What medications can make a weak heart beat stronger?

Medications to Strengthen a Weak Heart

For patients with heart failure and reduced ejection fraction (systolic dysfunction), ACE inhibitors combined with beta-blockers are the cornerstone medications that improve cardiac contractility, reduce mortality, and enhance quality of life. 1

First-Line Therapy: ACE Inhibitors

ACE inhibitors should be initiated first and titrated to maximum tolerated doses because they:

• Reduce mortality in patients with left ventricular systolic dysfunction 1, 2
• Attenuate ventricular remodeling and prevent progressive heart failure 2
• Improve hemodynamics by reducing both preload and afterload 3
• Provide survival benefits across all severity levels of heart failure 4

Start at low doses and double the dose at 2-week intervals until reaching target doses (e.g., enalapril 10-20 mg twice daily, lisinopril 20-40 mg daily). 1

If ACE Inhibitors Are Not Tolerated

• Use angiotensin II receptor blockers (ARBs) if intractable cough or angioedema occurs with ACE inhibitors 2
• Use hydralazine plus isosorbide dinitrate if both ACE inhibitors and ARBs are contraindicated, though this combination has higher discontinuation rates due to side effects 2, 3

Second-Line Therapy: Beta-Blockers

Add beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) to ACE inhibitors once the patient is stable because they:

• Significantly reduce mortality when added to ACE inhibitors 1, 2
• Attenuate ventricular remodeling and improve ventricular function 1, 2
• Improve clinical symptoms and functional class 1

Initiate at very low doses (e.g., carvedilol 3.125 mg twice daily) and titrate slowly over weeks to months to avoid symptomatic deterioration. 1 Beta-blockers should be started cautiously in patients with clinical evidence of decompensation. 1

Critical Warning About Beta-Blockers

• Temporary worsening occurs in 20-30% of patients during initiation 1
• Never stop beta-blockers abruptly due to risk of rebound myocardial ischemia and arrhythmias 1
• If worsening congestion develops, double the diuretic dose rather than stopping the beta-blocker 1

Third-Line Therapy: Digoxin

Add digoxin at low doses (0.125-0.25 mg daily, targeting serum levels ≤1.0 ng/mL) for patients who remain symptomatic despite ACE inhibitors and beta-blockers because it:

• Reduces hospitalizations for worsening heart failure 1
• Does not improve survival but helps control symptoms 1
• Is particularly useful for rate control in patients with atrial fibrillation 1

Digoxin is less effective than beta-blockers for rate control during exercise in patients with atrial fibrillation and heart failure. 1

Additional Therapies

Spironolactone

Add spironolactone (12.5-25 mg daily) in patients with severe symptomatic heart failure (NYHA class III-IV) already on ACE inhibitors, as it significantly reduces sudden death risk. 1, 2 Monitor potassium and renal function closely. 1

Diuretics

Use diuretics to relieve congestive symptoms (dyspnea, edema), but they should not be used alone for long-term therapy as they activate neurohormonal systems. 2, 3 Loop diuretics (furosemide, torsemide) are preferred for moderate to severe congestion. 5

Medications to AVOID in Systolic Heart Failure

Do not use the following agents as they worsen outcomes:

• Calcium channel blockers (verapamil, diltiazem) can depress myocardial function and increase heart failure risk 1
• Class I antiarrhythmic drugs increase mortality due to proarrhythmic effects 1, 4
• Phosphodiesterase inhibitors (except for acute decompensation) have shown uniformly negative survival results 4

Treatment Algorithm Summary

1. Start ACE inhibitor at low dose, titrate to maximum tolerated dose over weeks 1, 2
2. Add diuretic if congestion present 1, 2
3. Add beta-blocker once stable on ACE inhibitor, start very low and titrate slowly 1, 2
4. Add digoxin at low dose if still symptomatic or if atrial fibrillation present 1
5. Add spironolactone if severe symptoms persist (NYHA III-IV) 1, 2

Common Pitfalls to Avoid

• Do not use diuretics as monotherapy for chronic management 2
• Do not start beta-blockers during acute decompensation 1
• Do not use high-dose digoxin (keep serum levels ≤1.0 ng/mL) 1
• Do not combine ACE inhibitors with potassium-sparing diuretics without close monitoring of potassium and renal function 1
• Do not use inotropic agents chronically except digoxin, as they may increase mortality 6, 4