What medicines are used to manage heart failure?

You will probably need to take several medicines to manage your heart failure. It is important to know and understand your medicines. It is also very important that you take your medicines as directed by your doctor, nurse or pharmacist so that you get the most benefit from them.

The following is a list of the most common heart failure medicines, how they work and some possible side-effects although not everyone gets side-effects. The medicines listed below are also used in other heart conditions.

The first thing to know is that medicines often have two names: a brand name (which is the commercial name given by the pharmaceutical company that sells the medicine) and a generic name (which is the chemical name of the medicine).

In the examples below, we give the generic name.

Diuretics

Examples: Furosemide, bumetanide, (which are called ‘loop’ diuretics) and metolazone hydrochlorothiazide, bendroflumethiazide (which are called ‘thiazide’ diuretics).

What they do: These are often called ‘water pills’ because they make you pass urine more frequently and stop fluid from collecting in your body. Diuretics work very quickly and can improve symptoms in a few hours or days.

Side-effects: Low blood pressure causing dizziness, gout, rash and muscle cramps. Cramps may be due to changes in your blood chemistry. You will have routine blood tests to check for changes.

Angiotensin converting enzyme (ACE) inhibitors

Examples: Enalapril, lisinopril, captopril, perindopril, ramipril

What they do: ACE inhibitors relax or widen blood vessels, lower blood pressure and make it easier for a damaged heart to work. They may improve your symptoms, reduce the need for hospitalisation and help you live longer.

Side-effects: Dizziness as a result of low blood pressure, dry cough, rash. There may also be changes in kidney function and blood chemistry. These generally do not produce symptoms. You will have routine blood tests to check for changes.

Angiotensin II receptor blockers (ARBs)

Examples: Candesartan, losartan, telmisartan, irbesarten, valsartan

What they do: ARBs are ‘cousins’ of the ACE inhibitors discussed above. ARBs have many of the same actions as ACE inhibitors. They may be an alternative for people who can’t tolerate ACE inhibitors as they are less likely to cause dry cough.

Side-effects: Dizziness due to low blood pressure, rash. There may also be changes in kidney function and blood chemistry. These generally do not produce symptoms. You will have routine blood tests to check for changes.

Beta-blockers

Examples: Carvedilol, metoprolol, bisoprolol, nebivolol

What they do: Beta-blockers slow your heart rate and reduce your blood pressure, both of which are important in managing your heart failure. They may also help to improve heart function and reduce the risk of abnormal heart rhythms. As a result, beta-blockers may improve the quality of your life, reduce the need for hospitalisation, improve your heart function and help you live longer.

Side-effects: Dizziness, slow heartbeat, tiredness, headache, cold hands and feet, diarrhoea, upset stomach.

Aldosterone receptor antagonists

Examples: Eplerenone and spironolactone

What they do: These medicines block the effects of a hormone produced naturally by your adrenal glands which can cause your heart failure to get worse. They help lower blood pressure and fluid retention.

Side-effects: Dizziness as a result of low blood pressure, upset stomach, diarrhoea, headache, tiredness, enlargement of breasts in men. There may also be changes in kidney function and blood chemistry. These generally do not produce symptoms. You will have routine blood tests to check for changes.

Ivabradine

What it does: Ivabradine slows your heart rate and lets your heart work more effectively. It reduces the risk of hospitalisation and may improve your quality of life.

Side-effects: Dizziness, slow or irregular heartbeat, headache, temporary changes to your vision with flashing lights.

Angiotensin-receptor neprilysin inhibitors (ARNIs)

Examples: Sacubitril and valsartan in a single tablet is the only form available at present.

What it does: This is a medicine that combines an ARB (see page 19) with a medicine that stops the breakdown of proteins that protect your body. This approach lowers blood pressure, may improve your quality of life, reduce your risk of hospitalisation, and help you live longer.

Side-effects: Dizziness as a result of low blood pressure and headache. There may also be changes in kidney function and blood chemistry. These generally do not produce symptoms. You will have routine blood tests to check for changes.

Glycosides

Examples: Digoxin

What it does: Digoxin is an old drug which is no longer used much. It increases the strength of heart muscle contractions and helps to slow the heartbeat. It is more likely to be given to patients with a heart rhythm problem such as atrial fibrillation.

Side-effects: Upset stomach and bowel disturbance, visual disturbances.

Vasodilators

Examples: Glyceryl trinitrate/nitroglycerin (patch), isosorbide mononitrate, isosorbide dinitrate, hydralazine.

What they do: Nitrates relax and widen the blood vessels in the body. This reduces the work the heart and makes it less likely that congestion will develop.

Side-effects: Dizziness as a result of low blood pressure, headache and flushing (‘hot flushes’).

The following is a list of medicines that you may be taking for other heart conditions (such as high blood cholesterol, high blood pressure or angina – chest pain).

Statins

Examples: Atorvastatin, rosuvastatin, pravastatin, simvastatin.

What they do: Statins help lower cholesterol levels in the blood which helps prevent heart attacks and stroke.

Side-effects: Liver problems, diarrhoea, upset stomach. Tell your doctor if you get muscle pain or weakness, or joint pain or weakness.

Anticoagulants

Examples: Warfarin, rivaroxaban, dabigatran, apixaban

What they do: Anticoagulants help prevent blood clots. They are sometimes called ‘bloodthinners’ although they don’t actually make the blood thinner. By preventing blood clots, they help to prevent heart attacks and stroke.

Side-effects: Increased risk of bleeding. Tell your doctor if you have a history of bleeding as this may influence the decision to prescribe this medicine for you.

Anti-platelets

Examples: Aspirin, clopidogrel, dipyridamole, prasugrel.

What they do: They prevent the blood clotting cells (platelets) from sticking together. They reduce the chance of a blood clot forming in the blood vessels of the heart and help prevent heart attacks and stroke.

Side-effects: Upset stomach, heartburn, stomach ulcer, bleeding, stroke caused by a burst blood vessel, allergic reaction.

Do these medicines have side-effects?

All medicines can cause side-effects, including those used to manage heart failure. In many cases, these side-effects are mild and only happen when you start taking the medicine or when the dose is increased.

The following section gives the more common side effects of heart failure medicines and some tips on how to manage them. Check with your doctor, nurse or pharmacist if any side-effects continue or worry you, or if you have questions about them.

Dizziness (especially when standing up quickly)

Most heart failure medicines will reduce your blood pressure and may make you feel dizzy especially when you stand up after sitting or lying down.

If you get dizzy, sit or lie down.

Stand up slowly. Take your time and allow your body to adjust.

Your doctor, nurse or pharmacist may advise you to take your medicine before  going to bed rather than earlier in the day to prevent dizziness.

Needing to go to the toilet

Diuretics will make you pass more urine.

Take them at a time of day when you can get to the bathroom easily.

Try not to take diuretics too late at night because the need to go to the toilet will disturb your sleep.

Dry cough

ACE inhibitors may cause a dry, irritable cough, especially when you first start taking them or when the dose is increased. If the cough doesn’t go away or is bothering you, talk to your doctor, who may decide to stop the ACE inhibitor and prescribe a different medicine (an ARB) instead.

Irregular heartbeat

Many people with heart failure have an irregular heartbeat, but some medicines also cause an irregular heartbeat. If you notice that your heartbeat is irregular or slower or faster than usual, talk to your doctor or nurse. They may need to check the potassium level in your blood.

How should I manage my medicines?

It is very important to take your medicines at the right time and in the way your doctor has told you. Never stop taking your heart medicines without talking to your doctor first. If you don’t take your medicine as directed, it may not work or it may cause harmful side-effects.

There are some medicines that you should not take because they may interact with your heart failure medicines or make your heart failure worse. They include medicines you can buy ‘over-the counter’ such as anti-inflammatory pain killers (for example, ibuprofen). Always tell your doctor before you take any over-the counter medicines.

If you miss a dose of any medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the dose you missed and go back to your regular schedule. Do not take a double dose. 

If you have trouble remembering to take your tablets, try the following tips:

Take your medicines at the same time every day (for example, with breakfast).

Use special pill boxes that help you keep track of your medicines, such as the ones divided into sections for each day of the week. Ask your pharmacist about these.

Ask your pharmacist to put medicines into daily or weekly packs (‘blister packs’).

Ask people close to you to remind you.

Keep a ‘medicine calendar’ and make a note every time you take your dose.

Put a sticker or reminder note on your medicine cabinet or fridge.