How to handle polypharmacy in heart failure. A clinical consensus statement of the Heart Failure Association of the ESC

Abstract

The multiplicity of coexisting comorbidities affecting patients with heart failure (HF), together with the availability of multiple treatments improving prognosis in HF with reduced ejection fraction, has led to an increase in the number of prescribed medications to each patient. Polypharmacy is defined as the regular use of multiple medications, and over the last years has become an emerging aspect of HF care, particularly in older and frailer patients who are more frequently on multiple treatments, and are therefore more likely exposed to tolerability issues, drug-drug interactions and practical difficulties in management. Polypharmacy negatively affects adherence to treatment, and is associated with a higher risk of adverse drug reactions, impaired quality of life, more hospitalizations and worse prognosis. It is important to adopt and implement strategies for the management of polypharmacy from other medical disciplines, including medication reconciliation, therapeutic revision and treatment prioritization. It is also essential to develop new HF-specific strategies, with the primary goal of avoiding the use of redundant treatments, minimizing adverse drug reactions and interactions, and finally improving adherence. This clinical consensus statement document from the Heart Failure Association of the European Society of Cardiology proposes a rationale, pragmatic and multidisciplinary approach to drug prescription in the current era of multimorbidity and 'multi-medication' in HF.

Keywords: Adherence; Comorbidities; Heart failure; Polypharmacy.

Figure 1

Multidomain approach for managing polypharmacy in heart failure (HF). Reconciliation of treatments and periodical assessment of therapeutic appropriateness follow multistep and multidisciplinary processes, which should consider patient and drug characteristics. Periodical review of these aspects is pivotal. When the possibility and need of deprescribing is ascertained, the deprescribing protocol represents a point‐by‐point guide that can support physicians' decisions. Alternatives to definitive deprescribing (i.e. represcribing/replacement, variation in the way of administration) should be always evaluated. CV, cardiovascular.