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Best drugs to treat heart failure

The right type of medication can make all the difference

Published: August 2014

At a glance

Heart failure is a chronic disease where the heart weakens and loses some of its ability to pump blood. It occurs as a result of high blood pressure, having a heart attack, or from other conditions that affect the heart.

Heart failure is underdiagnosed and undertreated, especially in its early stages. People often assume the symptoms—fatigue, shortness of breath during exercise, wheezing, frequent coughing (especially at night), or swollen ankles—are a sign of normal aging, or are just not serious enough to see a doctor. And doctors can sometimes mistake it for other conditions—such as asthma, emphysema, and even anemia—all which can cause some or all of the same early symptoms.

People with heart disease are most at risk of heart failure. That includes anyone with angina or who has suffered a heart attack or bypass surgery. People with high blood pressure—even if it's controlled—also have a heightened risk of heart failure, as well as those who smoke, have diabetes, or are obese. If you've undergone chemotherapy treatment for cancer, you might have an increased risk of heart failure because some chemotherapy medications can damage the heart.

There is no cure, but lifestyle changes and medication can often help relieve symptoms and manage the condition. Eating a healthy diet, getting regular exercise, quitting smoking, and losing excess weight may help prevent heart failure from getting worse and could also extend your life. In addition, people with heart failure should get proper treatment for any underlying conditions, such as high blood pressure, diabetes, and high cholesterol, which increase the risk of heart failure.

The medications used to treat heart failure include three groups of drugs: diuretics, ACE inhibitors, and beta-blockers. The type of medication your doctor will recommend depends on the type of heart failure you have and how severe your symptoms are. People with heart failure are typically started on a diuretic first if needed, followed by an ACE inhibitor, and then a beta-blocker. Other medications might be used if they are needed.

Who is affected by heart failure?

Heart failure is a chronic disease that afflicts mostly seniors, but younger people can also develop the condition because of a reaction to a viral infection, abuse of alcohol or illicit drugs, such as methamphetamine or cocaine, or for unknown reasons.

About 5.8 million people in the U.S. have heart failure, according to the National Heart, Lung, and Blood Institute. The number of people each year who are hospitalized because of the condition has more than doubled over the last three decades to more than 1.1 million.

If heart failure is isn't treated, or treated well enough, it often gets worse over time. The heart then loses its pumping capacity little by little over the years. The heart compensates at first—by enlarging or pumping faster, for example. This can mask the condition. But over time, the heart can no longer compensate, and symptoms develop.  

What are the symptoms?

The most common symptoms of heart failure include fatigue, shortness of breath, wheezing, frequent coughing, and swollen ankles and neck veins (See Table 1). All of these are due to excess fluid buildup in the body. As the heart struggles to pump, blood and fluid can back up in the veins and build up in various areas of the body, such as the feet, ankles, and legs. In some cases, fluid can back up into the lungs. This condition is called pulmonary edema and it can be a medical emergency. Signs of pulmonary edema include waking up at night short of breath or needing to sleep in a chair or with your head propped up on extra pillows.

Table 1. The most common symptoms of heart failure

 

Bulging neck veins

Difficulty breathing, especially when lying flat

Fatigue

Frequent coughing (especially at night)

Shortness of breath with exercise

Swollen ankles

Unexplained weight gain (water retention)

Wheezing

Ask your doctor to check you for heart failure if you have any of these symptoms. To diagnose heart failure, your doctor will ask whether you’ve had other conditions that increase your risk, such as heart disease, high blood pressure, or diabetes. Your doctor also may use an echocardiography or get an ultrasound image of your heart, a chest X-ray, or other tests.

What causes heart failure?

The main causes of heart failure include heart disease, high blood pressure, and diabetes. Several other conditions also increase the risk, including certain heart-valve disorders, heart defects that have been present since birth, heart muscle disease (cardiomyopathy), high cholesterol, irregular heartbeat (arrhythmia), an overactive thyroid gland, or abuse of alcohol or illicit drugs.

All of those conditions can prevent the heart from contracting forcefully enough to expel all the blood from its main pumping chamber, a condition known as systolic heart failure. Or the heart can become overly stiff, preventing the chamber from filling before it contracts. That's called diastolic heart failure, an equally common form that affects about 50 percent of patients.

Who is at risk?

People with heart disease have the most risk of heart failure. As can you see in Table 2, this includes anyone who has angina or has had a heart attack or bypass surgery. People with high blood pressure—even if it's controlled—also have a heightened risk of heart failure, as well as those who smoke, have diabetes, or are obese. 

If you've undergone chemotherapy treatment for cancer, you might have an increased risk of heart failure because some chemotherapy medications damage the heart.

People who are at risk of developing heart disease also face an elevated risk of heart failure. This includes African Americans, men, and older people.

 

Table 2. Risk factors for heart failure

 

Heart disease—for example, a previous heart attack, bypass surgery, angina

High blood pressure

Diabetes

Smoking

Obesity

Abuse of alcohol or illicit drugs

Chemotherapy

Older people are at an increased risk because the causes of heart failure—especially heart disease—are more common in the elderly.

African Americans are more likely to have heart failure than people of other races. They are nearly twice as likely as Caucasians to develop the disease.

People who are obese face a greater risk of heart failure because the extra weight they carry strains the heart. Also, being overweight increases the risk of other conditions, such as heart disease and type 2 diabetes, that can lead to heart failure.

A heart attack can damage the heart muscle. This can weaken the heart's ability to pump. That in turn can increase the risk of heart failure.

 

Prevention


The first step toward avoiding heart failure is to make lifestyle changes: stop smoking, limit how much alcohol you drink, lose excess weight, exercise regularly, and eat a heart-healthy diet.


Equally important is getting screened regularly for conditions that can increase the chance of heart failure, such as high blood pressure, diabetes, and high cholesterol. Knowing that you have those conditions and keeping them under control with proper treatment can reduce your risk of developing heart failure. For example, people who get treatment for high blood pressure can cut their heart-failure risk in half.


How is heart failure treated?

Lifestyle changes and medications can often help control symptoms and help you live longer. In the most severe cases, implantable devices, such as defibrillators or a heart transplant might be necessary. This analysis focuses on lifestyle changes and medications, so they are discussed in more detail below.

The same lifestyle changes that help prevent heart failure—a healthy diet, exercise, quitting smoking, and losing excess weight—can also help keep the condition under control. In addition, people with heart failure should:

  • Avoid drugs that can worsen the condition. Those include painkillers such as ibuprofen (Advil and generic) and naproxen (Aleve and generic), as well as the type 2 diabetes medications pioglitazone (Actos and generic) and rosiglitazone (Avandia).
  • Cut back on salt. A diet high in sodium causes the body to retain fluid, forcing the heart to pump harder. See box for tips on how to reduce your salt intake.
  • Avoid alcohol.
  • Limit fluids. Drinking too much fluid can make heart failure worse. Ask your doctor how much and what types of fluid you should have each day.
  • Weigh yourself. Monitor your weight regularly to detect fluid buildup.

How to slash salt


Here are a few ways you can reduce the sodium in your diet, according to the U.S. Dietary Guidelines for Americans.


• Read the Nutrition Facts labels on food when grocery shopping.


• Consume more fresh fruit and vegetables, which are naturally low in sodium.


• Prepare more food yourself using less salt. When eating at restaurants, ask for lower-sodium options, if available.


• Eat less pizza, bread, and other processed food.


•Track what you eat. (In Consumer Report's recent diet Ratings MyFitnessPal, a free smart-phone app and website, got one of the top satisfaction scores.)


Medications

There are several types of medications, listed below in the order that they are most commonly used to treat heart failure. They include digoxin, diuretics, ACE (angiotensin converting enzyme) inhibitors, and beta-blockers. The type of medication your doctor will recommend depends on the type of heart failure you have and how severe your symptoms are. If you've been diagnosed with heart failure, you mostly likely will be started on a diuretic first, if needed, followed by an ACE inhibitor, then a beta-blocker. Other medications might be used.

 

Table 3. Medications used to treat heart failure

Medication What it does Notes

Diuretics

Examples:

Bumetanide (Bumex) and furosemide (Lasix)

Helps reduce fluid buildup in the body. Can cause low potassium levels, which can lead to fatigue, muscle cramps, and weakness. Your doctor should carefully monitor potassium levels while you are taking a diuretic.

ACE inhibitors

Examples:

Captopril (Capoten and generic), enalapril (Vasotec and generic), and lisinopril (Prinivil, Zestril, and generic)

• Relaxes blood vessels, which allows blood to flow more easily.

 

• Reduces premature death.

 

• Can slow progression of heart failure.

• Most common side effect is an irritating dry cough. People who can't tolerate an ACE inhibitor are usually switched to another type of medication called angiotensin receptor blockers or ARBs.

 

• ACE inhibitors can cause a rare but potentially life-threatening complication called angioedema, which is swelling of the face, tongue, lips, and throat. Higher risk in African-Americans.

Angiotensin receptor blockers

Examples:

Candesartan (Atacand and generic), losartan (Cozaar and generic), and valsartan (Diovan)

Similar to ACE inhibitors.

Are used as an alternative to ACE inhibitors, particularly when an ACEI is not well tolerated.

Beta-blockers

Examples:

Bisoprolol (Zebeta and generic), carvedilol (Coreg and generic), and metoprolol succinate (Toprol XL and generic)

• Slows down heart rate.

 

• Reduces premature death by about 30 percent and improves quality of life in people who have heart failure.

Because people with heart failure are at high risk of complications, treatment with a beta-blocker must be monitored carefully by a doctor, usually a cardiologist.
Hydralazine/ isosorbide dinitrate (Bidil) • May boost survival and cut hospitalizations in African-Americans with advanced heart failure.

• Unclear whether the two medications reduce premature death in other ethnic groups, too.

 

• Serious side effects include fainting, joint or muscle pain, fever, rapid heartbeat, chest pain, swollen ankles or feet, and numbing or tingling in hands and feet. Contact your doctor immediately if you experience any of those.

Aldosterone antagonists

Examples: Spironolactone (Aldactone and generic)

A type of diuretic that can help people in the later stages of heart failure by causing the body to pass more urine and preventing the fluid buildup that causes many heart-failure symptoms. Can elevate blood-potassium levels, which can harm the heart, so physicians must carefully monitor those levels.

Digoxin

• Makes the heart beat stronger so it pumps more blood.

 

• Reduces risk of hospitalization but it’s not clear if it reduces the risk of death.

Serious side effects include upset stomach, vomiting, diarrhea, swelling of the feet or hands, unusual weight gain, and difficulty breathing. Call your doctor immediately if you experience any of those.

Comparing drug safety and effectiveness for heart failure

Diuretics

Diuretics—often called “water pills”—are often the first type of medication used to treat heart failure symptoms. It helps reduce fluid buildup in your body, which in turn reduces the workload on your heart. Studies indicate diuretics might reduce premature death and hospitalization due to heart failure. Commonly prescribed diuretics include bumetanide (generic only), furosemide (Lasix and generic), and torsemide (Demadex and generic).

 

Safety

Some types of diuretics can cause low potassium levels, which can lead to fatigue, muscle cramps, and weakness. So your doctor should carefully monitor your potassium levels while you are taking a diuretic. Other side effects include numbness or tingling, heart palpitations, gout, depression, irritability, and urinary incontinence.

ACE Inhibitors

ACE inhibitors, such as lisinopril (Prinivil, Zestril, and generic) and ramipril (Altace and generic), have become a cornerstone of treatment for heart failure. They effectively—sometimes dramatically—slow the progression of the condition. By relaxing blood vessels and making them wider, they allow blood to flow more easily.

 

Safety

As with most medicines, ACE inhibitors can cause side effects. There is no clear evidence that any one ACE inhibitor has more or fewer side effects than the others.

 

The most common side effect is an irritating dry cough, which may be quite persistent. If it keeps up, talk to your doctor about switching to another ACE inhibitor or even another type of medication called angiotensin receptor blockers or ARBs.

 

Other, less common side effects include dizziness, excessively low blood pressure, fatigue, headache, high blood levels of potassium, loss of taste, nausea, kidney failure, and swollen ankles. All people taking an ACE inhibitor should have periodic blood tests to make sure they do not have elevated levels of potassium in their blood and that their kidneys are processing the drug effectively.

 

Though rare, ACE inhibitors can also cause swelling involving the face, tongue, lips, and larynx. This is called angioedema and is a potentially life-threatening complication if it closes off the larynx. The risk of this side effect appears to be higher in African-Americans.

 

All ACE inhibitors can also cause birth defects and should not be used by women who are pregnant.

Beta-blockers

Beta-blockers, such as carvedilol (Coreg and generic) or metoprolol succinate (Toprol-XL and generic), help protect the heart by slowing it down. They can be an additional medication taken along with an ACE inhibitor.

 

Because people with heart failure are at high risk of complications, treatment with a beta-blocker must be monitored carefully by a doctor, usually a cardiologist. Your medical condition and your doctor’s experience with particular beta-blockers will likely be an important factor in his or her choice among these four drugs.

 

Three beta-blockers—bisoprolol, metoprolol succinate, and carvedilol—have been proved to reduce deaths by about 30 percent and improve quality of life in people who have heart failure. Carvedilol has the strongest evidence of increasing survival in people with the most severe forms of heart failure.

 

Safety

Side effects are common among people taking beta-blockers. The majority of people can expect to experience at least one. These include fatigue or drowsiness, dizziness or lightheadedness, slow heartbeat, low blood pressure, difficulty breathing, numbness, tingling or coldness of fingers, toes or skin, weight gain, depression, disturbing dreams, reduced libido, erectile dysfunction in men, or reduced ability to achieve an orgasm in both men and women. Any of these should prompt a call to your doctor if it persists, especially breathing difficulties, dizziness, or fatigue.

 

Most side effects can be avoided or minimized by starting with a low dose and increasing it gradually, if that is necessary. Also, some adverse effects go away or diminish in time, after your body gets used to the drug.

 

There is no convincing evidence that any one beta-blocker produces more or less side effects than any other, but people do respond differently to the individual drugs. So if you can't tolerate the first beta-blocker you try, you might be able to switch to a different one with your doctor's help. In one study of heart failure patients, one in five could not tolerate the initial beta-blocker they were given. About half of that group was successfully switched to another beta-blocker.

Hydralazine/isosorbide dinitrate (Bidil)

The drug Bidil, which combines two drugs—hydralazine and isosorbide dinitrate—into one pill, appears to help people live longer, and cut hospitalizations in African-American people who have advanced heart failure. It's unclear whether the two medications reduce premature death in other ethnic groups, too. The medication is also given to people who can't tolerate an ACE inhibitor or an ARB due to high potassium levels, low blood pressure, or kidney problems.

 

Safety

Side effects caused by Bidil include flushing, headache, upset stomach, vomiting, loss of appetite, diarrhea, constipation, tearing, stuffy nose, and rash. Contact your doctor if you have any of those side effects, especially if they do not go away.

 

More serious side effects include fainting, joint or muscle pain, fever, rapid heartbeat, chest pain, swollen ankles or feet and numbing or tingling in hands and feet. Contact your doctor immediately if you experience any of those.

Aldosterone antagonists

This group includes medications such as spironolactone (Aldactone and generic). These drugs can help people in the later stages of heart failure by causing the body to pass more urine and preventing the fluid buildup that causes many heart-failure symptoms.

 

Safety

Aldosterone antagonists can elevate blood-potassium levels, which can harm the heart, so your doctor should carefully monitor those levels while you are taking one of these medications.

 

Spironolactone can cause several side effects including a deepening of the voice, diarrhea, dizziness, drowsiness, dry mouth, enlarged or painful breasts in men and women, erectile dysfunction, headache, thirst, vaginal bleeding in post-menopausal women, and vomiting. Tell your doctor if you experience any of those.

 

Contact your doctor immediately if you experience any of these more serious side effects: changes in heartbeat, confusion, difficulty breathing or swallowing, extreme tiredness, fainting, flu-like symptoms, inability to move arms or legs, muscle weakness, pain, or cramps, nausea, pain, burning, numbness, or tingling in the hands or feet, unusual bleeding or bruising, pain in the upper right part of the stomach, vomiting blood or blood in stools, yellowing of the skin or eyes.

Digoxin

This medication makes the heart pump stronger. Studies indicate digoxin reduces the risk of hospitalization due to heart failure but it’s not clear if it reduces the risk of premature death.

 

It's typically used when heart failure patients who are taking a combination of other options, including ACE inhibitors, beta-blockers, and diuretics, are still having problems.

 

Safety

Digoxin can cause several side effects, including dizziness, drowsiness, vision changes (vision may become blurred or things may seem yellow), rash, and irregular heartbeat. Contact your doctor if you experience any of those, especially if they are severe or do not go away.

 

Serious side effects associated with digoxin include upset stomach, vomiting, diarrhea, loss of appetite, swelling of the feet or hands, unusual weight gain, and difficulty breathing. Call your doctor immediately if you experience any of those side effects.

References

  1. Chatterjee S, Biondi-Zoccai G, Abbate A, D’Ascenzo F, Castagno D, Van Tassell B, et al. Benefits of β blockers in patients with heart failure and reduced ejection fraction: network meta-analysis. BMJ2013;346:f55
  2. Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med 1986;314:1547–1552.
  3. The Digitalis Investigation Group.  The effect of digoxin on mortality and morbidity in patients with heart failure.  New Engl J Med 1997;336:525-33.
  4. Helfand M, Peterson K, Christensen V, Dana T, Thakurta S. Drug class review: Beta adrenergic blockers. Update 4. 2009.  http://www.ncbi.nlm.nih.gov/books/NBK47172/
  5. Norris S, Weinstein J, Peterson K, Thakurta S. Drug Class Review: Direct Renin Inhibitors, Angiotensin Converting Enzyme Inhibitors, and Angiotensin II Receptor Blockers.http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0008642/
  6. Pitt B, Zannad F, Remme WJ, et al., Randomized Aldactone Evaluation Study Investigators. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999;341:709–17.
  7. Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004;351:2049–2057. [Erratum in: N Engl J Med 2005;352:1276]
  8. Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WH, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013 Oct 15;62(16):e147-239.
Editor's Note:

These materials are made possible by a grant from the state Attorney General Consumer and Prescriber Education Grant Program, which is funded by the multi-state settlement of consumer-fraud claims regarding the marketing of the prescription drug Neurontin (gabapentin).



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