Congestive heart failure drugs to avoid

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Initial and Serial Evaluation of the HF Patient
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Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Edzel Lorraine Co, DMD, MD[2]

Overview

Drugs like nonsteroidal anti-inflammatory drugs, antiarrhythmic agents, and calcium channel blockers should be avoided in patients with congestive heart failure as they are known to have negative or deleterious effects on cardiac contractility, the neurohormonal system, or may cause sodium retention.

Drugs to Be Avoided in Congestive Heart Failure

Calcium Channel Blockers

There is no direct role of calcium channel blockers in the management of CHF. Given that some agents (diltiazem and verapamil) have a negative inotropic effect, it has been hypothesized that calcium channel blockers might increase adverse outcomes among patients with CHF due to systolic dysfunction. [1]. Vasoselective calcium channel blockers such as amlodipine and felodipine have not been linked to adverse outcomes among patients with congestive heart failure, but there is likewise no evidence of efficacy for these drugs in the management of CHF.[2] If a congestive heart failure patient has either angina or hypertension as a concomitant disease, amlodipine and felodipine appear to be safe for the treatment of these patients.

Antiarrhythmic Agents

Negative inotropic effect exerted by most antiarrhythmic drugs can precipitate CHF in patients with reduced LV function, and [antiarrhythmic]] agents can also paradoxically be pro-arrhythmic. The reduction in LV function can also reduce the elimination of these drugs leading to further drug toxicity. Other antiarrhythmic drugs can induce some proarrhythmic effect, especially class 1 agents and class 3 agents Ibutilide and sotalol (which has a negative inotropic effect);[3] the same class 3 agents in addition to dofetilide can induce torsades to pointes. Amiodarone is considered the safest of the antiarrhythmic drugs because of its minimal proarrhythmic effect and is generally the preferred drug for treating arrhythmias in CHF patients.Dronedarone should be avoided in patients who were hospitalized with CHF (this is a boxed warning). Disopyramide is contraindicated in patients with heart failure.

Nonsteroidal Anti-Inflammatory Drugs (NSAID)

The administration of non-selective NSAIDs in CHF patients has been linked to:

COX-2 selective inhibitors

Observational data suggest that these agents may be linked with an increase in congestive heart failure exacerbations as well as an increased mortality.[4]

Aspirin

Aspirin is often prescribed as primary prevention in patients with risk factors for cardiovascular disease or as secondary prevention in patients with established cardiovascular disease. However, among patients with congestive heart failure, the risks and benefits of aspirin are not as well established. Concern has arisen regarding the potential interaction between aspirin with ACEIs and beta blockers. At this time the American College of Chest Physicians guidelines indicate that it is reasonable to withhold aspirin among patients who have non-ischemic heart failure, while it may be reasonable to continue aspirin among those patients who have ischemic heart failure.

Although there is some data to suggest that aspirin may attenuate some of the hemodynamic benefits of ACE inhibitors, there is no data indicating that the beneficial clinical outcomes associated with ACE inhibitors is reduced.
There is likewise some data to suggest that aspirin may attenuate the benefit of beta blockers on the left ventricular ejection fraction among patients with congestive heart failure.

Oral Hypoglycemic Agents

Metformin is associated with lactic acidosis, which can be fatal in patients with CHF.[5]
Administration of thiazolidinediones is associated with fluid retention which may in turn cause volume overload and worsening of patients with CHF.[6]

Antidepressants

Depression among patients with congestive heart failure is associated with poorer clinical outcomes including higher mortality.[7] Questions have been raised as to whether it isthe depression itself that directly harms congestive heart failure patients or whether the harm is mediated by treatment with drugs such as tricyclic antidepressants. It appears that it is the depression itself and not the drugs used to treat depression that is independently associated with worse clinical outcomes. There is no difference in the risk of adverse outcomes among heart failure patients treated with either tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs).

Phosphodiesterase inhibitors PDE

Chemotherapy

Cardiotoxic chemotherapeutic agents as Cyclophosphamide, Trastuzumab, Bevacizumab and Anthracyclines, should be avoided in CHF patients. [12]

Tumor Necrosis Factor alpha inhibitors (TNF-alpha)

New onset or worsening of pre-existing heart failure have been linked to TNF-alpha inhibitors.[13] Infliximab has been specifically contraindicated in doses over 5mg/kg in patients with heart failure.

Antihistamines

Some second generation antihistamines as terfenadine and astemizole have been reported to cause long QT syndrome and should not be used in CHF patients.[14]

Serum Potassium

Serum potassium should be closely monitored in CHF patients, in order of preventing either hypokalemia or hyperkalemia, which could greatly affect cardiac excitability and conduction, leading to sudden cardiac death.[15] Serum potassium should be maintained between 4.0 to 5.0 mEq per liter range, because low potassium level may affect digitalis and antiarrhythmic drugs treatment, while high potassium level can prevent the use of treatments known to prolong life.[15]

Supervision of CHF patients with close monitoring of treatment and diet is a very important aspect of the follow-up process in those individuals. Body weight and medications should be closely monitored, because any minor change in those parameters can have a significant effect over symptoms and hospitalization of patients with CHF.[16] Patient education is a crucial aspect of the management of CHF, patient and family surveillance over any new change of symptoms or body weight is important in allowing early detection of those changes and implementing new treatment strategies to reduce further complications.[17]

Theophyline

Decompensation of congestive heart failure can be associated with theophylline toxicity, even at normal theophylline levels. If theophylline must be administered, the dosing should be reduced in the heart failure patient.

2022 AHA/ACC/ HFSA Heart Failure Guideline (DO NOT EDIT) [18]

Drugs of Unproven Value or That May Worsen HF

Class III (No Benefit)
"1. In patients with HFrEF, dihydropiridine calcium channel-blocking drugs are not recommended treatment for HF.[19][20] (Level of Evidence: A) "
"2. In patients with HFrEF, vitamins, nutritional supplements, and hormonal therapy are not recommended other than to correct specific deficiencies. [21][22][23][24][25][26][27] (Level of Evidence: B-R) "
Class III (Harm)
"3. In patients with HFrEF, non-dihydropiridine calcium channel-blocking drugs are not recommended. [28][29][30][31] (Level of Evidence: A) "
"4.In patients with HFrEF, class IC antiarrhythmic medications and dronedarone may increase the risk of mortality. [32][33][34] (Level of Evidence: A) "
"5.In patients with HFrEF, thiazolidinediones increase the risk of worsening HF symptoms and hospitalizations. [35][36][37][38][39](Level of Evidence: A) "
"6.In patients with type 2 diabetes and high cardiovascular risk, the dipeptidyl peptidase-4 (DPP-4) inhibitors saxagliptin and alogliptin increase the risk of HF hospitalization and should be avoided in patients with HF. [40][41][42](Level of Evidence: B-R) "
"7.In patients with HFrEF, NSAIDs worsen HF symptoms and should be avoided or withdrawn whenever possible. [43][44][45][46] (Level of Evidence: B-NR) "

References

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