Features October 2016 Issue

Congestive Heart Failure: Common Medications Raise the Risk

Many drugs can cause congestive heart failure or make it worse. Some are prescription drugs, while others are over-the-counter medications.

The American Heart Association recently issued a list of medications that may cause heart failure or worsen it. These include drugs for serious diseases, such as cancer and Parkinson’s. The list also includes common over-the-counter medications, with nonsteroidal anti-inflammatory drugs (NSAIDS), antacids and decongestants being most worrisome.

“There are hundreds of drugs that directly or indirectly affect the heart. However, the magnitude of potential effects and the level of evidence supporting the risk vary greatly,” says Cleveland Clinic heart failure specialist David Taylor, MD.

How Drugs Can Harm Your Heart

Drugs can cause heart failure, worsen it or make it harder to treat by:

heart failure diagram

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In heart failure, the extra work done by the heart can cause the left ventricle to enlarge and weaken.

- Being toxic to cells in the heart
- Preventing the heart from beating as strongly as it should or relaxing between beats
- Slowing the heart rate
- Worsening hypertension
- Delivering a high sodium load
- Preventing your heart failure medications from working as well as they should

Drugs that can directly harm the heart include anthracyclines used to treat breast cancer and TNF-a inhibitors used to treat rheumatologic diseases. Doctors are aware of these and do everything they can to modify the risk of developing heart failure. Nevertheless, it can happen.

“We will try to ameliorate the damage by paying close attention to your heart failure or altering your heart failure medications to compensate,” says Dr. Taylor.

Indirect Ways Drugs Hurt Your Heart

Over-the-counter (OTC) drugs aren’t necessarily harmless, either. Diet pills, decongestants and bodybuilding drugs can contain amphetamines and epinephrine—stimulants known to cause heart failure. Sodium bicarbonate-based antacids can cause sodium and water retention, aggravating heart failure symptoms.

Use of NSAIDs is a red flag. “We recommend patients with heart failure avoid NSAIDs and take acetaminophen for pain,” says Brad Williams, PharmD, a Cleveland Clinic heart failure and heart transplant pharmacist.

Drugs that Cause or Exacerbate Heart Failure

Arryhthmia dronedarone, flecainide, disopyramide, sotalol
Cancer anthracyclines and many other agents
Depression citalopram, lithium
Diabetes thiazolidinediones,
dipeptidyl peptidase-4 inhibitors
Fungal Infections amphotericin B
Hypertension doxazosin, diltiazem, verapamil, moxonidine
Malaria chloroquine, hydroxychloroquine
Migraines ergotamine, methysergide
Pain prescription and nonprescription NSAID
Parkinson's pergolide, pramipexole, bromocriptine
Platelet Disorders anagrelide, cilostazol
Pulmonary Disease bosentan, epoprostenol, albuterol
Rheumatologic Diseases TNF-a inhibitors

Multi-Drug Interactions

A serious problem can occur when the combination of two drugs produces an undesirable result—a so-called drug-drug interaction. It’s a common problem in older patients, particularly those with more than one doctor.

“The average Medicare beneficiary with heart failure sees 15 to 23 different providers annually. This simply opens the door for drug-drug interactions,” says Dr. Taylor.

A drug-drug interaction may raise or lower your blood pressure too far or make you retain sodium and water. It may prevent one of the drugs from doing its job, or cause a new problem to develop—for example, a cardiac arrhythmia. That’s why it’s important to carry a list of all drugs you take, both prescription and nonprescription, and show it to every doctor you see.

“Most interactions are not severe, but they can be,” says Dr. Taylor.

Always Consult Your Doctor

It’s rarely an all-or-nothing scenario. “A lot of people take these drugs and don’t develop heart failure, or their heart failure doesn’t worsen,” says Dr. Taylor.

Don’t take a chance. Be your own advocate. Ask your cardiologist for a list of drugs that can worsen your heart failure. If you have a choice of drugs, take the one less likely to affect your heart.

If it’s necessary for you to take a drug on the list, have an honest discussion with your doctor.

“Your doctor needs to determine the risk the drug will affect your heart, and weigh that risk against your need for the drug," says Dr. Taylor.

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