Medications:

Many different medications are used in the treatment of heart failure. They include:

• Angiotensin-converting enzyme (ACE) inhibitors
• Angiotensin-receptor blockers (ARBs)
• Beta blockers
• Diuretics
• Aldosterone blockers
• Digitalis
• Hydralazine and nitrates
• Statins
• Aspirin and warfarin

ACE Inhibitors

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 treat Stage A high-risk conditions such as high blood pressure, heart disease, and diabetic nerve disorders (neuropathy). They also 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:

• Benazepril (Lotrel)
• Captopril (Capoten)
• Enalapril (Vasotec)
• Fosinopril (Monopril)
• Lisinopril (Prinivil, Zestril)
• Moexipril (Univasc)
• Perindopril (Aceon)
• Quinapril (Accupril)
• Ramipril (Altace)
• Trandolapril (Mavik)

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, but angiotensin-receptor blockers do not.
• Although ACE inhibitors can protect against kidney disease, they also increase potassium retention by the kidneys. This increases the risk for cardiac arrest if potassium levels become too high. Because of this action, they are not generally given with potassium-sparing diuretics or potassium supplements.
• A rare but severe side effect is granulocytopenia, an extreme reduction in infection-fighting white blood cells.
• In very rare cases, patients suffer a sudden and severe allergic reaction called angioedema that causes swelling in the eyes and mouth and may close off the throat.

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. Some patients with heart failure take an ACE inhibitor along with an ARB.

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 brand include:

• Candesartan (Atacand)
• Valsartan (Diovan)
• Losartan (Cozaar)
• Eprosartan (Teveten)
• Irbesartan (Avapro)
• Olmesartan (Benicar)
• Telmisartan (Micardis)

Common Side Effects

• Low blood pressure
• Dizziness and lightheadedness
• Raised potassium levels
• Drowsiness

Beta Blockers

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.

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). Patients with heart failure receiving beta blockers should probably be under the care of a specialist. Recent guidelines identify three drugs best for treating Stage C patients with heart failure:

• Carvedilol (Coreg)
• Bisoprolol (Zebeta)
• Metoprolol succinate (Toprol XL)

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.
• Beta blockers are categorized as non-selective or selective. Non-selective beta blockers, such as carvedilol and propranolol, can narrow bronchial airways. Patients with asthma, emphysema, or chronic bronchitis should not use these beta blockers.
• Beta blockers can lower HDL (“good”) cholesterol, although the benefits they provide for coronary artery disease and heart failure outweigh any detriments 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
• Depression
• Memory loss
• Dizziness and lightheadedness
• Reduced ability to exercise
• Coldness in extremities (legs, toes, arms, hands)

Check with your doctor about any side effects. Do not stop taking these drugs on your own.

Diuretics

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), block aldosterone, a hormone involved in heart failure. This drug class is beneficial for patients with more severe heart failure (Stages C and D).

Patients taking diuretics usually take a daily dose. Under the directions and care of a doctor or nurse, some patients may be taught to adjust the amount and timing of the diuretic when they notice swelling or weight gain.

Diuretics come in many brands and are generally inexpensive. Some need to be taken once a day, some twice a day. Treatment is usually started at a low dose and gradually increased. 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.

• These include amiloride (Midamor) and triamterene (Dyrenium).
• Potassium-sparing diuretics have their own risks, which include dangerously high levels of potassium in people with existing elevated levels of potassium or in those with damaged kidneys. However, all diuretics are generally more beneficial than harmful.
• Patients should not take potassium supplements at the same time as this type of diuretic without their doctor's knowledge, and may need to avoid foods with high potassium content.

Thiazide diuretics. These include chlorothiazide (Diuril), chlorthalidone (Hygroton), indapamide (Lozol), hydrochlorothiazide (Esidrix, HydroDiuril), and metolazone (Mykrox, Zaroxolyn).

Loop diuretics. These are considered the preferred diuretic type for most patients with heart failure.

• Loop diuretics include bumentanide (Bumex), furosemide (Lasix), and torsemide (Demadex).
• Loop and thiazide diuretics deplete the body's supply of potassium, which, if left untreated, increases the risk for arrhythmias. (Arrhythmias are heart rhythm disturbances that can, in rare instances, lead to cardiac arrest). In such cases, doctors will prescribe lower doses of the current diuretic, recommend potassium supplements, or use potassium-sparing diuretics either alone or in combination with a thiazide.
• Dehydration (loss of too much fluid) is also another concern.

Common Side Effects

• Fatigue
• Depression and irritability
• Reduced sexual function

Aldosterone Blockers

Aldosterone is a hormone that is critical in controlling the body's balance of salt and water. Excessive levels may play important roles in hypertension and heart failure. Drugs that block aldosterone are prescribed for some patients with symptomatic heart failure. They have been found to reduce mortality or death rates for patients with heart failure and coronary artery disease, especially after a heart attack. These blockers pose some risk for high potassium levels. Brands include:

• Spironolactone (Aldactone, Spirinol)
• Eplerenone (Inspra)

Elevated levels of potassium in the blood are also a concern with these drugs. Patients should not take potassium supplements at the same time as this drug without their doctor's knowledge and may need to avoid foods with high potassium content.

Digitalis

Digitalis is derived from the foxglove plant. It has been used to treat heart disease since the 1700s. Digoxin (Lanoxin) is the most commonly prescribed digitalis preparation. Digoxin decreases heart size and reduces certain heart rhythm disturbances (arrhythmias).

Unfortunately, digitalis does not reduce mortality rates, although it does reduce hospitalizations and worsening of heart failure. Controversy has been ongoing for more than 100 years over whether the benefits of digitalis outweigh its risks and adverse effects.

Digitalis may be useful for select patients with left-ventricular systolic dysfunction who do not respond to other drugs (diuretics, ACE inhibitors). It may also be used for patients who have atrial fibrillation.

Side Effects and Problems. While digitalis is generally a safe drug, it can have toxic side effects due to overdose or other accompanying conditions. The most serious side effects are arrhythmias (abnormal heart rhythms that can be life threatening). Early signs of toxicity may be irregular heartbeat, nausea and vomiting, stomach pain, fatigue, visual disturbances (such as yellow vision, seeing halos around lights, flickering or flashing of lights), and emotional and mental disturbances.

Many factors increase the chance for side effects.

• Advanced age
• Low blood potassium levels (which may be caused by diuretics)
• Hypothyroidism
• Anemia
• Valvular heart disease
• Impaired kidney function

Digitalis also interacts with many other drugs, including quinidine, amiodarone, verapamil, flecainide, amiloride, and propafenone.

A blood test that monitors drug levels in patients taking the drug can limit the rate of toxicity to about 2%. For most patients with mild-to-moderate heart failure, low-dose digoxin may be as effective as higher doses. If side effects are mild, patients should still consider continuing with digitalis if they experience other benefits.

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. In 2005, the FDA approved BiDil, a drug that combines isosorbide dinitrate and hydralazine. BiDil is approved to specifically treat heart failure in African-American patients.

Statins

Statins are important drugs used to lower cholesterol and to prevent heart disease leading to heart failure. These drugs include lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor). In 2007, the Food and Drug Administration (FDA) approved atorvastatin to reduce the risks for hospitalization for heart failure in patients with heart disease.

Anti-Platelet and Anticoagulation Drugs

Aspirin. Aspirin is a type of non-steroid anti-inflammatory (NSAID). Aspirin is recommended for preventing death in patients with heart disease, and can safely be used with ACE inhibitors, particularly when it is taken in lower dosages (75 - 81 mg).

Warfarin (Coumadin). Warfarin is recommended only for patients with heart failure who also have:

• Atrial fibrillation
• A history of blood clots to the lungs, stroke, or transient ischemic attack
• A blood clot in one of their heart chambers

Other Drugs

Nesiritide (Natrecor). Nesiritide treats patients who have arrived at a hospital with decompensated heart failure. Decompensated heart failure is a life-threatening condition in which the heart fails over the course of minutes or a few days, often as the result of a heart attack or sudden and severe heart valve problems. However, nesiritide may cause serious kidney damage. This drug should only be used in a hospital setting to treat patients with decompensated heart failure who have shortness of breath (dyspnea) and trouble breathing. It should not be a replacement for diuretics.

Erythropoietin. Many patients with chronic heart failure are also anemic. Treatment of these patients with erythropoietin has been shown to provide some benefit for heart failure control and hospitalization risk. However, erythropoietin therapy can also increase the risk of blood clots. The exact role of this drug for the treatment of anemia in patients with heart failure is not yet decided.

Tolvaptan. Tolvaptan is an investigational drug that is being studied in combination with standard therapy for treatment of heart failure. It is especially being investigated for acute decompensated heart failure, a type of heart failure categorized by fluid build-up in the lungs (pulmonary edema) for which there are few available treatments. In patients hospitalized with heart failure, tolvaptan plus standard drugs has been shown to improve breathing problems (dyspnea) and reduce fluid accumulation (edema) and body weight. However, the drug does not appear to reduce the risk of re-hospitalization or death.

Levosimendan. Levosimendan is an experimental inotropic drug that is being investigated as a treatment for severely ill patients with heart failure. It belongs to a new class of drugs called calcium sensitizers that may help improve heart contractions and blood flow. Clinical trials suggest that levosimendan may improve survival in patients hospitalized for heart failure. The drug also appears to reduce levels of BNP (brain natriuretic peptide), a chemical marker for heart failure severity.