Beta-blockers, ACE inhibitors, diuretics and aldosterone antagonists
The recommended initial drug treatment for heart failure caused by coronary heart disease and heart attack includes an ACE inhibitor and a beta-blocker and if necessary a diuretic ('water tablet'). Getting the balance of these three drugs right for each individual is complicated and may take time and as heart failure progresses the drugs may need to be taken in stronger doses. It is important that beta blockers and ACE Inhibitors are started on a low dose and gradually increased in a stepwise fashion allowing the body time to adjust after each change. People we spoke to often recalled their medicines being introduced in this way; some had yet to reach the best dose for them and Daniel was having difficulty tolerating his increases in dose. Achieving the best dose of the triple combination of drugs could lead to considerable improvements in the condition.
Paul explains that it took a couple of weeks for his body to recover from each increase in dose of medicines; it took 2 years to achieve the optimum level for him.
Daniel says that each time the dose of his beta-blocker and ACE inhibitor are increased it makes him ill and his body doesn’t seem to adjust.
When you say your body rejects it, what happens?
It just sends - I feel nauseous, bed-bound, can't walk, out of breathlessness. All the same symptoms. It drops my blood pressure. Pulse goes through the roof. Just become unstable. From being quite stable and feeling quite well, just simply trying to increase those particular pills can cause me to become unstable. But I try and ride it out, because they always do, one of the beta, the beta-blockers are horrible drugs to increase, you always feel ill for a little while, but it's supposed to go away. But it just doesn't with me. I mean, the heart failure nurse understands that. And we both despair when they try and up them.
The triple combination of drugs has made him feel much better.
Diuretics help the kidneys to pass more salt and water into the urine, which reduces ankle swelling, lowers blood pressure and should relieve breathlessness. Taking a diureticwas very common amog people we talked to, which they said was extremely effective at reducing excess fluid and helping relieve breathlessness. Most people accepted that they would need to go to the loo much more than before and that they needed to plan their lives accordingly; one woman found she was going to the loo at least 6 times between breakfast and lunch, others had been advised to take their diuretic earlier in the day to avoid being kept awake at night. Taking diuretics for long periods was linked with dehydration (see 'Common side effects of heart failure medication').
She explains how she copes with needing to go to the loo and taking diuretics.
Yes I have organised my life round them. I should do it more really, because if we go shopping to the local supermarket I know where the toilets are, if we go into town to do any shopping, I know where the toilets are! But it's just a case of I know how long, it's either that, or leaving my shopping in the car and running straight to the toilet, front door open, back door open, all doors open, just quick, get to the toilet!
She took advice from her pharmacist about when to take diuretics.
If Cathleen is going out she delays taking her diuretic until she returns to avoid the inconvenience of needing the toilet.
Nearly all except, except there’s warfarin, which I’m allowed to look after myself.
Yeah. So do you ever forget to take them, or is it easy ‘cos they’re in the box?
Very, very seldom, I often don’t take them exactly at noon or whatever, but I don’t think it matters.
And if I don’t take the furosemide immediately before I’m going out, probably if I’m going out early afternoon I tend to take it when I come back.
Would you like to explain, for the purpose of other people watching this, why that is?
Well it is a diuretic, it helps get rid of water, excess water in my legs. And it does it quite quickly after you take them, so it’s awkward to be on the bus into town and needing a toilet very badly. I just try not to do it.
Beta-blockers work by making the heart beat more slowly, and were thought of by many as the most important drug for heart failure; one man described beta-blockers as 'the big stuff' and another thought that his doctors and heart failure nurse were only really interested in his beta-blockers. Dizziness, nausea and diarrhoea were noticed by some people when they first started the beta-blocker, and one woman said that at first they made her feel more ill but that she knew she had to persevere with them nonetheless. Once the right level had been reached many people were comfortable with beta-blockers. Several men said that they had experienced loss of libido since taking beta-blockers and ACE inhibitors but were uncertain which had caused it. (See 'Other side effects of heart failure medication').
He feels that his doctors take most interest in his beta-blockers compared to his other medicines.
Since I've been in hospital and come out, it's nearly 6 months now, they haven't altered any other tablet apart from the beta-blocker, right. So you know, even when, I had to re-register my doctor and I thought he'd give me like a medical, nothing like that. Got my notes and says, 'Okay, you can have these whenever you want' because it's like a repeat prescription and what have you. Fine, no problem but you know, are there any different doses for the water tablets? You know like in the summer, you know could it be higher because there's more intake of fluid because of the weather? I don't know, nobody's said nothing to me, you know what I mean? So, I don't know, you just don't know, do you?
Have you noticed any side effects from any of them?
Well, it's hard to pin-point because I take 4, 5 in the mornings so I've got 5 tablets working around so I don't know if it's this or that. The only one I have, well obviously the beta-blocker, when I went up from the 1mg to 2.5 and then 3.75, then it went on to 5, oh that was, you know that was when I could feel the heart, you know what I mean?
Because obviously, well the way I look at it, it's slowing it down so if I'm continuing doing what I normally do it's putting extra pressure on my heart so obviously you're going to feel it more, ain't it? Because you've one slowing it down and there's you trying to work it and it's going, hang on, what's going on here, you know. This has said slow down and you're saying you want more, you know what I mean? So, I explained that to the nurses down there and they says, 'Oh, if you feel uncomfortable just drop that down to the one that you feel comfortable with.' Like again, none of the other tablets, nobody said nothing to me about the other tablets, you know what I mean? And it doesn't seem like they're interested about the other tablets, it's just the beta-blocker and that's it.
Felt ill at first with her beta-blocker but has persevered with them.
The only side effects I had, was when I first started taking the beta-blockers, and I was really ill, sick and dizzy and breathless again. But no, I'm... I suppose I should read the packets and it says, 'You may get this side effect' but I don't! I don't want to read what side effects I'm going to get, because who knows, in my head I might start getting them, and I don't want to do that. I know I trust my doctor, my consultant who put me on these tablets and I know that they're good for me, and if I didn't take them then I wouldn't be here probably.
ACE (Angiotensin converting enzyme) inhibitors are prescribed for those who have developed heart failure from coronary heart disease. They work partly by relaxing the arteries enabling blood to flow through them more freely. The triple combination of drugs makes it difficult for people to know which drugs are associated with which side effects (see 'Common side effects of heart failure medication'). People who experience unacceptable side effects from ACE inhibitors, such as a cough that won’t go away, may be swapped to an Angiotension Receptor Blocker (ARB), such as candesartan, which works in a similar way.
Brian says that his GP has carefully monitored his medication, prescribing alternatives to ACE inhibitors.
Last reviewed April 2016.
Last updated April 2016.