Understanding different congestive heart failure medicines and why they are important

The importance of medication for those with congestive heart failure

Your medications are your lifeline, almost literally. When the heart begins to fail, life is in a rather precarious position. Activities that you once did are not always possible and the risk of death is increased. The goal of congestive heart failure treatment is to get whatever heart function that still exists performing the best that it can. Fortunately there are a number of medications that can be used to optimize heart and blood vessel function. When these congestive heart failure medications are customized to meet the needs of the individual patient, both in terms of drug type and dose, the patient can enjoy a reasonably normal life. Depending on how badly the heart is failing, congestive heart failure medications can coax and cajole into pumping a little more efficiently and cause the blood vessels to permit more effective blood flow.

Optimizing your congestive heart failure medications

Your cardiologist or internist will spend a great deal of time and energy on optimizing your congestive heart failure medications. This optimization will depend on your heart’s performance on various tests and studies. An EKG (ECG; electrocardiogram), echocardiogram, and coronary angiogram may be used to get a good idea of your heart’s ability to pump. A cardiac stress test may be required to determine how your heart performs during exercise or simulated exercise. Blood tests, like BNP (brain natriuretic peptide) may be performed as well. The information gathered from these tests is analyzed and used to prescribe a cocktail of medications to treat your congestive heart failure.

Unfortunately there are a few ways that this elegant system can fall apart. Almost all of the stumbling blocks, though, are preventable. One of the more common ways that congestive heart failure treatment derails is through a lack of patient education. When people do not understand their medications, dislike the side effects, or forget to take them, the well-designed treatment system can slowly or abruptly fail.

Doctors call a situation in which a patient does not take medications as prescribed as “patient noncompliance.” Sadly, this medicolegal term does not get to the heart of the problem. Rather it places blame on the patient. In truth, there is enough blame to go around. Congestive heart failure treatment is complex and confusing. Complying with prescribed medications is challenging and medication failure is understandable. The physician and treatment team has a responsibility to the patient to provide adequate education and the patient has a duty to understand and follow their treatment plan.

The congestive heart failure medication you take home from hospital

The importance of education and compliance

A person that is first diagnosed with congestive heart failure will likely leave the hospital with at least three new medications. These medications will need to be taken every day or several times of day, likely for the rest of the patient’s life. They will have names as strange as a foreign language. When you think about it, it is surprising that as many patients manage to comply with a new congestive heart failure treatment plan as actually do.

Patients are much more likely to stick with a treatment regimen if they understand what each pill is called, what it is for, and why they are taking it. While it is a miracle of modern science, one of the problems with congestive heart failure treatment is that there are a tremendous number of different medicines that can be used in its treatment. Not only are there a multitude of drugs but there are also a large number of drugs classes used to treat congestive heart failure. A class of drugs, it should be mentioned, can refer to the drugs of a similar chemical structure or drugs that do pretty much the same thing in the body. For the present discussion, a class of drugs is a group of drugs that do the same thing to treat congestive heart failure.

Diuretics and their role in treating congestive heart failure.

One class of drugs used to treat congestive heart failure is a diuretic, which are drugs to get rid of fluid from the body. The less fluid that is in the pipes, the less likely that fluid will accumulate in the lungs or legs. The most common diuretic used in congestive heart failure is Lasix (generic name: furosemide). Lasix is different from the blood pressure fluid pills with which you might be familiar, namely HCTZ (hydrochlorothiazide). Lasix is not meant to be used as a blood pressure treatment. Its primary purpose is to remove fluid from the body by increasing urination. Because of its mechanism of action in the kidney, it is a powerful drug for removing fluid from the body.

Other diuretics that are used to remove or prevent swelling and fluid accumulation are torsemide (Demadex), spironolactone (Aldactone), and bumetanide (Bumex). If you are on one of these drugs for congestive heart failure it is being used to keep fluid from backing up in your lungs and tissues. Obviously taking these drugs as directed can directly improve or maintain your ability to breathe and function with little or no swelling in your extremities.

With the exception of spironolactone, these diuretic medications can be given orally or intravenously depending on the speed at which fluid needs to be removed from the body. For example, it is fairly common for a patient to receive a rather high dose of Lasix into a vein to rapidly correct severe breathing problems caused by fluid accumulation in the lungs. These medicines may also be given as oral medications for daily maintenance. In fact, most patients with congestive heart failure are taking an oral diuretic.

Vasodilators and their role in treating congestive heart failure.

Another class of drugs used to treat congestive heart failure is the vasodilator class. Vasodilators are drugs used to open (dilate) the pipes (vaso; blood vessels). If the pipes are wider it is easier for a weakened for failing heart to pump blood through them. While vasodilators, by definition, will lower blood pressure, they are not considered standard treatment for high blood pressure. Instead they are thought of as a way of helping the heart do its job.

The more common vasodilators are drugs that contain nitrates in some way. If you have ever seen a person slip a little pill under his tongue for chest pain (angina), that was a nitrate drug. In recent years there have been different formulations of nitrate drugs that are taken daily (and not under the tongue). These long-acting nitrate vasodilators keep blood vessels open more or less constantly.

Imdur (isosorbide mononitrate), Dilatrate (isosorbide dinitrate), and nitroprusside (Nitropress) are the most common vasodilators. Regular old nitroglycerin (the little pills under the tongue) may still be used to treat congestive heart failure, too, though less commonly. Sometimes isosorbide dinitrate is administered in a combination pill with hydralazine which is marketed under the brand name BiDil. In fact, hydralazine alone is a fairly powerful vasodilator.

If you have been started on a vasodilator for congestive heart failure, it is very important not to stop it abruptly. If you stop a vasodilator drug all of a sudden, the blood vessels could clamp down (narrowing of the pipes). This means the heart will need to work extremely hard to pump blood and may not be able to do so. Use vasodilators as directed and, if you are having troubles with them, talk to your doctor before you quit taking them or before you run out. This is a good rule of thumb for all congestive heart failure medications, but particularly important for vasodilators.

Blood pressure tablets as a medicine for congestive heart failure

There are a number of drugs used to treat high blood pressure (hypertension) that do double duty in congestive heart failure. They need to be used by doctors very carefully, though, since a failing heart has a difficult time pumping blood through the pipes. If you drop blood pressure too much, a failing heart cannot generate the needed force to get blood around the body. Still, there are many occasions in which blood pressure lowering medicines can help in congestive heart failure.

One class of blood pressure medications used in congestive heart failure that is easy to understand is beta blockers. There are many, many different beta-blockers, each with different names. The prototypical beta blocker is metoprolol. One way to recognize this class of drugs is by the end of their generic name. If a heart medication ends in –olol or –ilol, it is a beta blocker of some sort.

Beta blockers slow down the rate of the heart (among other cardiovascular effects). Why is a slow heart rate good in congestive heart failure? A heart that is moving relatively slowly (or not quickly) has a chance to give itself blood through the coronary arteries. This makes the heart work better. Also, a slower moving heart can generate a little more squeeze when it pumps, which is important in heart failure.

Two classes of drugs are very similar to one another and considered as the same class for practical purposes. The two classes are angiotensin-converting enzyme inhibitors (ACE-inhibitors) and angiotensin receptor blockers (ARBs). These drugs act on the kidneys to lower blood pressure but they do so much more. ACE-inhibitors and ARBs can protect the kidneys, open up the pipes, and decrease the heart’s need for oxygen. Virtually everyone that has congestive heart failure will be on some sort of ACE-inhibitor or ARB. The dose of this drug used in congestive heart failure may be very small—lower than what would be used as a blood pressure treatment.

There are a number of ACE-inhibitors and ARBs used today. Common names for ACE-inhibitors are lisinopril (the prototypical one), captopril, enalapril, quinapril, ramipril and perhaps others. In the case of ACE-inhibitors, the trick is to look at the end of the name; ACE-inhibitors will end in –pril. Angiotensin receptor blockers (ARBs), on the other hand, will end in –sartan like candesartan, losartan, and valsartan. These drugs (ACEs and ARBs) are used interchangeably in congestive heart failure though patients will usually only be on one of either type at any one time. If you are on more than one, ask your doctor why. It could be a medication error. Generally people are started on an ARB if they cannot take an ACE-inhibitor for some reason (though not always).

Heart strengthening drugs for those with congestive heart failure

So far we have discussed how to improve the pipes (blood vessels) to make the pump’s job easier. But there are drugs that can make the heart pump a little harder. The original heart strengthening drug was digitalis or specifically digitoxin. When it is administered today it is called digoxin (Trade name: Lanoxin). Drugs that make the heart pump harder are called inotropes.

Inotropes have to be used very carefully since they can cause problems at high doses. One of the more famous side effects of digoxin is that it causes visions of yellow streams—almost hallucinations (though not really). Vincent van Gogh’s Starry Night is theorized by many to have been inspired by this well known drug side effect.

Most inotropes are used in the intensive care unit more or less as last resorts. Examples of inotropes used in the hospital are dobutamine, dopamine, and norepinephrine. Some newer inotropic agents called phosphodiesterase enzyme inhibitors are proving useful in congestive heart failure because they cause the heart to pump harder and open the pipes (vasodilator). The two phosphodiesterase enzyme inhibitors used most often are milrinone and inamrinone. These drugs require close medical monitoring and, as such, are not used in patients outside of the hospital.

Human B-type natriuretic peptides (hBNP) for in hospital use

The most exciting recent advance in the treatment of congestive heart failure is the discovery and use of a class of drug called human B-type natriuretic peptides (hBNP). There is really only one of these drugs currently available and it is called nesiritide (Natrecor). The reason that it is exciting is that it is an excellent treatment for acute congestive heart failure exacerbation, as in emergency situations. It can clear fluid from the lungs faster than Lasix and other diuretics, which are the old standby treatments. Being a new treatment, nesiritide is expensive and is reserved for in-hospital use for the time being; however, it is proving to be a lifesaver. Human B-type natriuretic peptides is used when acute congestive heart failure comes on quickly and severely, a condition referred to as flash pulmonary edema.

Medicines for Congestive Failure in Conclusion

It is important to know what medications you are taking for congestive heart failure and to take them precisely as directed. Running out of medicines, forgetting to take a pill, or deciding to stop a medication can spell a trip to the emergency department. Unfortunately congestive heart failure treatment is about balance and control. That balance and control can easily be lost when treatment plans are not followed.

ABOUT THE AUTHOR: Michael T. Spako is an M.D. who specializes in medical writing. I am pleased to have him as the principal writer for this congestive heart failure site, and look forward to his further contributions. Donald Urquhart, Psychologist, Editor.

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