Patient education: Medicines for heart failure with reduced ejection fraction (The Basics)

What do heart failure medicines do? — If you have heart failure, your doctor will prescribe medicines to:

●Help you feel better and more able to do everyday tasks

●Reduce the symptoms of heart failure, like swelling or trouble breathing

One type of heart failure is called "heart failure with reduced ejection fraction." It is also called "systolic heart failure." If you have this type, medicines can also:

●Help you live longer

●Lower the chances that you will need to go to the hospital

Which medicines might I need? — Below is a list of the most common medicines used to treat heart failure with reduced ejection fraction. Very few people take all of the medicines listed. But if you have this type of heart failure, the list probably includes at least some of the medicines you take.

Many people take at least 3 medicines. That might seem like a lot. But each of these medicines does something different. They all work together to keep you as healthy as possible.

You should know:

●Your medicines or doses might change over time. Work with your doctor to find the combinations and doses of medicine that work best for you. The table has some tips for people who take several different medicines (table 1).

●If your heart failure gets worse, or if your body gets used to medicines, you might need to change your medicines. But if you pay attention to your health and follow all of your doctor's instructions, these changes can help you feel better and keep you out of the hospital.

●Keep a list of all of the medicines you take. Bring this with you each time you visit any doctor. You can find an example of this kind of list at the following website: www.fda.gov/drugs/resources-you-drugs/my-medicine-record.

●If you are having trouble getting your medicines or if they are too expensive, talk to your doctor.

The list below includes some basic information on the main medicines used for heart failure. If you would like more detailed information, including information about the side effects caused by specific medicines, ask your doctor or nurse.

Medicines to treat heart failure — These include the following categories:

●Diuretic (water pill) – When you have heart failure, your body holds on to extra fluid. A diuretic is a medicine that helps the body get rid of extra salt and fluid. It is sometimes called a "water pill." It can reduce your symptoms or keep them from getting worse. For example, a diuretic can help pull fluid out of your lungs, which makes breathing easier.

A diuretic makes you urinate a lot, especially when you first start taking it. This means that the medicine is working. But if the need to urinate a lot makes it hard for you to take the medicine, work with your doctor or nurse to find a good time to take it. Take it at the same time every day, and do not miss any doses. It's very important to take this medicine exactly the way that your doctor or nurse tells you to.

If you are not able to drink normally or are losing a lot of fluid, like if you have diarrhea, ask your doctor if your diuretic dose should change.

Some examples of diuretics include furosemide (brand name: Lasix), torsemide (brand name: Demadex), and bumetanide.

●Blood pressure and hormone blockers – Medicines called ACE inhibitors, ARNIs, and ARBs lower blood pressure and block hormones that control water in your body. This makes it easier for the heart to pump. It also helps prevent your body from holding on to water. These medicines can also help prevent or undo changes in the shape of the heart that can happen because of heart failure.

•Some examples of ACE inhibitors include enalapril, captopril, and lisinopril (brand name: Zestril). Some examples of ARBs include candesartan (brand name: Atacand) and valsartan (brand name: Diovan).

•The ARNI sacubitril-valsartan (brand name: Entresto) has 2 medicines in a single pill. One is the ARB valsartan. The other is called sacubitril, and can help your body retain less fluid and relax blood vessels.

●Beta blocker – A beta blocker slows the heart down and can lower blood pressure. It can help reduce the amount of work that the heart has to do.

When people first start taking a beta blocker, they sometimes feel a little worse than before. That is just while the body gets used to the medicine. But once the body gets used to the beta blocker, the medicine can really help. If your doctor prescribes a beta blocker, give it a little time to start working.

Some examples of beta blockers include carvedilol (brand name: Coreg), metoprolol (brand name: Toprol XL), and bisoprolol.

●Additional hormone blocker – Medicines called "mineralocorticoid receptor antagonists" also protect the heart from hormones that control water in your body. They help the body get rid of extra salt and fluid. But they also help the body hold on to potassium.

When taking this type of medicine, it is very important to have regular blood tests. These are done to check your potassium levels and see how your kidneys are working. Your doctor or nurse should follow the results of these tests closely.

Some examples of mineralocorticoid receptor antagonists include spironolactone (brand name: Aldactone) and eplerenone (brand name: Inspra).

●Medicines for high blood sugar – Medicines that treat high blood sugar, called "SGLT2 inhibitors," can be used to treat heart failure. These can be used even in people without diabetes. Examples are dapagliflozin (brand name: Farxiga) and empagliflozin (brand name: Jardiance).

Other medicines — In addition to the medicines above, many people also need to take other medicines to control their symptoms. These might include:

●Nitrate with hydralazine – A nitrate and hydralazine work together to relax and expand blood vessels. This makes it easier for the heart to pump blood throughout the body. This combination of medicines is sometimes used in people who cannot take an ACE inhibitor, ARNI, or ARB. Unfortunately, the medicines often cause side effects, like headaches and nausea, so doctors usually try other options before suggesting them.

These 2 medicines come in a single pill, but it is possible to get the 2 ingredients separately for much less money. The 2 ingredients come in pills of "isosorbide dinitrate" and "hydralazine."

●Ivabradine – Ivabradine (brand name: Corlanor) is another type of medicine that slows the heart down. Your doctor might prescribe ivabradine if your heart rate is still a little fast with a beta blocker.

●Digoxin – Digoxin helps the heart pump with more force. This can help reduce some of the symptoms of heart failure. People who take this medicine need regular blood tests to prevent problems.

Are there any medicines I should avoid? — Some medicines can "interact" with other medicines. Taking certain medicines can change how your heart medicines work or make them work less well. Your doctor or nurse will talk to you about whether you need to avoid certain prescription or over-the-counter medicines, herbs, or supplements. If you have any questions about whether it is safe to take a medicine, ask your doctor, nurse, or pharmacist.

For more detailed information about your medicines, ask your doctor or nurse for the patient handout from Lexicomp available through UpToDate. It explains how to use each medicine, describes its possible side effects, and lists other medicines or foods that can affect how it works.

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