What cough medication can be given to a patient with heart failure?

Safe Cough Medications for Heart Failure Patients

Guaifenesin (an expectorant) is the safest first-line cough medication for patients with heart failure, as it does not affect cardiovascular function. 1

Initial Assessment Before Treatment

Before prescribing any cough medication, you must rule out pulmonary edema as the underlying cause, especially if the cough is new or worsening. 1 Cough in heart failure patients commonly stems from:

• The heart failure itself or pulmonary congestion 1
• ACE inhibitor therapy (a common but usually tolerable side effect) 1
• Comorbid conditions such as smoking-related lung disease 1

Recommended Safe Options

First-Line Therapy

• Guaifenesin is recommended by the American College of Cardiology as it has no cardiovascular effects 1
• Saline nasal sprays can address post-nasal drip without systemic absorption 1
• Dextromethorphan may be used as a cough suppressant, though it is not specifically mentioned in heart failure guidelines 2

Starting Approach

• Begin with the lowest effective dose of any respiratory medication to minimize potential cardiovascular effects 1
• Optimize heart failure medications before adding respiratory treatments 1

Medications to Strictly Avoid

Opioid Cough Suppressants

Opioid-containing cough medications are associated with higher rates of mechanical ventilation, ICU admission, and mortality in heart failure patients and should be avoided. 1

Sympathomimetic Decongestants

• These agents (pseudoephedrine, phenylephrine) increase blood pressure and heart rate, potentially worsening heart failure 1
• They cause sodium and water retention, similar to NSAIDs 3, 4

NSAIDs in Combination Products

• Many over-the-counter cough/cold preparations contain NSAIDs 4
• NSAIDs cause sodium and water retention, impair renal function, and blunt the effects of diuretics, ACE inhibitors, and ARBs 4
• The American Heart Association recommends NSAIDs should be avoided or withdrawn in patients with current or prior heart failure symptoms 4

Managing ACE Inhibitor-Induced Cough

If the cough is determined to be from ACE inhibitor therapy:

• ACE inhibitor-induced cough rarely requires discontinuation 1
• When the cough is troublesome and proven to be ACE inhibitor-related, substitute with an angiotensin receptor blocker (ARB), which has significantly fewer cough side effects 1
• Do not simply add cough suppressants while continuing the ACE inhibitor if the cough is intolerable 1

Special Considerations for Inhaled Medications

If bronchodilators become necessary for concurrent respiratory conditions:

• Use spacer devices with metered-dose inhalers to optimize drug delivery while minimizing systemic absorption 1
• Avoid concurrent use of non-dihydropyridine calcium channel blockers (diltiazem, verapamil) with respiratory medications, as these are contraindicated in heart failure due to negative inotropic effects 3, 4

Common Pitfalls to Avoid

• Do not prescribe combination cough/cold products without carefully reviewing all active ingredients for contraindicated agents 1, 4
• Do not assume all over-the-counter medications are safe in heart failure patients 1, 4
• Do not treat cough symptomatically without first evaluating for worsening heart failure or pulmonary edema 1