Managing Medications for Heart Failure

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Even more than with most other conditions, medications play a major role in treating heart failure and controlling the symptoms that interfere with quality of life. Unfortunately, many people with heart failure -- also called congestive heart failure -- are undertreated and don't receive all the medications that could make them feel better.

As a caregiver, managing your loved one's medications to make sure they're working properly -- along with monitoring symptoms and side effects -- is one of the most important things you can do. Here's how:

Understand the function and purpose of all medications.

The medications the doctor prescribes for heart failure are likely to be different based on whether the patient suffers from systolic or preserved systolic heart failure. Knowing the difference between the two is important in managing care. In cases of systolic heart failure -- the most common type -- medications have two functions: to control symptoms in the short term and to strengthen the heart and reverse the damage (known as reverse remodeling) in the long term. In cases of preserved systolic heart failure, the main purpose of the medication regimen is to control blood pressure. There are more medications available for systolic heart failure than for preserved systolic heart failure.

The medications that have immediate, short-term benefits are easy for most patients to understand and comply with, whereas the ones with primarily long-term effects may be harder to understand. Make sure the doctor clearly explains what each medication does and what you can expect, both in the immediate future and over time. Ask the doctor how you'll know whether each medication is working. The doctor may explain that you won't know the success of a certain medication until certain tests are performed; if so, ask what the tests are and when they'll be scheduled.

Keep track of medications.

Most people with heart failure need to take several medications, which can make keeping track of them a challenge, especially if the person you're caring for is on medications for other conditions. Watching for side effects and medication interactions will also be an important task. Making a medicine chart can make it easier to keep track of all medications prescribed, the time of day they should be taken, and any other factors (such as if a medication needs to be taken with a meal).

Bring all medications to each doctor visit in their original bottles. Having the medications present with their labels is much more helpful than bringing a list.

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Advocate for the best heart failure regimen.

The treatment regimen for heart failure varies, depending on the cause, the stage, and other factors. But experts agree that all heart failure patients should get the following drugs, unless there's some reason they can't take them:

  • An ACE inhibitor. These block the function of angiotensin-converting enzymes (ACE), relaxing blood vessel walls. They provide some immediate effect in lowering blood pressure, but their most important function is to "reverse remodel" the heart, which means reshape it closer to its normal size and form. ACE inhibitors also decrease the risk of death; studies show a reduction in mortality of 20 to 25 percent.

  • An angiotensin II receptor blocker (ARB). These dilate blood vessels and lower blood pressure, providing some symptom relief, but their primary benefits are long-term. ARBs have been shown to work over time to decrease mortality and "reverse remodel" the heart. ARBs may be used as an alternative to an ACE inhibitor or, in some cases, in addition to an ACE inhibitor.

  • A beta-blocker. These drugs slow and steady the heart rate and lower blood pressure. They improve the heart output (measured by ejection fracture) over time. There are two types of beta-blockers, known as selective and nonselective, depending on which type of beta receptors they work on. Beta-blockers have been shown to reduce the death rate from heart failure by as much as 30 percent.

Other treatment options:

  • Diuretics. Also sometimes called "water pills," diuretics increase urination and help the kidneys flush salt and water from the blood. Diuretics prevent the fluid retention typical of heart failure. They're extremely important in relieving the fluid "congestion" that gave congestive heart failure its original name.

  • Aldosterone inhibitors. These drugs block the action of a hormone that causes the body to retain, or hold on to, sodium and water. They're powerful diuretics and have the short-term benefits of preventing fluid buildup.

  • Other vasoactive agents. In addition to an ACE inhibitor and an angiotensin II receptor blocker, the doctor may prescribe a calcium channel blocker or nitroglycerin to relax and widen blood vessels and prevent constriction of blood flow. Among African-Americans, a combination of hydralazine and a long-acting nitrate was shown in the African American Heart Failure Trial to be most effective (along with an ACE inhibitor and beta-blocker) for moderate to severe heart failure.

  • Digoxin. This drug makes the heart pump more strongly and also may help control certain types of arrhythmias. Digoxin has been shown to control symptoms and reduce hospitalizations in the short term, but it doesn't have a long-term effect on heart muscle strength or life expectancy. It shouldn't be prescribed for those with preserved systolic failure unless it's being prescribed for atrial fibrillation.

In addition to a regimen specifically to treat heart failure, the doctor may prescribe other heart medications, such as nitrates for chest pain, a statin to lower cholesterol, or blood-thinners to prevent blood clots.

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Report side effects.

Side effects from heart failure medications can be mild or bothersome. Make sure to report any side effects to the doctor or nurse, particularly if they're problematic enough that they might cause someone to stop taking the medication.

There's a great deal the doctor can do to help patients manage side effects, such as lowering the dosage or substituting a similar drug that's less likely to cause those particular side effects. Be aware that some of the drugs with the most potential to reduce the risk of death from heart failure may cause an increase in symptoms, such as fluid retention, in the short term. It's important not to just stop taking a drug when problems begin; talk to the doctor about what to do to reduce side effects so the drug is better tolerated. Often the doctor or a nurse can suggest simple techniques to reduce side effects, such as staggering the timing of medications or taking a particular medicine at a different time of day.

Understand that some medications take time to work.

The medications that have the most ability to actually rebuild the strength of the heart muscle -- ACE inhibitors and ARBs -- can be frustrating because their effects are largely invisible at first. These medications don't provide a great deal of immediate symptom relief, as the diuretics do. Instead, they gradually strengthen the heart over a period of months, leading to eventual improvement. There may even be a worsening of symptoms in the short term, which have to be controlled using other medications. Frustration leads some people to discontinue the medications, which is unfortunate, since -- without an ACE inhibitor or ARB -- there's less likelihood of reversing the damage that causes heart failure. Talk to the doctor right away about how to manage any side effects before they become disruptive.

Increase dosages over time as instructed.

Many heart failure medicines have two purposes: to improve comfort and quality of life in the short term and to treat the underlying disease. For this reason, over time the doctor may increase dosages, even when someone's getting better and the medicine appears to be working. This is because many heart failure drugs are known to be most effective at certain doses and need to be increased gradually. Make sure everyone understands the importance of following dosage instructions, even if a change seems unnecessary to control symptoms.