Medications to Avoid in Heart Failure

As seen in Consultant Connection June/ July 2012 Issue
Elise Weyrauch, PharmD Candidate

Heart failure is a significant disease state in the elderly population. The main goal in this patient population is to prevent acute exacerbations. These patients are more sensitive to changes in fl uid status and sodium retention than other patients. Therefore, as caregivers, it is important for these to be monitored and possibly restricted in our patients as well as avoiding treatments that further hinder the ability of the heart to pump blood effectively. An important way to prevent an exacerbation of heart failure is to avoid medications that can have these types of effects in our patients. The following medications are of concern in heart failure patients for a variety of reasons.

Nonsteroidal anti-infl ammatory drugs (NSAIDs) as a class have been shown to increase the likelihood of a patient to be readmitted to the hospital due to an exacerbation of heart failure. The main way that NSAIDs worsen this condition is by causing vasoconstriction. This increases the afterload, meaning the heart has to work harder to push the blood throughout the body. Increasing the stress on the heart further damages its ability to perfuse the body. In addition, the vasoconstriction counteracts the positive benefi ts of angiotensin converting enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs). ACEs and ARBs have been shown to decrease morbidity and mortality in heart failure patients.

Actos (pioglitazone) is part of the class of medication called thiazolidinediones. This class of medication has effects on the kidney that cause an increase in sodium reabsorption in the kidney which leads to sodium retention. The increase in sodium levels causes the body to hold on to fl uids, resulting in edema. This can lead to an exacerbation of heart failure since the heart cannot handle the extra fl uid. There has been shown to be an increased risk of hospitalization and death in heart failure patients when this drug is added. Actos should be avoided in most heart failure patients especially the more severe cases.

These two calcium channel blockers, diltiazem and verapamil, have the ability to decrease the contracting force of the heart, which sounds like it would be benefi cial in heart failure patients. However, in typical heart failure patients that have decreased ejection fraction, these drugs can actually activate damaging systems in the body. Due to the increased damage done to the heart, studies have shown that these two medications can increase risk for deterioration in the patient's status.

Hence, they are not recommended for use in most heart failure patients. Pletal (cilostazol) is used to treat intermittent claudication. Due to the way this drug works, it increases the patient's heart rate and can affect the heart rhythm. Other drugs in this same class have been shown to increase mortality due to these effects. Therefore, cilostazol is contraindicated for use in patients with heart failure.

Megace (megestrol) is often used to help increase weight in our patient population. This medication has the potential to cause increase in fl uid retention, which could lead to an exacerbation of heart failure in our patients. This is something to watch out for if this medication was recently added. Daily weights and evaluation of edema can help to catch an acute situation earlier.

As shown above, medications have the potential to worsen heart failure through various mechanisms, and this is just a sample of the large list of concerning medications. It is important that we are vigilant with this patient population to prevent increased morbidity and mortality.

References:
Amabile CM, Spencer AP. Keeping your patient with heart failure safe: a review of potentially dangerous medications. Arch Intern Med. 2004 Apr 12;164(7):709-20. Megace [package insert]. Bristol-Myers Squibb Company. Princeton, NJ. July 2002.

Available from: http://patient.cancerconsultants. com/druginserts/Megestrol_acetate.pdf.


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