How Do We Treat Heart Failure?

Medications & What They Actually Do.

If you have recently been diagnosed with heart failure, there is a good chance you left the clinic with several new prescriptions.

For many people, the thought of having to be on medications feels somewhat depressing, right alongside the many emotions that go with having a heart failure diagnosis.

It’s quite common to look at the list of medications and wonder:

“Do I really need all of these?”

Or perhaps:

“What does each one actually do?”

These are very reasonable questions.

Heart failure medications are not simply about controlling symptoms. Many of them are designed to protect the heart over the long term and improve survival.

Understanding their role can make the treatment plan feel far less mysterious.

Medications That Reduce the Heart’s Workload

Some medications help by reducing the pressure the heart has to pump against.

They relax blood vessels and improve blood flow, making it easier for the heart to circulate blood throughout the body.

When the heart does not have to push as hard with each beat, it can work more efficiently and experience less long-term strain.

Medications such as ACE inhibitors, ARBs, and ARNI therapies fall into this category.

They are among the most important treatments in heart failure care. They don't just modulate the pressure load in the heart, they also affect the hormones that drive the pressures and the salt and water balance in your body.

These things matter because they improve longer term survival. This group of medications has transformed survival in heart failure.

Medications That Protect the Heart Muscle

Another group of medications works by protecting the heart muscle from the effects of stress hormones.

You may hear these called beta-blockers.

They slow the heart rate slightly and reduce the impact of adrenaline-like hormones that can place extra strain on the heart over time.

This allows the heart muscle to function more efficiently and, in many cases, recover some strength.Whilst there are many types and even generations of beta blockers that have been created over many decades, particular types have been studied and proven to benefit heart failure patients.

These medications have been shown in large studies to significantly improve outcomes for people living with heart failure. They can impact survival significantly.

Medications That Remove Excess Fluid

One of the most noticeable symptoms of heart failure is fluid retention.

Fluid may build up in the lungs, causing breathlessness, or in the legs and abdomen, causing swelling.

Medications called diuretics help the body remove this excess fluid by increasing urine production.

These drugs are often referred to as “fluid tablets.”

They can provide rapid relief from symptoms, although they work best when combined with the other medications that support the heart muscle itself.

Some diuretics are very potent and they cause rapid improvement in symptoms of breathlessness, leg swelling, cough, abdominal bloating and loss of appetite. Used carefully, they can help to stop patients from bouncing in and out of hospital with congestion in their lungs.

The newest generations of these drugs are called MRA's or Mineralocorticoid Receptor Antagonists. These don't just help you lose salt and water. They have special hormonal effects on our vascular systems that help to protect the heart, lower the stress from excess salt and water retention, and improve remodelling or scarring in the heart over the longer term. There is a newer generation of these called a non-steroidal MRA. This type has been studied in kidney disease and is emerging as a therapy in HFpEF perhaps superior to the older generation MRA's.

Diuretics (particularly Loop diuretics) have also been around for many decades and remain invaluable. In the early days of heart failure management this was one of the few tools we had to try and help patients. Now we have many more.

Newer Treatments

Over the past decade, several newer medications have become available that improve heart failure treatment even further.

Some of these drugs help the kidneys remove extra sodium and glucose from the body, which indirectly reduces pressure on the heart. These you might know as SGLT2 inhibitors.

These were used primarily for diabetics but researchers found that they reduce death and hospitalisation in heart failure (in both types previously discussed). So now they form one of the essential arms of treatment, whether you have diabetes or not.

Others work on hormone systems that influence blood pressure and fluid balance.

These newer therapies have become an important part of modern heart failure management and are increasingly used alongside traditional medications.

There is another type of medication called Ivabradine. This is what we call a "Funny Channel Inhibitor". In basic terms, this slows heart rate without lowering blood pressure. It also does not affect the lungs, which can be a problem in patients who suffer from asthma. This can limit the use of drugs like beta blockers we mentioned earlier.

So Ivabradine can be a highly effective drug in taking the stress off a failing heart, without causing other problems.

Recently, there have been some developments in creating medication that can actually cause a stronger contraction in otherwise weakened heart muscle. This one is available for patients who meet the particular criteria and can be invaluable as an addition to therapy, when needed. More work is being done on developing these types of medications.

Finally, there are special drugs treatments for some of the conditions where the heart muscle thickens up and causes heart failure through stiffness and poorer efficiency. These are beyond the scope of this particular discussion but this is something you can ask your heart specialist, in case it applies to you.

Why Several Medications Are Often Needed

It’s helpful to think of heart failure treatment as a team effort.

Each medication targets a different part of the process affecting the heart.

One may reduce strain on the circulation.
Another protects the heart muscle.
Another helps control fluid balance.

Together, they create a treatment plan that supports the heart in multiple ways.

That’s why it’s common for people with heart failure to take more than one medication.

It isn’t duplication — it’s a coordinated strategy.

THE FOUR PILLARS OF HEART FAILURE MANAGEMENT.

You might hear some talk or read online about the four pillars of heart failure management.

In HFrEF we now have guidelines that recommend these 4 groups of medications as the basis for our treatment. This recommendation guides us to treat our patients early with all four groups of medications as soon as possible, provided that there are not reasons to withold any of those particular medication arms.

We know that if we can do this, the earlier we start, and the higher the doses we introduce, the better the results are (longer survival, less hospitalisation, patients get on with living their lives.)

So you can already see, that there is a very strong basis for more medications along these lines. This supports our goals for a longer better life, living with heart failure.

Moving Forward

Heart failure treatment has improved enormously over the past three decades.

The combination of modern medications, careful monitoring, and lifestyle adjustments has changed the outlook for many patients.

Understanding why each medication has been prescribed can make the process feel far less overwhelming.

Instead of simply taking tablets, you begin to see how each one plays a role in supporting your heart.

And that understanding makes it easier to stay engaged in your care.

In the next article we will show you why fluid can build up in the lungs.