Ask the Doctors April 2017 Issue

Ask the Doctors: April 2017

I have heart failure and am currently taking a number of medications. I am doing pretty well. I have heard that there is a new medication that can improve my life expectancy. How do I know if it is right for me?

Michael Rocco, MD

Michael Rocco, MD, medical director of Cardiac Rehabilitation and Stress Testing at Cleveland Clinic

You are likely referrring to a recently FDA-approved drug named Entresto®. This is a combination of a class of drug already used to treat heart failure, valsartan (an angiotensin receptor blocker or ARB) and a new drug, sacubitril (a neprilysin inhibitor). These two medications work in unison to reduce some of the adverse effects of heart failure on blood vessels and salt/fluid balance.

A recent clinical trial called PARADIGM-HF did show that when this combination drug was compared to a commonly used heart failure medication (enalapril, an agiotensin converting enzyme inhibitor or ACEI), in addition to other commonly used heart failure therapies, death from all causes was reduced by 16 percent and cardiovascular death or hospitalization for heart failure by 20 percent. New guidelines recommend this drug as a potential primary treatment choice in place of ACE inhibitors and ARBs in patients with heart failure and a reduced ejection fraction, as well as a reasonable replacement for an ACEI or ARB to further reduce morbidity and mortality.

No treatment is without some risk. A symptomatic drop in blood pressure may occur and limit dose or use. It may not be right for you if you have kidney dysfunction or elevated potassium level or a history of an allergic reaction to ACEI called angioedema. You are very likely already taking a drug like valsartan or an ACEI. This medication should not be added to either of these drugs but should replace them. Whether a specific medication is correct for you requires a careful weighing of the benefits against the risks and side effects. Only you and your doctor can decide if changing to this medication is appropriate.

I’m 83 and have low blood pressure. I was just prescribed fludrocortisone to raise my blood pressure. My doctor said not to worry about dietary sodium. But I’m concerned about my blood pressure getting too high. What should I know about this medication and my diet, given my blood pressure?

The medication you are referring to (also known as Florinef®) is typically used to treat insufficiency of the adrenal gland or orthostatic hypotension, which is a significant and often symptomatic drop in blood pressure with standing. You say you have low blood pressure. If your blood pressure drops further with standing, causing dizziness or passing out, this medication may be right for you. The drug can commonly cause an increase in blood pressure, sodium and fluid retention with possible swelling in the extremities. If you have symptoms related to low blood pressure, have normal heart muscle function and kidney function, the blood pressure-raising effects of this medications combined with compression stockings and a progressive exercise program improve symptoms.

The drug should be used with caution if you have a history of heart failure, heart attack, diabetes or kidney dysfunction. You and your doctor should carefully monitor your blood pressure, blood electrolytes (including potassium) and watch for fluid accumulation or heart failure. Weigh yourself daily. A sudden weight gain due to fluid retention should be reported to your doctor. You should also buy a home blood pressure monitor if you don’t already use one. Often with this condition blood pressure may be highest when lying down. In this case, raising the head of your bed during sleep my help. Although we are often told to avoid salt in the diet, particularly if blood pressure is elevated, when orthostatic hypotension is present increasing sodium and fluid intake may actually help.

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