What medications are contraindicated in patients with heart failure?

Medications Contraindicated in Heart Failure

Avoid NSAIDs, most calcium channel blockers (especially diltiazem and verapamil), most antiarrhythmic drugs (except amiodarone), and thiazolidinediones in patients with heart failure, as these medications adversely affect clinical status, worsen fluid retention, and increase mortality risk.

Primary Contraindications

NSAIDs (Including COX-2 Inhibitors)

• NSAIDs should be avoided or withdrawn whenever possible in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction 1.
• NSAIDs cause sodium and water retention, impair renal function, and blunt the effects of diuretics, ACE inhibitors, and ARBs 1, 2.
• The FDA explicitly warns to avoid ibuprofen in patients with severe heart failure unless benefits outweigh the risk of worsening heart failure 2.
• NSAIDs increase the risk of heart failure hospitalization approximately two-fold and increase mortality in patients with existing heart failure 2, 3.
• This contraindication applies to both traditional NSAIDs and selective COX-2 inhibitors, as both classes have similar renal effects 3.

Calcium Channel Blockers with Negative Inotropic Effects

• Calcium channel blockers are generally contraindicated in heart failure patients, with specific indications required if used 1.
• Diltiazem and verapamil are particularly harmful due to their negative inotropic effects and should be discontinued unless absolutely necessary 1.
• These agents should not be used in asymptomatic patients with ejection fraction less than 40% after myocardial infarction 1.
• If calcium channel blockers must be used for concurrent conditions (hypertension, angina), document the specific indication 1.

Most Antiarrhythmic Drugs

• Class I antiarrhythmic drugs should be avoided in patients with heart failure, cardiac ischemia, or previous myocardial infarction 4.
• Antiarrhythmics other than amiodarone are generally contraindicated in heart failure patients 1.
• There is no general indication for antiarrhythmic agents in heart failure 1.
• If antiarrhythmics other than amiodarone are prescribed, specific indications must be documented 1.

Thiazolidinediones (Glitazones)

• Thiazolidinediones cause fluid retention and should not be combined with other fluid-retaining agents in heart failure patients 5.
• These drugs synergistically worsen outcomes when combined with NSAIDs or calcium channel blockers 5.

Relative Contraindications and Cautions

Specific Digoxin Contraindications

• Bradycardia 1
• Second- and third-degree AV block 1
• Sick sinus syndrome 1
• Carotid sinus syndrome 1
• Hypokalemia and hypercalcemia 1

Beta-Blockers (Absolute Contraindications Only)

• Asthma bronchiale 1
• Severe bronchial disease 1
• Symptomatic bradycardia or hypotension 1

Note: Beta-blockers are recommended for heart failure treatment in stable patients (NYHA II-IV) and should not be stopped suddenly due to risk of rebound myocardial ischemia or arrhythmias 1.

Drugs Requiring Extreme Caution

Positive Inotropes (Other Than Digoxin)

• Long-term use of positive inotropic agents (dobutamine, milrinone, phosphodiesterase inhibitors) increases mortality 1.
• High-dose outpatient dobutamine infusions have been associated with increased mortality 1.
• These agents should only be used for acute decompensation or as a bridge to transplantation 1.

Pregabalin

• Monitor for jugular venous distension, dyspnea, orthopnea, weight changes, and new or worsening peripheral edema when using pregabalin 5.
• Avoid combining pregabalin with other fluid-retaining agents 5.
• Consider alternatives such as duloxetine or tricyclic antidepressants (with caution) for neuropathic pain 5.

Common Pitfalls to Avoid

• Do not assume COX-2 selective inhibitors are safer than traditional NSAIDs in heart failure—both classes carry similar risks for fluid retention and heart failure exacerbation 3.
• Never abruptly discontinue beta-blockers even if heart failure worsens; instead, adjust diuretics or ACE inhibitors first and seek specialist advice 1.
• Avoid potassium-sparing diuretics during ACE inhibitor or aldosterone antagonist initiation due to hyperkalemia risk 1.
• Do not use thiazide diuretics if GFR <30 mL/min except synergistically with loop diuretics 1.
• Monitor for drug interactions when prescribing any new medication, particularly combinations that affect renal function or fluid retention 1, 2.