Can a patient with a history of cardiac stents and heart failure take pregabalin (lyrica)?

Can a Patient with Cardiac Stents and Heart Failure Take Pregabalin?

Yes, pregabalin can be used in patients with cardiac stents and heart failure, but requires careful monitoring and dose adjustment, particularly in those with NYHA Class III-IV heart failure where caution is specifically warranted. 1

FDA Guidance on Pregabalin Use in Heart Failure

The FDA label for pregabalin provides specific warnings about cardiovascular considerations:

• Exercise caution when using pregabalin in patients with NYHA Class III or IV cardiac status due to limited data in this population 1
• Pregabalin can cause peripheral edema (6% vs 2% placebo) and weight gain, which may exacerbate or lead to heart failure 1
• The combination of pregabalin with thiazolidinedione antidiabetic agents significantly increases risk of edema (19%) and weight gain (7.5%) compared to either drug alone 1
• In short-term trials of patients without clinically significant heart or peripheral vascular disease, peripheral edema was not associated with cardiovascular complications such as hypertension or congestive heart failure 1

Evidence from Clinical Studies

Reassuring Data

The highest quality recent evidence suggests pregabalin does not increase heart failure risk:

• A 2020 nationwide Danish cohort study (the most recent and rigorous study) found no evidence of increased worsening heart failure with pregabalin compared to gabapentin (HR 0.79,95% CI 0.50-1.23) or duloxetine (HR 1.08,95% CI 0.60-1.94) 2
• This propensity-score matched study included 1,395 heart failure patients aged ≥50 years and followed them for 90 days 2

Concerning Data

However, case reports and systematic reviews raise caution:

• Case reports describe heart failure decompensation in patients with NYHA Class I heart failure after pregabalin initiation, with resolution upon discontinuation 3
• A 2011 case report documented peripheral and central edema development in a patient without cardiac history on 300 mg/day pregabalin 4
• A 2025 systematic review found gabapentinoids associated with increased thrombotic events (DVT, pulmonary embolism) as early as 3 months of use 5

Practical Management Algorithm

For Patients with Cardiac Stents (Without Heart Failure)

• Pregabalin can be used with standard monitoring 1
• Monitor for peripheral edema and weight gain at each visit 1
• Ensure dual antiplatelet therapy (aspirin plus clopidogrel/prasugrel/ticagrelor) is maintained per stent type and timing 6

For Patients with Heart Failure (NYHA Class I-II)

• Pregabalin can be initiated with close monitoring 1, 2
• Start with low doses (50 mg three times daily or 75 mg twice daily) 6
• Monitor specifically for:
  • Daily weights (report gain >2-3 lbs in 24 hours or >5 lbs in one week) 6
  • New or worsening peripheral edema 1
  • Dyspnea or orthopnea 6
  • Blood pressure changes 1
• Ensure guideline-directed medical therapy is optimized (ACE inhibitors/ARBs, beta-blockers, diuretics, aldosterone antagonists) before adding pregabalin 6, 7

For Patients with Advanced Heart Failure (NYHA Class III-IV)

• Use pregabalin with extreme caution due to limited safety data 1
• Consider alternative analgesics first (duloxetine for neuropathic pain, topical lidocaine) 6
• If pregabalin is necessary:
  • Start at the lowest possible dose (50 mg once or twice daily) 6
  • Increase diuretic monitoring frequency 6
  • Weekly weight checks and symptom assessment for first month 6
  • Have a low threshold for discontinuation if any signs of decompensation 3

Critical Monitoring Parameters

Monitor the following at baseline and regularly during treatment:

• Body weight (weekly initially, then monthly) 1
• Peripheral edema assessment (ankle/leg swelling) 1
• Volume status (jugular venous pressure, lung examination) 6
• Renal function (creatinine clearance affects pregabalin dosing) 6, 1
• Blood pressure (pregabalin can affect BP in some patients) 1

Common Pitfalls to Avoid

• Do not combine pregabalin with thiazolidinediones (pioglitazone, rosiglitazone) in diabetic patients with heart failure, as this dramatically increases edema risk 1
• Do not abruptly discontinue pregabalin if heart failure worsens; taper over minimum 1 week to avoid withdrawal symptoms 1
• Do not ignore early weight gain (>7% baseline weight occurred in 9% of patients); this may precede clinical heart failure 1
• Do not assume peripheral edema is benign; in heart failure patients, this may signal early decompensation requiring diuretic adjustment 6, 3

Drug Interactions Relevant to Cardiac Patients

• Pregabalin has minimal drug interactions and does not affect antiplatelet agents, anticoagulants, ACE inhibitors, beta-blockers, or other cardiac medications 6
• Dose reduction required for renal insufficiency (common in heart failure patients): adjust based on creatinine clearance 6, 1

Bottom Line for Clinical Practice

Pregabalin is not contraindicated in patients with cardiac stents and heart failure, but requires individualized risk assessment based on heart failure severity. 1, 2 The 2020 Danish study provides the strongest evidence that pregabalin does not increase heart failure hospitalization risk compared to alternatives 2, but the FDA warning about NYHA Class III-IV patients and case reports of decompensation mandate vigilant monitoring 1, 3. Start low, titrate slowly, monitor weight and edema closely, and maintain a low threshold for discontinuation if signs of volume overload develop. 1, 3