The Compendium for Drugs That May Cause or Exacerbate Heart Failure

The American Heart Association Scientific Statement “Drugs That May Cause or Exacerbate Heart Failure” by Page et al. is a very useful compendium for all providers taking care of heart failure (HF) patients. Guideline-directed medical therapy in heart failure includes a variety of classes of medications such as angiotensin converting enzyme inhibitors, β-blockers, aldosterone antagonists, and diuretics for congestion.1 With evidence of further clinical benefit with additional therapies to standard heart failure treatment, this list will likely expand. Additionally, most HF patients have comorbidities such as coronary artery disease, diabetes, hypertension, chronic lung disease, anemia, renal disease, depression, and atrial fibrillation,2 which usually require additional medications. Drugs to prevent or treat side effects, such as potassium supplements for diuretics or over-the-counter medications, can further expand polypharmacy in patients with heart failure.3 Furthermore, it should be recognized that approximately 35% of adult Americans including HF patients use an over-the-counter medication, and approximately 38% of adults use complementary and alternative medications such as naturoceuticals, underlining the importance of medication monitoring, reconciliation, and simplification in HF patients.4 Polypharmacy with prescribed or self-acquired medications can result in poor adherence to guideline-directed therapies, drug-drug interactions, adverse effects, and subsequent poor clinical outcomes. Known or emerging therapies with cardiotoxicity, such as certain anti-cancer therapies, should be recognized for risk and close monitoring in high-risk populations. In the last two decades, the proportion of patients with HF with comorbid chronic conditions and the mean number of prescription medications used to treat patients with HF have significantly increased.5 These underline the necessity for appropriate drug use with clear understanding of indications, contraindications, side effects, and toxicity profile in patients with HF. The scientific statement on “Drugs That May Cause or Exacerbate Heart Failure” provides a valuable and useful guide with compilation of such information on medications commonly used in HF patients.

The statement provides an in-depth review of drugs that may cause or exacerbate HF, including certain analgesics, anesthetic agents, antidiabetic medications, antiarrhythmic medications, antihypertensive medications, anti-cancer medications, biologicals, hematologic medication, neurological and psychiatric medications, pulmonary agents, rheumatologic medications, urological medications, over-the-counter medications, and alternative or complementary medications. It provides an overview of each drug class, with specific indications and contraindications for use in HF, specific clinical trial evidence in HF, potential mechanisms for toxicity or side effects, strategies for prevention, and/or treatment of toxicity for each specific drug used in HF patients. Thus, this statement constitutes one of the best compilations of providers’ drug reference for drugs used in patients with HF. It can be used as a reference for management of drug treatment, monitoring and prevention of drug toxicity, side effects in the management of HF patients by cardiologists, primary care or specialty physicians, advanced care specialists, nurses, trainees, pharmacists, or multidisciplinary consultation in outpatient or inpatient settings.

Furthermore, the statement provides specific strategies for minimizing polypharmacy and improving drug safety. Recommendations include comprehensive medication reconciliation at each clinical visit or admission; clarification of drug, dose, frequency of all medications including over-the-counter medications; evaluation of medication complexity; implementation of an updated medication flow-sheet; and discontinuation of medications that do not have an indication or are contraindicated. The authors recommend categorizing of the medications as “essential” to desired outcomes or “optional,” reviewing potential risks and benefits of each medication prior to initiation, and considering combination medications to reduce the number of medications taken daily. Education of patients regarding indications, side effect profile, and toxicity of medications is emphasized with specific attention to over-the-counter medications and complementary and alternative medications. Similar to the ACCF/AHA practice guidelines for management of HF,1 the authors recommend avoiding use of over-the-counter medications and complementary alternative medications or naturoceuticals with uncertain efficacy and safety.

Finally, the statement underlines the necessity of a team management approach with a provider being in charge of the medications. This usually is the HF provider who instructs the patient, family, and other specialists on appropriateness of the medications. It is critical for all providers and the HF team to update and reconcile the medication list that is easily shared with the patient and all team members.

Undoubtedly, this statement will play a major role in the medical management of HF patients and will be a valuable compendium to existing practice guidelines with a special emphasis on how to avoid or manage drugs that may cause or exacerbate HF.