Drugs for Heart Failure (HF) Simplified Overview
Key Classes of Drugs for Heart Failure
1. Symptom Relief: 2. Long-term Management and Improved Survival:
• Diuretics: Remove excess fluid to relieve swelling and shortness of breath.
• Nitrates: Improve blood flow and reduce chest discomfort.
• Digoxin: Helps control symptoms and slows heart rate, especially in atrial fibrillation.
2. Long-term Management and Improved Survival:
• ACE Inhibitors: Lower blood pressure, improve heart function, and reduce mortality.
• Beta-Blockers: Protect the heart by reducing its workload and improving survival.
• Aldosterone Antagonists: Reduce fluid buildup and improve outcomes in severe HF.
• ARNIs (Angiotensin Receptor-Neprilysin Inhibitors): Combine ARBs with neprilysin inhibitors to improve heart function and reduce hospitalizations.
• SGLT2 Inhibitors: Originally for diabetes, now proven to benefit HF patients.
• Sinus Node Inhibitors: Slow heart rate without affecting contraction strength.
Drug Choices Based on Heart Failure Type
1. Heart Failure with Reduced Ejection Fraction (HFrEF):
• Foundational Therapy:
• Beta-Blockers
• ARNI or ACE Inhibitors (or ARBs if not tolerated)
• Aldosterone Antagonists
• SGLT2 Inhibitors (e.g., empagliflozin, dapagliflozin)
• Additional Options: Sinus node inhibitors (e.g., ivabradine) if heart rate remains high despite therapy.
2. Heart Failure with Preserved Ejection Fraction (HFpEF):
• Focus on managing symptoms and associated conditions (e.g., hypertension,
diabetes).
• Common medications include ACE inhibitors, ARBs, and SGLT2 inhibitors (e.g., empagliflozin, which reduces hospitalizations and mortality).
• Beta-blockers are used cautiously, mainly for controlling heart rate or angina.
3. Heart Failure with Mildly Reduced Ejection Fraction (HFmrEF):
• Similar approach to HFrEF, with potential benefits from ARNIs and SGLT2 inhibitors.
Key Drugs and Their Roles
- ACE Inhibitors (e.g., Enalapril, Lisinopril)
• Benefits: Reduce mortality, improve heart function, delay nephropathy in diabetics.
• Side Effects: Cough, hyperkalemia, and rare but serious angioedema.
Beta-Blockers (e.g., Carvedilol, Metoprolol Succinate)
• Benefits: Improve survival and reduce symptoms in HFrEF.
• Use in HFpEF: Limited but helpful for atrial fibrillation or angina.
• Caution: Start low and increase slowly to avoid initial worsening of symptoms.
ARNIs (e.g., Sacubitril/Valsartan)
• Benefits: Superior to ACE inhibitors in reducing hospitalizations and mortality in HFrEF.
• Caution: Avoid combining with ACE inhibitors to prevent angioedema.
SGLT2 Inhibitors (e.g., Empagliflozin, Dapagliflozin)
• Benefits: Reduce hospitalization and mortality in HFrEF and HFpEF, regardless of diabetes status.
• Side Effects: Genital infections and mild, temporary drops in kidney function.
Aldosterone Antagonists (e.g., Spironolactone, Eplerenone)
• Benefits: Reduce mortality and hospitalizations in severe HFrEF.
• Caution: Monitor for hyperkalemia, especially with ACE inhibitors or ARBs.
Diuretics (e.g., Furosemide, Torsemide)
• Use: Symptom relief for fluid overload.
• Caution: Overuse can cause dehydration, kidney issues, and electrolyte imbalances.
Digoxin
• Use: Improves symptoms in HFrEF, particularly in atrial fibrillation.
• Caution: Narrow therapeutic window; toxicity risks require close monitoring.
Sinus Node Inhibitors (e.g., Ivabradine)
• Use: For HFrEF patients with high heart rates despite beta-blockers.
Patient Considerations
• Adherence to prescribed medications is crucial for improved outcomes.
• Monitor for side effects such as electrolyte imbalances, kidney issues, or low blood pressure.
• Always consult a doctor before stopping or adjusting medications.
References
1. McMurray JJ, Solomon SD, Inzucchi SE, et al: Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 381(21):1995–2008, 2019. doi: 10.1056/NEJMoa1911303.
2. Anker SD, Butler J, Filippatos G, et al: Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med 385(16):1451–1461, 2021. doi: 10.1056/NEJMoa2107038.
3. Pitt B, Pfeffer MA, Assmann SF, et al: Spironolactone for heart failure with preserved ejection fraction. N Engl J Med 370:1383–1392, 2014. doi: 10.1056/NEJMoa1313731.
