ACE inhibitors

Angiotensin-converting enzyme (ACE) inhibitors work by relaxing and opening up your blood vessels, which makes it easier for your heart to pump blood around the body.

Examples of ACE inhibitors include ramipril, captopril, enalapril, lisinopril and perindopril.

The most common side effect of ACE inhibitors is a dry, irritating cough. If you have a troublesome cough, an ACE inhibitor may be switched to an ARB.

ACE inhibitors can also cause your blood pressure to fall too low, and they may cause kidney problems. Your GP will monitor this.

Beta-blockers

Beta-blockers work by slowing your heart down and protecting your heart from the effects of adrenaline and noradrenaline, "fight or flight" chemicals produced by the body.

There are several different beta-blockers, but the main ones used to treat heart failure in the UK are bisoprolol, carvedilol, and nebivolol.

Possible side effects of beta-blockers include dizziness, tiredness, and blurred vision.

But most people taking them have either no or very mild side effects that become less troublesome with time.

Angiotensin receptor blockers (ARBs)

Angiotensin receptor blockers (ARBs) work in a similar way to ACE inhibitors, by relaxing blood vessels and reducing blood pressure.

They tend to be used as an alternative because they don't usually cause a cough, although they may not be quite as effective as ACE inhibitors.

Examples of ARBs include candesartan, losartan, telmisartanand valsartan.

Side effects of ARBs can include low blood pressure and high levels of potassium in your blood. Your doctor will carry out regular blood tests to monitor your potassium level.

Hydralazine with nitrate

Hydralazine in combination with nitrate can help relax and open up the blood vessels.

These medicines are sometimes prescribed by heart specialists (cardiologists) for people who are unable to take an ACE inhibitor or ARB.

Side effects can include headaches, a fast heartbeat, and a pounding, fluttering or irregular heartbeat (palpitations).

Diuretics

Diuretics(water pills) make you pass more urine, and help relieve ankle swelling and breathlessness caused by heart failure.

There are many different types of diuretic, but the most widely used for heart failure are furosemide (also called frusemide) and bumetanide.

Possible side effects of diuretics include dehydration and reduced levels of sodium and potassiumin the blood.

Aldosterone antagonists

Aldosterone antagonists work in a similar way to diuretics, but they don't cause reduced potassium levels. The most widely used aldosterone antagonists are spironolactone and eplerenone.

Spironolactone may cause enlarged breasts (gynecomastia) in men, and breast tenderness and increased hair growth in women. Eplerenone can cause sleeping difficulties, dizziness, and headaches.

The most serious side effect of these medicines is that they can cause the level of potassium in your blood to become dangerously high. Your doctor will carry out regular blood tests to check for this.

Sacubitril valsartan

Sacubitril valsartan is a new heart failure medication recommended by NICE. It's a single tablet that combines an ARB and a medication called a neprilysin inhibitor.

It's suitable for people with more severe heart failure, whose heart is only able to pump a reduced amount of oxygenated blood around the body despite taking other medication.

The most common side effects of sacubitril valsartan are low blood pressure, high potassium levels, and kidney problems.

You can read more about sacubitril valsartan for treating chronic heart failure on the NICE website.

Ivabradine

Ivabradine is a medicine that can help slow your heart down and is a useful alternative to beta-blockers if you can't take them or they cause troublesome side effects.

It can also be used alongside beta-blockers if they don't slow the heart enough.

Possible side effects include headaches, dizziness, and blurred vision.

Digoxin

Digoxin, derived from the foxglove plant, can improve your symptoms by strengthening your heart muscle contractions and slowing down your heart rate.

It's normally only recommended for people who have symptoms despite treatment with ACE inhibitors, ARBs, beta-blockers and diuretics.

Possible side effects include dizziness, blurred vision, feeling and being sick, diarrhea, and an irregular heartbeat.

Devices for heart failure

Some people with heart failure will need to have a procedure to implant a small device in their chest that can help control their heart's rhythm.

The most commonly used devices are:

• pacemakers
• cardiac resynchronization therapy (CRT)devices
• implantable cardioverter defibrillators (ICDs)
• CRT-Ds

Pacemakers

You may need to have a pacemaker fittedif your heart beats too slowly.

A pacemaker monitors your heart rate continuously, and sends electrical pulses to your heart to keep it beating regularly and at the right speed.

The pacemaker is implanted under the skin by a cardiologist, usually under local anesthetic.

You will usually need to stay in the hospital overnight to check it's working properly. Serious complications are unusual.

Pacemakers need to be checked regularly by specialist technicians at a pacemaker clinic.

You will also need to be careful about things that can affect how your pacemaker works, such as hospital equipment and security systems in shops or at airports.

You can also find out more about pacemakers on the British Heart Foundation website.

Cardiac resynchronization therapy

In some people with heart failure, the walls of the main pumping chamber(the left ventricle) do not work together and contract out of sync with each other.

Cardiac resynchronization therapy (CRT) is a special type of pacemaker that can correct the problem by making the walls of the left ventricle all contract at the same time. This makes the heart pump more efficiently.

Most pacemakers only have one or two wires to the heart, but CRT requires an extra wire that is a bit harder to get into place than the other wires.

Implantable cardioverter defibrillators (ICDs)

People who have, or are at high risk of developing, an abnormal heart rhythm may need to have a device known as an implantable cardioverter defibrillator (ICD) fitted.

An ICD constantly monitors the heart rhythm. If the heart starts beating dangerously fast, the ICDwill try to bring it back to normal by giving it a small, controlled electrical shock (defibrillation). If this fails, the ICD will deliver a larger shock.

As with pacemakers, ICDs are implanted in hospital, usually under local anesthetic. Like pacemakers, you will need to avoid things that can interfere with the way the ICD works, such as airport security systems.

The type of surgery you have will depend on what is wrong with the valve and how serious the problem is. Your doctor will discuss this with you.

Read about aortic valve replacement and surgery for mitral valve problems.

Angioplasty or bypass

If your heart failure is related to coronary heart disease, your doctor may recommend a:

• coronary angioplasty where a tiny balloon is used to stretch open a narrowed or blocked artery
• coronary artery bypass graft (CABG) where a blood vessel from another part of the body is used to divert blood around narrowed or clogged parts of an artery

These procedures will help make it easier for your heart to pump blood around your body.

Left ventricular assist devices

Left ventricular assist devices (LVADs) are mechanical pumps that can help if your left ventricle isn't working properly and medication alone isn't helping.

They may be used as a permanent treatment if you can't have a heart transplant, or as a temporary measure while you wait for a transplant.

In addition to the pump, LVADs also include an external battery. A wire connecting this to the pump will need to be placed under your skin during the operation.

There's also a shortage of hearts for transplantation, so some people have to wait years for a suitable donor heart to become available.