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The One Minute Counselor
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A Pharmacist's Guide to Heart Failure
ne Min Ie Counselor
Pharmacotherapy Angiotensin-converting enzyme inhibitors (ACEls) are first-line therapy for all heart failure (HF) patient . In addition to reducing morbidity and improving symptoms, ACEIs decrea e mortality in HF patients and reduce hospitalizations and prevent or delay left ventricular (LV) deterioration in patients with asymptomatic LV dysfunction (New York Heart Association [NYHA] class I). Recent data suggest that angiotensin II receptor blockers (ARBs) may have similar efficacy in HF patients. However, studies have been limited. ARBs may be considered as alternatives when ACEIs are not tolerated (angioedema, cough). Diuretics are the cornerstone of therapy for patients who have symptoms of fluid overload, such as edema, shortness of breath, and orthopnea. However, their effects on mortality are unknown. Thiazide diuretics may be used early in HF when mild diuresis is necessary and renal function is adequate (creatinine clearance > 30 mL/minute). Loop diuretics may be required as symptoms worsen and LV function deteriorates. Potassium-sparing drugs may be added to reduce potassium loss, but are weak diuretics and not usually useful alone. However, spironolactone may be a particularly useful adjunct to loop diuretics, by virtue of its action as an aldosterone
antagoni t. Recent data ugge t that pironolactone may reduce HF morbidity and mortality. Digoxin improve ymptom and exerci e capacity in patient with NYHA classe II-IV HF. Although digoxin has a neutral effect on urvival, it ignificantly reduce the need for hospitalization. In addition to it relatively weak inotropic action, digoxin appears to have important neurohumoral effects such as inhibiting sympathetic nervou system activity. {3-blockers, specifically carvedilol, metoprolol, and bisoprolol, reduce mortality in HF patients. ~-blockers are generally used in conjunction with ACEIs, diuretics, and digoxin and are indicated for patients with stable NYHA class II or III HF due to LV systolic dysfunction, unless they have a contraindication. These drugs must be initiated cautiously and titrated slowly, as HF symptoms may worsen before they improve. ~-blockers should not be initiated in NYHA class IV patients or those who are acutely ill or un table. Direct-acting vasodilators, such as the combination of isosorbide dinitrate and hydralazine, reduce symptoms and improve mortality in symptomatic patients (NYHA class II-IV). One or a combination of the e drugs may be added to ACEI for increa ed hemodynamic benefit.
Adverse Effects Contributing authors: 10 E. Rodgers, PharmD, BCPS, is cardiovascular pharmacotherapy fellow and clinical instructor; 1. Herbert Patterson, PharmD, is associate professor of pharmacy practice, University of North Carolina, Chapel Hill.
Thi s program was developed by
~
and
a~~p
ACEIs are generally very well tolerated. The most common adver e effect are hypoten ion, dizzine ,headache, fatigue, and cough. The incidence of these is generally less than 5%, with the possible exception of cough, which may be up to 20%. ACEIs should be initiated cautiou ly in patients at ri k for hypotension. Also, hypotension may be minimized by reducing the diuretic dosage. Due to their mechanism of action, an increase in serum potassium may develop. Other rare but serious adverse effects include neu-
© 1999 by the American Pharmaceutical Association. All rights reserved.
tropenialagranul yt i and angi drna. ACEI can cau e fetal and neonatal morbidity and death. ARB are conidered alternative when ACEI cau e intolerable cough or angioedema. Thiazide and loop diuretic may cau e electrolyte abnormalitie , such a hypokalemia, hyponatremia, hyperglycemia, and hyperuricemia. Hyperkalemia may be caused by the pota ium- paring diuretic . Digoxin toxicity may be cardiovascular or noncardiova cular, and is more frequent at erum digoxin concentration (SDC) above 2.0 nglmL and when certain electrolyte abnormalities are present. Ga trointe tinal symptom , vi ual changes, and central nervou y tern effects are the most common noncardiovascular symptom , while arrhythmias are the primary cardiova cular ymptoms. The dose-limiting adver e effects of ~-blocker include hypoten ion and bradycardia. Hypoten ive reaction may respond to decrea ed diuretic or vasodilator dose. Patients hould al 0 be monitored for wor ening of HF.
Drug Interactions Nonsteroidal anti-inflammatory drug and even low do e a pirin may reduce the effectivene of ACEI . Patient on diuretic therapy are at increa ed ri k for hypoten ion and a rever ible increa e in erum creatinine when tarted on an ACE!. Coadmini tration of veraparnil, broad- pectrum antibiotic ,propantheline, diphenoxylate, and certain antiarrhythmic agent (e.g., amiodarone) may increase SDC. Several medications may reduce inte tinal ab orption of digoxin (e.g., antacid chole tyramine, metocloprarnide), re ulting in low SDC. Concomitant u e of agents that may have an additive negative inotropic effect hould be a oided with ~-blocking agents.
A Patient's Guide to Heart Failure
y Doctor S y I Have Heart Failure-What Doe That Mean? H art failur d h art h fail d
ur
Y ur h art j bit pump bl d thr ugh y ur lung and around your b dy. The right ide f y ur heart pump bl d in and out of your lung , and the left ide pump blood to the r t of your b dy. Heart failure can be either right- ided or left- ided. Mo t people have left-sided heart failure- their hearts do not do a g d job of pumping blood to the rest of their bodie . When blood i not pumped ut of the left ide of the heart, blood on the right ide d e not flow as well as it h uld either. With in ufficient blood r hing th kidn Y , the kidney retain wat r which can cau the lung to fill with bI d and th r fluid . The extra fluid in y ur b dy pIa an even heavi r J ad n y ur h art.
What Will My Medicine Do For Me? t r ha pr art failure but it
mf rtable.
w
What If I Am Taking Other edicines? Make ure that your medicine for heart not interact with any other failure d medicin you are taking. Tell your doctor
Table 1. Medicines Used to Treat Heart Failure If I Am Taking:
Then I Should Watch For:
A ariety f medicine are u ed to treat heart failure. Each has been proven to be valuable in treating the di ea e, but a h can ha e ide effects in orne people. Find your medicine in the table below and tell your doctor or pharmaci t if you ha e any of the ymptom Ii ted. Photocopy this page and g' e 't t IV
I
0
Your Doctor May Watch For:
Headache An angiotensin-converting enzyme inhibitor (ACEI) Fatigue uch a : Cough Benazepril (Lotensin) Dizziness Captopril (Capoten) Enalapril (V asotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Quinapril (Accupril) Rarnipril (Altace) Moexipril (Univasc) Trandolapril (Mavik) Or an angiotensin receptor blocker such as: Losartan (Cozaar) Val artan (Diovan) Cande artan (Atacand) Irbe artan (Avapro) Eprosartan (Teveten) Telmi artan (Micardis)
Low blood pressure High potassium levels Pregnancy (contraindication)
A thiazide diuretic uch as: Dizziness HCTZ (HydroDIURIL, Muscle cramps or weakness variou other) Nausea/vomiting A loop diuretic such as: Diarrhea Furo ernide (Lasix) Tor emide (Demadex) Bumetanide (Bumex) A pota ium-sparing diuretic such as: Spironolactone (Aldactone) Triamterene (Dyrenium)
Low potassium levels Low sodium levels High blood sugar levels High uric acid levels
Digoxin (Lanoxin)
Nausea/vomiting Diarrhea Headache Changes in pulse readings Blurred or yellow vision Weakness Loss of appetite Confusion
A beta-blocker such as: Carvedilol (Coreg) Metoprolol (Lopressor, ToprolXL) Bisoprolol (Zebeta)
Dizziness Low blood pressure Fatigue Low heart rate Worsening of heart failure symptoms (e.g., shortness of breath)
A direct-acting vasodilator ( ometimes these are taken with ACEI ) such as: Nitrates (Isordil, various other ) Hydralazine (Apresoline)
Headache Nausea/vomiting Diarrhea Abdominal pain Dizziness
a tay
Will My Medicines Cause Any Side Effects?
or pharmacist the names of all other medicines you are taking before you begin taking your new medicine. It is smart to keep a list of all your medicines and update the list whenever you add a new one.
' t ' appropna e patients.
Electrolyte imbalances Changes in digoxin blood levels Changes in heart rhythm
Drug-induced lupus Low blood pressure
© 1999 by the American Pharmaceutical Association. All rights reserved.
,;"'Yo O ~j
lhe .
A Pharmacist's Guide to Heart Failure
ne Min Ie Counselor
Pharmacotherapy Angiotensin-converting enzyme inhibitors (ACEls) are first-line therapy for all heart failure (HF) patient . In addition to reducing morbidity and improving symptoms, ACEIs decrea e mortality in HF patients and reduce hospitalizations and prevent or delay left ventricular (LV) deterioration in patients with asymptomatic LV dysfunction (New York Heart Association [NYHA] class I). Recent data suggest that angiotensin II receptor blockers (ARBs) may have similar efficacy in HF patients. However, studies have been limited. ARBs may be considered as alternatives when ACEIs are not tolerated (angioedema, cough). Diuretics are the cornerstone of therapy for patients who have symptoms of fluid overload, such as edema, shortness of breath, and orthopnea. However, their effects on mortality are unknown. Thiazide diuretics may be used early in HF when mild diuresis is necessary and renal function is adequate (creatinine clearance > 30 mL/minute). Loop diuretics may be required as symptoms worsen and LV function deteriorates. Potassium-sparing drugs may be added to reduce potassium loss, but are weak diuretics and not usually useful alone. However, spironolactone may be a particularly useful adjunct to loop diuretics, by virtue of its action as an aldosterone
antagoni t. Recent data ugge t that pironolactone may reduce HF morbidity and mortality. Digoxin improve ymptom and exerci e capacity in patient with NYHA classe II-IV HF. Although digoxin has a neutral effect on urvival, it ignificantly reduce the need for hospitalization. In addition to it relatively weak inotropic action, digoxin appears to have important neurohumoral effects such as inhibiting sympathetic nervou system activity. {3-blockers, specifically carvedilol, metoprolol, and bisoprolol, reduce mortality in HF patients. ~-blockers are generally used in conjunction with ACEIs, diuretics, and digoxin and are indicated for patients with stable NYHA class II or III HF due to LV systolic dysfunction, unless they have a contraindication. These drugs must be initiated cautiously and titrated slowly, as HF symptoms may worsen before they improve. ~-blockers should not be initiated in NYHA class IV patients or those who are acutely ill or un table. Direct-acting vasodilators, such as the combination of isosorbide dinitrate and hydralazine, reduce symptoms and improve mortality in symptomatic patients (NYHA class II-IV). One or a combination of the e drugs may be added to ACEI for increa ed hemodynamic benefit.
Adverse Effects Contributing authors: 10 E. Rodgers, PharmD, BCPS, is cardiovascular pharmacotherapy fellow and clinical instructor; 1. Herbert Patterson, PharmD, is associate professor of pharmacy practice, University of North Carolina, Chapel Hill.
Thi s program was developed by
~
and
a~~p
ACEIs are generally very well tolerated. The most common adver e effect are hypoten ion, dizzine ,headache, fatigue, and cough. The incidence of these is generally less than 5%, with the possible exception of cough, which may be up to 20%. ACEIs should be initiated cautiou ly in patients at ri k for hypotension. Also, hypotension may be minimized by reducing the diuretic dosage. Due to their mechanism of action, an increase in serum potassium may develop. Other rare but serious adverse effects include neu-
© 1999 by the American Pharmaceutical Association. All rights reserved.
tropenialagranul yt i and angi drna. ACEI can cau e fetal and neonatal morbidity and death. ARB are conidered alternative when ACEI cau e intolerable cough or angioedema. Thiazide and loop diuretic may cau e electrolyte abnormalitie , such a hypokalemia, hyponatremia, hyperglycemia, and hyperuricemia. Hyperkalemia may be caused by the pota ium- paring diuretic . Digoxin toxicity may be cardiovascular or noncardiova cular, and is more frequent at erum digoxin concentration (SDC) above 2.0 nglmL and when certain electrolyte abnormalities are present. Ga trointe tinal symptom , vi ual changes, and central nervou y tern effects are the most common noncardiovascular symptom , while arrhythmias are the primary cardiova cular ymptoms. The dose-limiting adver e effects of ~-blocker include hypoten ion and bradycardia. Hypoten ive reaction may respond to decrea ed diuretic or vasodilator dose. Patients hould al 0 be monitored for wor ening of HF.
Drug Interactions Nonsteroidal anti-inflammatory drug and even low do e a pirin may reduce the effectivene of ACEI . Patient on diuretic therapy are at increa ed ri k for hypoten ion and a rever ible increa e in erum creatinine when tarted on an ACE!. Coadmini tration of veraparnil, broad- pectrum antibiotic ,propantheline, diphenoxylate, and certain antiarrhythmic agent (e.g., amiodarone) may increase SDC. Several medications may reduce inte tinal ab orption of digoxin (e.g., antacid chole tyramine, metocloprarnide), re ulting in low SDC. Concomitant u e of agents that may have an additive negative inotropic effect hould be a oided with ~-blocking agents.
A Patient's Guide to Heart Failure
y Doctor S y I Have Heart Failure-What Doe That Mean? H art failur d h art h fail d
ur
Y ur h art j bit pump bl d thr ugh y ur lung and around your b dy. The right ide f y ur heart pump bl d in and out of your lung , and the left ide pump blood to the r t of your b dy. Heart failure can be either right- ided or left- ided. Mo t people have left-sided heart failure- their hearts do not do a g d job of pumping blood to the rest of their bodie . When blood i not pumped ut of the left ide of the heart, blood on the right ide d e not flow as well as it h uld either. With in ufficient blood r hing th kidn Y , the kidney retain wat r which can cau the lung to fill with bI d and th r fluid . The extra fluid in y ur b dy pIa an even heavi r J ad n y ur h art.
What Will My Medicine Do For Me? t r ha pr art failure but it
mf rtable.
w
What If I Am Taking Other edicines? Make ure that your medicine for heart not interact with any other failure d medicin you are taking. Tell your doctor
Table 1. Medicines Used to Treat Heart Failure If I Am Taking:
Then I Should Watch For:
A ariety f medicine are u ed to treat heart failure. Each has been proven to be valuable in treating the di ea e, but a h can ha e ide effects in orne people. Find your medicine in the table below and tell your doctor or pharmaci t if you ha e any of the ymptom Ii ted. Photocopy this page and g' e 't t IV
I
0
Your Doctor May Watch For:
Headache An angiotensin-converting enzyme inhibitor (ACEI) Fatigue uch a : Cough Benazepril (Lotensin) Dizziness Captopril (Capoten) Enalapril (V asotec) Fosinopril (Monopril) Lisinopril (Prinivil, Zestril) Quinapril (Accupril) Rarnipril (Altace) Moexipril (Univasc) Trandolapril (Mavik) Or an angiotensin receptor blocker such as: Losartan (Cozaar) Val artan (Diovan) Cande artan (Atacand) Irbe artan (Avapro) Eprosartan (Teveten) Telmi artan (Micardis)
Low blood pressure High potassium levels Pregnancy (contraindication)
A thiazide diuretic uch as: Dizziness HCTZ (HydroDIURIL, Muscle cramps or weakness variou other) Nausea/vomiting A loop diuretic such as: Diarrhea Furo ernide (Lasix) Tor emide (Demadex) Bumetanide (Bumex) A pota ium-sparing diuretic such as: Spironolactone (Aldactone) Triamterene (Dyrenium)
Low potassium levels Low sodium levels High blood sugar levels High uric acid levels
Digoxin (Lanoxin)
Nausea/vomiting Diarrhea Headache Changes in pulse readings Blurred or yellow vision Weakness Loss of appetite Confusion
A beta-blocker such as: Carvedilol (Coreg) Metoprolol (Lopressor, ToprolXL) Bisoprolol (Zebeta)
Dizziness Low blood pressure Fatigue Low heart rate Worsening of heart failure symptoms (e.g., shortness of breath)
A direct-acting vasodilator ( ometimes these are taken with ACEI ) such as: Nitrates (Isordil, various other ) Hydralazine (Apresoline)
Headache Nausea/vomiting Diarrhea Abdominal pain Dizziness
a tay
Will My Medicines Cause Any Side Effects?
or pharmacist the names of all other medicines you are taking before you begin taking your new medicine. It is smart to keep a list of all your medicines and update the list whenever you add a new one.
' t ' appropna e patients.
Electrolyte imbalances Changes in digoxin blood levels Changes in heart rhythm
Drug-induced lupus Low blood pressure
© 1999 by the American Pharmaceutical Association. All rights reserved.