Which medications should be avoided in patients with symptomatic heart failure?

Medications to Avoid in Heart Failure

In patients with symptomatic heart failure, you must avoid NSAIDs/COX-2 inhibitors, thiazolidinediones (glitazones), and non-dihydropyridine calcium channel blockers (diltiazem and verapamil), as these medications increase the risk of heart failure worsening, hospitalization, and mortality. 1

High-Priority Contraindications

NSAIDs and COX-2 Inhibitors

• NSAIDs are not recommended in heart failure patients because they increase the risk of heart failure worsening and hospitalization (Class III recommendation, Level B evidence). 1
• The mechanism involves fluid retention, blunting of diuretic efficacy, and interference with ACE inhibitors and ARBs. 2
• The FDA label for ibuprofen specifically warns that NSAIDs cause approximately a two-fold increase in hospitalizations for heart failure and should be avoided in patients with severe heart failure. 2
• Even short-term NSAID use carries risk—avoid these medications entirely in symptomatic heart failure patients. 2

Thiazolidinediones (Glitazones)

• Thiazolidinediones are not recommended in heart failure as they increase the risk of heart failure worsening and hospitalization (Class III recommendation, Level A evidence). 1
• The FDA black box warning for pioglitazone explicitly states that thiazolidinediones cause or exacerbate congestive heart failure and are contraindicated in patients with NYHA Class III or IV heart failure. 3
• These agents should be avoided in all patients with symptomatic heart failure, regardless of severity. 1, 3

Non-Dihydropyridine Calcium Channel Blockers

• Diltiazem and verapamil are not recommended in patients with heart failure with reduced ejection fraction (HFrEF) because they increase the risk of heart failure worsening and hospitalization (Class III recommendation, Level C evidence). 1
• Verapamil has negative inotropic effects and should be avoided in patients with severe left ventricular dysfunction (ejection fraction <30%) or moderate-to-severe heart failure symptoms. 4
• The ACC/AHA guidelines specifically state that calcium channel blockers with negative inotropic effects should not be used in patients with EF <40% after myocardial infarction. 1

Additional Medications to Avoid or Use with Extreme Caution

Most Antiarrhythmic Drugs

• The ACC/AHA guidelines recommend that most antiarrhythmic drugs should be avoided or withdrawn in patients with symptomatic heart failure and reduced LVEF, as they adversely affect clinical status. 1
• The exception is that antiarrhythmics may be necessary for life-threatening ventricular arrhythmias, but this requires careful risk-benefit assessment. 1

Triple RAAS Blockade

• Do not combine an ARB with both an ACE inhibitor and an MRA (triple RAAS blockade), as this markedly increases the risk of renal dysfunction and hyperkalemia (Class III recommendation, Level C evidence). 1, 5

Inotropic Agents in Acute Heart Failure

• Inotropic agents are not recommended in acute heart failure unless the patient is symptomatically hypotensive or hypoperfused, due to safety concerns (Class III recommendation, Level A evidence). 1

Common Pitfalls to Avoid

• Do not assume that "low-dose" NSAIDs are safe—even short-term use increases heart failure risk, and there is no safe dose in symptomatic patients. 2
• Do not continue thiazolidinediones for diabetes management in heart failure patients; SGLT2 inhibitors are preferred as they actually reduce heart failure hospitalization. 1, 5
• Do not use verapamil or diltiazem for rate control in atrial fibrillation if the patient has HFrEF; beta-blockers or digoxin are safer alternatives. 1, 4
• Avoid prescribing NSAIDs for musculoskeletal pain—use acetaminophen or topical agents instead in heart failure patients. 6

Medications That Are Safe Despite Common Concerns

• Metformin can be used safely in stable heart failure as long as kidney function remains adequate (eGFR ≥30 mL/min/1.73m²). 1
• DPP-4 inhibitors (except saxagliptin, which showed increased heart failure hospitalization in SAVOR-TIMI 53) appear safe, though they provide no cardiovascular benefit. 1
• GLP-1 receptor agonists have not shown increased heart failure hospitalization risk and may reduce cardiovascular events. 1