General considerations

• Take your medications exactly as prescribed and never stop taking them before consulting your physician.
  
• Have your blood pressure taken and lab draws as directed by your physician.
  
• Your medications may be initially started at a lower dose, then gradually increased with time at each visit.

Angiotensin Converting Enzyme Inhibitors (ACEIs)

Why is this medication prescribed to me?

• ACE inhibitors dilate (widen) blood vessels and improve blood pressure. This increases blood flow and lessens the work the heart needs to do. These medications also block some of the harmful substances the body produces when you have a weak heart.
  
• These medications are essential in the treatment of heart failure and are proven to help you live a longer and better life.

When should I take this medication?

• Take them at the same time every day. You may take them with or without food. Avoid using salt substitutes that contain potassium. Choose low-salt, low-potassium foods. If you feel dizzy after taking this medication, you can try taking it at bedtime instead of in the morning.

Examples:

• Lisinopril (Zestril, Prinivil)
• Enalapril (Renitec, Vasotec)
  
• Ramipril (Renitec, Tritace)
• Benazepril (Cebacen, Lotensin)
• Captopril (Capoten, Novo-captopril)
• Fosinopril (Staril, Monopril)
• Perindopril (Coversyl)
• Quinapril (Acuitel, Accupril)

Side effects and what to do:

• Dizziness and/or lightheadedness from low blood pressure, especially when you get out of bed or a chair. Get up slowly to let your body adjust. Contact your physician if these symptoms are severe or keep happening.

• Dry Cough. Let your physician know if this doesn’t go away. Often changing to another medication will make this side effect go away.

• Swelling of your face, neck or tongue. Stop taking the medication and contact your physician right away.

• Signs of kidney problems, including the inability to pass urine or a change in the amount of urine passed.
  
• Increase in the potassium levels in your blood. Signs of too much potassium in your body: confusion, irregular heartbeat, nervousness, numbness and tingling in your hands, feet or lips and weakness or heaviness in your legs. Contact your physician immediately. You may need to have labs drawn.

Angiotensin II Receptor Blockers (ARBs)

ARBs work similarly to ACEIs. They dilate (widen) blood vessels and improve blood pressure. This increases blood flow and lessens the work the heart needs to do. These medications also block some of the harmful substances the body produces when the heart is weak.

Examples:

• Candesartan (Atacand)
  
• Losartan (Cozaar)
  
• Valsartan (Diovan)

Side effects and what to do:

• Dizziness and/or lightheadedness from low blood pressure, especially when you get out of bed or a chair. Get up slowly to let your body adjust. Contact your physician if these symptoms are severe or keep happening.
• Dry cough. Let your physician know if this does not go away. Often changing to another medication will make this side effect go away.

• Swelling of your face, neck or tongue. Stop taking the medication and contact your physician right away.

• Signs of kidney problems, including the inability to pass urine or a change in the amount of urine passed.
  
• Increase in the potassium levels in your blood. Signs of too much potassium in your body: confusion, irregular heartbeat, nervousness, numbness and tingling in your hands, feet or lips and weakness or heaviness in your legs. Contact your physician immediately. You may need to have labs drawn.

Compared to ACE inhibitors, cough occurs significantly less often with ARBs. ARBs usually are not prescribed for pregnant patients because they may cause birth defects. Individuals who have narrowing of both kidney arteries or have had a severe reaction to ARBs should avoid them.

Beta-blockers

Beta-blockers improve the heart’s ability to relax and decrease the production of harmful substances. Over time, beta-blockers may improve the heart’s pumping ability.

Examples:

• Carvedilol (Coreg, Dilatrend)
  
• Bisoprolol (Concor)
  
• Metoprolol succinate (Toprol XL)

Side effects:

• Dizziness and lightheadedness, from low blood pressure.
  
• Blurred vision.
  
• Sexual dysfunction.
• Sudden weight gain: weight gain is common as your physician increases your medication dose. If you gain more than one kilogram in one day or if you gain more than three kilograms in one week.
• Sudden withdrawal may worsen angina (chest pain) and cause heart attacks or sudden death. Do not stop taking your medication unless you talk with your physician first.
• Feeling tired or weak.
• Headache, depression, nightmares and difficulty sleeping.
• Shortness of breath in patients with asthma or other lung diseases.
• If you have high blood sugar (diabetes), you will need to watch your blood sugar closely. This medication may hide the symptoms of low blood glucose (hypoglycemia).

Diuretics (water pills)

Diuretics help the body get rid of excess fluids and sodium through urination. This helps to relieve the heart’s workload and decreases the buildup of fluid in the lungs and other parts of the body, such as the ankles and legs.

Special Instructions:

• Weigh yourself at the same time every day wearing the same amount of clothes.
  
• Call your physician or pharmacist if you gain more than one kilogram in one day or three kilograms in one week.
  
• Always, follow the instructions of your physician or pharmacist on how to adjust your dose based on your daily or weekly weight.

Examples:

• Furosemide (Lasix)
  
• Bumetanide (Bumex, Burinex)
  
• Torsemide (Demadex)
• Chlorothiazide (Diuril)
• Chlorthalidone (Hygroton)
• Metolazone (Metenix, Zaroxolyn)
• Amiloride (Midamor)
• Hydrochlorothiazide (Esidrix, Monozide, Hydrodiuril)
• Indapamide (Fludex, Indanorm, Netrilix SR, Lozol)

Side effects and what to do:

• Fluids and electrolyte problems. Signs include: muscle cramps, weakness, extreme thirst, confusion, excessive dryness of the mouth, decreased urine output, dark-colored urine and constipation. Ensure you are taking your potassium supplement if prescribed as diuretics might lower the potassium in your blood. Contact your physician if these symptoms persist. Don’t assume you need more fluids, call your physician instead.

• Dizziness and lightheadedness. Rise slowly from bed or sitting in a chair.

• Blurred vision, headache, confusion, sweating and restlessness. Contact your physician if these symptoms are severe.

• Ringing in your ears. Call your physician immediately as some of these medications can affect your hearing.

• Skin rash. Stop taking the medication and contact your physician immediately.

• Arrhythmia (abnormal heart rhythm).

Aldosterone Antagonists

Aldosterone Antagonists are also called potassium-sparing diuretics or aldosterone antagonists and can be used to get rid of excess swelling and water build-up. However, small doses of these medications prevent heart failure symptoms from getting worse and may help you live longer. The medications protect the heart from certain hormones the body produces.

Examples:

• Spironolactone (Aldactone)
  
• Eplerenone (Inspra)

Side effects and what to do:

• Abnormal enlargement of one or both breasts in men. May be associated with breast pain. This can be a side effect of spironolactone. You might be prescribed Eplerenone instead if these symptoms occur.

• Skin rash. Stop taking the medication immediately and call your physician.

• Confusion, irregular or slow heartbeat, nervousness, numbness or tingling in your hands, feet or lips.
  
• Increase in the potassium levels in your blood. Signs of too much potassium in your body: confusion, irregular heartbeat, nervousness, numbness and tingling in your hands, feet or lips, difficulty breathing, weakness or heaviness in your legs.

Vasodilators

Vasodilators relax blood vessels and increase the supply of blood and oxygen to the heart while reducing its workload.

Examples:

• Isosorbide dinitrate (Isordil)
  
• Isosorbide mononitrate (Imdur)
  
• Hydralazine (Apresoline)

Side effects:

• Lightheadedness or dizziness.
  
• Increased or irregular heart rate.
  
• Headache.
  
• Upset stomach, flushing of face or neck.

Digoxin

Digoxin helps to strengthen the heart muscle’s contraction. It is also used to treat a certain type of irregular heart rhythm (chronic atrial fibrillation).

Side effects and what to do:

• Loss of appetite, nausea and vomiting.
  
• Changes in vision such as flickering or flashes of light, sensitivity to light, blurring, color changes (yellow or green), and seeing halos or borders around objects.
  
• Drowsiness, headaches, confusion, depression, fatigue and muscle weakness.

Contact your physician right away if you have any of the above symptoms. The dosage of your medication may need to be adjusted.

Ivabradine (Procoralan, Corlanor)

Ivabradine is used to slow down your heart rate so that your heart does not have to work as hard to pump blood. This medication must always be taken with food.

Side effects and what to do:

• Changes in vision such as sudden changes in response to brightness may occur. This may affect your ability to drive at night. Discuss this side effect with your physician or pharmacist.
  
• Headache.
  
• Avoid drinking grapefruit juice while taking ivabradine as it may increase the amount of the medication in your body.

Sacubitril/valsartan (Entresto)

Sacubitril/Valsartan is a combination medication that may be used in place of ACEI or ARB. This medication also increases blood flow so that your heart does not have to work as hard to pump blood. It also blocks some of the harmful substances the body produces when you have a weak heart. This medication is proven to help you live a longer and better life.

If you are already on an ACEI it is important to allow for a 36 hour washout period from the time you stop the ACEI to the time you start this medication.

Side effects and what to do:

• Hypotension or low blood pressure is more common with this medication than with ACEI.
  
• Other side effects are similar to ACEIs and ARBs.

Medications to avoid

Nonsteroidal Anti-inflammatory Drug (NSAIDs):

NSAIDs such as ibuprofen (Advil, Profinal) which are sometimes used for pain or headaches and are not recommended for heart failure. These medications block some of the compensatory vasodilation that your kidneys may perform in response to your condition resulting in worsening of your kidney function, heart failure and further water retention. These medications should not be used unless prescribed by your physician. If you are to self-treat your headache or pain, paracetamol or acetaminophen (Panadol, Tylenol) is preferred.

Important points to remember

In heart failure, you may need to have devices and advanced therapies:

• Pacemaker: treats slow heartbeat or an out of sequence rhythm
  
• Defibrillator: treats abnormal rhythms when they become life-threatening
  
• Ventricular assist devices: boosts blood flow from the heart mechanically to replace the work of failing heart muscle
  
• Coronary arteries bypass graft: restores blood flow around blocked arteries of the heart
• Valve surgery: treats abnormal heart valves
• Heart transplant

Each patient will have a unique plan regarding these types of therapies based on their potential benefits and risks.

Worsening heart failure can present as increased shortness of breath, fatigue, leg swelling and rapid weight gain. Please weigh yourself daily and record your weight every day. Please bring your weight record to every clinic visit.

Please call if you have symptoms of worsening heart failure:

• Shortness of breath at rest, at night, or that is getting worse in any way
  
• Shortness of breath at rest, at night, or that is getting worse in any way
• Needing to use extra pillows at night to help with breathing
• Palpitations
• Weight gain of 2.2 kilograms (five pounds) or more in a week
• More swelling in your legs or ankles
• You gain 1.4 kilograms (three pounds) or more in a day, or more than your cardiologist says you should
• Abdominal pain or swelling
• More coughing
• Loss of appetite
• Feeling tired all the time
• Feeling hopeless or depressed, or losing an interest in things you used to enjoy
• Feeling worried or afraid
• Having questions or concerns about your condition or care

Seek care immediately or call 999 if you have any of the following signs of a heart attack:

• Squeezing, pressure or pain in your chest that lasts longer than five minutes or returns
  
• Discomfort or pain in your back, neck, jaw, stomach or arm
• Trouble breathing
• Nausea or vomiting
• Lightheadedness or a sudden cold sweat, especially with chest pain or trouble breathing
• A heartbeat that is fast, slow or uneven all the time
• If you have coronary artery disease and have chest pain that is not relieved with Nitroglycerin, please have someone drive you to the closest Emergency Room (ER)
• Eat a balanced diet with low salt content (two grams of salt or less per day)
• Limit total fluid intake to two liters (68 fluid ounces) per day
• Keep active. Walking is a great form of exercise
• Take all of your medications as prescribed. Do not stop your medications on your own when you feel better, keep taking them
• Always bring an accurate medication list or medication bottle(s) to your clinic visits

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