What polypharmacy means for heart failure
Polypharmacy, or taking multiple medications, is common among people living with heart failure. While many drugs are essential to manage symptoms and prevent progression, a heavy or uncoordinated medication load can introduce interactions and adverse effects that worsen outcomes. Recent evidence suggests that polypharmacy is significantly associated with higher mortality, while merely accumulating cardiovascular medications does not carry the same risk. A 2022 study reported a risk ratio of 1.31 (95% CI 1.07–1.61) for early death with polypharmacy, underscoring the need for careful medication stewardship in this population. At the same time, guideline-directed medical therapy remains a cornerstone for reducing mortality, highlighting that the goal is optimized, evidence-based regimens rather than a maximized number of drugs.
Mortality risk, and the economic burden
Beyond individual health, polypharmacy drives substantial health-system costs. Adverse effects often lead to more doctor visits, new prescriptions, emergency department care, or hospitalizations. In the United States, estimates place the aggregate cost of polypharmacy-related issues at about $528 billion, roughly 16% of all health expenditures. An ESC position paper from 2022 also outlines common pitfalls and practical patient scenarios that illustrate how these risks play out in real life.
Common stumbling blocks in daily practice
NSAIDs and fluid retention
A typical scenario involves an older patient with heart failure with reduced ejection fraction who self-medicates with ibuprofen for arthritis. NSAIDs can promote sodium and water retention, aggravating heart failure symptoms. The practical takeaway is clear: always ask about over‑the‑counter medications at every visit and, when appropriate, recommend alternatives such as acetaminophen to manage pain without compromising heart function.
Herbal supplements and DOAC interactions
Herbal remedies, such as St. John’s wort, can alter anticoagulant exposure. In one case, a patient treated with edoxaban for atrial fibrillation experienced a stroke after starting St. John’s wort, due to induction of P‑glycoprotein and reduced anticoagulant effect. Clinicians should specifically probe for phytotherapy and avoid potentially dangerous combinations with direct oral anticoagulants (DOACs).
Amiodarone with direct oral anticoagulants
Combining amiodarone with a DOAC can raise bleeding risk for patients with atrial fibrillation and reduced kidney function. If a patient experiences recurrent GI bleeding or other hemorrhagic events, it may be wiser to reconsider the antiarrhythmic strategy rather than cycling through DOACs without addressing the root interaction.
Statins and macrolide antibiotics
A further scenario involves a patient on atorvastatin who develops myopathy after clarithromycin therapy. Macrolides inhibit CYP3A4, which can increase statin levels. When such antibiotic use is necessary, clinicians may choose an alternative antibiotic or pause the statin for a short period to reduce myopathy risk.
Practical recommendations for clinicians and patients
- Regularly review all medications, including over-the-counter drugs and supplements, for potential interactions.
- Use drug interaction checkers and consult pharmacists when needed.
- Prioritize guideline-directed therapies and assess whether every additional drug is necessary.
- Engage in shared decision making and consider deprescribing when risks outweigh benefits.
- If complex regimens are unavoidable, adjust dosing or select safer alternatives to minimize adverse events.
Conclusion
Polypharmacy in heart failure is a double-edged sword: essential therapies exist alongside avoidable risks. By recognizing common stumbling blocks and maintaining vigilant medication reviews, clinicians can reduce early mortality and healthcare costs while preserving quality of life for people living with heart failure.
