Medications to Discontinue in Heart Failure Patients
Immediately discontinue diltiazem, verapamil, NSAIDs, and COX-2 inhibitors in patients with heart failure with reduced ejection fraction (HFrEF), as these medications directly worsen heart failure outcomes and increase hospitalization risk.
Medications That Must Be Stopped
Non-Dihydropyridine Calcium Channel Blockers
- Diltiazem and verapamil are contraindicated in HFrEF patients 1
- These agents increase risk of heart failure worsening and hospitalization (Class III recommendation, Level C evidence)
- Calcium channel blockers were associated with increased readmission risk (HR 1.225,95% CI 1.085-1.382) 2
- Despite guidelines, 9.7% of patients still receive these medications 3
NSAIDs and COX-2 Inhibitors
- Stop all non-steroidal anti-inflammatory drugs immediately
- NSAIDs are the most commonly prescribed potentially harmful drug in HF patients (67.4% of those receiving harmful medications) 4
- Associated with increased all-cause mortality in elderly ADHF patients 5
- Prescription rates remain high at 9.2% despite declining trends 3
- Women are disproportionately prescribed these agents 3
Triple Renin-Angiotensin System Blockade
- Do not combine ARB (or renin inhibitor) with both ACE-I and MRA 1
- This combination increases risk of renal dysfunction and life-threatening hyperkalemia (Class III recommendation, Level C evidence)
Additional Potentially Harmful Medications to Review
Thiazolidinediones
- Prescribed in 23.3% of HF patients with potentially harmful medications 4
- Can cause fluid retention and worsen heart failure
- Consider alternative diabetes management
Cilostazol
- Avoid in HF patients due to potential for worsening outcomes 3
Antiarrhythmics (Select Agents)
- Certain antiarrhythmics prescribed in 12.6% of patients receiving harmful drugs 4
- Review necessity and consider safer alternatives
Clinical Approach Algorithm
Step 1: Immediate Review
- Scan medication list for diltiazem, verapamil, NSAIDs, COX-2 inhibitors
- Discontinue these immediately without tapering
Step 2: Assess Triple RAS Blockade
- If patient on ACE-I + MRA, do not add ARB or renin inhibitor
- If already on triple therapy, discontinue the ARB or renin inhibitor
Step 3: Evaluate Other PIMs
- Review thiazolidinediones, cilostazol, specific antiarrhythmics
- Substitute with safer alternatives for the underlying condition
Step 4: Monitor High-Risk Groups
- Female patients receive NSAIDs and non-DHP CCBs more frequently 3
- Elderly patients with polypharmacy (≥6 medications) have higher PIM exposure 5
- Patients with severe obesity and Hispanic ethnicity show higher PIM prescription rates 2
Important Caveats
Polypharmacy Context
- Patients taking ≥6 medications have increased mortality risk independent of PIMs 5
- Median medication count in HF patients is 7 (IQR 0-18) 5
- Frailty increases GDMT discontinuation rates but should not justify continuing harmful medications 6
Monitoring After Discontinuation
- Systolic blood pressure <100 mmHg at admission predicts mortality 5
- Monitor for pain control alternatives when stopping NSAIDs
- Ensure adequate rate control when stopping non-DHP CCBs in atrial fibrillation patients
What NOT to Stop
- Do not discontinue guideline-directed medical therapy (ACE-I/ARB/ARNI, beta-blockers, MRAs, SGLT2 inhibitors) unless specific contraindications exist
- These medications reduce hospitalization and mortality (Class I, Level A evidence) 1
The evidence consistently demonstrates that despite declining trends, potentially harmful medications remain widely prescribed in HF patients 3, 7. Recent data from 2026 shows NSAIDs and non-DHP CCBs continue to be prescribed in approximately 10% of HF patients 3, representing a persistent quality gap that directly impacts morbidity and mortality.