celecoxib (Celebrex), Etoricoxib (Arcoxia), Nabumetone (Gambaran).
  • Aspirin (acetylsalicylic acid) (Aspegic, Sedergine, Aspirin) in high doses, > 3 grams per day.

Why?

These medicines have negative effects on the kidneys and can cause:

  • Increased retention of salt and fluid, which can increase symptoms of heart failure with increased shortness of breath, swelling of the legs and possibly the need for hospital admission.
  • A deterioration of kidney function and increase in the concentration of potassium in the blood. In patients who already have poor kidney function, this may lead to the need for kidney dialysis.

In addition, they increase the risk of stomach ulcers and stomach bleeding, especially if blood thinners are also taken.

  • Preparations that contain a lot of salt are best avoided. For example, effervescent tablets , certain powders and syrups. This can cause the body to retain more fluid and may increase symptoms of heart failure.

General principles and effects of the major medications

Many prescribed medicines relieve the burden and support the weakened heart. These medicines reduce the discomfort of heart failure (shortness of breath, swelling of the legs, etc.) and also significantly reduce the risk of being admitted to hospital or dying. Also read the table below.

  • Diuretics (also called ‘water pills’) are only necessary if the body retains fluid.
  • In patients with heart failure with impaired pump function of the left ventricle (HFrEF), the main treatment consists in the combination of 4 groups of drugs, namely 1) an ARNI/ACE inhibitor (or an ARB), 2) a beta-blocker, 3) a MRA and 4) a SGLT2 inhibitor.
  • In patients with heart failure with a normal pump function of the left ventricle, but especially a stiffened heart muscle (HFpEF), the most important treatment is the combination of a SGLT-2 inhibitor with, if necessary, a diuretic medication.

Other medications have a stabilizing effect on the heart rhythm, beneficial effects on the kidneys or prevent the clogging of blood vessels due to blood clots (such as blood thinners) or increasing arteriosclerosis (such as cholesterol-lowering medication).

These are the main effects of the prescribed medicines:

Diuretic effects
  • Help the kidneys remove salt and water through the urine, but sometimes also potassium and magnesium. The aim is to reduce and eliminate excess fluid buildup in the lungs, abdomen or legs. This will reduce shortness of breath and/or swelling of the lower limbs.
  • A too low dose is not good, because the body will then retain too much fluid, causing an increase in weight, increased shortness of breath and/or swelling of the lower legs.
  • A too high dose is not good either given the risk of dehydration, deterioration of kidney function, low blood pressure, muscle cramps, etc.
  • In case of illness, vomiting, diarrhea or hot weather in the summer, the dose may need to be temporarily reduced or even stopped. Discuss this with your doctor!
Lowering of blood pressure
  • Especially in heart failure with reduced pumping function of the left ventricle, these medications ensure that the weakened heart will work against lower pressure and can therefore work better. The heart will pump blood to the body more easily and the pressure in the heart will drop. Sometimes the pumping function of the left ventricle can partially or completely recover.
  • This medication is usually started at a low dose and then, during the following weeks, the dose is increased step by step. The aim is to achieve the recommended dose or the maximum tolerated dose. This is the highest possible dose at which blood pressure remains above 90 mmHg and there are no complaints of low blood pressure (dizziness when standing up, fatigue, etc.).
  • In patients with preserved pumping function of the left ventricle, these effects are less important and this medication is only used if blood pressure or heart rate is too high. The aim is to bring these parameters to normal values (blood pressure approximately 120-130/80 mmHg and heart rate < 100 /min).
Slowing down the heart rate
  • Especially in heart failure with reduced pumping function of the left ventricle, these medications ensure that the weakened heart can work more slowly and efficiently and thus work better. The heart will be able to fill longer and better. The time for blood flow to the heart muscle increases too. This can improve the contraction of the heart muscle. Sometimes the pumping function of the left ventricle can partially or completely recover.
  • This medication is started at a low dose and then increased gradually during the first following weeks. The aim is to achieve the recommended dose or the maximum tolerated dose. This is the highest possible dose at which the heart rate remains between 55 and 65 beats per minute and there are no complaints of low blood pressure or low heart rate (dizziness when standing up, fatigue, etc.).
  • In patients with preserved pumping function of the left ventricle, these effects are less important and these medications are only used if blood pressure or heart rate are too high. The aim is to bring these parameters to normal values (blood pressure approximately 120-130/80 mmHg and heart rate < 100 /min).
Reducing cardiac arrhythmias
  • Patients with heart failure can have cardiac arrhythmias such as atrial fibrillation, ventricular tachycardia or ventricular fibrillation. This is usually treated with medication that suppresses this, such as beta blockers, amiodarone or others. Sometimes other interventions are required, such as an ablation or the implantation of a pacemaker or defibrillator. Your cardiologist will discuss this with you if necessary.
Beneficial effects on the heart muscle
  • Several medications have direct beneficial effects on the heart muscle. They can slow down damage and scarring in the heart muscle. In the longer term, this can ensure that heart function remains stable for a longer period and deteriorates less quickly.
Beneficial effects on the kidneys
  • Some medicines have beneficial effects on the kidneys. They lower pressure in the kidneys and, in the long term, reduce damage and scarring in the kidneys. They can slow down the decline in kidney function and, in some patients, reduce the need for kidney dialysis. Poorly functioning kidneys are in the long term also bad for patients with heart failure. It is therefore very important to keep kidney function as good as possible for as long as possible.
Thinning the blood
  • Patients with heart failure have sometimes an increased risk of developing blood clots.
    • This can happen in the coronary arteries or in other arteries of the body, for example in the brain or in the legs. This causes a heart attack (if the blood clot is in a coronary artery) or a cerebral infarction (if the blood clot is in an artery of the brain). These blood clots are usually caused by platelets in the blood. To prevent this, blood thinners are prescribed that inhibit platelets, such as aspirin, clopidogrel, prasugrel or ticagrelor. These blood thinners must be taken promptly and continuously during the first months after placing a stent in the coronary arteries to prevent the stent from clogging. Follow your doctor's prescription carefully.
    • A blood clot can sometimes form in the heart chambers because blood stagnates more in certain places. The most common reason for this is atrial fibrillation, an arrhythmia in the atrial chambers. These blood clots can then move to other places in the body and cause damage by clogging arteries. This is called an embolism. These blood clots are usually caused by certain clotting proteins in the blood. To prevent this, blood thinners are prescribed that inhibit these clotting proteins, such as warfarin, apixaban, edoxaban, rivaroxaban, dabigatran.
Lowering LDL cholesterol
  • In patients with proven narrowing of the arteries, a very low LDL cholesterol < 55 mg/dl should be targeted (for example after a heart attack, placement of a stent, heart surgery with bridges, a cerebral infarction or narrowing of the arteries of the legs). This reduces the risk of developing new narrowing or new blockage of an artery.

Overview of different drugs with their possible side effects and concerns

Dynamic use of your diuretic medication, the diuretics

In heart failure, the body often retains salt and fluid. Then a diuretic medication is prescribed (water pill or diuretic). Normally a target weight is suggested. This is the best weight where the body is not retaining too much fluid and is not dehydrated either. Your weight should fluctuate slightly and stably around this target weight.

The dose of diuretic medication should always be adjusted according to the evolution of the weight and any symptoms of either fluid retention or dehydration. This is called dynamic diuretic use . Sometimes your doctor will give you a schedule whereby the dose of diuretic medication must be adjusted according to your weight.

  • Above a certain weight and especially if there are signs of increased fluid retention such as increased shortness of breath and/or swelling of the lower legs, a higher dose of diuretic medication must be temporarily taken or an additional diuretic medication must be taken for a few days until the weight has dropped again to the target weight. The therapy can usually be reduced back to the basic schedule afterwards.
  • Below a certain weight and especially in case of diarrhea, vomiting or signs of dehydration such as thirst, muscle cramps or lower blood pressure, the dose of diuretic medication must be temporarily reduced or stopped until the weight is returned to the target weight. The therapy can then be increased again to the basic schedule.

Belgian Working Group on Heart Failure (BWGHF)
Elyzeese Veldenstraat 63, 1050 Brussel
BTW N° BE 0556750603
www.bwghf.be

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