Common medications used to treat heart failure.

DEAR READERS:

Yesterday, I answered a question about treatments for heart failure. It’s a big topic, and so today I’m talking about the medicines that are typically used to treat heart failure.

As we discussed, heart failure is a condition in which the heart cannot pump efficiently enough to meet the body’s need for blood. As a result, tissues and organs throughout the body don’t get enough oxygen. Also, fluid builds up in the lungs and other body tissues.

Taking heart failure medicines as prescribed is perhaps the single most important thing you can do to feel better and live longer. The medicines available today are dramatically more potent than the medicines that were available when I was in medical school.

Most people with heart failure need a three-drug regimen. This includes a diuretic, a beta blocker, and an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin-receptor blocker (ARB).

Diuretics are also called water pills. They help the kidneys eliminate the excess sodium and water that builds up because of heart failure. This reduces blood volume, blood pressure, swelling and congestion.

Beta blockers reduce the heart’s workload. At times of stress and during exercise, nerve cells release hormones that stimulate the heart. One such hormone is adrenaline. At first, these hormones cause the heart to pump both faster and more forcefully, giving a brief boost to the performance of a failing heart. But when persistently high levels of adrenaline keep “whipping” the heart muscle to work harder, the muscle becomes exhausted. Beta blockers reduce the stimulation of the heart, slow the heart rate, lower blood pressure and decrease the heart’s workload. When the heart is not being constantly whipped to pump faster and harder, it pumps more efficiently.

ACE inhibitors and ARBs relax blood vessels. They work on the renin-angiotensin-aldosterone system. This is an intricate system that links the brain, heart and kidneys via hormones in the blood. (These hormones are different from adrenaline.) The renin-angiotensin-aldosterone system regulates blood pressure.

In a person with heart failure, the heart’s weak pumping activates the renin-angiotensin-aldosterone system. This raises the amount of fluid and sodium in the blood and blood pressure, creating extra work for the already weakened heart. ACE inhibitors and ARBs calm down the renin-angiotensin-aldosterone system, relaxing blood vessels and relieving high blood pressure.

On my website, AskDoctorK.com, I’ve put a table listing the names, actions and possible side effects of drugs in each of these categories.

Two other types of medicines are sometimes used to treat heart failure: aldosterone blockers and digoxin. Aldosterone blockers are another class of drugs that act on the renin-angiotensin-aldosterone system. Digoxin boosts the strength of the heart’s contractions. It used to be the main drug used to treat heart failure, but it was not as potent as the newer drugs and had more serious possible side effects.

In addition, research is developing exciting possible new treatments, particularly a drug called an angiotensin receptor-neprilysin inhibitor.

ACE inhibitors

Generic name
(Brand name)
Heart failure stage or indication Action Side effects Comments
benazepril* (Lotensin) Stage A: hypertension Inhibit angiotensin-converting enzyme (ACE) from activating the hormone angiotensin.Angiotensin signals the body to constrict blood vessels, thereby raising blood pressure.ACE inhibitors dilate arteries, decrease the resistance to blood flow in vessels, and lower blood pressure. Persistent dry cough, altered taste sensation, rash and other allergic reactions; may cause kidney damage and, rarely, decrease the number of white blood cells. A type of vasodilator. Considered first-choice treatment for people with heart failure.In addition to lowering blood pressure, ACE inhibitors reduce progression of heart damage in heart failure.
captopril* (Capoten) Stage A: hypertension; diabetesStage B: after heart attackStage C: heart failure
enalapril* (Vasotec) Stage A: hypertension; diabetesStage B: no symptomsStage C: heart failure
fosinopril* (Monopril) Stage A: hypertensionStage C: heart failure
lisinopril* (Prinivil, Zestril) Stage A: hypertension; diabetesStage B: after heart attackStage C: heart failure
moexipril* (Univasc) Stage A: hypertension
perindopril* (Aceon) Stage A: hypertension;cardiovascular risk
ramipril* (Altace) Stage A: hypertension; cardiovascular riskStage B: after heart attackStage C: after heart attack
trandolapril* (Mavik) Stage A: hypertensionStage B: after heart attackStage C: after heart attack
*An asterisk indicates that the drug is available in a generic version or is expected to be within the near future.

 

Angiotensin-receptor blockers (ARBs)

Generic name (Brand name) Heart failure stage or indication Action Side effects Comments
candesartan* (Atacand) Stage A: hypertensionStage C: heart failure Prevent angiotensin from exerting its blood vessel–constricting effects, thereby lowering blood pressure. Persistent cough, elevated potassium levels, dizziness, headache, drowsiness, diarrhea, abnormal taste sensation, rash. May be an alternative for people who can’t tolerate ACE inhibitors.
eprosartan* (Teveten) Stage A: hypertension
irbesartan* (Avapro) Stage A: hypertension; diabetes
losartan* (Cozaar) Stage A: hypertension; diabetesStage B: cardiovascular risk
olmesartan* (Benicar) Stage A: hypertension
telmisartan* (Micardis) Stage A: hypertension
valsartan* (Diovan) Stage A: hypertensionStage B: after heart attackStage C: after heart attack; heart failure
*An asterisk indicates that the drug is available in a generic version or is expected to be within the near future.

 

Beta blockers

Generic name (Brand name) Heart failure stage or indication Action Side effects Comments
acebutolol* (Sectral) Stage A: hypertension Lower demand on heart by slowing heart rate, decreasing force of contractions, and reducing blood ­pressure. Can worsen or provoke asthma or pain in legs from narrowed arteries; can worsen heart failure; can provoke Raynaud’s phenomenon (spasm of blood vessels to hands).Sometimes cause fatigue or depression, impotence, hallucinations, or bad dreams. Elderly people are more prone to these latter side effects. These drugs weaken the heart muscle’s contractions, so they can initially make heart failure worse.To avoid this problem, a person generally will start with a low dose, then increase gradually.
atenolol* (Tenormin) Stage A: hypertensionStage B: after heart attack
parbetaxolol* (Kerlone) Stage A: hypertension
bisoprolol* (Zebeta) Stage A: hypertensionStage C: heart failure
carvedilol* (Coreg) Stage A: hypertensionStage B: after heart attackStage C: heart failure; after heart attack
metoprolol succinate* (Toprol-XL) Stage A: hypertensionStage C: heart failure
metoprolol tartrate* (Lopressor) Stage A: hypertensionStage B: after heart attack
nadolol* (Corgard) Stage A: hypertension
penbutolol (Levatol) Stage A: hypertension
pindolol* Stage A: hypertension
propranolol* (Inderal) Stage A: hypertensionStage B: after heart attack
timolol* Stage A: hypertensionStage B: after heart attack
*An asterisk indicates that the drug is available in a generic version or is expected to be within the near future.

 

Diuretics

Generic name (Brand name) Heart failure stage or indication Action Side effects Comments
Loop diuretics
bumetanide (Bumex) Stage C: heart failure Reduce swelling and fluid buildup by causing the kidneys to remove sodium and fluid from the body. Fatigue, too-low blood pressure, poor kidney function, low potassium levels. Preferred diuretic for elimination of fluid buildup in people with heart failure.
furosemide* (Lasix)
torsemide (Demadex)
Thiazide diuretics
chlorothiazide* (Diuril) Stage A: hypertensionStage C: heart failure Lower blood pressure by eliminating excess fluid and relaxing the blood vessels. Muscle weakness, dizziness, cramps, thirst, stomach pain, upset stomach, vomiting, diarrhea, headache, hair loss, blurred vision, decreased sexual ability. Not as effective in eliminating fluid as loop diuretics, but better at lowering blood pressure.Sometimes used in people with mild fluid retention or to supplement the action of other diuretics.
chlorthalidone* (Hygroton, Thalitone)
hydrochlorothiazide* (HydroDiuril; also available in many combination drugs with other heart failure medications)
indapamide* (Lozol)
metolazone* (Diulo, Mykrox, Zaroxolyn)
Potassium-sparing diuretics
amiloride* (Midamor) Stage C: heart failure Reduce swelling and fluid buildup by causing the kidneys to remove sodium and fluid from the body, without lowering potassium levels. Dizziness, dehydration, nausea, vomiting, change in appetite, headache, constipation. Can raise potassium level, so you’ll need to be monitored with regular blood tests.Call your doctor immediately if you notice signs of high potassium, including muscle weakness or irregular heartbeat.
triamterene (Dyrenium)
*An asterisk indicates that the drug is available in a generic version or is expected to be within the near future.