Heart Failure Medications

Zachary Cox, PharmDAssociate Professor

Lipscomb University College of PharmacyClinical Pharmacist, Vanderbilt University Medical Center

Medications in HFACE Inhibitors

(ACEIs)Angiotensin

Receptor Blockers (ARBs)

Beta Blockers Aldosterone Antagonists

CaptoprilBenazeprilEnalaprilFosinoprilLisinopril

PerindoprilQuinaprilRamipril

Trandolapril

CandesartanLosartanValsartan

BisoprololCarvedilol

Carvedilol CRMetoprolol XL

SpironolactoneEplerenone

Medication Differences by Ejection FractionSystolic HF (HF r EF)

Diastolic HF (HF p EF)

Medication Studies Many StudiesPositive Results

Fewer StudiesFrustrating Results

Medication Outcomes Increased Length of LifeLess Hospitals Visits

Less Hospital Visits

Medication Goals Specific Doses Symptom ControlBlood Pressure Control

Medications that improve HF outcomes

ACEI, ARB, Valsartan/Sacubitril, Beta

Blocker, Aldosterone Antagonist,

Hydralazine/Nitrate, Ivadrabine, Digoxin

ARBs

Spironolactone

Symptom ControlHospital Avoidance

Increased length of life

ACE Inhibitors

-OR-

ARBs-OR-

Sacubitril/Valsartan

-OR-

Hydralazine + Nitrates

Beta Blockers

Carvedilol

-OR-

Metoprolol XL

-OR-

Bisoprolol

Aldosterone Antagonists

Spironolactone

-OR-

Eplerenone

Additional Symptom Control

Loop Diuretics

• Bumetanide• Furosemide• Torsemide• Ethacrynic

Acid

HF Medications

• Digoxin• Ivabradine• Nitrates• Tolvaptan

Disease States

• Heart Rhythm• Heart Arteries• Heart Valves• Diabetes• Cholesterol• Blood Pressure• Sleep Apnea• Kidney Disease• Lung Diseases

Loop DiureticsThreshold Effect Duration of Effect

0 1 2 3 4 5 6 7Hours

0 1 2 3 4 5 6 7Hours

DIU

RETI

C

DIU

RETI

C

Multiple Providers & Conflicting Advice

• HF patients with Medicare see an average of 15 providers a year and have 8 different prescribers

• 17% report conflicting advice from doctors

• 22% of HF patients taking wrong medications received conflicting medication instructions

• 2/3 HF patients have 2-3 different diets

State of the Science: Promoting Self-Care in Persons with Heart Failure. Circulation 2009;120:1141-63.

Medications to Avoid in HF

• Diltiazem/Verapamil• Itraconazole• Cilostazol• Flecanide• Propafenone• Pioglitazone/

Rosiglitazone• Minoxidil• Dronedarone• ADHD Medications

• NSAIDs– Ibuprofen– Naproxen– Celecoxib– Meloxicam– Diclofenac

• TNF Alpha Inhibitors– Infliximab (Remicade)– Etanercept (Enbrel)– Adalimumab (Humira)

Medication Adherence

1. Forgetful or Busy

2. Access to Pharmacy

3. Perception• Benefit• Risks

4. Organization• Administration times• Refill dates

1. Reminder Alerts

2. Home Delivery

3. Initiate Conversation• Real outcomes• Odds of adverse event• Individualized risk

Barriers Solutions

Medication Organization

Levothyroxine

Furosemide

Enalapril

Carvedilol

Hydralazine

Isosorbide Dinitrate

Hydralazine

Isosorbide Dinitrate Furosemide

Carvedilol

Hydralazine

Isosorbide Dinitrate

Enalapril

Atorvastatin

Furosemide

Enalapril

Carvedilol

Hydralazine

Isosorbide Dinitrate

Furosemide

Hydralazine

Isosorbide Dinitrate

AtorvastatinEnalapril

CarvedilolHydralazineIsosorbide Dinitrate

Levothyroxine

6 AM 7 AM Noon 3 PM 6 PM 10 PM

7 AM 3 PM 10 PM