Medications that Exacerbate Heart Failure

Aka: Medications that Exacerbate Heart Failure, Congestive Heart Failure Exacerbation due to Medications, Drug-Induced CHF Exacerbation, Medications that Provoke Heart Failure

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II. Epidemiology

  1. Up to half of Heart Failure patients take at least one medication that may result in a CHF exacerbation

III. Causes: Cardiovascular Agents that exacerbate Heart Failure

  1. Calcium Channel Blockers (except Amlodipine)
    1. In general, Calcium Channel Blockers reduce contractility and ejection fraction (except Amlodipine)
    2. Avoid Diltiazem, Verapamil and Nifedipine in Heart Failure with Reduced Ejection Fraction
  2. Beta Agonists
    1. Higher hospitalization and mortality rates in CHF
      1. Au (2003) Chest 123:1964-9 [PubMed]
    2. May be started slowly once CHF is stable and compensated

IV. Causes: Diabetes Agents that exacerbate Heart Failure

  1. Glitazones (e.g. Pioglitazone or Actos)
    1. Edema risk
  2. Gliptins (DPP-4 Inhibitors)
    1. Sitagliptin (Januvia) and Tradjenta (Linagliptin) appear to have least adverse effects on CHF exacerbation risk
  3. Consider alternative Type 2 Diabetes Mellitus medications which are not associated with exacerbation risk (or show CHF benefit)
    1. Continue Metformin
    2. Consider SGLT Inhibitor (Farxiga)
      1. Associated with reduced risk of Heart Failure hospitalization

V. Causes: Antidepressants that exacerbate Heart Failure

  1. Tricyclic Antidepressants (e.g. Amitriptyline)
    1. May decrease cardiac contractility and Blood Pressure

VI. Causes: Analgesic Agents that exacerbate Heart Failure

  1. Nonsteroidal Anti-inflammatory drugs (NSAIDS)
    1. NSAIDs block ACE Inhibitor activity, block Diuretic activity and increase Blood Pressure and edema
    2. Naproxen appears to have the least adverse cardiac effects of the NSAIDs
    3. Avoid in general, but if no alternative, use the shortest course at the lowest effective dose
    4. Consider Topical NSAIDs (e.g. Diclofenac Gel) or Acetaminophen

VII. Causes: Miscellaneous OTC Agents that exacerbate Heart Failure

  1. See Low Sodium Diet
  2. Medications with high Sodium (e.g. some OTC effervescent tablets contain 500 mg Sodium per tab)
  3. St John's Wort
    1. Multiple Drug Interactions (e.g. Digoxin, Eplerenone)

VIII. Causes: Toxins that may cause Heart Failure (Cardiomyopathy)

  1. Toxins
  2. Alcohol
  3. Doxorubicin
  4. Catecholamines
  5. Cobalt
  6. Cocaine

IX. References

  1. (2016) Presc Lett 23(9)
  2. (2022) Presc Lett 29(10): 57-8

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