Commonly Used Drugs Can Cause or Worsen Heart Failure

The first scientific statement from the American Heart Association (AHA) on drugs that may cause or exacerbate heart failure (HF) reports that patients with HF on average take 6.8 prescription medications per day, which is approximately 10.1 doses per day. Multimorbidity in patients with HF escalates the complexity of care. As the number and complexity of drug therapies increase, the potential for adverse events and drug-drug interaction also increases. The statement provides a clinically relevant list of medications which can lead to direct myocardial toxicity, exacerbate underlying myocardial dysfunction, or lead to induction or precipitation of HF. These agents should generally be avoided or used with caution and include medications commonly used in managing many conditions in HF patients, such as metformin, dipeptidyl peptidase-4 inhibitors, selective and non-selective COX inhibitors, non-dihydropyridine calcium channel blockers, class I and III antiarrhythmics, and urologic α-blockers. Other prescription drug classes highlighted in the statement include anti-neoplastic agents, anti-fungal medications, anti-malarials, stimulants, and TNF-α inhibitors, among many others.

The statement also includes a list of 14 medications with high sodium content, emphasizing the need to evaluate non-dietary sources of sodium in HF patients. Commonly used anti-infectives such as ampicillin/sulbactam, metronidazole infection, oxacillin, and azithromycin injection contain high sodium content. Use of over the counter (OTC) medications such as sodium phosphate solution and omeprazole do not exempt patients from routinely scrutinizing OTC labels, emphasizing the need for patient education. OTC NSAIDs, like their prescription counterparts, can exacerbate HF and increase the risk of HF hospitalization. Also of concern are complementary and alternative medications (CAM). The statement advises against the use of CAM products due to lack of studies on the safe use of these agents in HF patients.

The comprehensive list of medications and their implication on HF emphasizes the importance of conducting medication reconciliation at each patient encounter and encouraging patients to be actively engaged in their medication management. Specific recommendations provided by the AHA include implementing a medication flow sheet which should be updated at each visit, categorizing medications as essential or optional after a careful review of risks and benefits, minimizing the use of optional medications, discontinuing medications with no known indications, and avoiding when possible the use of new medications to treat side effects from an existing medication. A team management approach is crucial in implementing these recommendations with a healthcare provider being the "captain" of the medication management team and the point-person for patients to contact before initiating or substituting medications.


  1. Page RL, Cheng D, Dow TJ, et al. Drugs that may cause or exacerbate heart failure: a scientific statement from the American Heart Association. Circulation 2016;134:e32-69.

Keywords: Ampicillin, Anti-Arrhythmia Agents, Anti-Infective Agents, Anti-Inflammatory Agents, Non-Steroidal, Antimalarials, Calcium Channel Blockers, Comorbidity, Cyclooxygenase Inhibitors, Dipeptidyl-Peptidase IV Inhibitors, Dipeptidyl-Peptidases and Tripeptidyl-Peptidases, Heart Failure, Medication Reconciliation, Metformin, Metronidazole, Omeprazole, Oxacillin, Phosphates, Risk Assessment, Tumor Necrosis Factor-alpha, Geriatrics

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