The Most Common Medications for Heart Failure (and Ones That Make Heart Failure Worse)

Heart failure affects about 6.5 million people in the United States. It’s more common after the age of 60, but people of any age can have heart failure. Treatment for heart failure usually includes medication. Most people need several different types of medications to keep their heart running smoothly. These medications can be life-saving.

But, some medications can actually cause heart failure. And others can make existing heart failure worse. Many times, these medications are necessary to treat other medical conditions. But other times there may be other choices that are better. 

First, let’s start with the most common medications used for heart failure. 

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Diuretics

Diuretics are sometimes known as “water pills”. They stimulate the kidneys to make more urine. This helps the body get rid of extra fluid that can build up from heart failure. 

Common examples of diuretics are: 

• Furosemide (Lasix)

• Bumetanide (Bumex)

• Torsemide (Demadex)

• Metolazone (Zaroxolyn)

• Hydrochlorothiazide (Microzide)

• Chlorthalidone (Thalitone)

If you take diuretics, it’s normal to have to use the bathroom more often. But diuretics may have other side effects, including:

• Dehydration

• Low blood pressure

• Lightheadedness

• Dry mouth

• Low levels of potassium and magnesium

If you take a diuretic, you may need an occasional blood test to check your potassium and magnesium levels.

By limiting your fluid and salt intake, you may be able to cut back on your diuretic dose. But check with your healthcare provider before you make any big changes.

Beta blockers

Beta blockers are an important part of heart failure treatment. They’re especially important if you have a weak heart muscle. Beta blockers lower the heart’s workload by: 

• Lowering blood pressure

• Slowing down the heart rate

• Reducing how hard the heart squeezes

Some people with heart failure have what’s called a low ejection fraction. This means the heart muscle is weak, and can’t pump as much blood with each beat as a normal heart. There are only three beta blockers approved to treat heart failure caused by a low ejection fraction. These are:

• Metoprolol (Toprol)

• Carvedilol (Coreg)

• Bisoprolol (Zebeta)

Beta blockers can lower your risk of dying from heart failure. But sometimes beta blockers can worsen heart failure. This is why people often start at a low dose. Other side effects of beta blockers are:

• Low blood pressure

• Low heart rate

• Dizziness

• Fatigue

If you have any of these symptoms, it’s important to check in with your healthcare provider to see if you need to switch your medications.

ACE inhibitors and ARBs

Angiotensin converting enzyme inhibitors (ACE inhibitors) and angiotensin II receptor blockers (ARBs) are similar medications. They both work on angiotensin II. This is a natural chemical in the body that increases blood pressure. Since they lower the effect of this chemical, they often reduce blood pressure. 

These medications also have protective effects for the heart itself. So even if you have normal blood pressure, you may still benefit from an ACE inhibitor or ARB. Most people with a weak heart muscle will benefit from taking one of these medications. Even in small doses, these medications can help you live longer. 

But you might not be able to take ACE inhibitors or ARBs if: 

• Your blood pressure is too low.

• You have serious reactions to them.

• You have certain kidney problems.

Common examples of ACE inhibitors are:

• Lisinopril (Zestril)

• Benazepril (Lotensin)

• Captopril (Capoten)

• Ramipril (Altace)

• Quinapril (Accupril)

Common ARBs are:

• Losartan (Cozaar)

• Valsartan (Diovan)

• Candesartan (Atacand)

• Azilsartan (Edarbi) 

• Olmesartan (Benicar)

• Irbesartan (Avapro)

There’s also a combination ARB medication called sacubitril/valsartan (Entresto). This medication is used for people with reduced ejection fraction. It helps symptoms and also prolongs lifespan. If you take Entresto, it’s important that you avoid taking any other ACE inhibitors or ARBs. That’s because taking both together can cause dangerous side effects.

ACE inhibitors can cause a dry cough. This is uncommon with ARBs. Other side effects of ACE inhibitors and ARBs are:

• Dehydration

• Low blood pressure

• Lightheadedness

• Dizziness

• Kidney problems

• High potassium

In rare cases, these medications can cause swelling of the face, tongue, and throat. This is called angioedema, and it requires immediate medical attention.

Aldosterone receptor blockers

Aldosterone is a chemical in the body that tells the kidneys to hold onto salt and fluid. It can also cause the heart to work harder. The body makes aldosterone in response to stress in the heart. But over the long term, it can have bad effects. These include stiffness of the heart muscle and fluid retention. That’s why aldosterone can be a problem for people with heart failure. 

Aldosterone receptor blockers are medications that block the effects of aldosterone. Examples include: 

• Spironolactone

• Eplerenone 

These medications work like mild diuretics. They also can help prevent stiffening of the heart muscle. They’re particularly useful for people with a reduced ejection fraction.

Side effects of aldosterone inhibitors include:

• Stomach upset

• Breast tenderness

• More growth of body hair 

• Fatigue

• Diarrhea

• High potassium

• Abnormal kidney function

Because they can raise potassium levels, aldosterone inhibitors aren’t safe for everyone. For example, people with kidney disease are more likely to get high potassium. These medications can also interact with other medications that affect the kidneys and potassium levels. If you’re taking an aldosterone receptor blocker, a blood test can help monitor your potassium level.

Vasodilators

Vasodilators may be helpful if you can’t take an ACE inhibitor or ARB. That’s because these medications don't affect the kidneys or raise potassium levels. Vasodilators lower blood pressure by increasing the size of blood vessels. This makes it easier for the heart to pump blood forward. 

The two vasodilators used to treat heart failure are: 

• Hydralazine (Apresoline) 

• Isosorbide dinitrate (Imdur)

These two medications are usually used together. There’s also a combination pill — BiDil.

The combination treatment is especially helpful for treating heart failure in Black Americans with reduced ejection fraction. That’s because it has been shown to increase lifespan in this group. For other groups of people, the results have been mixed. 

Side effects of vasodilators are:

• Headaches

• Dizziness

• Nausea

• Vomiting

• Diarrhea

SGLT-2 inhibitors

Empagliflozin (Jardiance), dapagliflozin (Farxiga), and sotagliflozin (Inpefa) belong to a class of drugs known as SGLT-2 inhibitors. These three medications were originally developed to treat diabetes. But research has shown that they have many benefits for people with heart failure, even if they don’t have diabetes. 

These medications can reduce someone’s risk of hospitalization and death from heart failure. They are protective for people with both normal and low ejection fractions. An SGLT-2 inhibitor is usually added to other medications for heart failure.

Side effects of SGLT-2 inhibitors include:

• Urinary tract infections (UTIs)

• Yeast infections

• Dehydration

• Low blood sugar

• Dizziness

These three medications work well whether or not you have Type 2 diabetes. But people with Type 1 diabetes should not use them.

Digoxin

Digoxin is a little different from other heart failure medications. Rather than decreasing the workload on the heart, it increases the strength of the heart’s contractions. That’s why it’s sometimes used for heart failure with a low ejection fraction. 

Digoxin may lower the likelihood of being hospitalized for heart failure. But digoxin isn’t used as much as it was in the past. That’s because the other medications for heart failure are often safer and more effective.

Side effects of digoxin are:

• Poor appetite

• Nausea

• Vomiting

• Vision changes

• Confusion

• Abnormal heart rhythms

If you’re taking digoxin, you’ll need to check your digoxin blood levels from time to time. That’s because high levels can be toxic to the heart and body. 

Ivabradine

Ivabradine (Corlanor) is a medication that slows down the heart rate. It’s best for people with an ejection fraction lower than 35% and a resting heart rate above 70 beats per minute (even with high doses of beta blockers). In this group, it can help lower the risk for hospitalization or death.

Ivabradine can cause some side effects, including:

• Slow heart rate

• Fatigue

• Irregular heartbeat

• Dizziness

• Blurred vision

Omega-3 fatty acids

There’s evidence that prescription-strength omega-3 pills made from fish oil can help reduce hospitalizations for heart failure. Flax seed oil is also a source of omega-3. But it’s much less potent and doesn’t have the same benefits for heart failure.

Prescription-strength omega-3 fatty acids come from medically processed fish oil. They include:

• Lovaza

• Vascepa 

Side effects of omega-3 fatty acids include:

• Burping and indigestion

• A bad taste in the mouth

• Diarrhea

High doses of omega-3 fatty acids may also raise your risk for atrial fibrillation. So even if you aren’t prescribed these medications, it's best to check with your healthcare provider before starting a supplement.

Medications that can worsen heart failure

Below are five common categories of medications that can cause heart failure — or make it worse. This isn’t a complete list. So always check with your healthcare provider or your pharmacist if you have concerns about your medications.

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are common medications used to relieve pain, fever, and inflammation. Many are available over the counter while others are available by prescription only. Examples of NSAIDs include:

• Ibuprofen (Advil, Motrin)

• Naproxen (Aleve)

• Celecoxib (Celebrex)

• Meloxicam (Mobic)

Because of how NSAIDs work in the body, they can cause your kidneys to hold on to more water and salt. This can raise your blood pressure, which is stressful for your heart. These medications can also harm your kidneys when taken regularly, or at high doses. And that can make heart failure worse. 

Some people may need to take NSAIDs for pain relief from arthritis or other conditions. But check in with your healthcare provider if you take these medications more than once or twice per week. They’ll check your kidney function and ensure that you’re not experiencing these or other side effects.

Diabetes medications

There are several types of diabetes medications that may help protect the heart. But some can worsen heart failure, including:

• Thiazolidinediones (TZDs) like pioglitazone (Actos) and rosiglitazone (Avandia)

• DPP-4 inhibitors like saxagliptin (Onglyza) and sitagliptin (Januvia)

TZDs can cause fluid to build up in the body. This makes it harder for the heart to pump blood. DPP-4 inhibitors are also thought to destroy some heart muscle cells. If you have heart failure, this can make an already weak heart even weaker. 

Metformin is another common diabetes medication that seems to be protective for many people with heart failure. But if your kidney function is substantially below normal, it might make the problem worse. If you have heart failure and you take this medication, check in with your healthcare provider to be sure it’s right for you.

Calcium channel blockers

Calcium channel blockers (CCBs) are medications commonly used to treat high blood pressure. They’re all a little different. But two medications in this family are more likely to make heart failure worse:

• Diltiazem (Cardizem)

• Verapamil (Calan)

These two CCBs tend to slow down your heartbeat. A slower heartbeat can sometimes be helpful in heart failure. But these two CCB medications can reduce the strength of your heart’s contraction. When you stop the medications, the problem usually goes away. 

Two other CCBs can cause swelling in your legs:

• Nifedipine (Procardia)

• Amlodipine (Norvasc) 

That can happen even if your heart strength is normal. But these medications don’t usually make heart failure worse. They don’t affect your heart rate. And like the other CCBs, the problem will usually go away within a few days of stopping the medication.

Chemotherapy

Chemotherapy (chemo) is a medical treatment used to fight cancer. Sometimes chemo is given in pill form. But the more powerful types of chemo are usually given directly into your veins. Some of these medications can have harmful effects on the heart muscle. And in the worst cases, they can cause permanent heart damage. That damage causes heart failure. 

Often the more powerful chemo medications are also more likely to harm the heart. The chemo medications that are hardest on the heart are in the class of drugs known as anthracyclines. These include:

• Doxorubicin

• Daunorubicin

• Epirubicin

• Idarubicin

Oncologists (cancer specialists) will usually check the heart regularly for signs of trouble. Newer technology can pick up heart problems in the very early stages. When heart trouble is detected, your oncologist may lower your dose or choose a different option for treatment.

Trastuzumab (Herceptin) — often used for breast cancer — is another chemo medication that can affect the heart. It’s a very effective drug, and it can be life-saving. But many women will have a decrease in heart function while on this medication. That’s why oncologists check the heart regularly during treatment. Most of the time the heart will recover when the medication is stopped. And often the medication can be restarted after the heart function improves.

Stimulants

Stimulants are medications that usually increase mental alertness. Prescription stimulants treat health conditions like narcolepsy or attention deficit-hyperactivity disorder (ADHD). Common prescription stimulants include:

• Methylphenidate (Ritalin, Concerta)

• Amphetamine salt combo (Adderall)

• Vyvanse (lisdextroamphetamine)

Because of how these medications help increase alertness and attention, they can also raise your blood pressure and heart rate. That can put more strain on your heart. 

Pseudoephedrine (Sudafed) is another example of a stimulant. It’s a decongestant that many people take for cold symptoms and allergies. Even though it’s available over the counter, it can still have some harmful side effects. It can raise your blood pressure and your heart rate, which can also put more strain on the heart. 

It’s not just prescription stimulants that can be a problem. Illegal drugs like cocaine and methamphetamines are especially dangerous for the heart. They can make heart failure worse. And these drugs can also damage a healthy heart. In some cases, that damage can be permanent.

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Written by:

Sarah A. Samaan, MD

Sarah Samaan, MD, FACC, FACP, FASE is a board-certified cardiologist who practiced clinical cardiology for nearly 30 years. She is a member of the American College of Cardiology, the American College of Physicians, the American Society of Nuclear Cardiology, and the American Society of Echocardiography.

Edited by:

Katie E. Golden, MD

Katie E. Golden, MD, is a board-certified emergency medicine physician and a medical editor at GoodRx.

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