What medications should heart failure patients be on?

From the Guidelines

Heart failure patients should be on a combination of medications including ACE inhibitors or ARBs, beta-blockers, and mineralocorticoid receptor antagonists to reduce morbidity, mortality, and improve quality of life. According to the most recent and highest quality study 1, these medications are essential for the management of patients with chronic heart failure and a reduced ejection fraction. The study suggests that inhibitors of the renin–angiotensin system, neprilysin inhibitors (such as sacubitril/valsartan), beta-adrenergic blockers, and mineralocorticoid receptor antagonists are the most effective medications for reducing the risk of death and hospitalization in heart failure patients.

Some key points to consider when prescribing these medications include:

• Starting with low doses and gradually increasing to target doses as tolerated
• Regular monitoring of kidney function, electrolytes, and blood pressure
• Considering the type of heart failure (reduced vs. preserved ejection fraction), severity of symptoms, and individual patient factors like kidney function and blood pressure when selecting medications
• Using diuretics (such as furosemide, bumetanide) to manage fluid retention and reduce congestion, as recommended by the 2016 ESC guidelines 1
• Considering the use of newer medications like SGLT2 inhibitors (such as empagliflozin, dapagliflozin) for patients with more severe heart failure, as they have shown significant benefits in reducing hospitalizations and mortality.

It's also important to note that the 2016 ESC guidelines 1 recommend the use of ACE inhibitors, beta-blockers, and mineralocorticoid receptor antagonists for patients with symptomatic heart failure with reduced ejection fraction, and that these medications should be used in combination to achieve optimal results. Additionally, the study published in 2020 1 suggests that hydralazine and isosorbide dinitrate can prolong survival, but the combination may be inferior to ACE inhibitors with respect to mortality.

Overall, the goal of treatment is to reduce the heart's workload, improve cardiac function, prevent disease progression, and ultimately extend life while improving quality of life, as supported by the evidence from the studies 1.

From the FDA Drug Label

In two placebo controlled, 12-week clinical studies compared the addition of lisinopril up to 20 mg daily to digitalis and diuretics alone. The combination of lisinopril, digitalis and diuretics reduced the following signs and symptoms of heart failure: edema, rales, paroxysmal nocturnal dyspnea and jugular venous distention A large (over 3,000 patients) survival study, the ATLAS Trial, comparing 2. 5 mg and 35 mg of lisinopril in patients with systolic heart failure, showed that the higher dose of lisinopril had outcomes at least as favorable as the lower dose Key medications for heart failure patients:

• Lisinopril: an ACE inhibitor, which can be used in combination with digitalis and diuretics to reduce signs and symptoms of heart failure.
• Digitalis: used in combination with lisinopril and diuretics to reduce signs and symptoms of heart failure.
• Diuretics: used in combination with lisinopril and digitalis to reduce signs and symptoms of heart failure. 2

From the Research

Medications for Heart Failure Patients

Heart failure patients should be on the following medications:

• Beta-blockers: bisoprolol, carvedilol, and metoprolol succinate, as they have been shown to reduce mortality and improve quality of life in patients with heart failure 3, 4
• ACE inhibitors: lisinopril, as it has been demonstrated to reduce the risk of major clinical events and improve symptomatic end-points in patients with heart failure 5, 6, 7

Dosage and Administration

• Beta-blockers should be commenced at small doses and then titrated upward as tolerated to achieve the desired clinical effects on heart rate and symptom control 3
• High doses of lisinopril (32.5 to 35mg, administered once daily) have been shown to be more effective than low doses (2.5 to 5mg, administered once daily) in reducing the risk of major clinical events in patients with heart failure 5

Combination Therapy

• The combination of beta-blockers and ACE inhibitors has been shown to be effective in managing heart failure and reducing cardiovascular risk 7
• This combination can be used to control hypertension, manage arrhythmias, treat angina pectoris, and provide cardioprotection in patients with acute coronary syndromes and congestive heart failure 7