Pharmacologic pitfalls in heart failure: A guide to drugs that may cause or exacerbate heart failure. A European Journal of Heart Failure expert consensus document

Abstract

Heart failure (HF) exerts a global health burden, often complicated by polypharmacy due to the frequent coexistence of cardiovascular and non-cardiovascular comorbidities. While guideline-directed medical therapy and devices have significantly improved outcomes, a range of commonly prescribed medications may inadvertently worsen HF or precipitate decompensation. This expert consensus statement provides a comprehensive overview of drugs known to cause or exacerbate HF, offering practical guidance for clinicians to identify and avoid harmful pharmacologic exposures in this vulnerable population. The review examines the pathophysiological mechanisms, clinical evidence, and guideline-based recommendations for several drug classes, including antidiabetic agents (e.g. thiazolidinediones, dipeptidyl peptidase-4 inhibitors), antiarrhythmics (particularly Class I and III), calcium channel blockers, non-steroidal anti-inflammatory drugs, antifungals (e.g. itraconazole, amphotericin B), macrolide antibiotics, antihypertensives (e.g. α1-blockers, centrally acting sympatholytics), neurological and psychiatric medications (e.g. carbamazepine, pregabalin, lithium), and selected anaesthetic and anticancer agents such as anthracyclines and vascular endothelial growth factor inhibitors. Each section addresses clinical scenarios where these medications may be contraindicated or require close monitoring. Importantly, this document emphasizes the need for individualized therapy, close review of medication regimens, and collaborative care to minimize iatrogenic harm. The goal is to empower clinicians, pharmacists and nurses to optimize HF treatment while reducing the risk of drug-induced deterioration. Awareness of these pharmacologic pitfalls is critical to improving clinical outcomes and minimizing preventable adverse events and HF hospitalizations.