Heart Failure
Maria G. Tanzi, PharmD
Heart failure (HF)–exacerbating medications are commonly used in older adults hospitalized for HF and are often continued or even initiated after hospitalization, according to the results of an observational study published on November 8, 2019, in Journal of the American College of Cardiology. The study authors recommend strategies to improve safe prescribing in this patient population.
“Our data supports the need for clinicians to reconcile medication lists comprehensively, which should include prescription, OTC, and complementary/alternative medications,“ lead study author Parag Goyal, MD, MSc, from the divisions of cardiology and internal medicine at Weill Cornell Medicine in New York, told Pharmacy Today.
“I think a good first step is to become familiar with the 2016 American Heart Association (AHA) scientific statement on drugs that may cause or exacerbate heart failure.”
Observational data
Goyal and colleagues analyzed HF hospitalizations in Medicare beneficiaries from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) cohort study to determine prescribing patterns of HF-exacerbating medications at admission and discharge.
They assessed data on 558 patients, which showed that the prevalence of HF-exacerbating medications at hospital admission was 41%. The most common agents used were albuterol, metformin, NSAIDs, and diltiazem. At time of discharge, the prevalence decreased slightly to 36%, with the most common agents being albuterol, diltiazem, and metformin.
An examination of the patterns of medication changes between hospital admission and discharge showed that 17% of patients experienced a decrease in the number of HF-exacerbating medications between admission and discharge. However, 19% remained on the same number of medications, and 12% experienced an increase.
A multivariable analysis also revealed that diabetes and small hospital size were the strongest independent predictors of harmful prescribing patterns.
AHA’s 2016 statement
The 2016 AHA scientific statement includes lists of prescription (e.g., thiazolidinediones) and OTC (e.g., NSAIDs) medications that can exacerbate HF and those that are known to cause direct myocardial toxicity (e.g., anthracyclines).
For OTC medications, AHA noted that patients should be aware of products that contain NSAIDs, high amounts of sodium, and/or vasoconstrictors, as these medications may be problematic in those with HF.
For complementary or alternative medications, AHA made three recommendations:
None of these “natural” products should be used to manage HF symptoms or for secondary prevention of cardiovascular events.
Ephedra-like products (e.g., ma-haung) should be avoided because of their stimulant effects on blood pressure and heart rate and their increased risk of mortality and morbidity in this patient population.
Products with significant interactions with digoxin, vasodilators, beta-blockers, anti-arrhythmic agents, and anticoagulants should also be avoided. For example, St. John’s Wort, grapefruit juice, and black cohosh all interact with numerous HF medications.
Goyal advocates for increased awareness of these recommendations but told Today that “there are several research gaps regarding the safety of medications on the list that merit further investigation.”
Counseling pearls
The current data highlight the dangers of polypharmacy in patients with HF. At every encounter, pharmacists should ask patients about all the medications they take, including the dose and frequency of each agent.
Medications that are not essential and potentially problematic should be discontinued, and every effort should be made to limit the number of medications prescribed for these patients. For example, medications used to manage adverse effects from other drugs should be avoided, along with nonessential “as-needed” medications.
Given the potential risks with select OTC and complementary/alternative medications, encourage patients to discuss these medications with their provider before using them and to read all labels to determine their sodium content.
Pharmacists working in the community are well positioned to help patients with HF select appropriate OTC medications. Those working in the hospital can identify problematic agents at the time of admission or discharge and modify regimens accordingly.
Educate patients on the early warning signs of HF exacerbation (e.g., shortness of breath, fluid overload), and advise them to report any of these symptoms to their provider immediately.