What are the medications used to treat heart failure?

Medications for Heart Failure Treatment

The cornerstone medications for heart failure treatment include ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), diuretics, angiotensin receptor blockers (ARBs), cardiac glycosides, and the newer agent sacubitril/valsartan, with ACE inhibitors and beta-blockers forming the foundation of therapy for patients with reduced ejection fraction. 1

First-Line Medications

• ACE Inhibitors: Recommended as first-line therapy in patients with reduced left ventricular systolic function to reduce mortality and hospitalizations 1

  • Examples include lisinopril, enalapril, captopril
  • Should be titrated to target doses shown effective in clinical trials 1

• Beta-Blockers: Recommended for all stable patients with mild, moderate, and severe heart failure with reduced ejection fraction (NYHA class II-IV) 1

  • Examples include metoprolol, carvedilol, bisoprolol 2
  • Should be initiated after patient is stabilized on ACE inhibitors and diuretics 2
  • Require slow titration over weeks or months to reach maintenance doses 2

• Diuretics: Essential for symptomatic treatment when fluid overload is present 1

  • Loop diuretics (e.g., furosemide) or thiazides are first-line options 1
  • Should always be administered in combination with ACE inhibitors when possible 1
  • For insufficient response, increase dose or combine loop diuretics with thiazides 1

Second-Line and Add-On Medications

• Mineralocorticoid Receptor Antagonists (MRAs): Recommended for patients who remain symptomatic despite treatment with ACE inhibitors and beta-blockers 1

  • Spironolactone is recommended in advanced heart failure (NYHA III-IV) 1
  • Improves survival and reduces morbidity when added to ACE inhibitors and diuretics 1
  • Requires careful monitoring of potassium and renal function 1

• Angiotensin Receptor Blockers (ARBs): Alternative for patients who cannot tolerate ACE inhibitors 1

  • May be considered in combination with ACE inhibitors in patients who remain symptomatic 1, 3
  • Have fewer side effects like cough compared to ACE inhibitors 1

• Sacubitril/Valsartan: Recommended as a replacement for ACE inhibitors in patients who remain symptomatic despite optimal treatment 1

  • Indicated to reduce the risk of cardiovascular death and hospitalization for heart failure 4
  • Requires a 36-hour washout period when switching from an ACE inhibitor 4

• Cardiac Glycosides (Digoxin): Indicated for patients with atrial fibrillation and heart failure 1

  • Also recommended for patients in sinus rhythm who remain symptomatic despite ACE inhibitors and diuretics 1
  • Usual daily dose of oral digoxin is 0.25-0.375 mg if serum creatinine is normal (0.125-0.25 mg in elderly) 1

Special Considerations

• Potassium-sparing diuretics (triamterene, amiloride) should only be used if hypokalemia persists after initiation of ACE inhibitors and diuretics 1

  • Start with low doses and monitor potassium and creatinine levels closely 1

• Combination therapy should follow a logical sequence:

  • Start with ACE inhibitors and diuretics 1
  • Add beta-blockers once patient is stabilized 2
  • Add MRAs for patients who remain symptomatic 1
  • Consider sacubitril/valsartan as replacement for ACE inhibitors in patients who remain symptomatic despite optimal treatment 1, 4

Common Pitfalls and Caveats

• Avoid initiating beta-blockers in decompensated heart failure; wait until patient is stabilized 2
• Avoid potassium-sparing diuretics during initiation of ACE inhibitor therapy 1
• Avoid NSAIDs in patients on ACE inhibitors as they may worsen renal function 1
• Diltiazem and verapamil are not recommended in patients with reduced ejection fraction heart failure as they increase risk of worsening 1
• When switching from ACE inhibitor to sacubitril/valsartan, allow a 36-hour washout period to reduce risk of angioedema 4
• Careful monitoring of renal function and electrolytes is essential when using ACE inhibitors, ARBs, and MRAs 1, 3