Drugs that should be avoided or used with caution in patients with heart failure
- Wilson S Colucci, MD
Wilson S Colucci, MD
- Section Editor — Heart Failure
- Professor of Medicine
- Boston University School of Medicine
A number of medications that are in common clinical use are relatively or absolutely contraindicated in patients with heart failure (HF), either because they can cause exacerbations of HF or because there is a higher risk of adverse reactions in such patients (table 1) . Drug-induced exacerbation or decompensation of established HF is a relatively common occurrence. Its prevention requires frequent reassessment and meticulous management of often complex medication regimens.
Utilization of these drugs is common in patients with HF. In a study from Denmark, 34 percent of patients received at least one nonsteroid antiinflammatory agent or cyclooxygenase-2 inhibitor after discharge for first hospitalization for HF . Use of some of these drugs may be increasing. As an example, a review of Medicare beneficiaries hospitalized with the diagnoses of HF and diabetes mellitus found that the proportion using metformin and/or a thiazolidinedione increased from 13.5 percent in 1998 to 1999 to 24.4 percent in 2000 to 2001 .
Management of patients with HF is discussed separately. (See "Overview of the therapy of heart failure with reduced ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
General principles for avoiding drug-induced worsening of heart failure (HF) include the following:
●Recognition of the basic mechanisms by which drugs can exacerbate heart failure including:
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- GENERAL PRINCIPLES
- Nonsteroidal antiinflammatory drugs
- - COX-2 selective inhibitors
- - Aspirin
- Calcium channel blockers
- Potassium supplements and other drugs associated with hyperkalemia
- Oral hypoglycemic agents
- - Thiazolidinediones
- - Metformin
- Phosphodiesterase inhibitors
- - PDE-3 inhibitors
- - PDE-4 inhibitor
- - PDE-5 inhibitors
- Antiarrhythmic agents
- Chemotherapy agents
- Sodium-containing preparations
- TNF-alpha inhibitors
- "Natural" remedies and supplements
- SUMMARY AND RECOMMENDATIONS