Commonly used medications and nutritional supplements may cause or worsen heart failure – American Heart Association

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The American Heart Association (AHA) has cautioned that commonly used medications and nutritional supplements may cause or worsen heart failure in its first scientific statement, which provides guidance on avoiding drug-drug or drug-condition interactions for people with heart failure. The statement provides comprehensive information about specific drugs and “natural” remedies that may have serious unintended consequences for heart failure patients.

In addition to prescription medications, over the counter drugs may also have unintended consequences for heart failure patients.

• For example, non-steroidal anti-inflammatory drugs (NSAIDs), including commonly used painkillers such as ibuprofen, can trigger or worsen heart failure by causing sodium and fluid retention and making diuretic medications less effective.

• Over-the counter heartburn medications and cold remedies may also contain significant amounts of sodium, which is usually restricted in patients with heart failure.

Heart failure patients have, on average 5 or more separate medical conditions and they take 7 or more prescription medications daily, often prescribed by different healthcare providers. And, according to the statement, medications can cause problems in several ways: being toxic to heart muscle cells or changing how the heart muscle contracts; interacting with medications used to treat heart failure so that some of their benefits are lost; and containing more sodium than advised for patients with heart failure.

Robert L. Page II, Pharm.D., M.S.P.H., chair of the writing committee for the new scientific statement said that healthcare providers should talk to patients with heart failure at every visit about all prescription and over the counter medications they may be taking, as well as nutritional supplements and herbs.

The statement suggests that patients should show each of their healthcare providers a complete list of their medications, including over-the-counter drugs and natural supplements. They should consult with a health professional before starting or stopping any medication. (Source: AHA)

New treatment of heart failure with reduced ejection fraction

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Millions suffer from heart failure. New research suggests that a new medication, sacubitril-valsartan, might help these patients live longer.

In a study published in the Dec. 3 issue of the New England Journal of Medicine, researchers analysed data from nearly 8,400 heart failure patients with reduced ejection fraction. A team led by Dr Scott Solomon, director of non-invasive cardiology at Brigham and Women’s Hospital in Boston, estimated the patients’ survival time if they took sacubitril-valsartan or enalapril. Patients who took sacubitril-valsartan were projected to live 1.5 to two years longer than those who took enalapril.

Another randomized double-blind trial (PARADIGM-HF) in patients with HFrEF (heart failure with reduced ejection fraction ) found that sacubitril-valsartan reduced cardiovascular mortality and hospitalization for HF as well as all-cause mortality compared to a proven dose of the ACE inhibitor enalapril.

An analysis of nonfatal clinical deterioration among patients enrolled in the PARADIGM-HF trial found that patients treated with sacubitrial-valsartan reduced the combined end-point (intensification of medical treatment for HF, emergency department visits for worsening HF, hospitalization for HF, and need for intensive care) more effectively than ACE inhibitor therapy.

Treatment of heart failure

• In patients with heart failure with reduced ejection fraction (HFrEF), angiotensin II receptor blocker treatment reduces hospitalizations for HF.

• For patients with HFrEF who are intolerant of angiotensin-converting enzyme inhibitor (ACEI) due to cough, give an angiotensin receptor blocker (ARB) (candesartan or valsartan). But if ACEI intolerance is in the form of hyperkalemia or renal insufficiency, then the same risks would apply to an ARB and hence, this recommendation is not applicable in such a situation.

• If a patient has developed angioedema on ACEI, exercise caution in giving an ARB as angioedema has been infrequently reported with ARB therapy.

• When an ARB is indicated, give candesartan or valsartan

• Avoid using an ARB, an ACEI and a mineralocorticoid receptor antagonist all at the same time.

• Adverse effects of ARBs include hypotension, dizziness, worsening renal function and hyperkalemia.

• In a randomized double-blind trial in patients with HF with left ventricular ejection fraction (LVEF) =40%, sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor, reduced mortality and morbidity vs ACEI therapy when used in combination with other standard HF therapies.

• For patients with new diagnosis of NYHA class II to IV HFrEF (LVEF =40%), give ACEI (or single agent ARB) rather than sacubitril-valsartan as a component of initial medical therapy. Use of sacubitril-valsartan routinely as a component of initial therapy in such patients has been recommended by some.

• For patients with stable mild to moderate HFrEF (LVEF =40%), an elevated natriuretic peptide level or hospitalization for HF in the past 12 months, a systolic BP = 100 mm Hg and eGFR = 30 mL and who have tolerated high-doses of ACEI or ARB therapy (equivalent to at least enalapril 10 mg twice daily) for =4 weeks, start sacubitril-valsartan in place of the ACEI (or single agent ARB) component of therapy.

• Factors that impact the decision to switch to sacubitril-valsartan in place of ACEI (or single agent ARB) include patient acceptance/tolerance of drug changes (including need for a 36-hour ACE inhibitor washout period prior to starting sacubitril-valsartan), lack of data on the long-term effects of sacubitril-valsartan, and cost.

• When sacubitril-valsartan is used in patients with HFrEF, it is used in place of ACEI (or single-agent ARB). Sacubitril-valsartan should not be used in combination with an ACEI (or single-agent ARB).

Ivabradine in heart failure with reduced ejection fraction

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In patients with chronic stable heart failure with LVEF ≤ 35 percent, in sinus rhythm with a resting heart rate ≥70 bpm, and who are either on a maximum tolerated dose of a beta blocker or who have a contraindication to beta blocker use one can start ivabradine. The drug slows the sinus rate. In such patients, ivabradine has been shown to reduce the risk of hospitalization for worsening heart failure
(http://www.accessdata.fda.gov/drugsatfda_docs
/label/2015/206143Orig1s000lbl.pdf)

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