Heart failure medications — the cocktail that keeps them going

This article is for informational purposes only and does not constitute medical, legal, or financial advice. Please consult appropriate professionals for guidance specific to your situation.

When your parent gets a heart failure diagnosis, it sounds like the end is beginning. But heart failure is manageable. Your parent can live for years with heart failure, doing most of the things they want to do, as long as the medication is working and they're managing carefully. The problem is that heart failure medication is complicated. Your parent might be on four or five different medications, each doing something different, each with different side effects. You need to understand what each one does because you're going to be the one watching for problems, the one noticing when things are getting worse, the one figuring out when to call the doctor and when to go to the hospital.

Heart failure means the heart isn't pumping efficiently. Blood backs up into the lungs, causing shortness of breath. Or it backs up into the legs and abdomen, causing swelling. Or the heart just doesn't pump enough to deliver oxygen to the body, causing fatigue. Different medications address different aspects. Some make the heart pump better. Some make it easier for blood to flow through the body. Some help the kidneys get rid of extra fluid. Some help the heart muscle heal. Taken together, they keep your parent's heart working as well as possible.

I watched my uncle manage heart failure for years. He knew his medications cold. He knew his daily weight and knew that a gain of more than a couple pounds in a day meant calling the doctor. He watched his salt intake religiously. He exercised gently every day. He took his medications at the same time every day. When he didn't do all of this, his legs swelled, he got short of breath, and he'd end up in the hospital. When he was compliant with everything, he did well. It was work, but it kept him going.

Ongoing Monitoring

Your parent's heart failure needs regular check-ups, probably every few months or more often if things are unstable. At these check-ups, the doctor listens to the heart and lungs, checks for swelling, asks about shortness of breath and fatigue, and might order blood work and maybe an echocardiogram. Blood work includes checking kidney function and electrolytes like potassium and sodium, because the medications affect these. The echocardiogram shows how well the heart is pumping.

You might be the one noticing changes between appointments. Is your parent more short of breath than last month? Are their ankles swelling more? Are they tired all the time when they weren't before? Are they having trouble sleeping at night, or needing to get up frequently to urinate? These are all signs that heart failure might be worsening or that medications need adjustment. You're watching for signals that it's time to call the doctor.

Daily weight monitoring is useful for some people with heart failure. Your parent weighs themselves every morning, same time, same scale, and keeps track. A gain of two to three pounds in a day might just be from eating salty food or too much fluid. But if the gain continues for several days, it might mean fluid retention from heart failure getting worse. A gain of five pounds in a week is definitely time to call the doctor.

Your parent's medications probably need adjustment periodically. As heart function changes, as kidney function changes, as other medical conditions develop, the medications might need to be adjusted. The dose of a diuretic might need to increase if swelling is developing. A new medication might be added if the heart function is declining. Rarely, a medication might be stopped if it's no longer helping or is causing side effects.

The Medication Regimen

ACE inhibitors and ARBs relax blood vessels, making it easier for the heart to pump blood out. They help the heart heal and slow the progression of heart failure. Lisinopril, enalapril, and ramipril are ACE inhibitors. Losartan and valsartan are ARBs. They can cause a dry cough, especially ACE inhibitors. They require monitoring of kidney function and potassium because they can increase potassium to dangerous levels.

Beta blockers make the heart beat slower and with less force, which sounds like it would be bad for someone with heart failure, but actually it's protective. The constant stress of a failing heart beating too fast accelerates the damage. Slowing the heart allows it to rest and recover somewhat. Carvedilol, metoprolol, and bisoprolol are used in heart failure. Beta blockers can cause fatigue and sometimes slow the heart too much.

Diuretics remove excess fluid. Furosemide is the most common. Diuretics help with shortness of breath and swelling. The problem is that they increase sodium loss and potassium loss, which is why your parent's blood work needs monitoring. If your parent gets too much diuretic, they can become dehydrated and their kidney function can decline.

Aldosterone antagonists help the heart and also help with fluid retention. Spironolactone is the most common. These medications increase potassium, which is good in the context of heart failure but can be dangerous if potassium gets too high. Your parent on spironolactone needs regular blood work to watch potassium.

Newer medications like sacubitril/valsartan and SGLT2 inhibitors are increasingly used in heart failure. These actually improve heart function and reduce hospitalizations. They're expensive but might be worth it if your parent's heart failure is significant.

The combination of these medications is what makes heart failure manageable. One medication alone wouldn't do much. Together, they reduce the workload on the heart, help it heal, remove excess fluid, and keep it pumping as efficiently as possible.

When Things Change

Your parent's heart failure is stable when they're not short of breath at rest, when their legs aren't swelling, when they're able to do their usual activities. Decompensation is when things get worse. Your parent becomes short of breath with less activity. They swell. They gain weight. They're exhausted. This is an emergency. They need to go to the hospital or call their doctor immediately.

Sometimes decompensation comes suddenly. Your parent seems fine and then suddenly they're very short of breath and their heart is racing. Sometimes it develops gradually over days. Either way, when your parent is decompensating, they need medical attention.

Hospital readmission for heart failure is common. Your parent might be hospitalized for several days, get diuretics intravenously, get medications adjusted, and then go home. Each hospitalization carries risks. It's important to try to prevent them. This is where medication compliance matters. If your parent takes all their medications, monitors weight, restricts salt and fluid, and calls the doctor early when problems develop, they're less likely to end up hospitalized.

What counts as decompensation and what's just a bad day? This is something your parent and their doctor should discuss. If your parent gets short of breath after walking upstairs, that's probably normal for heart failure and not decompensation. If they get short of breath walking from the bedroom to the bathroom, that's new and significant. If they wake up at night short of breath, can't sleep flat, that's serious. Learning the difference between normal and concerning is important for you and your parent.

End-stage heart failure is different. Some older adults reach a point where medications aren't working anymore, where frequent hospitalizations happen, where quality of life is really compromised. At that point, the conversation might shift. Does your parent want to keep pursuing aggressive treatment, or would they rather focus on comfort? Would they want a defibrillator or a transplant, or would they prefer not to have more procedures? These conversations need to happen while your parent can still participate, ideally before they're too sick to decide.

Your parent's heart failure medications might feel overwhelming. Five pills a day, each one with different instructions, different times to take them, different things to watch for. But each one is there because it helps. Together, they keep your parent's heart working. Your job is understanding what each medication does, watching for side effects, monitoring for signs of decompensation, and making sure your parent takes them consistently. It's work, but it keeps your parent alive.

How To Help Your Elders provides educational content for family caregivers. This is not a substitute for professional medical, legal, or financial advice. Every family situation is different — what works for one may not work for another.