Heart Failure Medications:
A Patient & Caregiver Guide
Understanding Guideline-Directed Medical Therapy for Heart Failure with reduced ejection fraction (HFrEF)
Our Partner Organizations
What Guides
Heart Failure Medication Choices?
If you’ve been diagnosed with heart failure with reduced ejection fraction (HFrEF), you may be wondering about your treatment options. Many medications are available to treat heart failure depending on your individual health and needs. This Guide has been created to:
Explain what medications may be recommended to treat your symptoms and improve your quality of life.
Support your conversations with your health care team including your doctors, nurses, pharmacists, and others.
Help ensure that you receive the best heart failure care available by understanding practice guidelines and advocating for them in your care.
Heart failure with reduced ejection fraction (HFrEF): Heart failure caused by a problem with the pumping function of the heart, called ‘reduced ejection fraction.’
What guides heart failure medication choices?
What is Guideline-Directed
Medical Therapy?
The Canadian Cardiovascular Society (CCS) sets the standards for optimal heart failure care in Canada, known as “CCS/CHFS Heart Failure Guidelines.”1 In 2021, the CCS updated its treatment guidelines for people living with heart failure with reduced ejection fraction (HFrEF). These are the guidelines that your health care team follow to treat heart failure.
The CCS/CHFS Heart Failure Guidelines recommend that, whenever possible, people with HFrEF be treated with 4 different medications early after their diagnosis. This combination of medications is known as “guideline-directed medical therapy.” Additional medications may also be recommended, depending on your health and risk factors.
Note: The CCS/CHFS Heart Failure Guidelines were last updated in 2021. The next update may include new or additional recommendations for patients with a higher or ‘preserved’ left ventricular ejection fraction (HFpEF).
What guides heart failure medication choices?
Why Optimal
Medication Matters
What guides heart failure medication choices?
Challenges with Optimizing Medications
Despite clear and important benefits, studies suggest only 4 in 10 people living with heart failure are being treated with optimal medication. The reasons for this may include:
Knowledge
New research is always coming out and guidelines are updated every few years. It can be hard for health care providers and patients to stay ‘up to date’ with the latest treatment research. People with heart failure may also not fully understand their condition or how it should best be managed.
Uncertainty
Patients and/or providers may be unsure if they should change or add new medications. They may not realize the benefits of optimizing medications, or may not want to take additional pills everyday. Patients may not feel confident that their providers are up-to-date on their condition and needs.
Ability to access care
In Canada, most people with heart failure do not receive care from a heart failure specialist. Many face difficulties accessing care when it is needed most. GDMT requires close management by your health care provider.
Drug Costs
Not having coverage for your medications can be costly, particularly for newer medications. This can limit treatment choices.
What is Optimal Medication?
The CCS/CHFS Heart Failures Guidelines currently recommend the use of 4 different types of medications for people with HFrEF, where possible. Each of these 4 medications works in a unique way, and they work best when used together. On average, each of these medications adds an extra 1 to 2 years of life.
Click through the tabs to learn about each medication type.
ARNI, ACEi, ARBs
How They Work
They reduce salt and water retention and open up blood vessels. This makes it easier for your heart to pump blood to your body.
Commonly used drugs
ARNI Sacubitril-valsartan (EntrestoTM)
ACEi (“prils”) Perindopril, ramipril
ARB (“sartans”) Candesartan, valsartan
What to watch out for
- Symptoms of low blood pressure.
- ACEi and ARNI may cause a dry cough.
- Routine bloodwork to check kidney function and potassium (risk of high potassium).
Beta Blockers
How They Work
They block adrenaline so your heart does not have to work as hard and beat as fast.
Commonly used drugs
Bisoprolol
Carvedilol
Metoprolol
What to watch out for
- Symptoms of low blood pressure or heart rate.
- You may feel tired (low energy) when you first start this medicine. This will get better as your body gets used to the medicine.
- Do not stop this medicine suddenly unless your healthcare provider tells you to. Your heart may race if you stop it suddenly.
MRAs
How They Work
They block stress hormones that make the heart stiff and cause scarring.
Commonly used drugs
Eplerenone (Inspra™)
Spironolactone
What to watch out for
- Expect ongoing bloodwork for kidney function and potassium (risk of high potassium).
- Spironolactone: You may experience swelling of your breasts or tenderness. This is more common in men, and occurs in 9 out of 100 people.
SGLT2 Inhibitors
How They Work
They help lower stress on your heart.
Commonly used drugs
Dapagliflozin (Forxiga™)
Empagliflozin (Jardiance™)
What to watch out for
- Genital yeast infection or bladder infection (less than 1 in 100 people). You can reduce this risk by paying close attention to your hygiene.
- Expect ongoing bloodwork for kidney function.
- This medicine is also used to treat diabetes. Other diabetes medicines may need to be adjusted when you take this medicine.
What is optimal medication?
Possible Side Effects
You may experience common symptoms from taking these medications that are not serious but still noticeable. However, severe symptoms such as extreme weakness, dehydration or losing consciousness may require immediate medical attention.
Toggle through the common and severe side effects of each medication type to learn what to watch out for.
What to watch out for
- Symptoms of low blood pressure.
- ACEi and ARNI may cause a dry cough.
- Routine bloodwork to check kidney function and potassium (risk of high potassium).
What to watch out for
- Symptoms of low blood pressure or heart rate.
- You may feel tired (low energy) when you first start this medicine. This will get better as your body gets used to the medicine.
- Do not stop this medicine suddenly unless your healthcare provider tells you to. Your heart may race if you stop it suddenly.
What to watch out for
- Expect ongoing bloodwork for kidney function and potassium (risk of high potassium).
- Spironolactone: You may experience swelling of your breasts or tenderness. This is more common in men, and occurs in 9 out of 100 people.
What to watch out for
- Genital yeast infection or bladder infection (less than 1 in 100 people). You can reduce this risk by paying close attention to your hygiene.
- Expect ongoing bloodwork for kidney function.
- This medicine is also used to treat diabetes. Other diabetes medicines may need to be adjusted when you take this medicine.
Severe side effects
1 in 500 people may experience a severe allergic reaction to ACEi and ARNIs called angioedema. This involves swelling of the face, tongue, lips, and hands.
If you develop another illness and as a result are not able to eat or drink, or if you are experiencing a lot of vomiting or diarrhea, contact your health care provider or pharmacist.
What to do
Seek immediate medical attention.
Severe side effects
If you have a history of asthma or COPD (also known as chronic bronchitis/emphysema), beta-blockers may make you feel wheezy or short of breath.
What to do
Contact your health care provider immediately.
Severe side effects
If you develop another illness and as a result are not able to eat or drink, or if you are experiencing a lot of vomiting or diarrhea, contact your health care provider or pharmacist.
What to do
Contact your health care provider or pharmacist.
Severe side effects
If you develop another illness and as a result are not able to eat or drink, or if you are experiencing a lot of vomiting or diarrhea, contact your health care provider or pharmacist.
1 in 1,000 people may experience a serious condition called ‘ketoacidosis’ while taking SGLT2 inhibitors during times of medical stress or illness. Signs of ketoacidosis include dehydration, nausea and excessive fatigue.
What to do
Ketoacidosis can be life-threatening if not treated and requires admission to hospital and stopping this medication.
Other common symptoms can include:
- Insomnia or problems sleeping
- Problems with your stomach and digestion
- Sense of unease
- Feeling dizzy or lightheaded
- Feeling tired
You may also experience worry or anxiety through this process. Some side effects go away or become less bothersome with time. Some will continue. If you are concerned about a side effect, speak to your health care provider. Be aware that these symptoms are not always due to medications.
You should make sure your family and/or caregiver are aware of severe side effects from your medications, and what to do if you need help.
Getting to Optimal Medication
It is crucial that medications be started as soon as possible after heart failure diagnosis. There is no single best approach to starting and increasing your medications. Your health care team will work with you in making these decisions. Factors such as blood pressure, kidney function, medication coverage and possible side effects all play a critical role.
How are Heart Failure Medications introduced?
Generally, new medications are started at a low dose and increased over time until you reach your maximally targeted dose. Two common ways to start and increase medications are shown here. The goal is that people with HFrEF should be on all 4 guideline-directed medications, at a maximally tolerated dose for them, within 3 to 6 months from their initial diagnosis.
Strict Sequential
Introducing medications one at a time before adding a new drug.
This typically requires 6 months or more.
In Parallel
Introducing and increasing medications all at once.
All steps achieved within 4 weeks.
Depending on your unique health situation, your health care team may use either approach, or a combination approach, to best suit you and your needs.
Getting to Optimal Medication
How Are Medications Increased?
Medications are introduced at low doses and gradually, based on your response. This process is called “titration.” During titration, your health care provider will assess your symptoms, ask about any side effects and monitor your bloodwork as needed.
The doses of your medication may be adjusted (increased or decreased) based on your response.
Here is how titration works:
Initial dosage
Your medication dose is increased
Your medication dose is increased
Your dose is increased and may be lowered if needed
Maximally tolerated dose
Medication titration consists of adjusting a dose every 1 to 4 weeks, depending on how well you are tolerating changes and on the timing of follow-up appointments with your health care team.
Beyond Optimal Medication
There is no “one-size-fits-all.” For some people, optimal medical therapy will mean fewer medications than the 4 in the guidelines. You could need to avoid a medication due to a contraindication or because of how it interacts with another drug you are taking.
People with heart failure are often on medications to treat other conditions, such as high cholesterol (“statins”), or to reduce the risk of blood clots (“blood thinners”). You might also be prescribed other medications not described here like water pills or diuretics, digoxin or ivabradine.
How does my health care team measure my response to treatment?
Ongoing evaluations with your team
Most people with heart failure will need to continue medications long-term, many for the rest of their lives. In addition to taking medications as prescribed, learning about self-care is an important part of managing heart failure. Note any new symptoms, side effects or changes in your quality of life. Talk to your health care provider about how you feel you are managing.
Never adjust your own medications without guidance from your health care team.
Beyond Optimal Medication
Helpful Resources
Ask questions, take notes and make sure you feel comfortable with the treatment options being offered and chosen.
Resources that may be helpful to you, your caregiver or family:
The Heart Hub
Ted Rogers Centre for Heart Research & Peter Munk Cardiac Centre
Beyond Optimal Medication
Managing Your Care and Medications
Take medications as prescribed by your healthcare team.
Do not adjust your medications unless instructed by your healthcare team.
If you are vomiting, experiencing diarrhea, or are dehydrated, you may need to stop taking some medications for a short time.
Work with your team to determine the best treatment.
Keep a list of the name, dosage, how often, and why you take each of your medications in your wallet or on your phone.
Don’t take over-the-counter medicine, vitamins, or supplements without checking first with your doctor or pharmacist. Medications to AVOID include:
- Anti-inflammatory medications like ibuprofen (Advil™, Motrin™) or naproxen (Aleve™).
- Decongestant pills (“cold & sinus”) that include pseudoephedrine or phenylephrine.
- Acetylsalicylic acid (Aspirin), except for the 81-mg dose if prescribed or recommended by your healthcare team.
Know what side effects to watch out for and discuss them with your healthcare provider in a timely fashion.
Be patient and understand that it may take time for your body to adapt to certain medications.
If you are not sure what to do with your medications when dehydrated, ask your healthcare team about sick day management of your medications.
Try to be consistent with the time of day that you take your medication. Timing when you take your medication with another activity that you do at the same time every day, such as brushing your teeth, can be helpful.
Keep a list of everyone on your heart failure team (doctors, pharmacists, peer support, caregivers) and carry it with you to appointments.
Notify your healthcare team if any changes are made to your medicines by a different provider.
Glossary of Terms
Adrenaline
Also known as “epinephrine”, this is a chemical messenger that controls the sympathetic nervous system and causes the "fight or flight" response.
Contraindication
Anything (i.e., a symptom or medical condition) that is a reason for a person to not receive a particular treatment or procedure because it may be harmful.
Diuretics
Diuretics (commonly called ‘water pills’) rid the body of excess fluid, help to reduce swelling and bloating and make it easier to breathe.
Echocardiogram
An echocardiogram (ECHO) is an ultrasound of the heart that shows details of the heart’s structure and function.
Guideline-directed medical therapy (GDMT)
Wherever possible, CCS/CHFS Heart Failure Guidelines recommend that people with HFrEF be treated with 4 different types of medications early after diagnosis. This combination of medications is known as GDMT.
Heart failure with preserved ejection fraction (HFpEF)
Heart failure occurring as a result of a problem with the heart’s ability to relax, called ‘preserved ejection fraction.’
Heart failure with reduced ejection fraction (HFrEF)
Heart failure caused by a problem with the pumping function of the heart, called ‘reduced ejection fraction’.
Maximally tolerated dose
The maximal dose of a medication that you can tolerate without experiencing side effects such as dizziness, low blood pressure and light headedness.
Target dose, optimal dose
A target, or “optimal” dose, is the goal dose of medication recommended by the heart failure treatment guidelines.
Partners &
Acknowledgements
This Guide was created by a group of patient and clinical advisors, representing organizations that aim to improve heart failure care for all people in Canada. Thank you to our advisory committee:
Marc Bains, BBA
Co-founder, HeartLife Foundation, Vancouver
Tracy Bawtinheimer, BSc
HeartLife Champion, HeartLife Foundation, Victoria
Carolyn Gall Casey, BSc
Director, Canadian Cardiovascular Society, Ottawa
Michael McDonald, MD, FRCPC
Cardiologist, Peter Munk Cardiac Centre (UHN), Toronto
Caroline McGuinty, MD
Cardiologist, University of Ottawa Heart Institute, Ottawa
Jackie Ratz, BA
HeartLife Champion, HeartLife Foundation, Winnipeg
Anne Simard, BJ, MHSc
Staff Scientist, Ted Rogers Centre for Heart Research, Toronto
Ricky Turgeon, BSc (Pharm), ACPR, PharmD
Assistant Professor, University of British Columbia, Vancouver
We acknowledge our partner organizations: