It may be time to prescribe fewer pills for CV patients

Clinical takeaway: For patients with cardiovascular disease and polypharmacy, medication review should not wait for an adverse event; clinicians should proactively assess for drugs that are no longer indicated, harmful, burdensome, or misaligned with patient goals.

A new American Heart Association scientific statement in Circulation reframes deprescribing as a core element of high-quality cardiovascular prescribing, not a last resort. Polypharmacy, defined as use of 5 or more long-term medications, is common in CV care because guideline-directed medical therapy (GDMT) often requires multiple drugs across heart failure, hypertension, coronary disease, atrial fibrillation, dyslipidemia, diabetes, kidney disease, and other comorbidities.

The statement recommends considering deprescribing when patients have adverse drug events, polypharmacy, prescribing cascades, poor adherence, palliative or end-of-life goals, or a change in clinical status. Safe deprescribing should begin with medication reconciliation, assessment for potentially inappropriate medications, shared decision-making, and a clear plan for tapering and monitoring.

Drug-related opportunities highlighted include reassessing aspirin for primary prevention, prolonged antiplatelet therapy after PCI, beta-blockers after uncomplicated MI with preserved ejection fraction, rate-control or antiarrhythmic drugs after ablation when indications have expired, long-acting nitrates or ranolazine after successful revascularization without recurrent angina, and GDMT in patients with limited life expectancy. Clinicians should also look beyond CV drugs: NSAIDs, gabapentinoids, thiazolidinediones, anticholinergics, sedative-hypnotics, proton pump inhibitors, supplements, and other noncardiovascular agents may worsen CV disease or increase falls, bleeding, bradycardia, cognitive effects, or treatment burden.

The statement emphasizes that deprescribing is not simply stopping medicines. Some drugs, including beta-blockers, clonidine, cholinesterase inhibitors, CNS-active agents, gabapentinoids, and insulin regimens, may require tapering. Patients should be monitored for adverse drug withdrawal events, symptom recurrence, or disease worsening, and medications may need to be restarted or reduced more slowly.

The authors call for a multidisciplinary model involving cardiologists, primary care clinicians, pharmacists, nurses, patients, and caregivers. Validated tools such as STOPP/START, FORTA, Beers Criteria, Medication Appropriateness Index, and pediatric-specific tools can support, but not replace, clinical judgment.

Bottom line: In CV patients with complex medication regimens, “less” can be safer only when it is structured, individualized, and closely followed. Deprescribing should be built into routine cardiovascular care.

Source: DiDomenico RJ, et al. (2026 July 8) Circulation. Deprescribing in Patients With Cardiovascular Disease Experiencing Polypharmacy: A Scientific Statement From the American Heart Association