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Treat heart failure

Education and information

After a comprehensive diagnosis, you will have all the important information so that you can decide on further treatment after consulting your doctor. Keep asking until you really understand all of the results. We have formulated a few questions for you in the box.

Questions about the diagnosis:

  • Do we have all the important results together?

  • How resilient am I physically? Which NYHA stage do I have?

  • What treatment options are there? Which are suitable for me and why? What are their advantages and disadvantages?

  • Can the treatment extend my life?

  • What effects will the disease and the treatment have on my quality of life?

  • Should I get a second opinion?

  • How much time do I have to make a decision about treatment?

Which treatment is right for you depends heavily on your personal goals, your living environment and your medical history. It is therefore important that you discuss this with your doctor. It is up to you whether you then make the decision alone, leave it to your doctor or decide together. Perhaps the patient sheet "Discussing decisions together" will help you:

As a rule, you have enough time to make this decision in peace - if you so wish, together with relatives.

Second medical opinion

You may be unsure whether a suggested treatment is right for you. Or you don't feel well advised. If you have any doubts, speak openly about this in a second discussion with your treating doctor. If your doubts cannot be dispelled or if you feel that you have not been advised carefully enough, you can ask another doctor for her opinion. You can find out more about patient rights in the chapter Your good rights.

What are the treatment options?

Treatment aims to

  • relieve the discomfort;

  • delay the progression of the disease as long as possible;

  • to avoid premature death from heart failure;

  • Avoid hospital admissions;

  • that those affected become more physically resilient again;

  • to keep the burden of side effects and treatment consequences as low as possible.

Not always all goals can be achieved with the treatment. Together with your treatment team, you will consider which goals are particularly important to you and align the treatment accordingly. The following things also play a role in the planning: Your living environment, whether you have problems coping with everyday life, what is your mental health and how well you can cope on your own (see chapter Medical history and living conditions).

There are several effective treatment options, some of which are used together:

  • If a cause for the heart failure is known, then - if possible - the causative disease

  • One is especially important healthy lifestyle, especially physical training. You can find more about this in the chapter Behavior Changes: What is a Healthy Lifestyle ?.

  • For most sufferers, experts recommend several Medication. You can read more about this in the chapter Treatment with medication.

  • For some sufferers, an additional surgical intervention be beneficial to the heart, such as using a pacemaker or defibrillator. More on this can be found in the chapter on surgical interventions.

A healthy lifestyle is an integral part of your treatment. Treatment will only be effective if you adjust your lifestyle as best as possible and continue to take your medication as directed. You can read more about this in the chapter Adhering to treatment goals.

Treat the cause

Heart failure often arises as a result of another disease, for example constricted coronary arteries (CHD) or high blood pressure (more on this in the chapter on risk factors for heart failure). If the cause is treated in a targeted manner, the heart failure can also improve or even regress completely.


The treatment of the causative diseases is not part of these patient guidelines.

Behavioral Changes: What is a Healthy Lifestyle?

You contribute to the success of the treatment through your own behavior. In any case, it is important to have a healthy lifestyle. These include: exercise, eat a balanced diet and refrain from smoking. It is also advisable for people with a weak heart to take part in training courses and regularly check their weight. If you follow these guidelines, you can help slow the progression of the heart failure and reduce the occurrence of severe consequential damage.

Lifestyle - a personal matter ...

Most people know in theory that a balanced lifestyle can keep you healthy. But changing a lifestyle that is not yet balanced is not easy for everyone.

People are different. Not everyone is consistent, not everyone achieves the goals set by themselves or by the doctor.

Some people suffer from being unable to lose weight, exercise more, or drink less despite trying hard. And they feel belittled and not respected by others because of it. This can become a mental burden. But that is not the aim of lifestyle recommendations.

As with all medical recommendations, the following also applies here: How you ultimately decide also depends on your personal situation, your living conditions and values.

Promote exercise

Regular exercise improves the progression of the heart failure. It maintains physical resilience and can increase the well-being and independence of many sick people.

The guideline recommends:

The doctor should Recommend you to be physically active.

Studies show that regular exercise can improve life expectancy, alleviate discomfort and avoid hospital stays in people with heart failure. Therefore, in the opinion of the expert group, regular physical activity is the most important component of your treatment.

Daily exercise in the fresh air is good for you, like going for a walk or gardening. also should Your doctor advises you to do regular and long-term endurance training. If necessary, he can provide you with contact points. Cycling, swimming and Nordic walking are particularly suitable. Dancing or aerobics also keep you fit. Other people feel more comfortable with yoga or aqua aerobics. If you are not very agile, you can start on a home trainer. Strength exercises can also be added later. In so-called rehab sports groups, you will receive a training plan tailored to your needs. The doctor in a cardio group can monitor the training and make sure that you are exercising properly.

During physical exertion, symptoms may arise due to your weak heart. It is therefore important that the training is adapted to your strength. Before you start should Your doctor will check how strong you are physically resilient, for example by means of a so-called Spiro-ergometry. During this examination, the heartbeat and the breathing gases are measured. Together you can then agree on how intense the physical activity should be and in which steps you can increase the training. The examination can be repeated more often to see whether the resilience of the heart and lungs has increased. Here is an example of a plan for endurance training:

Table 3: Endurance Training Plan


Regular endurance training

1 to 2

Volume: 5 to 10 minutes (increase slowly)

Frequency: daily

3 to 4

Length: 10 to 15 minutes (increase slowly)

Frequency: daily

5 to 7

Length: 15 to 20 minutes (increase slowly)

Frequency: daily

In addition: strength exercises twice a week

8 to 12

Length: 20 to 30 minutes (increase slowly)

Frequency: 3 to 4 times a week

In addition: strength exercises twice a week

Do not overwhelm yourself at the beginning. You slowly get used to more exertion.

This is how you notice that you are really straining yourself:

  • You don't feel any discomfort, but you feel a little strained.

  • You sweat a little.

  • You breathe a little faster than normal, but you can still talk in full sentences.

It is best to choose a sport that you enjoy. You can also ask friends and acquaintances if someone would like to participate. Or you can join a sports group. A lot is easier together.

You can also get a compact overview in the patient sheet "Why exercise is important":

Please note: The recommendation for physical activity does not apply if the heart failure suddenly worsens (derails), for example in the case of severe shortness of breath. Then temporarily bed rest and rest are advisable.

quit smoking

Anyone who continues to smoke with an existing cardiac insufficiency must expect the cardiac insufficiency to progress worse. Quitting smoking is one of the most effective measures against it.

The guideline recommends:

Your doctor should We advise you to give up tobacco completely and to avoid passive smoking. Ask about suitable support offers.

The evaluation of a large study on heart failure with many thousands of participants shows that those who quit smoking can live longer:

  • Of 100 people with heart failure who continued to smoke despite their illness, 43 had died after about 3 years - compared to 36 who did not smoke or no longer smoked.

  • Quitting smoking saved 7 out of 100 people from premature death after 3 years.

  • Just two years after quitting smoking, the course of the disease was just as favorable as in people who had never smoked.

There are various offers for smoking cessation such as personal or telephone advice. A contact point can be the Federal Center for Health Education (BZgA): and telephone 0800 8313131. If necessary, the doctor can also offer you individual or group behavioral therapy or certain medications.

You can also read the patient information sheet "Why it helps to give up smoking":

Drink little or no alcohol

Too much alcohol is harmful to the heart muscle and can lead to cardiac arrhythmias.

The guideline recommends:

If your heart failure is not alcohol related and you are not addicted to alcohol, should At most, you drink alcohol in the usual proportions. Discuss with your doctor whether you can tolerate the amount of alcohol you usually drink.

There is evidence from studies that high amounts of alcohol have a bad effect on heart failure. This does not seem to be the case with alcohol in small quantities, unless the heart failure is caused by alcohol.

It is best to drink little alcohol - no more than one or two small glasses a day. Of course, this depends on the alcohol content of the drink and on gender: The maximum amount is 10 g of pure alcohol per day for women and 20 g for men. This corresponds to a small glass of wine (115 ml) or beer (250 ml) a day for women and a small glass of wine (230 ml) or beer (500 ml) a day for men. Alcohol in these small amounts is not harmful to the heart. Remember that alcohol is high in calories.

Please note:

The expert group is of the opinion that you absolutely do not drink alcohol shouldif your heart failure is caused by alcohol. Studies suggest that the heart muscle can then recover by abstaining from alcohol.

The expert group also recommends total abstinence if you have or have had an alcohol problem. If this is difficult for you, ask about suitable support offers.

Healthy eating

Anyone with heart failure does not need a specific diet or special dietary supplements (more on this in the chapter on complementary and alternative treatments). As with healthy people, a balanced diet with lots of fresh vegetables and little sugar is cheap. The same recommendations apply to salt as to healthy people. The amount you drink should be adapted to your symptoms. Care should be taken with dietary supplements.

>> How much can you drink?

If the heart is weak, more water is stored in the body because the heart no longer pumps properly. For example, you get fat legs. It was therefore recommended in the past to drink little. Today, drinking 1.5 liters per day is recommended. In addition, there is the liquid from food. Studies show that taking in too little fluid can be harmful. This can lead to serious consequences: confusion, falls, the kidneys are no longer working properly and the heart is beating too fast.

There are exceptions, however: if water retention leads to severe symptoms such as high blood pressure or shortness of breath, the body should be given less fluid at times. This includes all beverages, but also the liquid in food. According to the expert group should The amount you drink must be adapted to the function of your kidneys and the stored water. Basically, it is best to discuss the amount you drink with your doctor.

Water and unsweetened teas are best. You should avoid sugary drinks such as fruit juices or lemonades as much as possible.

>> Should you forego salt?

Most people eat more salt than is good for them. This is mainly due to the consumption of heavily salted foods such as chips, smoked and cured foods. Many finished products also contain a lot of salt. Most of the salt is consumed through bread, sausage and cheese. Nutrition professionals recommend about 6 grams of salt per day. This is equivalent to about 1.5 teaspoons of salt. Much more is not healthy. But you do should According to the expert group, so does the amount of salt Not restrict even more. There are no benefits to this; it can possibly even harm.

You can also read about nutrition in the case of cardiac insufficiency in the patient leaflet "Do I have to pay attention to my diet?":

Further information is available from the German Nutrition Society. V .:

Control weight

If the heart is weak, a lot of water can accumulate in the body in a short period of time. This is a sign that the heart's pumping power is deteriorating. You can tell by the fact that you put on a lot of weight in a short period of time. Therefore should According to experts, you check your weight every day. In this way, serious changes can be identified and treated at an early stage.

Let your doctor's office know if you do

  • gain more than 1 kilo overnight;

  • gain more than 2 kilos within 3 days;

  • gain more than 2.5 kilos within a week.

Then it is important to clarify what is the reason for this increase. Usually there is no emergency behind it. It is often enough to adjust the amount of water tablets (diuretics) you take. Some sufferers learn to adjust the daily amount of tablets themselves to their particular situation. You can discuss with your doctor whether this is also an option for you.

If you have not yet noticed any symptoms of cardiac insufficiency (stage NYHA I; see table 1 in the chapter Severity degrees of cardiac insufficiency), it is best to discuss with your doctor how often you should weigh yourself.

>> What should you watch out for when weighing?

If you want to reliably determine weight gain, you need to weigh yourself under roughly the same conditions. This means:

  • always at a fixed time, for example in the morning after getting up after using the toilet;

  • always in similar clothing, for example without clothes and without shoes.

It is best to write down the weight immediately after weighing. Trained nurses or medical assistants can support and advise you. A weight log can also be helpful.

>> What is a weight log?

The weight log is a kind of table in which you can enter the weight that you measure at regular intervals. It can be expanded to include additional information such as blood pressure, pulse or temperature. Here you can find an example template for such a weight log:


Weight / kg

Blood pressure
(upper value / lower value)

Pulse / min

Temperature / ° C

You can also use the heart diary provided by the German Heart Foundation: Krankungen/herzinsuffendung.

You can also get a compact overview of this topic in the patient sheet "Should I check my weight regularly?":

Hold weight

Being overweight can lead to heart failure.However, if you already have heart failure, being moderately overweight can actually have beneficial effects on your illness. Studies have shown that overweight sufferers live a little longer and have to go to hospital less often than those of normal weight. Experts do not know exactly why this is so. Not only weight, but also fat distribution and physical fitness seem to play a role. The expert group could not find any studies on the question of whether weight loss is beneficial. Therefore, she does not regularly advise overweight people with heart failure that they should lose weight. Physical training is also strongly recommended for those who are overweight.

It is also clear that underweight and obesity are associated with a worse course of cardiac insufficiency.

Attend training courses

It is important that you understand your illness and learn to combine it with your everyday life in the best possible way. Patient training helps with this. This enables you to better organize the conversation with the doctor and make it easier for you to comply with the recommended treatment.

The guideline recommends:

Your doctor should Offer and convey training to you right at the beginning of the illness and repeatedly during the course of treatment.

Studies indicate that taking part in training courses can improve the course of the disease.

The guideline recommends the following contents of such training:

  • Understanding of illness: the basics of heart failure with its consequences and treatment options are taught;

  • Education about a healthy lifestyle, for example physical training, smoking cessation and a healthy diet;

  • correct handling of the drugs, benefits and harms of the individual active ingredients, recommended vaccinations;

  • Information on the advantages and disadvantages of surgical interventions, structure and function of a pacemaker and a defibrillator;

  • Change of pacemaker and defibrillator due to an exhausted battery, possibility of switching off the device at the end of its life;

  • Help and support in order to be able to take responsibility for the treatment (see chapter Dealing with the disease independently);

  • Opportunities for sexual activity, information on the use of potency-enhancing agents, impotence as a result of heart failure or as a possible side effect of medication;

  • Information on trips to the mountains or the tropics, medication plan abroad, information on driving motor vehicles (more on this in the chapter Fitness to drive);

  • psychological support in coping with illness, coping with stress, for example with relaxation training;

  • behavioral training programs specifically for smokers or for people with memory problems;

  • Training courses specially tailored to you, for example on self-monitoring of blood sugar if you have diabetes, or self-monitoring of blood pressure in the case of high blood pressure.

It is best to ask your doctor or a nurse or medical specialist assigned to you which type of training is suitable for you. Your relatives can also be included in the counseling and training courses.

Treatment with medication

If you have heart failure, you usually get several medications. The drugs are supposed to relieve the symptoms of heart failure and have a beneficial effect on the further course of the disease.

As drugs come in the first place ACE inhibitorsand Beta blockerstogether for use (more information in the ACE inhibitor chapter). These drugs lower blood pressure and relieve the heart. Those who cannot tolerate the ACE inhibitor are given a so-called one instead AT-I blockers (see chapter Angiotensin-I-Blocker) available.

In addition, many sufferers need dehydrating tablets - so-called Diuretics (see chapter on diuretics). These are diuretic drugs that keep the water balance in balance. A diuretic is often in one tablet with another active ingredient. The technical term for this is Combination preparation. For example, the diuretic can be combined with an ACE inhibitor, a beta blocker, or another diuretic.

The medicines can only work properly if you take them as prescribed. A clear medication plan is helpful here (see chapter Information on your medication). You can also find this information compactly in the patient sheet "My most important medications":

The medication you are given depends primarily on whether you have heart failure with reduced or maintained pumping function (see chapter Types of heart failure). Your accompanying illnesses also play a role.

General information on medication

Important information about the medication

  • All drugs mentioned are started with a small amount because of possible side effects.

  • The optimal amount is that which works best and at the same time causes the fewest side effects.

  • It may take several months until a tolerated and effective amount is found.

  • The symptoms improve slowly. This can take a few weeks to several months.

  • Especially if you are taking more than one medication, it can be difficult to tell which side effect is caused by which medication and whether a lower or higher amount makes sense.

Let your doctor know if you experience any side effects. It may be possible to adjust the dose or switch to a different medication.

Questions that you can discuss with the doctor

  • How long does the drug treatment last?

  • When should an effect be felt?

  • What are the possible side effects of taking these drugs for a long time?

  • What interactions can be expected between the prescribed medication and other medications or agents?

  • What consequences can be expected if no or too few medications are taken?

  • What consequences can be expected if the medication is taken irregularly?

For the treatment of heart failure, the expert group sometimes recommends drugs that are not (yet) approved by the drug authorities in Germany and are therefore known as Off-label use come into use.

Off-label use

The use of drugs that have not yet been approved in Germany for this clinical picture is referred to as off-label use. Some active ingredients are only approved for certain NYHA stages in heart failure. The approval procedure for drugs prescribes the proof of the benefit of a drug in high-quality studies for each individual clinical picture that is to be treated with the drug. If there is no approval but there is good evidence of efficacy in your situation and if no other equally good treatment is available, then off-label use can make sense. However, it is often associated with greater uncertainty for the doctor and patient with regard to the effects and side effects. Together with your doctor, you can decide whether this type of treatment is suitable for you. You can read more about off-label use from the Federal Joint Committee (G-BA):

Be careful with certain medications

Medications given to you for heart failure are important. They help you and can prolong life. But other remedies that you may take for other illnesses or ailments can have an unfavorable effect on the heart failure: the heart pumps even worse or it stores even more water in the body. This applies to drugs that you can get without a doctor's prescription, such as pain relievers. However, this can also apply to medicines that may have been prescribed for you. Depending on the drug, the deterioration occurs immediately or after a while.

With these active ingredients, experts advise caution, especially when taken regularly:

  • some pain relievers such as ibuprofen, diclofenac, naproxen, celecoxib, or etoricoxib;

  • some blood pressure reducers such as doxazosin, terazosin, diltiazem, verapamil, nifedipine;

  • some remedies for cardiac arrhythmias;

  • some remedies for depression, seizures, prostate discomfort or diabetes.

Ask your doctor which combination of different drugs is suitable. They are also happy to advise you in the pharmacy.

You can also find this information compactly in the patient information sheet "Be careful with certain drugs":

Side effects - important to know

In addition to the desired effects of drugs, undesirable effects can also occur. If you experience adverse drug effects, discuss them with your doctor. When you receive a new medication, you will be asked to go to the practice more frequently to see how well the treatment is working and how you are tolerating it. The key question is how much the side effects affect you and how well the medicine helps.

You should also pay attention to so-called interactions: some drugs reinforce or reduce each other's effects. It is therefore a good idea to bring a list of all medications and products that you are taking with you to the doctor's consultation (see medication plan in the chapter Information on your medication).

Active ingredient name? Trade name?

All drugs are presented in this patient guideline with their active ingredient name. The trade name that a company gives its drug is usually better known. For example, the active ingredient ASA is called "Aspirin" by one manufacturer®The drug package always shows the active ingredient and the trade name. It is best to ask your treatment team for the trade name.

ACE inhibitors

What are ACE inhibitors?

These drugs lower blood pressure and improve the pumping capacity of the heart. ACE inhibitors are called for example Captopril, Enalapril, Lisinopril and Ramipril.

How do ACE inhibitors work?

They inhibit a certain protein (enzyme). The enzyme is called "Angiotensin Converting Enzyme" and is abbreviated to ACE. ACE causes two things in the body through several intermediate steps: The blood vessels contract and thereby become narrower. More salt and water remain in the blood, which increases the amount of blood. Both of these mean that the heart has to beat faster in order to pump blood to the body.

If ACE is inhibited,

  • the vessels remain;

  • more water and table salt are excreted;

  • blood pressure drops;

  • the heart is relieved and it can pump better.

For whom are ACE inhibitors not useful?

Reasons that speak against taking ACE inhibitors are, for example, pregnancy and breastfeeding, constricted blood vessels in the kidneys or advanced kidney failure. An ACE inhibitor must also not be used if an allergy-like reaction, such as a swollen face, during previous treatment with an ACE inhibitor (see Angioedema), occurred.

Is there anything special to consider?

At the beginning you take the ACE inhibitor in a low dose. Your doctor should According to experts, increase this every 2 weeks up to the final dose. Longer or shorter distances are possible. In order for the ACE inhibitor to work properly, it is important to reach this final dose. If that doesn't work, should You are being given the highest dose you can tolerate.

After increasing the dose, your doctor will check the kidney values ​​and the minerals in the blood. In people with diabetes, an ACE inhibitor can cause blood sugar to drop and cause hypoglycaemia.

It can take weeks, sometimes months, for an effect to occur. It is important to be patient. Contact your treatment team if you are unsure and have any questions.

What are the known side effects?

Common side effects are weakness and dizziness. It is recommended not to discontinue the drug in the event of these side effects, but to reduce the amount in consultation with a doctor until it becomes more tolerable.

About 5 to 10 out of 100 people develop a dry cough, also known as a dry cough.

Occasionally an allergy-like reaction occurs, such as swelling of the face, lips, or tongue. The technical term is Angioedema.

Angiotensin I blockers (sartans)

Angiotensin-I blockers (AT-I blockers for short) are drugs that lower blood pressure. They are also called Sartans designated. The individual active ingredients are called for example Candesartan, Losartan and Valsartan. Sartans work in a similar way to ACE inhibitors.

Is there anything special to consider?

The dose of AT-I blockers should be increased gradually. After each dose increase, the doctor checks the kidney values ​​and the minerals in the blood.

A sartan should not be used if angioedema, such as a swollen face, has occurred during previous treatment with a sartan. In addition, extreme caution should be exercised if angioedema occurred during previous treatment with an ACE inhibitor (see chapter ACE inhibitors).

What are the common known side effects?

Kidney disorders, increased blood potassium levels and low blood pressure can occur as side effects.

A disturbed kidney function can be recognized at an early stage by a rising creatinine level in the blood. Creatinine is a breakdown product of the muscles. It is excreted in the urine through the kidneys.

Beta blockers

What are beta blockers?

These are drugs that lower blood pressure and slow the heartbeat.

Beta blockers is a collective term for several drugs with a similar effect that block certain binding sites for hormones in the body. These binding sites are called beta receptors. That is why experts also refer to this group of drugs as Beta receptor blockers. The individual active ingredients are called for example Bisoprolol, Carvedilol, Metoprolol succinate and Nebivolol.

How do beta blockers work?

Beta blockers inhibit the effects of stress hormones. These stress hormones are called norepinephrine and adrenaline. When beta-blockers occupy the receptors, they prevent the body's own stress hormones noradrenaline and adrenaline from attaching to them. This lowers the blood pressure and the heart's need for oxygen. The heart is relieved.

Is there anything special to consider?

In 20 to 30 out of 100 people, symptoms get worse when they start taking a beta blocker. Therefore, experts recommend initially only about a tenth of the amount you should take later. The amount increases slowly. According to the expert group should there should always be an interval of at least 2 weeks between dose increases. The final dose you will take will depend on how fast your heart is beating (target: 55 to 60 times per minute) and how your symptoms improve.

It can take several months for the symptoms to improve. Those affected often perceive only a slight improvement.

Women break down certain beta blockers more slowly than men. This means that they sometimes have significantly higher amounts in their blood, which can lower the blood pressure more. At the same time, serious side effects may be more common in women. Then the dose can be reduced or another beta-blocker can be prescribed.

If for any reason you no longer want to take the beta-blocker or in a changed amount, you should definitely discuss this with your doctor beforehand. You shouldn't just suddenly leave out beta-blockers, as blood pressure and heartbeat can rise suddenly and uncontrollably.

What are the known side effects?

Slow heartbeat and low blood pressure can occur as side effects. Tiredness, feelings of weakness, dizziness, headaches and the feeling of cold or tingling hands and feet can occur.

Occasionally, some beta blockers can cause erectile dysfunction or a decrease in sexual desire. Dry mouth and reduced tearing with conjunctivitis of the eye are also rare side effects.

Beta blockers can narrow the airways. Anyone who has asthma at the same time should therefore discuss with their doctor whether beta blockers are an option.

Beta blockers can also mask signs of hypoglycaemia, such as cravings and sweating. This is important for people with diabetes. Ask your doctor what to look for if you have diabetes and heart failure.

Aldosterone antagonists

What are aldosterone antagonists?

There are two terms in the word aldosterone antagonist: aldosterone and antagonist. Aldosterone is a natural hormone that affects the body's water balance. antagonist comes from the Greek and means opponent. Accordingly, these drugs inhibit the hormone aldosterone. The individual active ingredients are called for example Spironolactone and Eplerenone.

How do aldosterone antagonists work?

They inhibit the body's own hormone aldosterone. This reduces the amount of water in the body and lowers blood pressure.In the case of cardiac insufficiency, aldosterone antagonists are used in low doses, so that these effects are only slightly pronounced.

Is there anything special to consider?

Treatment with an aldosterone antagonist may increase the amount of potassium in the blood. To recognize this in time, shouldIn the opinion of the expert group, your blood should be checked regularly when you start taking it. How often these checks should be also depends on your age. Subsequently shouldAccording to experts, these blood tests take place at least every 4 months.

What are the known side effects?

It can become a Hyperkalemia come. That means there is far too much potassium in the blood. This can lead to a life threatening situation. In order to recognize this in good time, frequent blood tests are necessary.

Kidney function may deteriorate. If you vomit or have diarrhea while taking spironolactone, it is advisable to contact your doctor.

Spironolactone can cause the mammary gland to enlarge in men. This can be painful. Women can also experience chest pain. If these side effects occur, you can switch to the active ingredient eplerenone in consultation with a doctor.


What are diuretics?

These are drugs that flush water out of the body. Colloquially they are also called "water tablets" or "drainage tablets". Experts differentiate between so-called Loop diuretics and Thiazide diuretics. The active ingredients of loop diuretics are called for example Furosemide and Torasemid. The thiazides and the thiazide-like diuretics include active ingredients such as Hydrochlorothiazide (short: HCT), Indapamide and Chlortalidone.

How do diuretics work?

Diuretics are used when symptoms arise from stored water in the body. You will notice this, for example, when you gain weight or your ankles and backs of the feet swell. Diuretics have a diuretic effect. That is, they increase the build-up of urine in the kidneys. As a result, the body excretes more water. As a result, you have to urinate more often. This can be uncomfortable, but it shows that the drugs are working and that the heart is relieved.

Is there anything special to consider?

You can tell whether your diuretic medication is well adjusted by regularly monitoring your weight. The expert group recommends that you weigh yourself every day. You can find out more about this in the chapter Controlling weight.

Usually the water tablets should be taken in the morning. It is advisable to take it by 4 p.m. at the latest so that you do not have to get up at night because of the increased urge to urinate.

With the increased amount of water excreted, the body also increasingly loses minerals (salts) in the blood. In order to recognize excessive losses in good time, it is important to check your blood values ​​frequently.

It is not advisable to suddenly stop taking a diuretic without consulting your doctor. This could cause fluid to build up in the lungs. Experts speak of one Pulmonary edema. That can be life threatening.

There are times when a diuretic stops working as well over time. Then the doctor can increase the dose or add another diuretic.

What are the known side effects?

You may feel tired, weak and dizzy. The blood pressure may be too low. The uric acid level in the blood can rise and the blood sugar levels can be disrupted. Kidney values ​​can also deteriorate.

Medicines for selected patient groups

The drugs presented in the chapter on treatment with drugs are suitable for many people with heart failure and their use is widespread.

But there are also certain medications that experts only recommend if you still have symptoms despite the usual treatment.

In the following, we will also introduce you to these additional drugs and replacement drugs.

Sacubitril / valsartan

Valsartan is a blood pressure lowering drug from the group of angiotensin I blockers (see chapter Angiotensin I blockers).

The active ingredient sacubitril inhibits certain proteins in the body in several steps. As a result, more and more messenger substances accumulate which can favorably influence a heart failure with reduced pumping function. It is approved as a combination with the active ingredient valsartan. Sacubitril itself does not lower blood pressure.

Is there anything special to consider?

Because ACE inhibitors have similar side effects, it is recommended that you stop taking an ACE inhibitor at least 36 hours before taking sacubitril and valsartan for the first time.

This combination of active ingredients is out of the question if what is known as angioedema occurred during previous treatment with an ACE inhibitor or sartan. This means that parts of the body - such as the face or tongue - swell.

So far, there is not much experience with the combination of sacubitril / valsartan in people with advanced kidney failure. Special recommendations therefore apply to them (more on this in the recommendation on sacubitril / valsartan). It is advisable to discuss this with a doctor specializing in kidney diseases (specialist area: nephrology).

What are the known side effects?

Known side effects of this combination of active ingredients are low blood pressure, increased potassium levels in the blood and disorders of kidney function. Sacubitril / Valsartan may (further) worsen kidney function in more than 1 in 10 people. In less than 1 in 100 people, parts of the body such as the face, tongue or throat may swell. Experts speak of angioedema.


This group of drugs was developed for the diabetes mellitus disease. Gliflozins inhibit the so-called SGLT-2 transport protein. Experts therefore also speak of SGLT-2 inhibitors or SGLT-2 inhibitors. They inhibit the return transport of glucose in the kidneys. As a result, the kidneys excrete more glucose and blood sugar drops. There is also weight loss and a lowering of blood pressure. The active ingredients are called for example Dapagliflozin or Empagliflozin.

Is there anything special to consider?

Gliflozins for people without diabetes are currently not yet approved by the pharmaceutical authorities. There is evidence from a good study that Gliflozine can also be beneficial for people with cardiac insufficiency with reduced pumping function. However, it is not yet known exactly how they work with heart failure and how great the benefit is. Due to these uncertainties, the expert group is currently not making a recommendation for this drug group. However, if you still have symptoms despite all the recommended treatment options, a gliflozin could be a trial option.

What are the known side effects?

You may experience low blood pressure, dizziness, and broken bones from falls. In addition, the kidneys may not function properly. According to the expert group, dehydration, bladder weakness and bladder infections can occur in older people in particular. So far there is no data on the long-term side effects of gliflozinen in people with heart failure without diabetes.

A known side effect in people with diabetes is low blood sugar.


The drug Ivabradine slows the heartbeat and thus reduces the heart's consumption of oxygen. The heart is relieved. In this way, it relieves discomfort and also increases resilience.

Is there anything special to consider?

The expert group recommends taking ivabradine with a heart specialist (Cardiologist) to discuss. Before you receive ivabradine, your doctor will check whether you are really taking a beta blocker at the highest tolerated dose. Those who tolerate beta blockers in high doses usually have no additional benefit from ivabradine.

What are the known side effects?

Side effects of ivabradine can include: increased sensations of light such as colored flashes or brief moments of increased brightness, blurred vision, slow heartbeat, headache and dizziness. Cardiac arrhythmias can also occur. Regular medical check-ups are therefore important.

Digitalis-like drugs

What is digitalis?

Digitalis is the Latin name for a plant called foxglove. The active ingredient in these drugs is extracted from it. These drugs are also known as Heart glycosides. The individual active ingredients are called for example Digoxin and Digitoxin.

Who are these drugs for?

These drugs are mainly used for cardiac arrhythmias such as Atrial fibrillation for use. They are suitable for people with heart failure, regardless of the severity, if the heartbeat is too fast at rest despite taking a beta blocker. The recommendations of the expert group can be found in the recommendation on digitalis-like drugs.

Is there anything special to consider?

The active ingredient digoxin is completely broken down by the kidneys. When the kidneys are not working properly, it means digoxin is being excreted too slowly and higher amounts can build up. This can lead to increased side effects or even poisoning. In the case of kidney weakness, lower doses and frequent medical check-ups are therefore necessary. This is particularly true of women and the elderly.

In contrast to digoxin, the active ingredient digitoxin is not broken down by the kidneys but by the liver. That is why digitoxin is preferred for kidney damage.

What are the known side effects?

With these active ingredients, it is particularly important that the step from the desired effect to the undesired side effect is sometimes only very small. Signs of poisoning can be: cardiac arrhythmias, nausea, confusion, diarrhea, poor appetite and visual disturbances.

Heart failure with reduced pumping function - what the guideline recommends

The treatment of cardiac insufficiency with reduced pumping function differs fundamentally from the treatment of cardiac insufficiency with preserved pumping function. Therefore, each shape is shown separately.

In this section we only provide you with the medical recommendations for people with heart failure diminished Pump function before.

You can find extensive information on the individual drug groups, including their side effects and special features, in the ACE inhibitor chapter.

ACE inhibitors

The guideline recommends:

For cardiac insufficiency with reduced pumping function with or without complaints should You are receiving an ACE inhibitor.

Studies show that ACE inhibitors can extend the life of people with mild, moderate or severe persistent symptoms. In addition, the progression of the pumping weakness can be delayed and the number of hospital stays can decrease. The symptoms can also improve. The higher the severity of the disease, the greater the benefit.

You don't know exactly how great the benefits are. This is because different patient groups were observed in the different studies. Depending on the study, the numbers fluctuate quite considerably: out of 100 people treated, around 5 to 15 were saved from death due to cardiac insufficiency within the observed period.

For patients without physical complaints (NYHA stage I), the gain in years of life has not been clearly proven. However, studies suggest that if they take ACE inhibitors, they may also have to go to hospital less frequently because of heart failure and that the progression of the disease may be delayed.

There is some evidence that ACE inhibitors work differently in men and women. It is believed by professionals that men get more benefits from taking an ACE inhibitor than women.

Based on the available findings, it is not possible to say whether one active ingredient from the group of ACE inhibitors is better than the other.

Angiotensin I blockers (sartans)

The guideline recommends:

Do you have heart failure symptoms (NYHA stage II to IV) and an ACE inhibitor is out of the question for you from a medical point of view or you cannot tolerate it, should The doctor offers you an AT-I blocker.

According to the expert group can If you are intolerant of the ACE inhibitor, you will also be offered an AT-I blocker if you have not noticed any symptoms of cardiac insufficiency (NYHA stage I, see table 1 in the section on the severity of cardiac insufficiency).

It cannot be said with certainty whether an AT-I blocker improves the survival of those with NYHA stages II to IV or leads to fewer hospital stays compared to a sham drug or an ACE inhibitor. The study situation is not clear and partly contradicting. Therefore, an AT-I blocker only comes into question if an ACE inhibitor is not suitable or not well-tolerated for you.

For those affected without symptoms (NYHA stage I), the expert group could not find any studies that examined AT-I blockers. From experience, however, the use of AT-I blockers also seems possible here if ACE inhibitors are out of the question. It is unclear whether the treated people benefit from it.

Beta blockers

The guideline recommends:

With complaints of cardiac insufficiency (NYHA stage II to IV, see Table 1 in the chapter Severity of cardiac insufficiency) and a stable general condition should Your doctor will offer you one of the following beta blockers: Bisoprolol, Carvedilol or Metoprolol succinate. If you are older than 70 years, the active ingredient will also come Nebivolol into consideration.

If you have been taking a beta blocker for a long time and your heart failure suddenly worsens, should In the opinion of the expert group, you should continue to take this beta blocker if possible.

Reliable studies show that these active ingredients have a positive effect on survival in people with heart failure. In addition, there were fewer hospital admissions for heart failure. In summary, it can roughly be said that a beta blocker will save about 5 in 100 people from harm within about 2 years. The higher the severity of the disease, the greater the benefit. Therefore, from the point of view of the expert group, a worsening of the heart failure or of accompanying illnesses is no reason to discontinue the beta-blocker.

By stable general condition we mean: There are no signs that your heart failure is suddenly worsening. And with water retention you are well prepared with drainage tablets. You can recognize this, for example, by the fact that your body weight remains unchanged for 1 to 2 weeks.

You and your doctor will discuss whether to start with an ACE inhibitor or a beta blocker first. It is also possible to start both drugs at the same time if you can tolerate them both.

Aldosterone antagonists

The guideline recommends:

Your doctor should Also offer you an aldosterone antagonist if you have symptoms despite treatment with an ACE inhibitor and a beta blocker.

The expert group is of the opinion that people may also receive an aldosterone antagonist in this situation shouldwho have diabetes, kidney failure or a slightly increased level of potassium in the blood.

For the additional treatment with an aldosterone antagonist in case of complaints, a survival advantage for people with cardiac insufficiency with reduced pumping function is proven. Furthermore, this can mean that those affected do not have to be treated in hospital as often.

It is possible that an aldosterone antagonist is used in so-called off-label use (see chapter Off-label use).


The guideline recommends:

If you have water stored in your legs, for example, then should Your doctor will offer you medicines to take water (diuretics).

For these diuretic drugs, the expert group could not find any studies that demonstrate a survival benefit. However, diuretics have been part of the basic treatment of heart failure for many years. Most of the studies examining ACE inhibitors and beta blockers for heart failure also usually give the participants additional diuretics. From the point of view of the expert group, diuretics are indispensable so that stored water is excreted and thereby alleviate the symptoms of cardiac insufficiency.

Sacubitril / valsartan

The guideline recommends:

If you still have symptoms despite treatment with an ACE inhibitor, a beta blocker and an aldosterone antagonist, should Your doctor will give you the combination of active ingredients instead of the ACE inhibitor Sacubitril and Valsartan to offer.

However, this recommendation applies Notif you have advanced kidney failure in addition to heart failure. Advanced kidney weakness here means a filtration rate of the kidneys of less than 30 milliliters per minute (in short: eGFR <30 ml / min). This means that the kidneys clean very little blood per minute.

There is evidence from a study that this combination of active ingredients may be associated with survival benefits and fewer hospital stays compared with an ACE inhibitor: about 5 out of 100 people changed to sacubitril and valsartan within about 2 years Saved from death from cardiac insufficiency or admission to hospital for cardiac insufficiency. There is some evidence that the drug may work less well in people with diabetes. And for people with advanced kidney disease, there is hardly any experience with sacubitril / valsartan. It is known that this combination of active ingredients can further worsen kidney function. In addition, the results of this study cannot be applied to all those affected. It is possible that side effects may occur more frequently than was the case in the study. Furthermore, we still do not know enough about the long-term effects and side effects.

Due to similar side effects, there should be an interval of at least 36 hours between the discontinuation of an ACE inhibitor and the first intake of sacubitril and valsartan (for more on this, see chapter Sacubitril / Valsartan).


The guideline recommends:

In case of complaints should Your doctor will also give you the medication Ivabradine offer if the following conditions apply:

  • the ejection fraction of the left ventricle does not exceed 35 percent (LVEF ≤ 35%, see chapter Types of cardiac insufficiency);

  • the heart beats regularly;

  • You are taking an ACE inhibitor or an AT-1 antagonist plus an aldosterone antagonist;

  • Your heart beats more than 75 times per minute when you are at rest, even though you have a good beta-blocker setting OR you cannot tolerate a beta-blocker and your heart beats more than 75 times per minute when you are at rest.

During treatment with ivabradine should Your doctor will regularly check that your heart is beating in a normal rhythm. If the heart beats irregularly, should the doctor will stop ivabradine again.

Studies indicate that adding ivabradine can be associated with improved survival and fewer hospital stays: about 5 in 100 people got a benefit after about 2 years. However, this benefit diminishes as the dose of a beta blocker increases. In addition, the results only seem unambiguous for people who have a resting heart beating more than 75 times per minute. In addition, it is so far unclear whether ivabradine also works for people with Atrial fibrillation - some form of heart rhythm disorder - is beneficial. Therefore, the current recommendation only applies to people with a normal heart rhythm (technical term: sinus rhythm).

Digitalis-like drugs

The guideline recommends:

Do you have symptoms despite treatment with an ACE inhibitor or AT-I antagonist, a beta blocker and an aldosterone antagonist, can Your doctor will offer you a digitalis-like drug.

If you have persistent kidney failure in addition to heart failure, should According to experts, your doctor will only give you a small dose of digoxin or offer you the active ingredient digitoxin.

Drugs similar to digitalis are used to treat cardiac arrhythmias. In certain situations they can also be used as an additional medication for people with moderate to severe cardiac insufficiency (NYHA stages III and IV, see Table 1 in the chapter Severity degrees of cardiac insufficiency