Why do I need to take special medication precautions if I have heart failure?
Some kinds of medications, including those used to treat heart and blood vessel disease, can actually make your heart failure symptoms worse or interfere with important parts of your heart failure treatment. These include common pain-relieving drugs ( aspirin, Advil, Aleve, and others) that many women would not think twice about taking for minor pain or headaches.
Some drugs should be avoided in all patients with heart failure, while others may be helpful in certain patients when their use is strictly monitored by your doctor.
The following advice is valid for everyone, but is especially important for patients with heart failure. Women with heart failure are often treated with a combination of several types of drugs to maintain the heart's pumping ability and minimize symptoms. The more drugs you are taking, the higher the risk of a harmful drug-drug interaction. Working with your doctor to make sure you know what medications you are taking, what they do, and what precautions you should take will help you avoid unpleasant or even dangerous side effects.
Before starting a new medication, be sure to discuss with your doctor any other medications you are taking (even if you do not take them every day), including:
- Over-the-counter medications (including pain relievers or cold medicines)
- Prescription medications for other conditions
- Herbal or other dietary supplements (including vitamins)
Ask your doctor if there are any special instructions when starting a new medication (for example, specific dietary changes), and carefully follow them. Stick to your dosing schedule as closely as possible. Be sure you know what side effects to watch for, and talk to your doctor about any side effects you experience. Changing the dose or type of medication you are on may allow to you continue to benefit from the treatment while reducing or eliminating unpleasant side effects.
If you are unsure if an over-the-counter medicine is safe for you, discuss it with your doctor or pharmacist.
What medications should I avoid if I have heart failure?
Below is a list of medications that should generally be avoided in women with heart failure. Don't start taking any new medications without discussing them with your heart failure doctor. If you are taking any of these medications because a doctor prescribed it, ask your heart failure doctor if it is safe to continue using (never stop taking any medication without talking to your doctor first).
Non-steroidal anti-inflammatory drugs (NSAIDS): Drugs that relieve pain, fever, and inflammation.
- Ibuprofen (Advil, Motrin)
- Naproxen (Aleve, Naprosyn)
- Aspirin (unless your doctor has prescribed a low-dose aspirin regimen; see here for more)
- COX-2 inhibitors such as the arthritis drug celecoxib (Celebrex)
- Why: These drugs can cause your body to retain salt and water and cause the arteries in your legs and arms to constrict, worsening fluid buildup and swelling. They can also interfere with other heart failure medications such as diuretics and ACE inhibitors. Taking NSAIDS is a common cause of hospitalization for heart failure.1
- Alternatives: For relief of aches, pains, or fever, take acetaminophen (Tylenol, Panadol).
Most antiarrhythmic (heart rhythm) drugs
- Class I (sodium channel blockers) and some class III (potassium channel blockers) antiarrhythmic drugs should be avoided in women with heart failure.
- Exceptions: amiodarone and dofeditilide (Tikosyn) are the only two available heart rhythm drugs that have been shown not to lower the odds of survival in women with heart failure.2
- Why: Antiarrythmic drugs can slow the heart rate, worsening heart failure symptoms, and can even make heart rhythm problems more likely.
- Alternatives: There are a few kinds of heart rhythm drugs (see Exceptions above) that can be used in women with heart failure if necessary. For women with potentially dangerous heart rhythm problems, implantation of an ICD or pacemaker may also be an option.
Most Calcium Channel Blockers: To treat high blood pressure, chest pain, and sometimes for short-term control of heart rhythm problems.
- Why: Calcium channel blockers decrease the strength of the heart muscle's contractions and lower the heart rate: this can help lower blood pressure, but also can dangerously lower the heart's pumping ability. Their use can lead to worsening heart failure and increased risk of heart attack in women with past or present symptoms of heart failure.3
- Alternatives: Other drugs available to treat high blood pressure are cornerstones of heart failure treatment, including ACE inhibitors and diuretics. A few specific calcium channel blockers have been shown not to decrease survival: amlodipine (Norvasc) and felodipine (Plendil).4,5
Antacids that contain sodium (salt): To relieve heartburn or indigestion.
- Why: Just like eating salty foods, sodium from medications can cause your body to retain fluid, making swelling and shortness of breath worse and raising blood pressure.
- Alternatives: Some companies produce low-sodium antacids. Look at the ingredients list and warning statements to see if sodium is listed (companies are required to put it on the label if there are 5 mg or more of sodium per dose). If you are not sure, ask your doctor or pharmacist.
Other Drugs to Avoid
- Decongestants containing pseudoephedrine (such as Sudafed), which can raise blood pressure and force the heart to work harder
- Alcohol and illicit drugs; they are a common cause of hospitalization for heart failure
- Some nutritional supplements and growth hormone therapies (talk to your doctor about any you are considering taking)
Women with heart failure are at increased risk of developing blood clots because, as the heart's pumping ability gets worse, blood is allowed to sit still for longer inside the heart and in the blood vessels in the legs and arms. They may be prescribed blood-thinning medications such as clopidogrel, warfarin, or aspirin to prevent blood clots from forming.
Women who have already had a heart attack or stroke, or who have had a procedure such as angioplasty or bypass surgery, should take daily aspirin to prevent future heart problems and heart damage that could lead to heart failure. The use of aspirin in other patients, including those who have heart failure, remains controversial.
In an ACE inhibitor study which raised concern that women with heart failure were more likely than men to suffer strokes and blood clots, the use of a blood thinner like aspirin reduced the chances of these complications.6 On the other hand, there are concerns that taking aspirin may blunt the benefits of ACE inhibitors, one of the first-choice heart failure medications, when the two medications are taken together. Other studies indicate that ACE inhibitors are equally beneficial whether or not a person is taking aspirin.7,8 Studies are currently underway to determine the best course of treatment for women with heart failure but no other major risk factors for blood clots. For now, this is a decision that needs to be made after carefully considering your personal risks and benefits with your doctor.1
Because of the potential risks, a woman with heart failure should not take aspirin unless she has been advised by her doctor to start a daily low-dose aspirin regimen. Instead, take acetaminophen (Tylenol) for occasional aches and pains.
- Hunt SA, Abraham WT, Chin MH, et al. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol. Apr 14 2009;53(15):e1-e90.
- Torp-Pedersen C, Moller M, Bloch-Thomsen PE, et al. Dofetilide in Patients with Congestive Heart Failure and Left Ventricular Dysfunction. N Engl J Med. September 16, 1999 1999;341(12):857-865.
- Packer M, Kessler PD, Lee WH. Calcium-channel blockade in the management of severe chronic congestive heart failure: a bridge too far. Circulation. Jun 1987;75(6 Pt 2):V56-64.
- Reed SD, Friedman JY, Velazquez EJ, Gnanasakthy A, Califf RM, Schulman KA. Multinational economic evaluation of valsartan in patients with chronic heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT). Am Heart J. Jul 2004;148(1):122-128.
- Elkayam U. Calcium channel blockers in heart failure. Cardiology. 1998;89 Suppl 1:38-46.
- Dries D, Rosenberg Y, Waclawiw M, Domanski M. Ejection fraction and risk of thromboembolic events in patients with systolic dysfunction and sinus rhythm: evidence for gender differences in the studies of left ventricular dysfunction trials. J Am Coll Cardiol. April 1, 1997 1997;29(5):1074-1080.
- Teo KK, Yusuf S, Pfeffer M, et al. Effects of long-term treatment with angiotensin-converting- enzyme inhibitors in the presence or absence of aspirin: a systematic review. Lancet. Oct 5 2002;360(9339):1037-1043.
- Harjai KJ, Solis S, Prasad A, Loupe J. Use of aspirin in conjunction with angiotensin-converting enzyme inhibitors does not worsen long-term survival in heart failure. Int J Cardiol. Apr 2003;88(2-3):207-214.