Heart failure

Beta-blockers, ACE inhibitors, diuretics and aldosterone antagonists

The recommended initial drug treatment for heart failure caused by coronary heart disease and heart attack includes an ACE inhibitor and a beta-blocker and if necessary a diuretic ('water tablet'). Getting the balance of these three drugs right for each individual is complicated and may take time and as heart failure progresses the drugs may need to be taken in stronger doses. It is important that beta blockers and ACE Inhibitors are started on a low dose and gradually increased in a stepwise fashion allowing the body time to adjust after each change. People we spoke to often recalled their medicines being introduced in this way; some had yet to reach the best dose for them and Daniel was having difficulty tolerating his increases in dose. Achieving the best dose of the triple combination of drugs could lead to considerable improvements in the condition.

Diuretics help the kidneys to pass more salt and water into the urine, which reduces ankle swelling, lowers blood pressure and should relieve breathlessness. Taking a diureticwas very common amog people we talked to, which they said was extremely effective at reducing excess fluid and helping relieve breathlessness. Most people accepted that they would need to go to the loo much more than before and that they needed to plan their lives accordingly; one woman found she was going to the loo at least 6 times between breakfast and lunch, others had been advised to take their diuretic earlier in the day to avoid being kept awake at night. Taking diuretics for long periods was linked with dehydration (see 'Common side effects of heart failure medication').

The effect diuretics had on their lives could make people feel resentful, particularly when they wanted to travel long distance  or go out, and so sometimes they did not take them exactly as prescribed (see 'Attitudes to medication'). Doctors had discussed with some people how they could vary the dose of their diuretic depending on their level of fluid retention (as measured by their weight), or the timing of it to avoid the inconvenience of needing the toilet when out and about (see ‘Heart failure monitoring at home). One woman said she only took the diuretic when she needed it because her ankles were swollen or she felt breathless. By contrast, one man said he had not been given advice about varying his dose but would like to be able to do that.
Some people we spoke to were also taking aldosterone antagonists such as spironolactone and eplerenone. These may be prescribed if symptoms persist despite taking beta blockers and ACE Inhibitors. They work in a similar way to diuretics and have been shown to relieve symptoms, reduce the risk of hospitalisation and extend the life expectancy of people with heart failure. People taking these medicines require regular blood tests to monitor their potassium levels.

Beta-blockers work by making the heart beat more slowly, and were thought of by many as the most important drug for heart failure; one man described beta-blockers as 'the big stuff' and another thought that his doctors and heart failure nurse were only really interested in his beta-blockers. Dizziness, nausea and diarrhoea were  noticed by some people when they first started the beta-blocker, and one woman said that at first they made her feel more ill but that she knew she had to persevere with them nonetheless. Once the right level had been reached many people were comfortable with beta-blockers. Several men said that they had experienced loss of libido since taking beta-blockers and ACE inhibitors but were uncertain which had caused it. (See 'Other side effects of heart failure medication').

If beta-blockers do not slow the heart enough a drug called ivabradine may be added. It may also be prescribed for people who cannot tolerate beta-blockers.

ACE (Angiotensin converting enzyme) inhibitors are prescribed for those who have developed heart failure from coronary heart disease. They work partly by relaxing the arteries enabling blood to flow through them more freely. The triple combination of drugs makes it difficult for people to know which drugs are associated with which side effects (see 'Common side effects of heart failure medication'). People who experience unacceptable side effects from ACE inhibitors, such as a cough that won’t go away, may be swapped to an Angiotension Receptor Blocker (ARB), such as candesartan, which works in a similar way.


Last reviewed April 2016.
Last updated April 2016.


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