Avoiding Meds That Worsen, Cause HF: AHA Presents Action Plan

Patrice Wendling

July 20, 2016

DALLAS, TX — Getting providers and heart-failure (HF) patients to consider a medication's sodium load is just one of the steps highlighted in the American Heart Association's (AHA) first-ever scientific statement on medications that may worsen or cause HF[1].

The 35-page document features a comprehensive list of medications that can promote HF through direct myocardial toxicity, increases in blood pressure, high sodium loads, or drug–drug interactions.

The evidence-based statement also provides considerations for minimizing polypharmacy and improving medication safety.

"Most important, these considerations include engaging patients to be actively involved with their medication management and to approach polypharmacy with a team strategy," writing committee chair Dr Robert L Page II (University of Colorado, Aurora) told heartwire from Medscape.

HF patients are particularly vulnerable because of a high comorbidity burden and frequent physician visits. Medicare beneficiaries with HF see 15 to 23 providers annually, the document says.

Patients with HF also take on average at least six medications per day—not including over-the-counter or herbal medicines. The risk of an adverse drug-drug interaction climbs from 13% for patients taking at least two prescription medications to 82% with seven or more medications.

"Comprehensive medication management, as described in the document's nine recommendations, should be a routine part of medical practice to improve outcomes. Otherwise, many of our patients with heart failure are put at tremendous risk for harm from the many medications we prescribe and the potent medications they acquire without a prescription," Dr Kumar Dharmarajan (Yale University School of Medicine, New Haven, CT), who was not involved in the statement, told heartwire .

Older Adults

Dr Daniel Forman (University of Pittsburgh, PA), who also was not involved in the study but is chair-elect for the AHA committee on CVD in older populations, commented to heartwire that polypharmacy is endemic in older adults and that the AHA statement "implicates almost every medication most older patients are taking."

"This document seems a mandate to reorganize cardiovascular care to routinely address these priorities as part of standard cardiac management," he added.

Forman pointed out that polypharmacy also has a clear bearing on rehospitalization.

"The AHA is taking a bold step in fostering such a holistic perspective as part of the current heart-failure rehospitalization priorities" and "is essentially saying that cardiology experts must look well beyond the heart . . . and develop much broader expertise and rigor of assessment as part of heart-failure management."

Page said the committee developed the scientific statement independently of the American Geriatrics Society's Beers Criteria for potentially inappropriate medications in older adults and targeted it toward HF patients of all ages. Nonetheless, in the context of HF, the AHA statement appears to be in line with the Beers Criteria, he added.

Forman agreed that it resonates well with Beers, which also lists NSAIDs, cilostazol, and the cardiac drugs diltiazem, verapamil, and dronedarone.

Sodium Load

Dharmarajan said cardiologists are unlikely to be surprised by the antiarrhythmics and antihypertensives that are listed, but that some may be surprised by the many antibiotics and commonly used treatments for gastroesophageal reflux disease and osteoporosis highlighted because they deliver significant amounts of sodium.

"Health providers should therefore think carefully before prescribing these agents and consider these sodium loads when formulating diuretic regimens," he said.

High-sodium medications include the intravenous antibiotics ampicillin/sulbactam, nafcillin, and metronidazole, which when dosed appropriately can quickly exceed more than 500 mg of sodium per day, Page said. This can be particularly problematic when the provider is treating a patient who already has been admitted for acute decompensated HF and is receiving fluid and sodium restriction.

High-sodium over-the-counter medications are also included. For example, Gaviscon has 52 mg of sodium per 15 mL, which if the recommended 30-mL dose is taken four times daily equates to over 400 mg of sodium per day.

"From an outpatient perspective, we teach patients how to read food labels for sodium content, but not labels on over-the-counter medications," Page said.

Feasibility of Implementation

Forman said implementing the nine recommendations into daily practice "is a challenge." The document calls for considerations of a team approach, improved communication, and greater efforts to anticipate potential problems by multiple providers once any medication is prescribed. It also implicitly calls upon clinicians in the team to work together to discontinue medications and/or achieve a regimen that is most likely to be effective.

"In many ways this challenges the paradigm of autonomous medicine. The cardiologist seems compelled to work in a new integrated team approach," he added.

Page said the keys to successful monitoring and management of an HF patient's medication load are communication, education, and transparency between the patient and team, which includes patients, physicians, nurses, advanced practice providers, and pharmacists.

"By playing to each member's strengths rather than duplicating efforts, we believe the considerations that are suggested in the statement can be achieved. Most important, patients must be engaged and actively participating in their medication management."

Page reported no relevant financial relationships; disclosures for the coauthors are listed in the article. Forman, and Dharmarajan reported no relevant financial relationships.

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