From the Guidelines
Medications such as nondihydropyridine calcium channel-blocking drugs, class IC antiarrhythmic medications, dronedarone, thiazolidinediones, and NSAIDs should be avoided in patients with heart failure with reduced ejection fraction (HFrEF) due to their potential to worsen cardiac function or increase the risk of mortality. When considering the management of heart failure, it is crucial to prioritize medications that improve morbidity, mortality, and quality of life. The following medications are contraindicated in heart failure:
- Nondihydropyridine calcium channel-blocking drugs, such as verapamil and diltiazem, which have negative inotropic effects that can worsen HFrEF 1
- Class IC antiarrhythmic medications and dronedarone, which may increase the risk of mortality in patients with HFrEF 1
- Thiazolidinediones, which increase the risk of worsening HF symptoms and hospitalizations 1
- NSAIDs, which worsen HF symptoms and should be avoided or withdrawn whenever possible 1
- Dipeptidyl peptidase-4 (DPP-4) inhibitors saxagliptin and alogliptin, which increase the risk of HF hospitalization and should be avoided in patients with HF 1 It is essential to note that these contraindications exist because these medications can either directly depress cardiac function, increase fluid retention, or interfere with the body's compensatory mechanisms for heart failure. In clinical practice, the use of these medications should be carefully evaluated, and alternative treatments should be considered to minimize the risk of adverse effects and improve patient outcomes, as supported by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1.
From the Research
Contraindications for Heart Failure Medication
- Nonsteroidal anti-inflammatory drugs (NSAIDs) are contraindicated in patients with heart failure, as they can impair renal function and lead to cardiac decompensation 2.
- Calcium antagonists are contraindicated in congestive heart failure (CHF) due to systolic dysfunction 3.
- The use of NSAIDs in patients with type 2 diabetes mellitus (T2DM) is associated with an increased risk of heart failure hospitalization, particularly in those with advanced age, elevated HbA1c levels, and new users of NSAIDs 4.
Medications to Use with Caution
- Nonprescription medications, such as NSAIDs, should be used with caution in patients with heart failure, as they can add complexity to medication therapy regimens 5.
- Angiotensin receptor-neprilysin inhibitors (ARNIs) should be used with caution in patients with heart failure, as they can increase the risk of angioedema 6.
Alternative Therapies
- Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor antagonists are effective alternatives to calcium antagonists in the management of hypertension and heart failure 3.
- ARNIs, such as sacubitril-valsartan, have been shown to be superior to ACEIs in reducing mortality and heart failure hospitalization in patients with heart failure with reduced ejection fraction (HFrEF) 6.