Heart failure affects approximately 920,000 people in the United Kingdom, according to the British Heart Foundation, with around 200,000 new diagnoses each year. It is the leading cause of hospitalisation in people aged over 65, and medicines management is central to reducing both mortality and readmission rates.
Community pharmacists dispense the core heart failure medicines daily — ACE inhibitors, beta-blockers, mineralocorticoid receptor antagonists and, increasingly, SGLT2 inhibitors. The dispensing interaction is an opportunity to reinforce adherence, check for side effects and identify deterioration early.
The four pillars of HFrEF therapy
NICE guideline NG106 recommends that patients with heart failure with reduced ejection fraction (HFrEF) receive all four classes of medicine, titrated to target doses where tolerated. In practice, many patients remain on sub-optimal doses due to concerns about hypotension, renal function or side effects — concerns that pharmacists can help address through counselling.
Pillar 1: ACE inhibitors / ARBs
| Medicine | Target dose | Key counselling |
|---|---|---|
| Ramipril | 10mg daily | Dry cough in ~10% — switch to ARB if persistent. Monitor potassium and renal function |
| Enalapril | 20mg daily | As ramipril. Twice-daily dosing |
| Candesartan | 32mg daily | ARB alternative. No cough. Same renal/potassium monitoring |
| Sacubitril/valsartan | 97/103mg twice daily | ARNI — replaces ACE/ARB. 36-hour washout from ACE inhibitor before starting. Hypotension common during uptitration |
Pharmacist counselling focus: First-dose hypotension risk — advise taking the first dose at bedtime. Renal function and potassium should be checked within 1–2 weeks of dose changes (reinforce this at dispensing).
Pillar 2: Beta-blockers
| Medicine | Target dose | Key counselling |
|---|---|---|
| Bisoprolol | 10mg daily | First-line choice. Start low (1.25mg), uptitrate every 2–4 weeks |
| Carvedilol | 25mg twice daily | Non-selective — may cause more fatigue and dizziness |
| Nebivolol | 10mg daily | Licensed for HF in patients over 70 |
Pharmacist counselling focus: Patients may feel worse initially (fatigue, dizziness, worsening of symptoms) — this is expected during uptitration and improves over weeks. Never stop abruptly — rebound tachycardia risk.
Pillar 3: Mineralocorticoid receptor antagonists (MRAs)
| Medicine | Dose | Key counselling |
|---|---|---|
| Spironolactone | 25–50mg daily | Gynaecomastia in men (breast tenderness, swelling) — switch to eplerenone if problematic |
| Eplerenone | 25–50mg daily | More selective. More expensive. Less gynaecomastia |
Pharmacist counselling focus: Hyperkalaemia risk, especially in combination with ACE inhibitors and renal impairment. Advise patients to have potassium checked regularly and to avoid potassium-rich salt substitutes (Lo-Salt).
Pillar 4: SGLT2 inhibitors
| Medicine | Dose | Key counselling |
|---|---|---|
| Dapagliflozin | 10mg daily | Licensed for HFrEF regardless of diabetes status since 2020 |
| Empagliflozin | 10mg daily | Licensed for HFrEF since 2021 |
Pharmacist counselling focus: Genital mycotic infections (thrush) — more common in women and patients with diabetes. Advise good hygiene and early treatment. Volume depletion risk in patients already on diuretics — maintain fluid intake. Euglycaemic diabetic ketoacidosis is rare but possible in patients with diabetes — advise seeking medical attention for nausea, vomiting, abdominal pain or excessive thirst.
Loop diuretics: symptom control
Furosemide and bumetanide do not improve survival in heart failure but are essential for managing fluid retention. Pharmacists should counsel on:
- Taking the dose in the morning (to avoid nocturia)
- Daily weight monitoring — a gain of more than 2kg in 48 hours may indicate fluid overload and should prompt medical review
- Potassium monitoring when combined with ACE inhibitors and MRAs (the combination can go either way — depletion from diuretics, retention from ACE/MRA)
Medicines to avoid in heart failure
Community pharmacists should be alert to medicines that can worsen heart failure:
- NSAIDs (including OTC ibuprofen): fluid retention and renal impairment
- Verapamil and diltiazem: negative inotropic effect — contraindicated in HFrEF
- Thiazolidinediones (pioglitazone): fluid retention
- Dronedarone: contraindicated in NYHA class III–IV heart failure
This is particularly relevant in community pharmacy, where patients may request OTC ibuprofen for musculoskeletal pain without mentioning their heart failure diagnosis. A simple prescription history check can prevent harm.
The NMS and SMR opportunity
Heart failure medicines — particularly the newer SGLT2 inhibitors — are NMS-eligible. The structured follow-up at 7–14 days and 21–28 days is valuable for identifying early side effects (genital infections, postural hypotension) and reinforcing the importance of continued therapy.
Structured Medication Reviews are equally important: many heart failure patients are on five or more regular medicines, making polypharmacy and interaction management a core pharmacy function.
PharmSee's tracker records 1,715 active pharmacy vacancies across England as of April 2026. For pharmacists interested in cardiology roles, the PharmSee job search tracks NHS specialist positions, and the salary guide covers clinical pharmacist pay bands.
Data sources: NICE NG106 (Chronic Heart Failure), British Heart Foundation prevalence data, DAPA-HF and EMPEROR-Reduced trial data, PharmSee vacancy tracker (April 2026, 1,715 active roles).