Ace Inhibitors (ACE)
Examples: Ramipril, Lisinopril, Perindopril
How they work
These reduce the workload of the heart by relaxing blood vessels, thus making it easier for your heart to pump blood around your body. They also lower blood pressure.
When to take
They are usually taken once a day, preferably at bedtime, but can be given as a twice daily dose.
Potential side effects
Low blood pressure - this needs to be checked after initiation and with each increase in dose to ensure it does not go too low. Symptoms of low blood pressure are feeling lightheaded, dizzy and unsteady.
Dry cough - this can occur after starting and often resolves, however if it persists, it may need to be stopped and replaced with an angiotensin receptor blocker (ARB).
A kidney blood test is needed after each titration of dose and should be monitored regularly to ensure these do not affect kidney function.
Angiotensin Receptor Blockers (ARB)
Examples: Candesartan, Iosartan
How they work
These work similar to ace inhibitors and are an alternative if ace inhibitors are not tolerated.
When to take
As with ace inhibitors, they can be taken as a single or split dose.
Potential side effects
As with ace inhibitors, they can lower blood pressure and kidney function should be checked regularly.
Angiotensin Receptor Neprilysin Inhibitors (ARNI), Sacubitril Valsartan (Entresto)
How they work
These work by relaxing the blood vessels and getting rid of excessive salt and fluid to reduce the workload of the heart.
When to take
This is taken twice daily.
Potential side effects
They can lower blood pressure and raise potassium levels in the blood. Blood pressure and a kidney function blood test should be done with each change of dose.
Beta Blockers
Examples: Bisoprolol, Carvedilol, Nebivolol
How they work
These make the heart beat slower but stronger and also lower blood pressure.
When to take
Beta blockers are taken once or twice daily, initially on a low dose and gradually increased to a tolerated dose.
Potential side effects
As they lower heart rate and blood pressure, they can cause light-headedness, dizziness, tiredness and cold hands/feet. Symptoms can worsen after commencing and usually resolve, however if they persist, with/without an increase in breathlessness, please contact your GP or heart failure nurse.
Mineralocorticoids Receptor Antagonists (MRAs)
Examples: Spironolactone, Eplerenone
How they work
They help prevent water and salt building up in the body and lower blood pressure. They can increase the potassium levels in your blood.
When to take
Once daily dose, usually in the morning or at midday.
Potential side effects
They can make you pass urine more frequently. As they also lower blood pressure, they may make you feel lightheaded/dizzy.
Spironolactone can potentially cause breast tenderness; if this occurs, it is usually stopped and switched to Eplerenone.
Sodium-Glucose Co-transporter- 2 Inhibitors (SGLTi2)
Examples: Dapagliflozin (Forxiga)
How they work
This is a medication for diabetes. It lowers the glucose (sugar) levels in the blood, but evidence suggests it reduces the workload of the heart if you have heart failure. It has now been added to the guidelines for heart failure management.
When to take
It is a once daily tablet.
Potential side effects
This medication can lower the blood glucose level (hypoglycaemia) if taking other diabetic medications such as sulphonylureas (for example gliclazide) or insulin. Other potential side effects include thrush, urinary tract infections, lower blood pressure and altered frequency of urine. It is important to maintain an adequate daily fluid intake.
Loop Diuretics
Examples: Furosemide, Bumetanide
How they work
These are water tablets. They help your kidneys to get rid of excess fluid and can reduce swelling in the feet, legs and abdomen, make you less breathless and lower blood pressure. You are either on furosemide or bumetanide - never both.
When to take
It is best to take water tablets in the morning or at midday.
Potential side effects
This medication can affect your frequency to pass urine, lower blood pressure and cause dizziness. Kidney function should be monitored.
Thiazide Diuretics
Examples: Bendroflumethiazide, Metolazone, Amiloride
How they work
These are water tablets and have the same action as loop diuretics.
When to take
As these can make you pass more urine, it is best to take these in the morning or at midday. Your doctor or heart failure nurse will advise.
Potential side effects
Side effects can be the same as loop diuretics, however thiazides are potassium-sparing medications and can make you retain more potassium. Therefore, kidney function should be monitored once started.
Digoxin
How it works
This steadies, strengthens and slows the heartbeat and helps to increase the contractility of the heart.
When to take
It is best to take digoxin at the same time every day; most people take it in the morning.
Potential side effects
Dizziness, blurred vision, nausea or diarrhoea.
Ivabradine (also known as Procoralan)
How it works
This works by slowing the heart rate but does not affect blood pressure. This makes the heart beat slower and stronger, thus reducing the workload of the heart. If you have atrial fibrillation (irregular heart rate), you will not be able to have these prescribed.
When to take
Ivabradine is taken twice daily.
Potential side effects
It may slow your heart rate too much, causing dizziness and a headache. A rare side effect is visual disturbances.
