Medications that Exacerbate Heart Failure


Medications that Exacerbate Heart Failure, Congestive Heart Failure Exacerbation due to Medications, Drug-Induced CHF Exacerbation, Medications that Provoke Heart Failure

  • Epidemiology
  1. Up to half of Heart Failure patients take at least one medication that may result in a CHF exacerbation
  1. Calcium Channel Blockers (except Amlodipine)
    1. In general, Calcium Channel Blockers reduce contractility and ejection fraction (except Amlodipine)
    2. Avoid Diltiazem, Verapamil and Nifedipine in Heart Failure with Reduced Ejection Fraction
  2. Beta Agonists
    1. Higher hospitalization and mortality rates in CHF
      1. Au (2003) Chest 123:1964-9 [PubMed]
    2. May be started slowly once CHF is stable and compensated
  1. Glitazones (e.g. Pioglitazone or Actos)
    1. Edema risk
  2. Gliptins (DPP-4 Inhibitors)
    1. Sitagliptin (Januvia) and Tradjenta (Linagliptin) appear to have least adverse effects on CHF exacerbation risk
  3. Consider alternative Type 2 Diabetes Mellitus medications which are not associated with exacerbation risk (or show CHF benefit)
    1. Continue Metformin
    2. Consider SGLT Inhibitor (Farxiga)
      1. Associated with reduced risk of Heart Failure hospitalization
  1. Tricyclic Antidepressants (e.g. Amitriptyline)
    1. May decrease cardiac contractility and Blood Pressure
  1. Nonsteroidal Anti-inflammatory drugs (NSAIDS)
    1. NSAIDs block ACE Inhibitor activity, block Diuretic activity and increase Blood Pressure and edema
    2. Naproxen appears to have the least adverse cardiac effects of the NSAIDs
    3. Avoid in general, but if no alternative, use the shortest course at the lowest effective dose
    4. Consider Topical NSAIDs (e.g. Diclofenac Gel) or Acetaminophen
  1. See Low Sodium Diet
  2. Medications with high Sodium (e.g. some OTC effervescent tablets contain 500 mg Sodium per tab)
  3. St John's Wort
    1. Multiple Drug Interactions (e.g. Digoxin, Eplerenone)
  • References
  1. (2016) Presc Lett 23(9)
  2. (2022) Presc Lett 29(10): 57-8