Which of the following medications is contraindicated in a patient with heart failure?

October 8, 2025 •

4 min read

Approximately 6.7 million adults in the United States have heart failure [1.10.1]. For these individuals, understanding which of the following medications is contraindicated in a patient with heart failure is critical for preventing worsening symptoms and hospitalizations. Many common drugs can be harmful.

Quick Summary

Managing heart failure requires avoiding specific drugs that can worsen the condition. Key medication classes to avoid include NSAIDs, non-dihydropyridine CCBs, and TZDs due to risks like fluid retention and reduced heart function [1.2.1, 1.2.4].

Key Points

NSAIDs: Common pain relievers like ibuprofen and naproxen are contraindicated as they cause salt and water retention, which can worsen heart failure [1.5.1].
Non-Dihydropyridine CCBs: Medications such as diltiazem and verapamil should be avoided in systolic heart failure because they can weaken the heart's pumping action [1.2.1, 1.6.5].
Thiazolidinediones (TZDs): These diabetes drugs (pioglitazone, rosiglitazone) are known to cause fluid retention and increase the risk of heart failure hospitalization [1.7.1].
OTC Decongestants: Products containing pseudoephedrine or phenylephrine can dangerously increase blood pressure and heart rate in heart failure patients [1.9.2].
Patient Vigilance: Always read labels and consult with a doctor or pharmacist before taking any new prescription, over-the-counter medication, or supplement [1.3.3].
Safer Pain Relief: Acetaminophen (Tylenol) is generally the recommended over-the-counter pain reliever for individuals with heart failure [1.11.2].
Certain Antiarrhythmics: Class I antiarrhythmic drugs like flecainide are generally avoided due to their potential to weaken the heart muscle [1.8.3, 1.2.5].

Understanding Medication Risks in Heart Failure

Heart failure is a chronic condition where the heart muscle doesn't pump blood as well as it should. Because the heart's function is compromised, patients are particularly vulnerable to the effects of certain medications. Drugs that are normally safe for the general population can cause serious problems for someone with heart failure by disrupting the delicate balance of fluid, blood pressure, and cardiac function [1.5.1].

The primary reasons certain medications are contraindicated are their potential to:

Cause Sodium and Water Retention: An already weakened heart struggles to pump existing fluid, so medications that cause the body to hold onto more salt and water can lead to fluid overload (congestion), swelling (edema), and acute decompensation [1.5.1].
Weaken Heart Muscle Contraction (Negative Inotropy): Some drugs directly reduce the force of the heart's contractions, which can be dangerous in systolic heart failure where the pumping ability is already diminished [1.2.5, 1.6.5].
Increase Blood Pressure: Medications that constrict blood vessels force the heart to work harder to pump blood against increased resistance, adding extra strain [1.9.4].

Key Medications Contraindicated in Heart Failure

It is crucial for patients and caregivers to be aware of both prescription and over-the-counter (OTC) drugs that pose a risk. The American College of Cardiology and American Heart Association have identified several groups of drugs that should be avoided in most heart failure patients [1.2.4].

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

This is one of the most significant classes of medications to avoid. NSAIDs work by inhibiting prostaglandins, which can lead to reduced blood flow to the kidneys, causing sodium and water retention [1.5.1]. This increases fluid volume and blood pressure, which can trigger a heart failure exacerbation. The risk is present with both prescription and OTC NSAIDs [1.3.2].

Common Examples: Ibuprofen (Advil, Motrin), Naproxen (Aleve), Celecoxib (Celebrex), Diclofenac [1.3.2, 1.2.1].
Safer Alternative for Pain: Acetaminophen (Tylenol) is generally considered a safer option for pain relief in heart failure patients as it does not carry the same risks of fluid retention [1.11.2, 1.11.3].

Non-Dihydropyridine Calcium Channel Blockers (CCBs)

These medications have a negative inotropic effect, meaning they decrease the strength of the heart's contractions [1.6.1, 1.6.5]. In patients with heart failure with reduced ejection fraction (HFrEF), this can lead to clinical deterioration. While they may sometimes be used in patients with preserved ejection fraction (HFpEF), they are generally contraindicated in systolic heart failure [1.2.1, 1.2.5].

Common Examples: Diltiazem (Cardizem), Verapamil (Calan) [1.2.1].
Note: Dihydropyridine CCBs, like amlodipine, do not have the same potent negative inotropic effect and are sometimes used to treat hypertension in heart failure patients.

Thiazolidinediones (TZDs)

TZDs are a class of drugs used to treat type 2 diabetes. A major side effect is fluid retention, which can lead to or worsen heart failure [1.7.1, 1.7.3]. Both pioglitazone and rosiglitazone have been associated with an increased risk of heart failure hospitalization [1.7.4].

Common Examples: Pioglitazone (Actos), Rosiglitazone (Avandia) [1.3.5].
Alternative Diabetes Medications: Newer classes of diabetes medications, such as SGLT2 inhibitors (e.g., empagliflozin, dapagliflozin), are now recommended as first-line therapy for heart failure patients, regardless of diabetes status, due to their proven cardiovascular benefits [1.4.1, 1.4.5].

Certain Antiarrhythmic Drugs

Many drugs used to control heart rhythm disturbances are contraindicated in patients with structural heart disease, including heart failure. Class I antiarrhythmics, in particular, can have negative inotropic effects and have been shown to increase mortality in this population [1.2.5, 1.8.3].

Common Examples: Flecainide, Propafenone (Class Ic); Disopyramide (Class Ia) [1.3.5, 1.8.3].

Over-the-Counter (OTC) Cold and Cough Medications

Many OTC remedies for colds, flu, and sinus issues contain decongestants like pseudoephedrine or phenylephrine [1.9.2]. These ingredients can raise blood pressure and heart rate, which is risky for heart failure patients [1.3.3]. Additionally, some multi-symptom products contain NSAIDs [1.3.3]. It is essential to read labels carefully and consult a pharmacist or doctor.

Comparison of Contraindicated Medications in Heart Failure


Medication Class	Mechanism of Harm in Heart Failure	Common Examples	Potential Safer Alternatives (Consult Doctor)
NSAIDs	Cause sodium and water retention; increase blood pressure [1.5.1].	Ibuprofen, Naproxen, Celecoxib [1.2.1]	Acetaminophen, topical pain relievers [1.11.2]
Non-Dihydropyridine CCBs	Weaken heart muscle contraction (negative inotropy) [1.6.5].	Diltiazem, Verapamil [1.2.1]	Beta-blockers, Dihydropyridine CCBs (e.g., Amlodipine) for hypertension [1.6.2]
Thiazolidinediones (TZDs)	Cause significant fluid retention [1.7.1, 1.7.3].	Pioglitazone, Rosiglitazone [1.3.5]	SGLT2 inhibitors (e.g., Dapagliflozin, Empagliflozin), Metformin [1.4.2]
Decongestants	Increase blood pressure and heart rate [1.3.3].	Pseudoephedrine, Phenylephrine [1.9.2]	Saline nasal sprays, antihistamines (check with doctor) [1.9.3]
Class I Antiarrhythmics	Negative inotropic effects; proarrhythmic potential [1.2.5, 1.8.3].	Flecainide, Propafenone [1.8.3]	Amiodarone, Beta-blockers (used cautiously and specifically for HF) [1.2.5]

Conclusion

Managing heart failure effectively involves more than just taking prescribed beneficial medications; it requires vigilantly avoiding those that are harmful. Non-steroidal anti-inflammatory drugs (NSAIDs), non-dihydropyridine calcium channel blockers, thiazolidinediones, and certain other common medications are contraindicated because they can lead to fluid retention, weakened heart function, and ultimately, worsening heart failure [1.2.2]. Open and continuous communication with healthcare providers about all medications—including over-the-counter products and supplements—is the most critical step a patient can take to ensure their safety and well-being. Always consult a physician or pharmacist before starting any new medication.

For more information, a reliable resource is the American Heart Association's page on heart failure.

Frequently Asked Questions

No, you should avoid ibuprofen and other NSAIDs. They can cause your body to retain salt and water, which puts extra strain on your heart and can worsen heart failure symptoms. Acetaminophen (Tylenol) is a safer choice for pain relief [1.11.2, 1.11.3].

No. Specifically, non-dihydropyridine calcium channel blockers like diltiazem and verapamil are generally contraindicated in systolic heart failure because they can weaken the heart's contractions [1.2.1, 1.6.5]. However, other classes like ACE inhibitors, beta-blockers, and ARNIs are cornerstones of heart failure therapy [1.4.1].

Acetaminophen (Tylenol) is the most frequently recommended over-the-counter pain reliever for people with heart failure [1.11.2]. Topical pain relievers like creams and gels can also be safe options. Always adhere to the recommended dosage and consult your doctor [1.11.2].

Do not stop taking any prescribed medication without first talking to your doctor. While TZDs like pioglitazone and rosiglitazone are contraindicated in heart failure due to fluid retention, your doctor needs to be the one to transition you to a safer alternative, such as an SGLT2 inhibitor [1.7.1, 1.4.2].

You must avoid cold medicines containing decongestants like pseudoephedrine or phenylephrine, as well as those containing NSAIDs [1.9.2]. It is best to ask your pharmacist or doctor to recommend a product that will not interfere with your condition, such as a simple saline nasal spray or a plain guaifenesin product for cough.

Alka-Seltzer products are contraindicated because they contain a high amount of sodium, which leads to fluid retention and can significantly worsen heart failure symptoms and lead to congestion [1.2.1, 1.3.2].

Not necessarily. Some herbal products, such as St. John's wort and black cohosh, can interfere with heart failure medications or have unintended effects [1.3.2, 1.3.3]. It is essential to discuss every supplement and vitamin you plan to take with your cardiologist.