Heart failure (HF) is certainly one of the most common and impactful chronic medical conditions seen by healthcare practitioners, and the authors of the current Scientific Statement from the American Heart Association provide some background on the challenges in HF management.
HF is the most common diagnosis on hospital discharge among US adults at least 65 years old. The annual cost of HF care is $31 billion for Medicare recipients, and most of this cost is from hospital charges.
The complexity of treatment for HF can itself contribute to negative outcomes such as hospitalization. The average number of daily prescription medications for patients with HF is 6.8. These drugs are not used to treat HF alone — 40% of Medicare patients with HF have 5 or more other chronic medical conditions, with osteoarthritis and diabetes 2 of the most common. Moreover, one study found that 88% of patients with HF took over-the-counter medications, and 34.8% took herbal medications.
Given these challenges for patient and clinician alike, it is important to try to limit the use of all medications to those that are truly necessary for the patient. It is also critical to not just prescribe less, but also prescribe intelligently. The current statement describes medications to avoid, if possible, among patients with HF.
- NSAIDs can exacerbate HF by promoting sodium and water retention, higher intravascular resistance, and reduced response to diuretics. Whenever possible, NSAIDs should be avoided among patients with HF.
- Thiazolidinediones can exacerbate existing HF and promote new HF. The risk for HF complications appears to be stronger with rosiglitazone vs pioglitazone.
- The dipeptidyl peptidase-4 (DPP-4) inhibitors are also associated with an increased risk for HF exacerbation, with an odds ratio of 1.19 in one meta-analysis.
- In contrast, metformin has been associated with reduced mortality risk among patients with HF in recent studies. However, metformin still should be avoided among patients with moderate or severe chronic kidney disease.
- Treatment with doxazosin was associated with a 2-fold increase in incident HF compared with treatment with chlorthalidone in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).
- Amlodipine does not reduce mortality risk among patients with HF and may promote HF exacerbation. Diltiazem and verapamil may worsen HF even more than the dihydropyridine calcium channel blockers.
- Anthracyclines are classically cardiotoxic drugs. A retrospective modern analysis suggests that the risk for HF associated with the use of anthracyclines is approximately 5%. The cumulative dose of anthracycline is the most important risk factor for anthracycline-related cardiotoxicity.
- Stimulants have been associated with a risk for sudden cardiac death, although these events appear to be very rare. Stimulants are best avoided among patients with HF.
- Long-term treatment with clozapine was associated with myocarditis among approximately 1% of patients in one study.
- Tricyclic antidepressants may affect cardiovascular health through prolongation of the QT interval, but they are not known to promote structural cardiac damage. Citalopram has also been cited in prolonging the QT interval and should be avoided among patients with decompensated HF.
- Although postmarketing data have implicated tumor necrosis factor-alpha agents in promoting HF, a recent meta-analysis found no association between these agents and incident or worsening HF.
- Regarding complementary and alternative medications, the authors recommend that no such treatment should be used to treat HF or be used for the secondary prevention of cardiovascular events. Products such as ma huang should be expressly avoided.
- HF is the most common diagnosis on hospital discharge among US adults at least 65 years old. The annual cost of HF care is $31 billion for Medicare recipients, and most of this cost is derived from hospital charges. The average number of daily prescription medications for patients with HF is 6.8, and 40% of Medicare patients with HF have 5 or more other chronic medical conditions. Moreover, one study found that 88% of patients with HF took over-the-counter medications, and 34.8% took herbal medications.
- Many drugs can either promote incident HF or worsen existing HF, including NSAIDs, calcium channel blockers, and DPP-4 inhibitors. Metformin should be used with caution among patients with HF, but recent data suggest that it may actually be beneficial for patients with HF and preserved renal function. The risk for cardiac complications associated with selective serotonin reuptake inhibitors, particularly other than citalopram, in patients with HF appears to be minimal.
- Implications for the Healthcare Team: The medication list of patients with HF should be reviewed at every clinic visit to assure adherence to medications that can prevent morbidity and mortality, as well as to exclude extraneous and potentially harmful drugs. This review should include more than 1 person going through a patient’s medication list. It may include multiple team members and/or decision support technology within an electronic health record.
Source of Information: Medscape Pharmacist. LLC.