Many commonly used medications and nutritional supplements can either cause heart failure or exacerbate existing heart failure, according to a scientific statement from the American Heart Association published in Circulation.
“Since many of the drugs heart failure patients are taking are prescribed for conditions such as cancer, neurological conditions, or infections, it is crucial but difficult for healthcare providers to reconcile whether a medication is interacting with heart failure drugs or making heart failure worse,” said Robert L. Page II, PharmD, MSPH, professor at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in Aurora, Colo.
Patients with heart failure have an average of 5 or more distinct medical conditions and take 7 or more prescriptions medications daily. Healthcare providers should discuss medication use with all heart failure patients, including over-the-counter medications, prescriptions, and nutritional supplements.
The medications that can cause or exacerbate heart failure are outlined in the following 13 tables:
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Table 1. Analgesics that may cause or exacerbate heart failure
| Drug or therapeutic class | Does it cause direct myocardial toxicity? | Does it exacerbate underlying myocardial dysfunction? | Magnitude of heart failure induction/precipitation | Possible mechanism(s) |
| COX, nonselective inhibitors (NSAIDs) |
No |
Yes |
Major |
Prostaglandin inhibition leading to sodium and water retention, increased systemic vascular resistance, and blunted response to diuretics |
| COX, selective inhibitors (COX-2 inhibitors) |
No |
Yes |
Major |
Prostaglandin inhibition leading to sodium and water retention, increased systemic vascular resistance, and blunted response to diuretics |
Table 2. Anesthesia medications that may cause or exacerbate heart failure
| Drug or therapeutic class | Does it cause direct myocardial toxicity? | Does it exacerbate underlying myocardial dysfunction? | Magnitude of heart failure induction/precipitation | Possible mechanism(s) |
| Desflurane |
No |
Yes |
Major |
Myocardial depression, peripheral vasodilation, attenuated sympathetic activity |
| Enflurane |
No |
Yes |
Major |
Myocardial depression, peripheral vasodilation, attenuated sympathetic activity |
| Halothane |
No |
Yes |
Major |
Myocardial depression, peripheral vasodilation, attenuated sympathetic activity |
| Isoflurane |
No |
Yes |
Major |
Myocardial depression, peripheral vasodilation, attenuated sympathetic activity |
| Sevoflurane |
No |
Yes |
Major |
Myocardial depression, peripheral vasodilation, attenuated sympathetic activity |
| Dexmedetomidine |
No |
Yes |
Moderate |
α2-Adrenergic agonist |
| Etomidate |
No |
Yes |
Moderate |
Suppression of adrenal function |
| Ketamine |
No |
Yes |
Major |
Negative inotrope |
| Propofol |
No |
Yes |
Moderate |
Negative inotrope, vasodilation |
Table 3. Diabetes mellitus medications that may cause or exacerbate heart failure
| Drug or therapeutic class | Does it cause direct myocardial toxicity? | Does it exacerbate underlying myocardial dysfunction? | Magnitude of heart failure induction/precipitation | Possible mechanism(s) |
| Metformin |
No |
Yes |
Major |
Increased anaerobic metabolism and elevated lactic acidosis |
| Thiazolidinediones |
No |
Yes |
Major |
Possible calcium channel blockade |
| Saxagliptin |
No |
Yes |
Major |
Unknown |
| Sitagliptin |
No |
Yes |
Major |
Unknown |
Table 4. Antiarrhythmics medications that may cause or exacerbate heart failure
| Drug or therapeutic class | Does it cause direct myocardial toxicity? | Does it exacerbate underlying myocardial dysfunction? | Magnitude of heart failure induction/precipitation | Possible mechanism(s) |
| Flecainide |
No |
Yes |
Major |
Negative inotrope, proarrhythmic effects |
| Disopyramide |
No |
Yes |
Major |
Negative inotrope, proarrhythmic effects |
| Sotalol |
No |
Yes |
Major |
Proarrhythmic properties, β-blockade |
| Dronedarone |
No |
Yes |
Major |
Negative inotrope |
