What medications can cause heart failure?

From the Guidelines

Medications that can cause or worsen heart failure include nonsteroidal anti-inflammatory drugs (NSAIDs), certain diabetes medications like thiazolidinediones, antiarrhythmic agents, calcium channel blockers, corticosteroids, and some psychiatric medications. These medications can lead to fluid retention, increased blood pressure, direct damage to heart muscle cells, or decreased heart contractility, ultimately contributing to heart failure exacerbation. According to the most recent guidelines 1, several factors can precipitate acute decompensated heart failure, including nonadherence to medication regimens, acute myocardial ischemia, uncorrected high blood pressure, arrhythmias, and the use of certain medications such as NSAIDs, calcium channel blockers, and thiazolidinediones. The European Society of Cardiology guidelines 1 also recommend avoiding certain treatments that may cause harm in patients with symptomatic systolic heart failure, including thiazolidinediones, most calcium channel blockers, and NSAIDs. It is essential for patients with existing heart conditions or risk factors to discuss their medication choices carefully with their healthcare providers and report any new symptoms promptly. Key medications to avoid or use with caution in heart failure patients include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen and naproxen
• Certain diabetes medications such as thiazolidinediones (pioglitazone, rosiglitazone)
• Antiarrhythmic medications like flecainide and propafenone
• Calcium channel blockers, especially verapamil and diltiazem
• Corticosteroids and some psychiatric medications (tricyclic antidepressants, clozapine) Patients should be monitored carefully for changes in serum potassium and should avoid excessive sodium and fluid intake to prevent acute heart failure exacerbation 1. Regular follow-up and patient education are crucial in preventing nonadherence and detecting changes in clinical status early enough to institute treatments that can prevent clinical deterioration 1.

From the FDA Drug Label

To minimize the potential risk for an adverse CV event in NSAID-treated patients, use the lowest effective dose for the shortest duration possible. The Coxib and traditional NSAID Trialists’ Collaboration meta-analysis of randomized controlled trials demonstrated an approximately two-fold increase in hospitalizations for heart failure in COX-2 selective-treated patients and nonselective NSAID-treated patients compared to placebo-treated patients In a Danish National Registry study of patients with heart failure, NSAID use increased the risk of MI, hospitalization for heart failure, and death. Doxorubicin may cause heart failure, the probability of developing impaired myocardial function based on a combined index of signs, symptoms and decline in left ventricular ejection fraction (LVEF) is estimated to be 1 to 2% at a total cumulative dose of 300 mg/m 2 of doxorubicin. Ibuprofen may worsen heart failure, avoid the use of ibuprofen tablets in patients with severe heart failure unless the benefits are expected to outweigh the risk of worsening heart failure. The medications that can cause heart failure are:

• Doxorubicin: may cause heart failure, especially with cumulative doses in excess of 400 mg/m 2 2 2
• Ibuprofen: may worsen heart failure, and increase the risk of hospitalizations for heart failure 3

From the Research

Medications that can Cause Heart Failure

• Nonsteroidal anti-inflammatory drugs (NSAIDs) can cause heart failure due to their effects on fluid retention and blood pressure 4
• Certain anti-inflammatory drugs, such as Coxibs, cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) inhibitors, can also increase the risk of heart failure 4
• Trastuzumab, a targeted breast cancer therapy, can cause heart failure and loss of left ventricular contractile function, especially in patients with cardiovascular disease risk factors, advanced age, and previous anthracycline treatment 5
• Other medications, such as antimicrobial drugs, psychotropic medications, and methadone, can prolong the QT interval and provoke torsades de pointes, a type of arrhythmia that can lead to heart failure 6

Mechanisms and Risk Factors

• The mechanisms of heart failure caused by these medications can involve direct myocardial toxicity, drug-drug interactions, or both 7
• Risk factors for medication-induced heart failure include cardiovascular disease, advanced age, and previous treatment with certain medications, such as anthracyclines 5
• Cardiac biomarkers, such as troponins and pro-BNP, and imaging assessments, such as echocardiogram, can help identify patients at risk of medication-induced heart failure 5

Prevention and Management

• Initiating beta-adrenergic antagonists and angiotensin converting enzyme inhibitors may prevent heart failure in patients taking certain medications, such as trastuzumab 5
• Discontinuation of the offending medication and following treatment guidelines for the specific arrhythmia or heart failure can help manage medication-induced heart failure 6
• Awareness of the potential for medications to cause heart failure and knowledge of the distinct mechanisms and risk factors are essential for clinicians to provide optimal care for patients 7, 6