Effect of medications used in congestive heart failure (CHF) on exercise (14):
To review the effects of medications used for congestive heart failure on exercise, please see “VI. Medication effect upon exercise” in the aerobic exercise section of Preventive Health Advisor.
Assessment and Plan: Congestive Heart Failure
- Please see the following sections of Preventive Health Advisor to address underlying conditions of CHF: coronary artery disease, cigarette smoking, hypertension, aerobic exercise, resistance training, weight loss, and diabetes mellitus.
- Prevention of exacerbation in known CHF:
- Maintain strict compliance to prescribed medications, sodium intake, fluid intake, and weight monitoring.
- Sodium intake is to be limited to 2 grams per day. Avoid any added salt to home prepared foods. Limit canned foods, canned soups, catsup, soy sauce, lunch meats, restaurant foods, sodas, prepackaged snacks, and others by following food labels closely. Try spices instead of salt and be aware that salt substitutes may contain excess potassium which can accumulate in renal insufficiency.
- Limit fluid intake to about 1-2 liters per day, based on physician advice.
- Follow daily weight and contact physician for weight gain of 2 pounds in a day or 5 pounds in a week.
- Contact physician for Increasing shortness of breath, requirement for head to be up or needing more pillows to breathe, swelling of the legs feet or ankles, cough, wheezing, high heart rate over 120 sustained or under 50 sustained, and palpitations. For new onset fast heart rate, severe chest pain, lightheadedness, or passing out (syncope), call emergency medical services.
- Integrative Medicine therapy for congestive heart failure (CHF):
- Hawthorne extract (Crataegus monogyna) was shown to offer a variety of benefits for CHF in the majority of research reviewed by Preventive Health Advisor. The benefits were somewhat variable across different trials, but some trials showed no benefit.
- In a meta-analysis by Pittler, M et al using 10 controlled trials with 855 patients, hawthorne extract used as a standardized preparation including 18.8% oligomeric procyanidins at a daily dose of 160 mg to 1800 mg for 3 to 26 weeks. This agent improved exercise tolerance, decreased shortness of breath, reduced fatigue, and lowered heart oxygen consumption over placebo. (1)
- Standard treatment plus either hawthorne at a dose of 450 mg oral twice daily for 6 months or placebo had no effect on six-minute-walk test distance in heart failure patients with New York Heart Association (NYHA) class II-III, but hawthorne did lead to a small improvement in left ventricular ejection fraction (2).
- According to Dahmer and Scott, hawthorne improves heart function, ability to exercise, shortness of breath and fatigue with most effective dose range determined to be 600 to 1,800 mg (in two or three divided doses daily) for patients with mild congestive heart failure (NYHA classes I-III). These same authors reviewed one study which found that hawthorn extract was as effective as low dose captropril (37.5 mg) in improving symptoms of congestive heart failure, but also found that in another large-scale international study that hawthorn extract does not reduce the risk of cardiac death. (3)
- Holubarsch CJ et al used hawthorne with17.3% to 20.1% oligomeric procyanidins at a dose of 450 mg oral twice daily or placebo for 2 years by randomizing 2681 patients with NYHA class II-III heart failure plus left ventricular ejection fraction (LVEF) <35%. Hawthorne did not have a significant effect on heart failure related sudden cardiac death due to progressive heart failure, fatal heart attack, nonfatal heart attack, or hospitalization measured at 24 months. However., patients taking hawthorne extract showed significant relative-risk reductions of cardiac mortality after six months (by 41%, p=0.009) and 18 months (by 20%, p=0.046) but not at the 12-month or 24-month follow-ups (by 18% and 9.7%, respectively). In a subgroup analysis, patients who received hawthorne extract and had a LVEF of less than or equal to 25% showed a significantly reduced risk of sudden heart death (by 39.7%). (4)
- A study for 8 weeks on patients with NYHA II CHF taking hawthorne extract vs placebo showed a significant improvement in heart function, reduced shortness of breath, less ankle swelling, and an overall better quality of life (especially mental well-being) while subjects in the placebo group became worse (5).
- For patients with NYHA II CHF, study participants were administered either 30 drops of the extract three times daily (n = 69) or placebo (n = 74) over 8 weeks, and a significant increase in exercise tolerance was seen compared to placebo (6).
- Hawthorne adverse reactions and interactions:
- In most research reviewed, hawthorne was used with standard heart failure medications including nitrates, beta-blockers, and angiotensin converting enzyme inhibitors (1).
- A meta-analysis by Pittler, M et al reported minor side-effects of nausea, dizziness, heart and gastrointestinal complaints (1).
- There were more adverse effects in the hawthorne group compared with placebo, but no serious side-effects were reported (2).
- According to Dahmer and Scott, hawthorne was considered safe to take with standard heart failure medications (such as ACE inhibitors, vasodilators, cardiac glycosides), but patients should be careful when taking other herbal supplements that have cardiovascular effects such as danshen, epimedium, ginger, Panax ginseng, turmeric, and valerian (3).
- This agent was safe at a dose of 900 mg per day for 2 years when combined with diuretics, ACE inhibitors, beta blockers, glycosides, and aldosterone blockers (4).
- Hawthorne extract was well tolerated in general (3,5).
- Coenzyme Q10 (CoQ10) was found in the majority of trials reviewed by Preventive Health Advisor to have documented improvements in many objective parameters of CHF. Additionally, low levels of coenzyme Q10 have been linked with heart failure.
- Rosenfeldt F performed a systematic review of trials and found that Coenzyme Q10 (CoQ10) showed a significant improvement in severity of heart failure symptom class, improved exercise time, improved ejection fraction, and reduced mortality (7).
- Patients with NYHA Classes III and IV taking 100 mg of CoQ10 over 6 years established average levels of 2.89 mcg per ml, improved ejection fraction from 44% to 60%, improved 1-2 NYHA classes in 85% of patients, and showed no evidence of toxicity or intolerance (9).
- Langsjoen PH, et al found that coenzyme Q10 appeared to have the greatest effect in patients with a level of at least 2.5 mcg per ml and increased ejection fraction (EF) as follows (40-48% of patients had very low control levels of co-enzyme Q10) (10):
- Starting EF of 10%-30%: Improved EF 115%-210% during activity.
- Starting EF of 50%-80%: Improved EF 10%-25% during activity.
- A meta-analysis by Soja and Mortensen reported a significant improvement in stroke volume, ejection fraction, cardiac output, cardiac index, and end-diastolic volume index, as a result of coenzyme Q10 supplementation. (18)
- Sander et al authored a meta-analysis of 11 studies with CoQ10 doses ranging from 60 to 200 mg/day and treatment periods ranging from 1 to 6 months and reported a 3.7% net improvement in the ejection fraction and an average increase in cardiac output of 0.28 L/min (19).
- Molyneux, SL et al studied 236 heart failure patients at the average age of 77 for 5.75 years and found that 39% with coenzyme Q10 levels under 0.63 mcg per ml died, compared with only 22% of subjects with higher levels translating to a 67% higher risk of mortality and the author believed coenzyme Q10 levels were an independent predictor of survival (8).
- Creatine taken by male patients with chronic heart failure (documented left ventricular dilatation and dysfunction) for 3 months were given 20 g of creatine for 5 days increased the amount of exercise subjects could complete before exhaustion, as well as had less ammonia and lactic acid by-products of exercise with no effect in the placebo group (11). Caution with use of creatine in patients with chronic kidney disease.
- A small study with L-carnitine given daily at 100 mg/kg showed improvement in heart failure symptoms of patients by increasing effort tolerance, reduced shortness of breath and improved systolic function (12). Confirmation studies are needed.
- Thiamine was given in a small study to nine diuretic-treated patients aged 45-75 years with symptomatic chronic heart failure plus left ventricular ejection fraction (LVEF) < 40%. The subjects were randomly assigned to receive 300 mg per day of thiamine or placebo for 4 weeks, and after a 6-week washout period, the mean LVEF was significantly higher after thiamine treatment than after placebo (32.8% vs. 28.8%). (13)
- Safe exercise for congestive heart failure (CHF):
- In a study on patients with New York Heart Association II and III heart failure , study subjects did cycle ergometry (20 minutes 4-5 times per week at an intensity of 70%-80% of peak heart rate with 1-3 minute warm up and cool down) or cycle ergometry combined with body weight exercises (5 days/week with stationary running) for 6 to 16 weeks. Patients on a combined exercise regimen achieved significantly better VO2 (2.7 vs 1.2 ml.kg.min-1) and after longer (16 weeks) of training VO2, was significantly higher than after 6 weeks (2.6 vs 0.3 ml.kg.min-1) and no significant side effects were reported. (15)
- Hambrecht R et al, found that 6 months of exercise training in patients with stable chronic heart failure and moderate-to-severe left ventricular (LV) dysfunction for 2 weeks of in-hospital ergometer exercise for 10 minutes 4 to 6 times per day plus 6 months of home-based ergometer exercise training for 20 minutes per day at 70% of peak oxygen uptake lead to an increase in LV stroke volume at rest and during exercise and to a small but significant decrease in LV end diastolic diameter and volume. The results according to the author of the study suggested that in patients with stable chronic heart failure, regular physical exercise for 6 months is associated with a significant afterload reduction and increase in stroke volume. (16)
- To review the effects of medications used for congestive heart failure on exercise, please see “VI. Medication effect upon exercise” in the aerobic exercise section of Preventive Health Advisor.