Congestive heart failure Drugs to avoid

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Drugs like nonsteroidal anti-inflammatory drugs, antiarrhythmic agents, and calcium channel blockers should be avoided in patients with congestive heart failure as they are known to have negative or deleterious effects on cardiac contractility, the neurohormonal system, or may cause sodium retention.

Drugs to Be Avoided in Congestive Heart Failure

Calcium Channel Blockers

There is no direct role of calcium channel blockers in the management of CHF. Given that some agents (diltiazem and verapamil) have a negative inotropic effect, it has been hypothesized that calcium channel blockers might increase adverse outcomes among patients with CHF due to systolic dysfunction. Vasoselective calcium channel blockers such as amlodipine and felodipine have not been linked to adverse outcomes among patients with congestive heart failure, but there is likewise no evidence of efficacy for these drugs in the management of CHF. If a congestive heart failure patient has either angina or hypertension as a concomitant disease, amlodipine and felodipine appear to be safe for the treatment of these patients.

Antiarrhythmic Agents

Negative inotropic effect exerted by most antiarrhythmic drugs can precipitate CHF in patients with reduced LV function, and antiarrhythmic agents can also paradoxically be pro-arrhythmic. The reduction in LV function can also reduce the elimination of these drugs leading to further drug toxicity. Other antiarrhythmic drugs can induce some proarrhythmic effect, especially class 1 agents and class 3 agents Ibutilide and sotalol (which has a negative inotropic effect); the same class 3 agents in addition to dofetilide can induce torsades to pointes. Amiodarone is considered the safest of the antiarrhythmic drugs because of its minimal proarrhythmic effect and is generally the preferred drug for treating arrhythmias in CHF patients.Dronedarone should be avoided in patients who were hospitalized with CHF (this is a boxed warning). Disopyramide is contraindicated in patients with heart failure

Nonsteroidal Anti-Inflammatory Drugs (NSAID)

The administration of non-selective NSAIDs in CHF patients has been linked to:

• An increased risk of CHF exacerbation
• A decline in renal function
• Abnormal responses to both ACEIs and diuretics
• Poorer survival in observational studies, particularly in the post MI period

COX-2 selective inhibitors

Observational data suggest that these agents may be linked with an increase in congestive heart failure exacerbations as well as an increased mortality.

Aspirin

Aspirin is often prescribed as primary prevention in patients with risk factors for cardiovascular disease or as secondary prevention in patients with established cardiovascular disease. However, among patients with congestive heart failure, the risks and benefits of aspirin are not as well established. Concern has arisen regarding the potential interaction between aspirin with ACEIs and beta blockers. At this time the American College of Chest Physicians guidelines indicate that it is reasonable to withhold aspirin among patients who have non-ischemic heart failure, while it may be reasonable to continue aspirin among those patients who have ischemic heart failure.

• Angiotensin-Converting Enzyme Inhibitors

Although there is some data to suggest that aspirin may attenuate some of the hemodynamic benefits of ACE inhibitors, there is no data indicating that the beneficial clinical outcomes associated with ACE inhibitors is reduced.

• Beta Blockers

There is likewise some data to suggest that aspirin may attenuate the benefit of beta blockers on the left ventricular ejection fraction among patients with congestive heart failure.

Oral Hypoglycemic Agents

• Metformin

Metformin is associated with lactic acidosis, which can be fatal in patients with CHF.

• Thiazolidinediones

Administration of thiazolidinediones is associated with fluid retention which may in turn cause volume overload and worsening of patients with CHF.

Antidepressants

Depression among patients with congestive heart failure is associated with poorer clinical outcomes including higher mortality Questions have been raised as to whether it is the depression itself that directly harms congestive heart failure patients or whether the harm is mediated by treatment with drugs such as tricyclic antidepressants. It appears that it is the depression itself and not the drugs used to treat depression that is independently associated with worse clinical outcomes. There is no difference in the risk of adverse outcomes among heart failure patients treated with either tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs).

Phosphodiesterase inhibitors PDE

• The PDE-3 inhibitors such as Cilostazol and the PDE-4 inibitor Anagrelide should be avoided in patients with CHF, because of an increase risk of high-output heart failure and fluid retention that is associated with those drugs.

• PDE-5 inhibitors such as sildenafil, vardenafil, and tadalafil, are widely used in the management of erectile dysfunction in men. The use of those agents with any form of nitrate therapy is contraindicated because of severe hypotensive effect that can be life threatening. In a trial where sildenafil and placebo were randomly assigned to 34 CHF patients, no significant difference of symptomatic hypotension was observed, but CHF patients with borderline low blood pressure and/or low volume status are at risk of severe hypotension and should avoid any PDE-5 inhibitors use. There is some data to suggest that sildenafil may be of benefit in patients who have heart failure associated with severe pulmonary hypertension.

Chemotherapy

Cardiotoxic chemotherapeutic agents as Cyclophosphamide, Trastuzumab, Bevacizumab and Anthracyclines, should be avoided in CHF patients

Tumor Necrosis Factor alpha inhibitors (TNF-alpha)

New onset or worsening of pre-existing heart failure have been linked to TNF-alpha inhibitors. Infliximab has been specifically contraindicated in doses over 5mg/kg in patients with heart failure.

Antihistamines

Some second generation antihistamines as terfenadine and astemizole have been reported to cause long QT syndrome and should not be used in CHF patients.

Serum Potassium

Serum potassium should be closely monitored in CHF patients, in order of preventing either hypokalemia or hyperkalemia, which could greatly affect cardiac excitability and conduction, leading to sudden cardiac death. Serum potassium should be maintained between 4.0 to 5.0 mEq per liter range, because low potassium level may affect digitalis and antiarrhythmic drugs treatment, while high potassium level can prevent the use of treatments known to prolong life.

Supervision of CHF patients with close monitoring of treatment and diet is a very important aspect of the follow-up process in those individuals. Body weight and medications should be closely monitored, because any minor change in those parameters can have a significant effect over symptoms and hospitalization of patients with CHF. Patient education is a crucial aspect of the management of CHF, patient and family surveillance over any new change of symptoms or body weight is important in allowing early detection of those changes and implementing new treatment strategies to reduce further complications.

Theophyline

Decompensation of congestive heart failure can be associated with theophylline toxicity, even at normal theophylline levels. If theophylline must be administered, the dosing should be reduced in the heart failure patient.

2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Antiarrhythmics in Patients Presenting With Heart Failure (DO NOT EDIT)

Class I

"1. Drugs known to adversely affect the clinical status of patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF) should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs.(Level of Evidence: B) "

Considerations for Minimizing Polypharmacy and improving Drug Safety

Class I

1. Healthcare providers should conduct comprehensive medication reconciliation at each clinical visit and with each admission. Patients should be specifically asked about drug, dose, and frequency of all their medications, including Otc medications and cAMs. If possible, these should be verified with the pharmacy or prescriber. (Class I, Level of Evidence: B)

2. Evaluating the potential risks and benefits of each medication should be considered before initiation. Medications should be categorized as either essential to desired outcomes or optional, with an attempt made to reduce or eliminate optional medications. (Class I, Level of Evidence: C)

Class IIa

1. It can be beneficial to implement a medication flow sheet and to update it at each visit. this flow sheet may include any laboratory tests needed for specific medications such as warfarin or amiodarone. It can be useful to provide patients with a copy of this final list and to encourage them to carry it with them at all times. (Class IIa, Level of Evidence: C)

2. It is reasonable to discontinue medications that do not have an indication or are contraindicated. (Class IIa, Level of Evidence: C)

3. When possible and affordable, it is reasonable to consider combination medications to reduce the number of medications taken daily or medications that can be used to treat >1 condition. (Class IIa, Level of Evidence: C)

4. It is reasonable to consider avoiding prescribing new medications to treat side effects of other medications. the use of as-needed medications should be limited to only those that are absolutely necessary. (Class IIa, Level of Evidence: C)

5. It can be beneficial to educate patients on the following aspects of Otc medications and cAMs: communicate with their healthcare provider first before taking any Otc medications and cAMs; avoid the use of Otc medications and cAMs with uncertain efficacy and safety; and evaluate all labels of Otc medications and cAMs for sodium content. (Class IIa, Level of Evidence: C)

6. It is reasonable to establish a team management approach in which a healthcare provider acts as “captain” of the medications and instructs patients to notify this individual whenever a medication is changed or added to the medication list. Ideally, this call should made before the product is purchased or the prescription is filled. (Class IIa, Level of Evidence: C)

Class IIb

1. Although not associated with improved outcome, the use of complexity tools may be considered to identify issues within a medication regimen. (Class IIb, Level of Evidence: C)