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Medical Author:

Terrence X O'Brien, MD, FACC

Medical Editor:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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• ACE inhibitors and ARBs may cause the body to retain potassium, but this is generally only a problem in people with significant kidney disease, or in people who are also taking a potassium-sparing diuretic, such as triamterene or spironolactone. Potassium levels can be monitored with lab testing.
• Calcium channel blockers (CCBs) are arterial vasodilators that are not used for treatment of heart failure because clinical trials have proven no specific benefit. However, calcium channel blockers are useful for lowering blood pressure. If the cause of the congestive heart failure is high blood pressure and the patient is not responding to ACE inhibitors or ARBs, a CCB may be considered. Some CCBs include diltiazem (Cardizem), verapamil (Calan, Isoptin), nifedipine (Procardia, Adalat), and amlodipine (Norvasc).

Nitrates are venous vasodilators that include isosorbide mononitrate (Imdur) and isosorbide dinitrate (Isordil). They are commonly used in combination with an arterial vasodilator, such as hydralazine (see below).

• Nitroglycerin is a nitrate preparation that is administered to treat acute chest pain, or angina.

Hydralazine (Apresoline) is a smooth muscle arterial vasodilator that may be used for congestive heart failure. Clinical trial data has shown hydralazine plus nitrates to be especially effective in African-Americans with heart failure, when used in addition to ACE inhibitors or ARBs.

• Isosorbide dinitrate and hydralazine (BiDil) is a fixed dose combination of isosorbide dinitrate (20 mg/tablet) and hydralazine (37.5 mg/tablet). This drug is indicated for heart failure in African-Americans based in part on results of the African American Heart Failure Trial (A-HeFT).
• Hydralazine is also especially valuable in patients who have poor kidney function and/or are intolerant to ACE inhibitors and ARBs.

Beta-blockers: These drugs slow down the heart rate, lower blood pressure, and have a direct effect on the heart muscle to lessen the workload of the heart. Specific beta-blockers, such as carvedilol (Coreg) and long-acting metoprolol (Toprol XL), have been shown to decrease symptoms, hospitalization due to congestive heart failure, and deaths. Other beta-blockers include bispropolol (Zebeta), atenolol (Tenormin), propranolol (Inderal), and bystolic (Nebivolol), but they are generally not used with significant congestive heart failure.

• Beta-blockers work in part by blocking the action of norepinephrine on the heart muscle. They prevent norepinephrine from binding to beta-receptors in the heart muscle and arterial walls. Norepinephrine may be toxic to the heart in prolonged, high doses. Clinical trials have proven that beta-blockers gradually improve the systolic function of the left ventricle, thereby improving symptoms and prolonging life.
• The foundation of modern therapy of systolic heart failure is a combination of ACE inhibitors and beta-blockers. If at all possible, every patient should be on both drugs for improvement of left ventricular function and prolongation of life.

Inotropes: IV inotropes are stimulants, such as dobutamine and milrinone, which increase the pumping ability of the heart. These are used as a temporary support of a very weak left ventricle that is not responding to standard congestive heart failure therapy. Commonly used inotropes are dobutamine (Dobutex) and milrinone (Primacor). Phenylephrine (Neo-Synephrine) may be used when a patient is suffering with severe low blood pressure.

These above-mentioned medications can be very effective in treatment of patients with systolic heart failure. There are not many successful therapies proven with clinical trial results available for patients with diastolic heart failure. Patients with diastolic heart failure are often prescribed these medications to treat their underlying conditions, such as hypertension or coronary disease, and as an extrapolation of favorable results, in the treatment of systolic heart failure. Several clinical trials are ongoing.

The medications listed above are very commonly used, but other mediations may be prescribed depending on the underlying cause of the heart failure or medical condition.

Getting the most out of congestive heart failure medications involves the following:

• Keep a diary of daily weight, and bring it to the doctor every follow-up visit.
• Since people with heart failure are often on many drugs, the likelihood of drug interactions increases. The medications taken for other medical problems may affect what drugs are prescribed for heart failure. Because of this, people are advised to always bring a current list of medications and any other supplements or nonprescription drugs with them every time they visit a doctor. Note that many of these medications come in combination pills under different marketing names.
• Take medication as directed by the health care provider. If he or she does not tell the patient how to take their medication or the patient does not understand how to dose the medication, ask the doctor or medical caregiver to explain the medication treatment in detail to the patient.
• Follow the recommendations of the health care provider about diet, exercise, and other lifestyle issues.
• Be informed about the side effects of medications.
• Develop an action plan with the doctor so the patient and their family know what to do promptly if congestive heart failure symptoms worsen.

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