Most people with heart failure are treated with medicines. Depending on your symptoms, you may need to take several medicines. The usual combination of medicines for people with heart failure and heart failure due to left ventricular systolic dysfunction (LVSD) includes:
- a diuretic
- an angiotensin-converting enzyme (ACE) inhibitor
- a beta-blocker
- an aldosterone antagonist
Many patients with heart failure with preserved ejection fraction (HFPEF) will require similar treatment.
Your doctor will discuss the available treatments with you. Most medicines are started at low doses which are gradually increased over a period of weeks or months. Increasing the dose too quickly may cause side effects. Failing to increase the dose to effective levels may result in you not getting the full benefits of treatment.
Ask your doctor if you are not sure whether you are on the best dose for you. The first medicine you try may not work properly or suit you, so changes may be needed until you and your GP find a combination that works for you.
You may also be offered other medicines if you have another condition or other symptoms that also need treatment.
Diuretics (water pills) make you pass more urine and help relieve ankle swelling and breathlessness caused by heart failure.
There are many different types of diuretic, but some of the most widely used for heart failure are bumetanide and furosemide (also called frusemide). In some mild cases, a diuretic called bendroflumethiazide may be used.
A diuretic called metolazone may be used together with bumetanide or furosemide in people with severe fluid retention.
Angiotensin-converting enzyme (ACE) inhibitors work by dilating your blood vessels (opening them up), which makes the blood flow more easily and reduces blood pressure. This makes it easier for your heart to pump blood around the body.
ACE inhibitors often have a positive impact on the heart's performance, and may improve your quality of life. They reduce the risk of hospitalisation and prolong life.
Examples of ACE inhibitors include ramipril, captopril, enalapril, lisinopril and perindopril.
The most common side effect is a dry, irritating cough. If you have a troublesome cough, an ACE inhibitor may be switched to an ARB (see below).
ACE inhibitors can also cause your blood pressure to fall too low and they may upset kidney function. Your GP will monitor this.
Beta-blockers are usually used to treat people with heart failure due to systolic dysfunction (where the left ventricle that pumps blood around the body doesn't work properly).
They reduce the risk of hospitalisation and prolong life in patients with a low LVEF.
However, beta-blockers may not be suitable for people with asthma, although most patients with chronic obstructive pulmonary disease (COPD) will be able to tolerate them.
Beta-blockers work by slowing your heart down and protecting your heart from the effects of chemicals produced by the body called adrenaline and noradrenaline.
Your doctor may start you on a low dose and increase it over a few weeks or months. There are several different beta-blockers, but the ones used to treat heart failure in the UK are bisoprolol, carvedilol and nebivolol.
As long as the heart is in a normal rhythm (sinus), ivabradine will slow the heart rate. It can be a useful alternative for some people when beta-blockers cannot be used or are not tolerated.
If beta-blockers do not slow the heart enough, the addition of ivabradine can provide added protection leading to improved heart function and symptoms, reduce the risk of hospitalisation and prolong life in people with a low LVEF.
Aldosterone antagonists are suitable for some people with heart failure. They work in a similar way to diuretics, but they can stop the diuretics from washing out potassium and may also help reduce scarring of the heart muscle. They improve symptoms, reduce the risk of hospitalisation, and prolong life in people with a low LVEF.
The most widely used aldosterone antagonists are spironolactone and eplerenone. Spironolactone may cause swelling and pain around the nipples in men and testicular atrophy (shrinking of the testicles). Eplerenone rarely causes such effects.
The most serious side effect of these medicines is that they can cause the level of potassium in your blood to go too high, which can cause problems. Your doctor will carry out regular blood tests to monitor your potassium level.
Angiotensin receptor blockers (ARBs)
Angiotensin receptor blockers (ARBs) work in a similar way to ACE inhibitors by widening blood vessels and reducing blood pressure. They tend to be used as an alternative because they do not usually cause a cough.
Examples of ARBs include candesartan, losartan, telmisartan and valsartan. Side effects include low blood pressure (hypotension) and high levels of potassium in your blood. Your doctor will carry out regular blood tests to monitor your potassium level.
Although ARBs do not cause coughs, they may not be quite as effective as ACE inhibitors.
Hydralazine with nitrate
When hydralazine is combined with nitrate, the blood vessels dilate (open up). These medicines are sometimes prescribed by heart specialists for people who are unable to take an ACE inhibitor or ARB.
Digoxin, derived from the foxglove plant, can increase the strength of your heart muscle contractions and slow down your heart rate. It can improve symptoms and reduce hospitalisation, however, it does not appear to prolong life.
It is recommended for people who have symptoms despite treatment with ACE inhibitors, ARBs, beta-blockers and diuretics. It is used earlier in people who have both heart failure and a condition called atrial fibrillation (where the heart beats irregularly).
Anticoagulants make it more difficult for your blood to clot, helping to prevent a stroke.
Warfarin is the most commonly used anticoagulant, and requires careful monitoring by your GP or doctor to make sure you get the right amount.
Platelets are cell fragments that are part of the clotting system. Aspirin and clopidogrel reduce the stickiness of blood platelets which may reduce the risk of a heart attack or stroke. Aspirin is not usually taken with warfarin. Speak with your GP if you are concerned.