What is the best medication for congestive heart failure (CHF)?
In this article what is the best medication for congestive heart failure (CHF).
Diuretics
1. Bendroflumethazide (thiazide diuretic) or furosemide (loop diuretic)
These are sometimes known as ‘water tablets’ because they remove excess fluid from the body, including from the blood. This means there is less pressure on the blood vessel walls. Both can worsen kidney function and affect salt levels (e.g. sodium and potassium levels), which need to be monitored.
2. Aspirin
This prevent blood clots.
Blood clots can block the flow of blood through the arteries and lead to heart attack or stroke. Aspirin is the most common antiplatelet agent given to prevent blood clots. It can reduce inflammation associated with heart disease.
Doctors prescribe a daily aspirin to patients who have had a prior heart attack, had a stent implanted in the coronary arteries or legs, and patients who have had a prior stroke or valve replacement.
After a heart attack and stenting procedure, patients are recommended to take and prescribed an additional antiplatelet medication to help prevent clots. Examples include clopidogrel, tigagrelor and prasugrel, usually up to 12 months alongside aspirin.
Angiotensin converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs)
3. Rampiril or Losartan
Angiotensin converting enzyme (ACE) inhibitors (e.g. Ramipril) and angiotensin receptor blockers (ARBs; e.g. Losartan) dilate, or widen, blood vessels. This helps improve the flow of blood, eases the demands on the heart and lowers blood pressure.
These drugs are often given for high blood pressure and chronic heart failure (CHF). They help decrease the risk of heart attack or stroke in people with heart disease. When given after a heart attack, they help prevent heart damage and future heart attacks. Both can worsen kidney function, which should be monitored.
Anti-arrhythmics
4. Digoxin or Amiodarone
People with abnormal heart rhythms may be prescribed anti-arrhythmic medications. Their heart may beat too quickly, too slowly, or irregularly. These drugs help regulate the heart’s electrical activity so that the heart beats normally.
They may be used alone or combined with procedures – such as an ablation, or devices (such as pacemakers, PPMs; and/or internal cardiac defibrillators, ICDs) – to treat the underlying rhythm problem of the heart.
Digoxin is normally cleared by the kidneys. There is a increased risk of digoxin toxicity in CKD; so lower doses should be used. It is important to report any unusual symptoms such as nausea, vomiting, loss of appetite, blurry vision, and changes to your heart rate.
Amiodarone has a long half-life, meaning it stays in your body for an extended period. Patients on amiodarone long-term require regular monitoring of their thyroid function and liver function (through blood tests), and periodic lung function assessment.
Anticoagulants (blood thinners)
5. Apixaban (a DOAC; or rivaroxaban, edoxaban or dabigatran) or Warfarin
These prevent blood clots. Even though anticoagulants are often called ‘blood thinners’, they do not actually thin your blood. They help prevent blood from coagulating or clotting.
Direct oral anticoagulants (DOAC) or warfarin are often taken by people with atrial fibrillation (AF) which is the commonest abnormal heart rhythm. AF can disrupt normal blood flow through the heart, increasing the risk of blood clot formation. If the clot breaks loose, this can travel to the brain circulation and cause strokes. Warfarin is used in patients with artificial mechanical heart valves (DOACs are not licensed for these patients).
Beta-blockers
6. Bisoprolol – or atenolol, nebivolol, metoprolol and propranolol
These help your heart work better. Beta blockers as are often prescribed after a heart attack to help the heart recover. After a heart attack, they have been found to lower the risk of death by 40% compared to those who do not take them. They can also be used in CHF, as some can also help improve the heart’s ability to pump blood. Others may be given to treat high blood pressure, angina and abnormal heart rhythms.
Combined alpha and beta-blockers are used to treat high blood pressure and heart failure, e.g. carvedilol and labetalol.
Vasodilators
7. Isosorbide mononitrate (ISMN) or Hydralazine
These drugs relax blood vessels and decrease blood pressure.
ISMN is from a category of vasodilators called nitrates. They increase the supply of blood and oxygen to the heart while reducing its workload which can ease chest pain (angina). In some patients, the widening of blood vessels in the heart can lead to throbbing headaches. It can also cause sudden drop in blood pressure, leading to faints.
Another vasodilator nitroglycerin is used to control an angina attack. It is available as a pill to be swallowed or absorbed under the tongue (sublingual), a spray, and as a topical application (cream).
Hydralazine is a vasodilator that primarily targets the arteries, reducing the resistant against which the heart pumps. As a result, it improves blood flow and reduces workload on the heart. Hydralazine can be combined with isosorbide mononitrate (or dinitrate) in patients with chronic heart failure (CHF), if they cannot tolerate ramipril or losartan.
HMG CoA reductase inhibitors (‘statins’)
8. Atorvastatin – or simvastatin or rosuvastatin
HMG CoA- reductase inhibitors (‘statins’) help to lower the levels of low-density lipoprotein (LDL) cholesterol (‘bad’ cholesterol) in the blood. They can also lower triglyceride levels, which are another type of normal fat in the blood that when elevated increases the risk of atherosclerosis (plaque build up).
Statins decrease bad cholesterol production in the liver and inflammation in cholesterol plaques. They provide significant benefits in reducing the risk of heart attacks by about 30% and the risk of strokes by around 20% – especially in people who are at high risk of cardiovascular disease.
SGLT2is
9. Dapagliflozin– or empagliflozin and canagliflozin
SGLT2 (sodium-glucose co-transporter-2) inhibitors increase the amount of sugar you pass in the urine, meaning there is less in your blood. They also remove sodium and water from the body, which makes them useful for chronic kidney disease (CKD) and chronic heart failure (CHF). They can worsen kidney function, which should be monitored.
Your urine will test positive for sugar because of the way they work. It can also contribute to weight loss. It should not be taken during a severe illness or major surgery, because it can lead to dehydration and worsen kidney function.
In patients with type 2 diabetes who become poorly, an uncommon but serious complication of SGLT2 inhibitors is diabetic ketoacidosis (DKA; high blood sugar, ketone production and increase acidity of blood).
Angiotensin receptor-neprilysin inhibitors (ARNIs)
10. Sacubitril/valsartan (Entresto)
ARNIs are a drug combination of a neprilysin inhibitor and an angiotensin-receptor blocker (valsartan, similar to losartan).
Neprilysin is an enzyme that breaks down natural substances in the body that open narrowed arteries. By limiting the effect of neprilysin, it increases the effects of these substances and improves artery opening and blood flow, reduces sodium (salt) retention, and decreases strain on the heart.
They have been found to lower the risk of heart-related deaths and need for hospital admissions due to heart failure by around 20% in patients with a weak heart. They can worsen kidney function, which should be monitored.
Other drugs
Calcium channel blockers – e.g. amlodipine, verapamil and diltiazem
Calcium channel blockers decrease the heart’s workload by increasing its supply of blood and oxygen. They do this by preventing calcium from entering the cells of the heart and arteries. They are used to treat high blood pressure, abnormal heart rhythms and angina.
Mineralocorticoid receptor antagonists (MRAs) – spironolactone and eplerenone
These are weak diuretics (water tablets) that are helpful in heart failure (CHF). They block the effects of a natural hormone in our body called aldosterone, which usually controls our sodium and water balance. As a result, they increase the amount of excess fluid and salt removed in the urine.
They can also help by lowering blood pressure. Both can worsen kidney function and increase potassium levels in the blood, and so should be monitored regularly through blood tests.
Summary
We have described what is the best medication for congestive heart failure (CHF). We hope it has been helpful.
Other resources
Common CKD drugs
10 best water tablets
This article was reviewed by Dr Patrick Tran, ST in Cardiology.
Last Reviewed on 11 May 2024