Common types of medication

Angiotensin-converting enzyme (ACE) inhibitors help relax your veins and arteries to lower your blood pressure. ACE inhibitors prevent an enzyme in your body from producing angiotensin II, a substance that narrows your blood vessels. This narrowing can cause high blood pressure and force your heart to work harder. Angiotensin II also releases hormones that raise your blood pressure.

ACE inhibitors help to reduce the workload of the heart and help to improve heart function. 

There are various types of ACE inhibitors and you can recognise them as their names always end in ‘pril’. Ramipril is most commonly prescribed for people diagnosed with Dilated cardiomyopathy.

The side effects of ACE inhibitors include:

• a dry cough 

• increased blood potassium levels (which can cause kidney failure)  

• Fatigue (tiredness) 

• dizziness  

• reduced kidney function 

Side effects may vary according to the type of ACE inhibitor you have been prescribed. If you are struggling with any side effects, we recommend getting in touch with your GP/Cardiologist. See Dr Robert Cooper discuss ACE inhibitors here.  

Non-selective beta blockers are active in blocking adrenaline and noradrenaline in other areas of the body including the heart. Selective beta blockers are used more commonly by cardiologists because their activity mostly affects the heart.

In people diagnosed with hypertrophic cardiomyopathy, they are effective in reducing symptoms of chest pain and shortness of breath. In Dilated cardiomyopathy beta blockers have been shown to reduce the energy requirement of the heart muscle and improve the relaxation of the heart.

Bisoprolol, carvedilol

The side effects of beta blockers include:

• Fatigue 
• Dizziness
• Disturbed sleep
• Cold fingers and toes  

Beta blockers are given at a low dose initially, to allow the body to become accustomed to their action. The aim is then to gradually increase the dose over a period of weeks. It can for some people take a while for their body to adjust to starting and dose increases of beta blockers as beta blockers can lower blood pressure and heart rate. See Dr Robert Cooper discuss beta blockers here.

The DAPA-HF trial demonstrated that Dapaglilozin in addition to standard care, reduced the risk of worsening heart failure hospitalisation versus placebo by 26%. 

The EMPEROR-Reduced trial demonstrated in addition to standard care reduced the risk of hospitalisation for heart failure and cardiac death by 25%.

• Angiotensin converting enzyme inhibitor (ACE inhibitor) or Angiotensin receptor antagonist (ARB) with a beta blocker and a mineralocorticoid receptor antagonist ( MRA)  if tolerated or; 

• Sacubitril valsartan, with beta blockers, and, if tolerated, MRAs.  

DAPA-HF was a double-blind randomised clinical trial comparing Dapagliflozin (a sodium-glucose cotransporter-2 inhibitor) plus standard care with placebo plus standard care. 

People in the trial had HFrEF defined by an ejection fraction of 40% or less who despite being 'optimally treated with pharmacological and/or device therapy' remain symptomatic. Symptomatic HFrEF was defined as New York Heart Association (NYHA) functional class 2 to 4 present for at least 2 months. 

• For an adult, 10 mg once a day by mouth with or without food.

• Common side effects can include a bladder infection or vaginal infection in women frequent urination, dizziness or light-headedness may occur tell your GP if you have any serious side effects, including: signs of a urinary tract infection (such as burning/painful/frequent/urgent urination, pink/bloody urine) or concerns about a change in the amount of urine you are passing and/or swelling of ankles or feet or abdomen

• We advise you to tell your GP if you have any signs of dehydration, such as urinating less than usual, unusual dry mouth and/or thirst, fast heartbeat, or dizziness and /or feeling lightheaded or feeling faint or fainting. 

• See the NHS website for further information about potential side effects: Side effects of dapagliflozin - NHS (www.nhs.uk)

If you miss a dose, take it as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take 2 doses of dapagliflozin at the same time.

If you take too much dapagliflozin, call your healthcare provider or go to the nearest emergency room right away.

Dapagliflozin was also studied in patients with heart failure in the DELIVER study (heart failure with preserved ejection fraction - HFpEF), this trial showed that Dapagliflozin in addition to standard care reduced the risk of worsening heart failure episodes and cardiac death. NICE guidance is due to be published on 29th March 2023

There is a possibility that if you have a longer spell of illness you could become dehydrated therefore we would advise you to speak to your GP or cardiac nurse if you are unwell with vomiting or diarrhoea, or if you eat or drink less than usual due to illness.

See Dr Robert Cooper discuss Dapagliflozin here.

The Empagliflozin Outcome Trial in Patients with Chronic Heart Failure and Reduced Ejection Fraction (EMPEROR-Reduced) is the second large-scale true heart failure trial, after DAPA-HF, to investigate the effects of SLGTi on cardiovascular hard outcomes. Compared to DAPA-HF, the EMPEROR-Reduced trial enriched patients with a greater severity of left ventricular systolic dysfunction. Like DAPA-HF, HFrEF patients with or without T2DM were enrolled.

An adult dose is 10 mg once daily by mouth with or without food.

Common side effects can include a bladder infection or vaginal infection in women. Other potential side effects include: frequent urination, dizziness or light-headedness or fainting or feeling faint, constipation, thirst.

We advise you to tell your GP if you have any serious side effects or if you have any signs of dehydration, such as urinating less than usual, unusual dry mouth/thirst, fast heartbeat, or dizziness/ feeling lightheaded or fainting. 

See the NHS website for more information about possible side effects: Empagliflozin: medicine used to treat type 2 diabetes - NHS (www.nhs.uk)

Take the medicine as soon as you can, but skip the missed dose if it is almost time for your next dose. Do not take two doses at one time.

There is a possibility that if you have a longer spell of illness you could become dehydrated therefore we would advise you to speak to your GP or cardiac nurse if you are unwell with vomiting or diarrhoea, or if you eat or drink less than usual due to illness.

Entresto is used in certain people with chronic heart failure. This medicine helps lower the risk of needing to be hospitalized when symptoms get worse, and helps lower the risk of death from heart failure.

• This is recommended for patients not currently taking an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB), and for patients previously taking low doses of these medications.
• You should not take Entresto if you are allergic to Sacubitril or valsartan or if you have had an allergic reaction to an ACE inhibitor or ARB.
• You should not take Entresto within 36 hours before or after you have taken any ACE inhibitor medication.
• You may take Entresto with or without food.
• Take the medication at the same time each day.

• Starting dose of Sacubitril is 24 mg / Valsartan 26 mg twice a day

• Initial dose; Sacubitril 49 mg / Valsartan 51 mg orally, twice a day

• Maintenance dose: Sacubitril 97 mg / Valsartan 103 mg orally, twice a day

• Entresto is a film-coated tablet, therefore it is not recommended for it to be split or cut in half

• The dose should be increased after 2-4 weeks to achieve the target maintenance dose as tolerated 

• Dizziness; or
• Cough

We would advise you to contact your GP or call 111 if you experience: 

• a light-headed feeling, like you might pass out; 
• extreme tiredness; 
• high potassium - slow heart rate, weak pulse, muscle weakness, tingly feeling; or 
• kidney problems - little or no urinating, painful or difficult urination, swelling in your feet or ankles, feeling tired or short of breath. 

See Dr Robert Cooper discuss Entresto here.

It is for adults diagnosed with hypertrophic cardiomyopathy with obstruction (where the thickening of the heart muscle affects blood leaving the heart) who have good pumping function of the heart who have symptoms due to the obstruction of blood leaving the heart.