Drugs That Can Exacerbate Heart Failure

If you're living with congestive heart failure (CHF), it's important to be aware there are certain medications that could exacerbate your condition.

Some drugs, including many used to treat other ailments, are known to worsen heart failure, typically by raising blood pressure and heart rate, creating an irregular heartbeat, or causing edema (swelling) due to a buildup of fluid in the body. Others may interact with medications you're taking to treat congestive heart failure. If you have heart failure, check with your healthcare provider before taking any medications, vitamins, or supplements.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Nonsteroidal anti-inflammatories treat pain and inflammation caused by conditions like arthritis, tendonitis, bursitis, and musculoskeletal injuries. They're effective for relieving headaches, lowering fevers, and preventing blood clots.

Drugs in this class include both over-the-counter (OTC) medications as well as prescription-strength treatments. Most people can safely take NSAIDs, but there are some potential risks associated with long-term or frequent use, such as stomach ulcers and kidney problems.

Examples include:

• Aspirin
• Advil, Motrin (ibuprofen)
• Aleve, Naprosyn (naproxen)
• Clinoril (sulindac)
• Daypro (oxaprozin)
• Etodolac
• Nabumetone
• Vimovo (naproxen/esomeprazole)
• Zorvolex (dilofenac)
• COX-2 inhibitors, such as Celebrex (celecoxib)
• Feldene (piroxicam)
• Indocin (indomethacin)
• Mobic (meloxican)

Why They Worsen Heart Failure

For people with congestive heart failure, even short-term use of NSAIDs can increase blood pressure and interfere with blood-pressure-lowering drugs. When blood pressure is high, the heart must work harder to pump blood which can contribute to weakening of the heart muscle over time.

Precautions and Contraindications

The Food and Drug Administration (FDA) warns NSAIDs can increase the chance of a heart attack or stroke, either of which can lead to death. Those serious side effects can occur as early as the first few weeks of using an NSAID, and the risk might rise the longer an NSAID is taken. Besides exacerbating heart failure, NSAIDs can worsen hypertension (high blood pressure).

Thiazolidinediones (TZD)

Thiazolidinediones (also called glitazones) are a class of oral medications for treating type 2 diabetes. They're prescribed to lower glucose (sugar) levels in the blood by reducing the body’s resistance to insulin. They do this by targeting the PPAR-gamma receptor, which activates a number of genes in the body and plays an important role in how the body metabolizes glucose and stores fat.

Examples include:

• Avandia (rosiglitazone)
• Actos (pioglitazone)
• Combination pills containing pioglitazone and rosiglitazone along with other diabetes medications such as metformin

Why They Worsen Heart Failure

Thiazolidinediones can cause people with moderate to severe heart failure to retain dangerous levels of fluid that can potentially compromise the function of the lungs.

Precautions and Contraindications

The risk of heart failure appears to be a class side effect of TZDs, based on research. In one review of three randomized controlled trials of more than 10,000 people taking TZDs it was revealed the drug doubled the risk of heart failure compared with control subjects.

Hormonal Therapies

These include estrogen replacement therapy prescribed to help assuage hot flashes, vaginal dryness, bone loss, and other symptoms associated with menopause as well as oral contraceptives (birth control pills) containing estrogen and, sometimes, synthetic progesterone as well. The latter are used not only to prevent pregnancy but also to treat menstrual issues such as painful periods, PMS, irregular cycles, and excessive bleeding.

Examples include:

• Synthetic estrogens like Premarin and Ethinylestradiol
• Estradiol (Estrace, Estratab, Yuvafem, Vivelle-Dot, Delestrogen, EstroGel)
• Progestin, a synthetic progesterone (Endometrin, Prometrium, First Progesterone, Provera)
• Birth control pills combining various combinations of synthetic progesterone and estrogen (Microgynon, Rigevidon, Ovranette)

Why They Worsen Heart Failure

Birth control pills and hormone replacement can raise blood pressure and they can increase the risk of blood clots, heart attack, and stroke. However, it is not necessarily the elevated blood pressure that leads to the blood clots, strokes, heart attack.

Precautions and Contraindications

High-blood pressure must be well-controlled before initiating a trial of hormone therapy and blood pressure must be closely monitored.

Stimulants

These include psychotropic drugs for treating conditions such as attention deficit hyperactivity disorder (ADHD), narcolepsy, and social anxiety disorder, among others. They increase alertness, attention, and energy by raising the levels of certain brain chemicals.

Examples include:

• Adderall (dextroamphetamine/amphetamine)
• Focalin (dexmethylphenidate)
• Vyvanse, Zenzedi, Procentra, Dextrostat, Spansule (lisdexamfetamine)
• Dexedrine (dextroamphetamine)
• Ritalin, Concerta (methylphenidate)
• Adipex-P, Lomaira (phentermine)

Why They Worsen Heart Failure

Stimulants pose a risk to people with heart failure because they are known to elevate both blood pressure and heart rate.

Precautions and Contraindications

Package inserts for stimulants warn that people with preexisting heart disease or cardiac abnormalities should not take these medications due to risk of myocardial infarction, stroke, or even sudden death.

In 2011, the FDA issued a safety announcement regarding the safety of stimulants for people with cardiac conditions.

Chemotherapy Drugs

A number of medications used to treat cancer are associated with potential heart issues. However, the class of drugs of most concern are anthracyclines, which are derived from antibiotics that inhibit DNA and RNA synthesis and prevent cancer cells from growing.

Examples include:

• Cerubidine (daunorubicin)
• Doxil (doxorubicin liposomal)
• Ellence (epirubicin)
• Idamycin (idarubicin)
• Valstar (valrubicin)

Why they Worsen Heart Failure

Anthracyclines can permanently damage the heart muscle, especially when given at a high dose. They do so by causing the formation of free radicals—pairs of electrons that damage the body's cells, ultimately causing damage to the heart's left ventricle.

Precautions and Contraindications

Because chemotherapy drugs are known for the risk they pose to the heart, an oncologist will carefully consider a person's cardiac health when prescribing them.

Antidepressants

Antidepressants help relieve symptoms of depression, social anxiety disorder, anxiety disorders, and other mental health conditions by altering brain chemicals (neurotransmitters) that pass along signals from one nerve cell to another in the brain. These chemicals include serotonin, dopamine, and norepinephrine. Different antidepressants seem to affect how these neurotransmitters work in different ways.

There are five classes of antidepressant:

• Selective serotonin reuptake inhibitors (SSRIs): Prozac (fluoxetine), Zoloft (sertraline), Celexa (citalopram), and Lexapro (escitalopram), and others
• Serotonin and norepinephrine reuptake inhibitors (SNRIs): Cymbalta (duloxetine), Effexor (venlafaxine), Pristiq (desvenlafaxine), and others
• Tricyclics: Elavil (amitriptyline), Anafranil (clomipramine), and others
• Monoamine oxidase inhibitors (MAOIs): including Nardil (phenelzine), Marplan (isocarboxazid), and others (which can cause dangerous interactions with certain foods—such as cheeses, wines, and pickles)
• Atypical antidepressants: Wellbutrin (bupropion), and others
  

Why They Worsen Heart Failure

Antidepressants can have numerous negative effects on the heart and the cardiovascular system. According to one review these may include:

• Bradycardia (slowed heart rate)
• Tachycardia (increased heart rate)
• Arrhythmias (irregular heartbeats)
• Hypertension
• Hypotension (depressed blood pressure)
• Orthostatic hypotension (dizziness upon rising from a sitting or prone position)
• Electrocardiogram (EKG) changes
• Electrolyte imbalances
• Reduced cardiac conduction and output
• Sudden death

However, for the most part cardiac side effects caused by antidepressants are relatively rare and are not associated with all classes of the drugs. Some literature shows SSRIs may increase the risk of clotting and other literature shows they increase the risk of bleeding.

Precautions and Contraindications

Because of the potential blood clotting issues linked to SSRIs, they may not be a safe option for people who take a daily aspirin for heart health (or any other NSAID, for that matter).

Tricyclics may affect heart rhythms and for people for whom arrhythmias are an issue an SSRI is likely safer.

Opioids

Opioids are a class of drug derived from the opium poppy plant. They primarily are prescribed to relieve severe pain, such as after a serious injury or surgical procedure. They work by blocking pain signals between the brain and the body.

Examples include:

• Codeine
• Morphine
• Vicodin (hydrocodone)
• Percocet (oxycodone/paracetamol)
• Actiq, Fentora, Duragesic (fentanyl)
• Oxycontin (oxycodone)

Why They Worsen Heart Failure

Opioids are associated with a host of heart issues, including an increase in low-density lipoproteins and free triglycerides, heart infections, and atrial fibrillation. They also can slow the heart rate, lower blood pressure, cause ventricular tachycardia, atrial fibrillation. If opioids are injected with dirty needles, there is a risk of  infectious endocarditis. 

Precautions and Contraindications

Opioids are highly addictive and must be prescribed and used with care. In fact, heroin, an illicit street drug, is an opioid, as is methadone, a medication often used to treat heroin addiction. An opioid generally should be considered a drug of last resort for treating chronic pain, as taking one for an extended period significantly heightens the risk of addiction.