3 Heart Failure Medications

Different roles of heart-failure medicines

Heart-failure medicines do not all serve the same purpose. Some reduce congestion and symptoms, while disease-modifying medicines—especially the four foundational classes used for many people with heart failure with reduced ejection fraction (HFrEF)—can also reduce hospitalization and death.

The appropriate regimen depends on ejection fraction, blood pressure, kidney function, potassium, symptoms, and other conditions. Do not stop or change a medicine without consulting the care team.

Congestion relief and foundational treatment

Loop diuretics, such as furosemide, increase urine output to reduce excess fluid and help relieve swelling or breathlessness. They can ease fluid buildup, but they are not the only type of heart-failure medicine and do not replace disease-modifying treatment.

For many people with HFrEF, disease-modifying treatment includes an ARNI or, when appropriate, an ACE inhibitor or ARB; an evidence-based beta blocker; an MRA; and an SGLT2 inhibitor. SGLT2 inhibitors can benefit people with HFrEF whether or not they have diabetes.

ARNI and ACE-inhibitor precautions

Sacubitril/valsartan is an ARNI. It must not be taken with an ACE inhibitor or within 36 hours of the last ACE-inhibitor dose because of angioedema risk. For example, someone who took lisinopril that morning should not take sacubitril/valsartan at the same time.

Blood pressure, kidney function, and potassium should be monitored as directed. Seek emergency care for swelling of the face, lips, tongue, or throat, or for difficulty breathing.

MRA and potassium safety

Spironolactone and eplerenone are MRAs that can improve outcomes in selected patients. They may also cause dangerously high potassium, especially when kidney function is impaired or other medicines that raise potassium are used.

Follow the prescribed monitoring plan for kidney function and blood potassium. Ask the prescriber or pharmacist before using potassium supplements or potassium-based salt substitutes.

Using evidence-based beta blockers

Carvedilol, bisoprolol, and extended-release metoprolol succinate are the beta blockers named as having evidence for reducing death and hospitalization in HFrEF. The material does not say that all beta blockers have the same evidence.

These medicines are generally started at a low dose and adjusted as tolerated. Starting or adjusting treatment should happen with clinical guidance and take account of clinical stability, heart rate, and blood pressure. Do not stop a beta blocker abruptly without advice.

SGLT2 inhibitor safety

SGLT2 inhibitors can be used for heart failure whether or not a person has diabetes. Genital infections and volume depletion are important safety concerns. Contact the care team promptly about possible genital or urinary infection, or symptoms of dehydration or low blood pressure, such as unusual weakness or light-headedness.

Severe nausea, vomiting, abdominal pain, or trouble breathing warrants urgent medical assessment because ketoacidosis can occur, sometimes without very high blood glucose.

Monitoring and day-to-day precautions

Diuretics increase urine output, so excessive fluid loss or changes in electrolytes can cause problems. Monitoring may include blood pressure, weight, kidney function, and electrolytes such as potassium and magnesium. With furosemide, light-headedness and muscle cramps after increased urination are reasons to report concerns to the care team; weakness or reduced urination should also be reported.

Track weight as instructed and follow the care team’s directions for reporting rapid weight gain or worsening symptoms. Do not independently change a diuretic dose. Depending on the medicines used, monitoring may also include pulse and blood electrolytes.

Ask before using over-the-counter medicines, supplements, potassium products, or salt substitutes. Follow prescribed doses, and do not stop or adjust treatment on your own.