Angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), and angiotensin receptor neprilysin inhibitors (ARNIs) can treat systolic heart failure. A doctor may also suggest beta-blockers, diuretics, or other medications.
Systolic heart failure occurs when the heart’s left ventricle cannot pump enough blood for the body’s needs.
The percentage of blood the left ventricle pumps with each heartbeat is called ejection fraction (EF). A typical EF is
Systolic heart failure has an EF of
This article discusses the goal of medications and summarizes the available options.
Heart failure is typically a chronic condition that worsens over time. However, medication is one of the treatments that can help.
The goal of medications is to:
- slow heart failure progression
- ease symptoms
- extend life span
- improve quality of life
- reduce the frequency of hospitalizations
Medication for systolic heart failure can help by:
- improving the heart’s ability to pump
- widening blood vessels
- reducing sodium and water in the body
“First-line” is the term that describes the first treatment or therapy doctors prescribe for a disease or condition.
According to
- angiotensin converting enzyme (ACE) inhibitor
- angiotensin receptor blocker (ARB)
- angiotensin receptor neprilysin inhibitor (ARNI)
ACE inhibitors reduce the workload on the heart muscle and make it easier for the heart to pump blood. They also decrease blood pressure.
An ACE inhibitor is a type of vasodilator medication, which means it prevents blood vessels from narrowing. It does this by blocking the protein called angiotensin from converting to angiotensin ll, which can narrow blood vessels.
Dosage
Doctors usually prescribe an oral version of ACE inhibitor medication, but they can also administer it using an intravenous (IV) line.
The dosage can
| Initial daily dose in milligrams (mg) | Target dosage | |
|---|---|---|
| captopril | 6.25 mg, three times daily | 50 mg, three times daily |
| enalapril | 2.5 mg, twice daily | 10–20 mg, twice daily |
| fosinopril | 5–10 mg, once daily | 40 mg, once daily |
| lisinopril | 2.5–5 mg, once daily | 20–40 mg, once daily |
| quinapril | 5 mg, twice daily | 20 mg, twice daily |
| perindopril | 2 mg, once daily | 8–16 mg, once daily |
| trandolapril | 1 mg, once daily | 4 mg, once daily |
| ramipril | 1.25–2.5 mg, once daily | 10 mg, once daily |
Side effects and considerations
ACE inhibitor side effects are uncommon and usually minor.
Some side effects may
- dry cough, which is one of the most common side effects
- low blood pressure
- dizziness
- fainting
- high potassium levels (hyperkalemia)
- increased creatinine and blood urea nitrogen, which can be possible indicators of kidney problems
Angioedema is a rare side effect of ACE inhibitors. A person may experience swelling of the face, lips, and upper airway. It can be a life threatening side effect.
ACE inhibitors are not suitable for people who are pregnant or have a history of angioedema.
Additionally, a person
ARBs offer an alternative for people who cannot tolerate ACE inhibitors.
ARBs widen blood vessels to allow easier blood flow. They can reduce the risk of:
- death from a cardiac issue
- stroke
- heart attack
ARB medication is also a vasodilator that affects angiotensin. ARBs prevents angiotensin ll from interacting with its receptors, which transmit the signals to constrict blood vessels.
Dosage
ARBs come in tablet form in varying doses. It is available in combination with other medications if necessary.
A doctor can recommend which medication to try and the starting dosage.
Some options
| Initial daily dosage | Target dosage | |
|---|---|---|
| candesartan (Atacand) | 4–8 mg, once daily | 32 mg, once daily |
| losartan (Cozaar) | 25–50 mg, once daily | 50–150 mg, once daily |
| valsartan (Diovan) | 20–40 mg, twice daily | 160 mg, twice daily |
Side effects and considerations
Certain people should not take ARBs. They include people who:
- have high potassium levels
- have low blood pressure
- are pregnant
Otherwise, ARBs have a
- cough
- rash
- anaphylaxis
- blood vessel inflammation
- low white blood cells
- abnormal liver tests
ARNI medication is a combination of an ARB and a neprilysin inhibitor. ARNIs relax blood vessels to decrease heart rate and blood pressure.
A 2014 trial found that ARNI medication is better than ACE inhibitors or ARBs at decreasing the chance of heart failure after a heart attack.
Healthcare professionals may switch an ACE inhibitor or ARB for an ARNI medication if the person has chronic symptomatic HFrEF, provided they tolerate ACE inhibitors or ARBs.
Before starting an ARNI medication, a person should stop taking ACE inhibitor medication and wait at least
Dosage
Sacubitril/valsartan (Entresto) is the ARNI doctors prescribe for heart failure. It is available as an oral tablet.
Sacubitril/valsartan (Entresto) comes in
| Tablet dose | Sacubitril portion | Valsartan portion |
|---|---|---|
| 50 mg | 24 mg | 26 mg |
| 100 mg | 49 mg | 51 mg |
| 200 mg | 97 mg | 103 mg |
Dosing depends on the person’s status:
| Person’s status | Dosage range |
|---|---|
| no previous ACE inhibitors or ARBs | 50–200 mg, twice daily |
| previous low dose ACE inhibitors or ARBs | 50–200 mg, twice daily |
| previous moderate to high ACE inhibitors or ARBs | 100–200 mg, twice daily |
Side effects and considerations
ARNI medication side effects include:
- nausea
- headache
- diarrhea
- vomiting
- itching
- skin rash
A person should seek prompt medical care if they experience:
- severe headache or chest pain
- shortness of breath
- allergy symptoms, such as swelling of the tongue, lips, or mouth
People who may not be able to use ARNI medication include those who:
- have liver impairment
- are pregnant
- are breastfeeding or chestfeeding
It is also worth noting that Ernesto does not have a generic form, so it may be more expensive than an ACE inhibitor or ARB.
Beta-blockers stop the effects of epinephrine, the hormone also known as adrenaline. They also prevent the kidneys from producing angiotensin ll.
Beta-blockers slow heart rate, relax the heart muscle, and reduce blood pressure.
Dosage
Doctors commonly prescribe beta-blockers as oral medication in tablet form. They are also available intravenously and as an injectable.
Beta-blocker dosages can vary. Examples
| Initial daily dosage | Target dosage | |
|---|---|---|
| metoprolol succinate (Toprol-XL) | 12.5–25 mg, once daily | 200 mg, once daily |
| carvedilol (Coreg) | 3.125 mg, twice daily | 25–50 mg, twice daily |
| carvedilol (Coreg CR) | 10 mg, once daily | 80 mg, once daily |
| bisoprolol | 1.25 mg, once daily | 10 mg, once daily |
Side effects
Beta-blockers have some side effects, which may include:
- fatigue
- lightheadedness
- dizziness
- reduced blood supply to hands and feet
- sleep disruption
- nausea
- erectile dysfunction
More serious side effects include:
- shortness of breath
- cough worsened by exercise
- irregular heart rate
- leg and ankle swelling
- chest tightening
- wheezing
- yellowish skin
- yellow whites of eyes
Diuretics make it easier for the heart to pump blood. They cause the kidneys to produce more urine, which helps flush excess water and salt out of the body.
Diuretics can:
- reduce the heart’s workload
- lower blood pressure
- ease shortness of breath
- lessen bloating and swelling
- increase urination frequency
People usually take diuretics orally. If a person has advanced heart failure, they can receive this medication intravenously in a hospital.
There are different categories of diuretics, including:
- loop
- thiazide
- potassium-sparing
- carbonic anhydrase inhibitors
Dosage
The
Loop diuretics
The following table outlines the dose options for loop diuretics:
| Dose range | Daily maximum | |
|---|---|---|
| furosemide (Lasix) | 40–240 mg | 600 mg |
| torsemide (Demadex) | 5–20 mg | 200 mg |
| bumetanide (Bumex) | 1–5 mg | 10 mg |
| ethacrynic acid (Edecrin) | 25–100 mg | 200 mg |
Thiazide-type diuretics
The following table outlines the dose options for thiazide-type diuretics:
| Dose range | Daily maximum | |
|---|---|---|
| hydrochlorothiazide (Esidrix) | 12.5–100 mg | 200 mg |
| chlorothiazide (Diuril) | 250–500 mg | 1,000 mg |
Thiazide-like diuretics
The following table outlines the dose options for thiazide-like diuretics:
| Dose range | Daily maximum | |
|---|---|---|
| chlorthalidone (Thalitone) | 12.5–25 mg | 100 mg |
| metolazone (Mykrox) | 2.5–10 mg | 20 mg |
| indapamide (Lozol) | 2.5–5 mg | 5 mg |
Potassium-sparing diuretics
The following table outlines the dose options for potassium-sparing diuretics:
| Dose range | Daily maximum | |
|---|---|---|
| amiloride (Midamor) | 5–20 mg | 20 mg |
| triamterene (Dyrenium) | 100–200 mg | 200 mg |
| spironolactone (Aldactone) | 12.5–50 mg | 200 mg |
| eplerenone (Inspra) | 50–200 mg | 200 mg |
Carbonic anhydrase inhibitors
The following table outlines the dose options for carbonic anhydrase inhibitors:
| Dose range | Daily maximum | |
|---|---|---|
| acetazolamide – oral (Diamox) | 250–375 mg | 500 mg |
| acetazolamide – IV | 500 mg | 500 mg |
Side effects
Prescription diuretics may have side effects that include:
- low fluid volume
- dizziness
- fainting
- headache
- thirst
- muscle cramps
- dehydration
- fatigue
- weakness
- skin rash
- frequent urination
- nausea
- vomiting
- constipation
- mineral deficiencies after long-term use
Ivabradine (Corlanor) was the first HCN channel blocker medication approved to treat heart failure. It is taken orally.
A
Dosage
The starting dosage of ivabradine is
Side effects
Ivabradine may have side effects, including:
- pulse that is too slow
- high blood pressure
- atrial fibrillation
- vision changes
Doctors may also prescribe other medications to treat heart failure, such as:
- Digoxin: This is a drug classified as a cardiac glycoside. It
can help decrease hospitalization but does not reduce the risk of death. - Vericiguat (Verquvo): This is a newer drug to treat heart failure. It is classified as a guanylyl cyclase stimulator. It may decrease the likelihood of death and hospitalization in people with heart failure.
Medication for systolic heart failure can make it easier for the heart to circulate blood. These medications can help widen blood vessels, reduce fluid and sodium volume, and increase the heart’s ability to pump.
First-line heart failure medications include beta-blockers and ACE inhibitors, but a doctor may also prescribe other options.