Heart failure: Which medications can make it worse?

Heart failure (HF) is a condition that occurs when the heart does not pump blood effectively around the body due to weak or stiff heart muscles. This causes a build-up of fluid in the body, leading to symptoms such as breathlessness, oedema (swollen ankles, legs and feet), fatigue, weight gain and lightheadedness. (1)  

While there are several medicines used to treat heart failure and relieve its symptoms, there are many which should be avoided. This is because they can cause exacerbations of HF. (2) Therefore, it is best to check with your doctor or pharmacist before taking any prescription or over-the-counter medicines. 

Here is a list of medicines which should be avoided or used with caution in patients with heart failure:

Drug	Why should it be avoided?	Alternatives
NSAIDs e.g ibuprofen	They can make the condition worse by increasing sodium and water retention, leading to fluid overload. (3)(4)	Alternative painkillers include: -paracetamol for mild pain  -Paracetamol and codeine for more severe pain. (3)
Calcium channel blockers such as verapamil and diltiazem	These decrease the heart’s ability to pump blood around the body, particularly with systolic heart failure. (4)	Alternative calcium channel blockers can be used, such as amlodipine or felodipine, if other medicines for HF are contraindicated or ineffective. (4)
Tricyclic antidepressants	These medicines are generally not recommended to be used in patients with any heart disease as they increase the heart rate and rhythm and are cardiotoxic in overdose(5)	Preferred antidepressants include selective serotonin reuptake inhibitors (SSRIs) such as sertraline or fluoxetine, as they have fewer cardiac side effects. (5)
Thiazolidinediones (e.g. rosiglitazone, pioglitazone)	These drugs exacerbate heart failure by causing fluid retention and weight gain; therefore are contraindicated. (4)	Several diabetic medications, particularly sodium-glucose co-transporter inhibitors (SGLT2i), e.g dapagliflozin and glucagon-like peptide-1 receptor (GLP-1)receptor agonists, have been recommended to treat heart failure as an alternative. (4)
Corticosteroids	Studies have been found to shown that prolonged use of corticosteroids causes sodium and water retention, increasing blood pressure and can exacerbate heart failure. (5)	When using corticosteroids, they should be used at the lowest effective dose and for the shortest duration. Symptoms of HF, such as shortness of breath and weight gain associated with the use of corticosteroids, should be monitored. (5)

References:

1. Website, N. (2024, April 8). Heart failure. nhs.uk. https://www.nhs.uk/conditions/heart-failure/

2. Colucci, W. S. (2016). Drugs that should be avoided or used with caution in patients with heart failure.

3. Varga, Z., rafay ali Sabzwari, S., Vargova, V., & Sabzwari, S. R. A. (2017). Cardiovascular risk of nonsteroidal anti-inflammatory drugs: an under-recognized public health issue. Cureus, 9(4).

4. Page, R. L., O’Bryant, C. L., Cheng, D., Dow, T. J., Ky, B., Stein, C. M., ... & Lindenfeld, J. (2016). Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation, 134(6), e32-e69.

5. Amabile, Celene M., and Anne P. Spencer. "Keeping your patient with heart failure safe: a review of potentially dangerous medications." Archives of internal medicine 164.7 (2004): 709-720.

Assessed and Endorsed by the MedReport Medical Review Board