This leaflet has been designed to discuss aspects of heart medication and answer questions commonly asked by patients.

Symptoms of heart failure usually respond to medication. Drugs used include diuretics (water tablets), ACE inhibitors, beta-blockers, Digoxin and anticoagulants.

Diuretics

Diuretics (water tablets) – examples: Furosemide, Bumetanide (loop diuretics), Bendroflumethiazide (thiazide diuretic), Spironolactone or Eplerenone.

What is a diuretic?

A diuretic is a drug that increases the amount of water that you pass through your kidneys, increasing your urine output. They are sometimes called ‘water tablets’.

Several types of diuretics are available and you may be prescribed more than one.

Why are diuretics necessary?

Heart failure may cause fluid to accumulate in your body due to the heart not pumping blood around the body as well as normal.

You may become breathless, as fluid accumulates in the lungs, and your ankles and legs may swell with extra fluid in the tissues (oedema).

Diuretics help clear excess body fluid and are also effective in lowering blood pressure.

What is the dose?

The dose of diuretics will depend on which drug you are taking. The dose may often change depending on your condition.

This will be assessed by your GP or heart failure nurse.

How often do I take diuretics?

Diuretic tablets are normally taken in the morning, ensuring the extra trips to the toilet are during the day and not at night.

The drug (loop diuretics) will start to take effect within half an hour and lasts about six hours.

Diuretics are often taken at other times of the day. A dose taken at lunchtime should be taken between 12noon and 2pm.

Thiazide diuretics are taken once a day, generally in the morning.

Some people can develop cold hands or feet.

Other less common side effects may include tiredness, depression, erectile dysfunction, vivid dreams and other sleeping problems.

Can I miss doses of diuretics to suit my lifestyle?

It is important to take the correct dose regularly as prescribed.

However, you could take the drug at a flexible time during the day to suit you. For example, if you want to go out early in the morning for a few hours and do not want to have to find a toilet, you may be able to postpone the dose until later in the day when it may be more convenient.

Discuss this with your GP or nurse.

Are there any side effects with diuretics?

When routine low doses of loop diuretics are used, side effects are uncommon. The risk of side effects increases with a higher dose.

Sometimes, the salt balance in the bloodstream is upset, which can cause low blood levels of potassium and sodium. These effects may cause weakness, confusion and, rarely, abnormal heart rhythms to develop.

If you have diabetes or gout, these conditions may be made worse by diuretics as the blood sugar level may rise and uric acid levels may increase.

Other possible side effects include an upset stomach, dizziness on standing (due to low blood pressure) and nausea.

Side effects of taking Spironolactone may also include erectile dysfunction, painful breasts in men, high potassium levels and lethargy.

Will I need any specific monitoring whilst on diuretic therapy?

Yes. In view of the potential for abnormal blood salts, you will need your kidney function checked periodically by a blood test.

How long do I need to take this medication for?

It is likely that you will need to take it long term, but the dose may change as your GP or heart failure nurse tries to get the ACE inhibitor to the maximum dose appropriate for you.

Do all patients with heart failure receive ACE inhibitor medication?

No. As with all medications, there are exceptions.

Patients who are not advised to have this treatment may be considered for alternatives.

Angiotensin II receptor antagonists

Candesartan, Valsartan, Irbesartan and Losartan

What is an angiotensin II receptor antagonist?

These medications work in a similar way to ACE inhibitors. They also have similar side effects but do not cause a dry persistent cough.

Beta-blockers

Carvedilol, Bisoprolol and Nebivolol

What is a beta-blocker?

Beta-blocker is the name given to a group of drugs which have been shown, through a number of medical studies, to be beneficial to people with poor heart function.

How do beta-blockers work?

They slow your heart rate, lower the blood pressure and improve the heart’s ability to pump blood around the body.

Why do I need to take them?

Studies have shown that if these drugs are taken in combination with other medications, people are:

• more likely to live longer than those who do not take them
• less likely to be admitted to hospital
• less likely to have episodes of worsening heart failure in the long term.

What dose and for what period should I take beta-blockers?

The dose of your beta-blocker medication may change.

The aim will be to start you on a small dose and increase it slowly until the best dose is achieved for you.

Generally, you will stay on beta-blockers long term.

Are there any side effects with taking beta-blockers?

Most people who take beta-blockers have no side effects or only minor ones.

Examples of side effects are:

• you may feel dizzy or feel faint
• if you have diabetes, you need to be aware that beta-blockers may dull the warning signs of a low blood sugar level (hypo).

Are there any other considerations when taking beta-blockers?

Do not stop beta-blockers suddenly without first consulting a doctor or heart failure nurse.

Anticoagulants

Warfarin

What is an anticoagulant?

Anticoagulants thin the blood and help to prevent blood clots from forming in the blood vessels. Warfarin is a drug prescribed to achieve this.

Why do I need to take Warfarin?

You may be at risk of developing blood clots that lead to heart attacks and strokes, or you have an artificial heart valve or an irregular heart rhythm (atrial fibrillation).

What dose of Warfarin do I take?

The dose of Warfarin will vary and change depending on your INR. This is the blood test taken to measure the thickness of your blood.

Your Warfarin clinic will monitor and advise you regarding this. They will also advise you when your next INR blood test is due.

Your Warfarin dose should be documented in your yellow anticoagulation treatment booklet.

What are the side effects from taking Warfarin?

The main side effect of an anticoagulant is the risk of bleeding. Other side effects include rash, alopecia (loss of hair), diarrhoea, liver dysfunction, nausea and vomiting.

Are there any drugs I should avoid when taking Warfarin?

Yes, possibly. Many drugs increase the effects of Warfarin, resulting in an increased risk of bleeding.

It is very important that you inform your GP or heart failure nurse of all your medications, including alternative or herbal remedies and fruit juices.

When you take beta-blockers regularly, the body becomes used to them. So, suddenly stopping them can sometimes cause problems, such as palpitations, a rise in blood pressure or a recurrence of angina pains.

If they need to be stopped, your GP or heart failure nurse may advise a gradual reduction in dose.

Do all patients with heart failure have to take beta-blockers?

No. If you have asthma, you should not take beta-blockers. This is because beta-blockers can narrow the airways and make breathing symptoms worse.

There are some exceptions when a beta-blocker is prescribed under careful supervision.

Cardiac glycosides

Digoxin

What is a cardiac glycoside?

Cardiac glycosides are a group of drugs derived from digitalis, a substance that occurs naturally in foxglove plants. The most frequently used cardiac glycoside is Digoxin.

Why do I need to take Digoxin?

Digoxin is given to patients with heart failure and irregular heartbeats (atrial fibrillation) to control their heart rate. It will slow the heart but does not restore its regularity.

Digoxin is also sometimes used for heart failure patients with a normal heart rhythm who suffer with ongoing symptoms despite diuretics, ACE inhibitor and beta-blocker medication.

When do I take my Digoxin tablets? What dose? For how long?

When starting Digoxin, larger doses are sometimes given initially. Then a regular daily dose is taken in the morning.

Digoxin is taken in the long term unless indicated otherwise.

What are the side effects of Digoxin?

Digoxin may cause loss of appetite and nausea. It can also cause abdominal pain, vomiting, painful or enlarged breasts, headaches, rash, palpitations, fainting, drowsiness, blurred vision and confusion.

You should inform your doctor or nurse specialist if you experience any of these symptoms, as you may need a different dose.

Many drugs can interact with Digoxin and therefore it is vital that you inform your GP or heart failure nurse of all your medications.

Please note the following rules about medication

1. store medication as instructed on the box or bottle
2. dispose of unwanted medication by returning it to a pharmacist
3. take your medication (dose and frequency) as directed on the label – if this differs from your usual directions, please seek advice from your GP or the heart failure team
4. read the information leaflet which comes with your medication for a full list of possible side effects
5. if you experience any side effects, please inform your GP or the heart failure team.

• ensure you do not run out of tablets by ordering repeat prescriptions from your surgery
• please inform the heart failure nurse if you are taking complementary medicines or alternative therapies.

Medication record

Cardiac medication you are already taking:

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Cardiac medication that has been started today, with date:

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Cardiac medication that has been stopped, with date:

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If you have any questions about your medication, please speak to your GP or heart failure nurse.