Heart Failure: The Critical Role of Long-Term Medication

Heart Failure Patients at Continued risk Even With Improved Pump Function

Patients who experience an enhancement in heart pump function after treatment for heart failure remain at a higher risk of heart-related death or hospitalization if they discontinue their prescribed medications,according to new research from Karolinska Institutet published in Circulation.

“our finding raises awareness about the importance of implementing and not withdrawing medical treatments in daily clinical practice even if patients with heart failure experience an improvement in symptoms and pump function,” says Gianluigi Savarese, docent and senior lecturer at the Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet and senior cardiologist at Södersjukhuset.

The study analyzed data from over 8,700 heart failure patients in the Swedish Heart Failure Registry (RiksSvikt) whose ejection fraction initially fell below 40 percent but later improved to 40 percent or higher. Researchers linked RiksSvikt data with other national registers to track hospitalizations and deaths among patients who either stopped or continued their heart failure treatments.

Increased Morbidity and Mortality

The observational study revealed that patients who stopped taking medications – specifically RASi (renin-angiotensin system inhibitors), ARNi (angiotensin receptor-neprilysin inhibitors), or MRA (mineralocorticoid receptor antagonists) – faced a 36 to 38 percent higher risk of heart-related death or hospitalization within one year of discontinuation.

Stopping beta-blocker medication was associated with increased risk only in patients with moderate improvements in heart function.

“Our results show that heart failure medications continue to provide critically important benefits even when heart function has improved,” Savarese explains. “this supports the current recommendation to continue RASi/ARNi and MRA treatment, but also opens up the possibility of reconsidering whether beta-blockers can be discontinued in certain patients whose heart function has recovered well.”

More Tailored Treatment Strategies

While the study is observational and cannot definitively prove causation, the findings highlight the need for continued research. Researchers are planning further studies to validate these results and develop more refined guidelines for medication management in heart failure patients.

“Our goal is to understand how heart failure medications effect patients with improved heart function and to develop guidelines for when/if it is indeed safe to discontinue certain treatments. This can lead to more tailored and effective treatment strategies for heart failure patients,” says Christian Basile, the study’s first author and PhD student in Savarese’s research group.

The study was funded by the Swedish Heart-Lung Foundation and the EU Horizon project MORE-europa. The researchers reported no conflicts of interest.

What are the potential benefits of SGLT2 inhibitors, like dapagliflozin, in treating both HFrEF and HFpEF?

Understanding Heart Failure & Medication Needs

Heart failure isn’t about the heart stopping; it’s about the heart’s inability to pump enough blood to meet the body’s needs. This can lead to fatigue, shortness of breath, and swelling in the legs and ankles. While lifestyle changes are crucial, long-term medication is often the cornerstone of managing this chronic condition and improving quality of life. Effective heart failure treatment relies heavily on consistent adherence to a prescribed medication regimen.

Key Medication Classes for Heart Failure

Several classes of medications are commonly used to treat heart failure. The specific combination will depend on the type of heart failure (reduced ejection fraction, preserved ejection fraction) and the individual’s overall health.

ACE Inhibitors & ARBs: These medications (like lisinopril, valsartan) help relax blood vessels, lowering blood pressure and making it easier for the heart to pump. They are frequently enough a first-line treatment for heart failure with reduced ejection fraction (HFrEF).

Beta-Blockers: medications like metoprolol and carvedilol slow the heart rate and reduce blood pressure,giving the heart a chance to rest and recover. They are also vital in managing HFrEF.

Diuretics (Water Pills): These medications (furosemide, hydrochlorothiazide) help the kidneys remove excess fluid and sodium from the body, reducing swelling and shortness of breath. They manage symptoms but don’t address the underlying heart failure.

Aldosterone antagonists: Spironolactone and eplerenone help block the effects of aldosterone, a hormone that can contribute to fluid retention and heart damage. Used in HFrEF.

ARNI (Angiotensin Receptor-Neprilysin Inhibitor): Sacubitril/valsartan is a newer medication that combines an ARB with a neprilysin inhibitor. It’s often used as a replacement for ACE inhibitors or ARBs in HFrEF.

SGLT2 Inhibitors: Originally used for diabetes, these medications (dapagliflozin, empagliflozin) have shown notable benefits in both HFrEF and heart failure with preserved ejection fraction (HFpEF), reducing hospitalizations and improving outcomes.

Digoxin: this medication can help strengthen the heart’s contractions and control heart rate, but it’s used less frequently now due to potential side effects.

Why Long-Term Adherence is Crucial

Stopping or inconsistently taking heart failure medications can have serious consequences.

1. Symptom Rebound: Symptoms like shortness of breath, fatigue, and swelling can quickly return.
2. Worsening Heart Function: The heart may become weaker and less efficient.
3. Increased Hospitalizations: Non-adherence is a leading cause of hospital readmissions for heart failure patients.
4. Reduced Lifespan: Consistent medication use is linked to improved survival rates.

Potential Side Effects & Management

All medications have potential side effects. It’s vital to discuss any concerns with your doctor. Common side effects of cardiac medications include:

Dizziness: Especially with ACE inhibitors, ARBs, and beta-blockers.

Fatigue: Common with beta-blockers and ACE inhibitors.

Electrolyte Imbalances: Diuretics can cause low potassium or sodium levels.

Kidney Problems: Some medications can affect kidney function.

Regular monitoring by your healthcare team is essential to manage side effects and adjust medications as needed. Never stop a medication without consulting your doctor.

The Importance of Regular Check-Ups & Monitoring

Managing heart failure effectively requires ongoing monitoring. This typically includes:

Regular Doctor Visits: to assess your condition, adjust medications, and address any concerns.

blood Tests: To check kidney function, electrolyte levels, and medication levels.

Echocardiograms: To assess the heart’s structure and function.

Weight Monitoring: Daily weight checks can help detect fluid retention.

Blood Pressure Monitoring: To ensure blood pressure is well-controlled.

Real-World Example: The Impact of SGLT2 Inhibitors

Recent clinical trials have demonstrated the remarkable benefits of SGLT2 inhibitors in heart failure patients, even those without diabetes. A patient I recently treated, a 72-year-old with HFpEF, experienced a significant reduction in shortness of breath and improved exercise tolerance after starting dapagliflozin. This illustrates the evolving landscape of heart failure therapy and the importance of staying informed about new treatment options.

Practical Tips for Medication Adherence

Use a Pill Organizer: Helps you keep track of which medications to take and when.

Set Reminders: Use your phone or a medication reminder app.

Link Medication to Daily Activities: Take your medication with a meal or before brushing your teeth.

Keep a Medication List: Carry a list of all