Medications are an important part of treating heart failure.
For heart failure with reduced ejection fraction – when you heart is not squeezing as it should – there are now four classes, or types, of medications that are especially important for most people to be taking. Cardiologists sometimes call these the four pillars of heart failure management. Many of these medications are proving to be helpful for people with heart failure whose ejection fraction is normal, too.
Below is a list of some common medications used, and how each one works. Many of these medications work together and give added benefits.
The four essential medicines include:
Mineralocorticoid receptor antagonists (MRAs)
Angiotensin receptor-neprilysin inhibitor (ARNI)
Angiotensin-converting enzyme inhibitor (ACE-inhibitor)
Angiotensin II receptor blockers (ARB)
Sodium-glucose cotransporter 2 (SGLT2) inhibitors
- Beta blockers help the heart by slowing the heart rate and lowering your blood pressure. Common ones include bisoprolol (Zebeta), carvedilol (Coreg) and metoprolol succinate (Toprol).
- Mineralocorticoid receptor antagonists and potassium-sparing diuretics (spironolactone and eplerenone) help the body to get rid of salt and water through urine. This lowers the volume of blood that the heart must pump. But they have other benefits for heart failure, too.
- Angiotensin receptor-neprilysin inhibitor (ARNI) – sacubitril/valsartan (Entresto) – is a combination of an ARB and a medicine that inhibits the production of neprilysin, an enzyme. This enzyme breaks down natural substances in the body that widen blood vessels and reduce sodium retention. The effect is to lower blood pressure and decrease strain on the heart.
- Angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) relax your blood vessels and reduce strain on your heart and improve blood flow. They also lower blood pressure.
- Sodium-glucose cotransporter 2 (SGLT2) inhibitors were originally used to treat diabetes. In studies, these medicines have clear benefits for people with heart failure, including fewer heart-related deaths and hospitalizations, and often people report feeling better. Common ones include dapagliflozin (Farxiga), empagliflozin (Jardiance) and sotagliflozin (Inpefa), with others being studied.
Other medications that might be recommended:
- Additional diuretics, also called water pills, help keep fluid from building up in your body or lungs – they will also make you urinate more often.
- Digoxin slows heart rate and strengthens heart muscle contractions to pump more blood. It can make you feel better.
- Nitrates and hydralazine is a combination of drugs that has been shown to improve outcomes in Black patients. It is often used if someone is allergic to or can't take ACE inhibitors or ARBs.
- Sinoatrial node modulator (ivabradine) is a drug used with beta blockers when they cannot lower your heart rate enough. It helps reduce the amount of oxygen your heart needs and the amount of work your heart does to pump blood through the body.
- Soluble guanylase cyclase stimulator (vericiguat) can result in beneficial relaxation of blood vessels and decrease strain on the heart. This medication may result in fewer heart-related deaths and hospitalizations in people with heart failure who have recently been hospitalized and are already on optimal medical therapy.
Always take your medication as prescribed.
Try to review the medications you take, including any over-the-counter medicines or supplements, at each visit with your doctor to make sure you are on the best medications, and to check the amount (dose) of each.
Often medications need to be changed over time, and sometimes even when you are feeling reasonably well. Studies have shown that patients with heart failure have the best outcomes when they are on the highest dose of certain medications. Your doctor may increase your doses even if you are feeling well.
If you are having trouble paying for your medications, tell your cardiology team or pharmacist so they can help.