AHA Advises Physicians to Monitor Medications That Might Cause or Worsen Heart Failure

Many medications can worsen heart failure in patients who have the condition already or even cause new cases. But much can be done to address the potential for toxicity or drug-drug interactions, according to a scientific statement released Monday by the American Heart Association (AHA) that gathers together existing evidence on the issue.

Using a team-based approach to care and paying more close attention to nonprescription drugs could help ease the situation. Specifically, the statement provides evidence-based drug and treatment options to help providers better manage polypharmacy, or the long-term use of five or more drugs.

On average, heart failure patients take nearly seven different prescription medications and more than 10 doses each day, the AHA document says. This is on top of any over-the-counter and complementary and alternative medications.

“The purpose of this statement is not so much to show there’s a huge laundry list, because this is a dynamic document [and] things change in medicine every single day,” writing committee chair Robert L. Page II, PharmD (University of Colorado, Aurora), told TCTMD. Instead the message is “to be mindful in patients with heart failure that there are drugs that can possibly exacerbate their condition.”

Up-to-Date and Evidence-Based

The AHA statement contains detailed advice on medications ranging from analgesics to urological agents and highlights the potential for both direct myocardial toxicity or drug-drug interactions. Patients with heart failure are particularly vulnerable given their high comorbidity burden that necessitates many medications and frequent visits to different healthcare providers.

“This is really a very valuable resource to be able to have this, having been adjudicated and collected by a panel of experts and really put together very nicely and comprehensively regarding the medication that can significantly impact the health of heart failure patients,” Gregg Fonarow, MD (Ronald Reagan UCLA Medical Center, Los Angeles, CA), who was not involved in creating the AHA statement, told TCTMD. “To have that all collected in an up-to-date and evidence-based document is really of substantial value.”

The tables and recommendations in the statement focus on showing the balance between the risks and benefits of prescribing specific drugs to heart failure patients. It’s also important, Page said, to be aware of peripheral effects of over-the-counter drugs and supplements as well as the presence of sodium in many drugs.

“The key to this in this day and age is preventing readmissions,” Craig Beavers, PharmD (University of Kentucky, Lexington), said, commenting on the document for TCTMD. “And if you can eliminate some iatrogenic-induced causes of readmission such as prescribing drugs that may not be the best choice for a patient or mitigate the risks of those medications, I think it’s good to have that consensus statement.”

Sodium as a Hidden Danger

One of the AHA’s recommendations is that physicians should look more closely at any drugs and supplements patients might be taking outside of their prescription regimen. For example, a drug’s contribution to sodium intake could cause problems.

“[For] a lot people, it doesn’t cross their minds when [prescribing] a drug to a heart failure patient how much sodium is in that medication,” Beavers said. Oftentimes a heart failure patient might be prescribed an antibiotic such as piperacillin/tazobactam, which according to the paper contains up to 256 mg of sodium per a 4.5-gram vial. “And a lot times you are giving them that drug up to four to five times a day. That really adds up in terms of total salt intake,” he noted.

Page also highlighted the negative effects of the sodium content in many medications, whether prescribed or purchased over the counter, as a main takeaway from the paper. Sodium is not the primary focus when monitoring medication routines and can easily be missed by providers, he said.

Recommending a Team Effort

An organized, team-based approach is another key to managing effects of medication, according to Beavers.

“It’s critical to have to have a pharmacist there as a medication therapy expert,” Beavers said. “And you can see the impact here from even the global perspective that pharmacists helped organize and put this document together.”

Pharmacists played an important role in crafting the statement, as evidenced by Page’s role as the chair of the committee. But while the team as a group needs to offer solutions, there should be defined roles for all the players involved in a patient’s care.

“For example in heart failure we particularly have multiple individuals that lay hands on the patient,” Page said. “You have their primary care provider, you have their cardiologist, you have nurse practitioners, and you have pharmacists, and each time we are gleaning information from the patient. Where that needs to be focused then is primarily to whoever that ‘captain’ is who is in charge of managing that patient.”

Advice Feasible to Implement

In total the paper contains nine recommendations for how to better monitor and manage a heart failure patient’s medication load. Most of them reference systems of organization such as the team approach or flow charts, but the first encourages in-depth consultation with patients to determine all of the drugs, doses, and frequencies of use. Another recommendation suggests taking time to further educate a patient about possible over-the-counter and complementary and alternative drugs.

The advice is “challenging, though, if you do look at some of these recommendations and think about the time that would be involved,” Fonarow said. “Having a medication flow sheet reviewed at each visit and updated is really great and worthwhile, but having a system in place to do this efficiently and accurately is going to be something that really will take some attention.”

The additional time and energy might be challenging, but Fonarow doesn’t think that it would be beyond the scope of a provider. And in the end, the statement is meant to help physicians improve care wherever possible, Page commented.

“[A] large number of providers, particularly cardiologists, are not used to prescribing some of the medications like, let’s say, oncology or psychiatric medications,” Page said. “Therefore, we hope it would be a good reference to at least to look at to see whether or not for a patient [the drug] would potential exacerbate their heart failure.”

Michael H. Wilson is the 2016 recipient of the Jason Kahn Fellowship in Medical Journalism.

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