Are there any contraindications for a patient with New York Heart Association (NYHA) class III heart failure prescribed Captopril, Bisoprolol, Furosemide (Lasix), and Verapamil?

From the Guidelines

There is a significant contraindication in this medication regimen, specifically the use of Verapamil in a patient with NYHA class III heart failure, as it can worsen heart failure and cause excessive bradycardia and atrioventricular block when combined with bisoprolol. The combination of a non-dihydropyridine calcium channel blocker (verapamil) with a beta-blocker (bisoprolol) can cause additive negative inotropic and chronotropic effects, leading to worsening heart failure 1. Additionally, verapamil itself is generally contraindicated in heart failure with reduced ejection fraction as it can further depress cardiac function.

The other medications (captopril, an ACE inhibitor; bisoprolol, a beta-blocker; and furosemide/Lasix, a loop diuretic) represent appropriate guideline-directed medical therapy for heart failure. The prescriber should remove verapamil from this regimen and consider adding an aldosterone antagonist like spironolactone if the patient has reduced ejection fraction, as this would provide mortality benefit, according to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1. If blood pressure control is needed, other antihypertensives that don't worsen heart failure could be considered.

Some key points to consider in the management of heart failure include:

• The use of diuretics, ACE inhibitors, beta-blockers, and aldosterone receptor antagonists as first-line therapy for heart failure with reduced ejection fraction 1
• The importance of monitoring and adjusting medication regimens to optimize symptoms and reduce morbidity and mortality 1
• The need to avoid certain medications, such as non-dihydropyridine calcium channel blockers, in patients with heart failure due to their potential to worsen cardiac function 1

From the FDA Drug Label

CONTRAINDICATIONS Captopril tablets are contraindicated in patients who are hypersensitive to this product or any other angiotensin-converting enzyme inhibitor (e.g., a patient who has experienced angioedema during therapy with any other ACE inhibitor). The patient's NYHA class III heart failure is not directly mentioned as a contraindication for Captopril in the provided drug label. However, there is a contraindication for patients who are hypersensitive to Captopril or any other angiotensin-converting enzyme inhibitor.

• The label does not mention Bisoprolol, Furosemide (Lasix), or Verapamil.
• The only clear contraindication is for patients with hypersensitivity to Captopril or other ACE inhibitors 2.

From the Research

Contraindications for Captopril, Bisoprolol, Furosemide, and Verapamil in NYHA Class III Heart Failure

• There are no direct contraindications mentioned in the provided studies for the combination of Captopril, Bisoprolol, Furosemide (Lasix), and Verapamil in patients with New York Heart Association (NYHA) class III heart failure.
• However, the studies suggest that patients with severe chronic heart failure may require higher doses of diuretics, such as Furosemide, to achieve maximal symptomatic benefit 3.
• The use of Captopril in patients with heart failure has been shown to be effective in reducing symptoms and improving exercise duration, but it may cause hypotension in some patients 4, 5.
• Bisoprolol, a beta-blocker, has been shown to be effective in improving survival and reducing hospitalization in patients with stable chronic heart failure, but it may cause adverse effects such as dizziness, bradycardia, and hypotension 6.
• Verapamil, a calcium channel blocker, is not directly mentioned in the provided studies as part of the treatment regimen for NYHA class III heart failure, but it is often used to treat hypertension and angina.
• The combination of Captopril and spironolactone has been shown to be effective in treating refractory congestive heart failure, but the use of Verapamil in this context is not well established 5.
• Overall, the provided studies suggest that the combination of Captopril, Bisoprolol, Furosemide, and Verapamil may be effective in treating NYHA class III heart failure, but careful monitoring of patients is necessary to minimize adverse effects 6, 3, 4, 5.

Potential Interactions and Side Effects

• The use of Captopril and Furosemide together may increase the risk of hypotension and electrolyte imbalances 3, 4.
• The combination of Bisoprolol and Verapamil may increase the risk of bradycardia and hypotension 6.
• Patients with renal impairment may require dose adjustments for Captopril and Furosemide 3, 4.
• The use of Verapamil in patients with heart failure has not been well established, and its potential interactions with other medications, such as Captopril and Bisoprolol, are not well understood 6, 3, 4, 5.

Monitoring and Dose Adjustments

• Patients treated with Captopril, Bisoprolol, Furosemide, and Verapamil should be closely monitored for signs of hypotension, electrolyte imbalances, and renal impairment 6, 3, 4, 5.
• Dose adjustments may be necessary to minimize adverse effects and optimize therapeutic benefits 6, 3, 4, 5.
• Regular monitoring of blood pressure, electrolyte levels, and renal function is necessary to ensure safe and effective treatment 6, 3, 4, 5.