Congestive Heart Failure

Introduction:

Heart failure is a condition in which the heart is unable to pump enough blood to the rest of the body. Heart failure is often a long-term condition, but it can sometimes develop suddenly. Heart failure often occurs over a long term from chronic conditions such as coronary artery disease, cardiomyopathy, valvular heart disease, hypertension, infection, diabetes, smoking, and many others. As the heart’s pumping becomes less efficient, blood may back up in other areas of the body. Fluid may build up in the lungs, liver, gastrointestinal tract, and the arms and legs resulting in congestive heart failure (CHF). Diagnosis of CHF is usually established by findings on a physical exam and an echocardiogram.

The patient will need to be educated on the importance of lifestyle changes for managing precipitating cause of CHF, and address potentially reversible factors. Primary care providers along with cardiologists will need to provide education and medication management. The focus on CHF by Preventive Health Advisor is three-tiered: 1) Intervention on underlying conditions which may result in CHF in the near or distant future based on family history and current health problems. 2) After a diagnosis of CHF has been established, it is important to prevent acute exacerbations of CHF by following salt intake, weight, and fluid balance. 3) Integrative Medicine therapy options will be discussed.

 

Congestive heart failure (CHF) prevention by addressing underlying etiology:

CHF etiologies: CHF may potentially be prevented by intervention on underlying causes leading to the condition. The NHANES I epidemiologic study followed 13,643 subjects over 19 years initially without CHF, and out of 1382 cases of CHF, the following causes were determined (17):

• Coronary heart disease (coronary artery disease) was found to be the most frequent cause of CHF in over 60% of patients.
• Smoking cigarettes, 17.1%
• Hypertension, 10.1%
• Physical inactivity, 9.2%
• Lower educational levels, 8.9%
• Overweight, 8.0%
• Diabetes, 3.1
• Valvular heart disease, 2.2%

Please see the following sections of Preventive Health Advisor: To address underlying conditions of CHF, prevention starts with the necessary lifestyle changes and/or risk factor modification of the conditions which may lead to CHF aforementioned above. Please see the respective sections in Preventive Health Advisor for coronary artery disease, cigarette smoking, hypertension, aerobic exercise, resistance training, weight loss, and diabetes mellitus.

 

 

 

Prevention of exacerbation in known congestive heart failure (CHF):

• Compliance: Maintain strict compliance to prescribed medications as well as compliance to sodium intake, fluid intake, and weight monitoring as described below.
• Limit sodium intake: 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: Limit fluid intake to about 1-2 liters per day, based on physician advice.
• Daily weight: Follow daily weight using the same scale without clothing to reduce variation of weight measurement. Contact physician for weight gain of 2 pounds in a day or 5 pounds in a week.
• Symptoms triggering physician contact: Contact physician for the following: 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, chest pain, lightheadedness, or passing out (syncope), call emergency medical services.

 

Heart Health Risk Assessment Tool:

Heart Health Risk Assessment, “My Life Check,” is a free screening tool designed to determine risk of heart disease. This simple tool evaluates 7 simple achievements used to improve heart health. The tool will be a quick assessment of heart health by entering blood pressure, cholesterol, fasting blood sugar, activity level, fruit/vegetable intake, body weight, and smoking. This takes about 2 minutes to complete. It has been determined that a greater achievement in heart health in these 7 simple guidelines results in a lower lifetime occurrence of heart disease including heart failure (114).

 

 

Congestive heart failure (CHF) Integrative Medicine therapies:

Plant extract and chronic heart failure:

Hawthorn (Crataegus monogyna) is a plant which produces antioxidant rich berries which has been used with success in heart failure patients.

In an analysis that combined the results of 10 controlled trials (n=855 patients), hawthorn extract was found to be significantly better than placebo for improving exercise tolerance (average difference [AD] in favor of hawthorn, 122.76 watt x min), decreasing shortness of breath and fatigue (AD, -5.47), and enhancing the physiologic function (AD, 5.35 watts) of the heart in individuals suffering from chronic heart failure (CHF). The hawthorn extract used in the studies reviewed by the author used standardized preparations including 18.8% oligomeric procyanidins at a daily dose of 160 mg to 1800 mg for 3 to 26 weeks. A measure of heart oxygen consumption also showed a beneficial decrease with hawthorn treatment (AD, -19.22 mmHg/min) compared to placebo. Minor side-effects were reported including nausea, dizziness, heart and gastrointestinal complaints. (1)

Hawthorne given for 6 months had no effect on six-minute-walk distance (6MWD), a test used to estimate functional exercise capacity, in patients (aged 18 and older) with chronic heart failure (NYHA II-III). All patients received standard treatment plus either hawthorne (450 mg twice daily) or placebo. Results show no significant differences between the hawthorne group and placebo group in 6MWD, quality of life, functional capacity, neurohormones, oxidative stress, or inflammation. However, a measure of how much blood is being pumped out of the left ventricle of the heart showed a greater benefit for hawthorne. No serious side-effects were reported. (2)

Hawthorn (Crataegus monogyna) produces antioxidant rich berries that have been used in herbal medicine. The most common hawthorn formulations include WS 1442 (standardized to 18.75% oligomeric procyanidins, responsible for cardiovascular effects) and LI 132 (standardized to 2.2% flavonoids, widen blood vessels) with a dosing ranging from 160 to 1,800 mg in most studies, though doctors think a dose ranging from 600 to 1,800 mg (in two or three divided doses daily) is more effective. Although hawthorn has traditionally been used to treat a variety of conditions (asthma, high blood pressure, abnormal heart rhythms, anxiety, angina, heart failure, indigestion, and dyslipidemia), the best scientific evidence for its benefits derives from its use in people with mild congestive heart failure (NYHA classes I-III), a health condition in which the heart is unable to pump adequate amounts of blood to other organs in the body. Studies concluded that hawthorn improves heart function, ability to exercise, and improved symptoms of the disease (such as shortness of breath and fatigue). One study found that hawthorn extract was as effective as low dose (37.5 mg) captropril (a leading heart medication) in improving symptoms of congestive heart failure. Another study, a large-scale international determined that hawthorn extract does not reduce the risk of cardiac death in patients with this disease. Hawthorne has been found to be well tolerated and considered safe to take with standard heart failure medications (such as ACE inhibitors, vasodilators, cardiac glycosides). However, people should be careful when taking herbal supplements that have cardiovascular effects (danshen, epimedium, ginger, Panax ginseng, turmeric, valerian). (3)

A long-term placebo-controlled study of a herbal remedy’s effect on heart death, extract of Crataegus (WS-1442), also known as hawthorn, failed to show any significant benefit when given with standard drug therapy to patients with chronic systolic heart failure. The trial did suggest, however, that it’s safe to use WS-1442 in combination with standard heart failure (HF) medications such as ACE inhibitors and beta blockers. The Crataegus extract used in the study consisted of 17.3% to 20.1% concentration of oligomeric procyanidins, which are responsible for its cardiovascular effects. The trial, randomized 2681 patients with a New York Heart Association (NYHA) functional class, 2-3 heart failure and an a left ventricular ejection fraction (LVEF) <35% to receive either 900 mg/day WS-1442 (2 film-coated tablets each 450 mg) or placebo for two years; all participants received standard HF drug therapy, which included diuretics, ACE inhibitors, beta blockers, glycosides, and aldosterone blockers. WS-1442 was found to have no significant effect on sudden cardiac death, death due to progressive heart failure, fatal heart attack, nonfatal heart attack, or hospitalization due to HF progression, measured at 24 months. The rates were statistically similar, at 27.9% and for actively treated patients and 28.9% for controls. The average time to first heart event was similar for both groups: 620 days for WS-144 versus 606 days for placebo. Patients taking WS-1442 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). The rates of adverse events and of serious adverse events were about 68% and 40%, respectively, for both groups. In a subgroup analysis, patients who received WS-1442 and had an LVEF equal to 25% or less showed a significantly reduced risk of sudden heart death (by 39.7%). (4)

A placebo-controlled double-blind study found that Crataegus-Special extract WS 1442 had beneficial effects in the treatment of patients with cardiac insufficiency (NYHA II), a condition in which the heart can’t pump enough blood throughout the body. For 8 weeks patients (n=136) were treated with either Crateugus-Special extrakt (CS) or placebo. Results show a significant improvement in heart function in the CS group while participants in the placebo group became worse. CS patients also reported reduced shortness of breath, ankle swelling, and an overall better quality of life (especially mental well-being) compared to placebo and the treatment was well tolerated. (5)

Researchers found extract of fresh berries of Crataegus oxyacantha effective for the treatment of mild to moderate (NYHA II) congestive heart failure, when the heart can’t pump enough blood to the rest of the body. For 8 weeks study participants were administered 30 drops of the extract three times daily (n = 69) or placebo (n = 74). Findings showed a significant increase in exercise tolerance, with a greater improvement reported in the extract group (8.3 watts greater improvement compared to placebo). (6)

 

Hawthorne adverse reactions and interactions:

A meta-analysis by Pittler, M et al reported minor side-effects of nausea, dizziness, heart and gastrointestinal complaints (1). In most research reviewed, hawthorne was used and tolerated with standard heart failure medications including nitrates, beta-blockers, and angiotensin converting enzyme inhibitors (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 (3,5).

 

Coenzyme Q10 and congestive heart failure (CHF):

Low levels of coenzyme Q10 have been linked with heart failure and multiple clinical trials have suggested benefits from coenzyme Q10 (CoQ10) supplementation.

When studied in 35 patients with heart failure, CoQ10 resulted in a significant improvement in severity of heart failure or symptom class. Exercise time also tended to improve. Additionally, a meta-analysis of 9 randomized trials of CoQ10 in heart failure showed a beneficial effect of CoQ10 in the amount of blood pumped out of the heart (ejection fraction) and reduced mortality. (7)

Several clinical trials have suggested benefits from coenzyme Q10 (CoQ10) supplementation in patients with chronic heart failure (CHF). A meta-analysis by Soja and Mortensen that included 8 double-blind placebo-controlled studies reported a significant improvement in stroke volume, ejection fraction, cardiac output, cardiac index, and end-diastolic volume index, as a result of CoQ10 supplementation. In a separate meta-analysis of 11 studies with CoQ10 doses ranging from 60 to 200 mg/day and treatment periods ranging from 1 to 6 months, Sander et al. reported a 3.7% net improvement in the ejection fraction and an average increase in cardiac output of 0.28 l/min. In the current study, Molyneux and colleagues are the first to formally study the relationship between CoQ10 and outcomes in CHF in a longitudinal observational study. The study included 236 heart failure patients with a median age of 77 years. Plasma samples were analyzed for CoQ10 and other factors. Over the 5.75 year follow-up period, 39% of the participants who had CoQ10 levels lower than 0.63 micrograms per milliliter died, compared with only 22% of those whose levels were higher. This study also indicated that those with lower CoQ10 were 67% more likely to die. These findings suggests that CoQ10 levels are an independent predictor of survival in chronic heart failure patients. (8)

Coenzyme Q10 (CoQ10) was found to be safe and effective long-term therapy in 143 people with chronic cardiomyopathy (diseases of the heart muscle), 98% of whom were in NYHA Classes III and IV. The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying the extent of heart failure into four classes, with the highest (IV) being the worst. In addition to conventional medical treatment, study participants were given 100 mg of CoQ10 orally. Blood CoQ10 levels, clinical status, myocardial (heart) function and survival were recorded in this 6-year open-label study. In 3 months, mean CoQ10 levels rose to 2 micrograms/ml from 0.85 micrograms/ml. Mean ejection fraction which is a measurement of how well the heart is pumping increased from 44% to 60% in 6 months and stabilized at that level with a majority of patients showing statistically significant improvement. NYHA class in 85% of patients improved by one or two. Survival was estimated at 11.1% mortality in 12 months and 17.8% mortality in 24 months. There was also no evidence of toxicity or intolerance in 368.9 patient-years of exposure. (9)

The effects of Coenzyme Q10 (CoQ10) on ejection fractions, cardiac output, and improvements in functional classifications (NYHA) in 88 patients with cardiomyopathy (diseases related weakness of the heart muscle) were studied. The New York Heart Association (NYHA) Functional Classification provides a simple way of classifying the extent of heart failure into IV classes, with the highest being the worst. Of the 88 patients, 75%-85% showed statistically significant increases in two cardiac parameters. Patients with the lowest ejection fractions which is a measurement of how well the heart is pumping (approx. 10%-30%) showed the highest increases (115 delta %-210 delta %) and those with higher ejection fractions (50%-80%) showed increases of about 10 delta %-25 delta % on therapy. Delta % is the response during exercise. By functional classification, 17 out of 21 in class IV, 52 out of 62 in class III, and 4 out of 5 in class II improved to lower classes.  Forty-eight percent of patients in class IV, 42% in class III, and 40% in class II had very low control blood levels of CoQ10. In summary, CoQ10 therapy appears to have the greatest effect in patients with blood levels at about 2.5 micrograms CoQ10/ml and higher during therapy. (10)

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).

 

Creatine supplementation and congestive heart failure (CHF):

Muscle endurance improved in a double-blind, placebo-controlled crossover study of patients with chronic heart failure. Treatment with 20 g of creatine for 5 days increased the amount of exercise they could complete before they reached exhaustion. No effect was reported in the placebo group. Chemicals produced during exhaustive exercise (ammonia and lactate) were reduced (-2.7 and -0.05 mumol/l/contraction, respectively) with use of creatine but not placebo. (11)

 

L-carnitine and congestive heart failure symptoms (CHF):

L-carnitine, important for energy production in cells, supplementation (given daily at 100 mg/kg) showed improvement in the heart failure symptoms in patients (n=14) with dilated cardiomyopathy (DCM), a condition where the heart is weak and enlarged resulting in restricted blood flow. Results show that after L-Carnitine administration average levels of carnitine significantly increased as did effort tolerance (ability to endure exercise and/or maximum work) and shortness of breath decreased. Additionally systolic function in the part of the heart that pumps blood was improved after L-carnitine. In conclusion, L-carnitine administration in patients with DCM may be beneficial. (12)

 

Thiamine supplementation for chronic congestive heart failure (CHF):

Thiamine supplementation may be beneficial for individuals taking diuretic drugs to manage chronic heart failure. Nine diuretic-treated patients (aged 45-75 years) with symptomatic chronic heart failure and a left ventricular ejection fraction (LVEF), a measurement of how much blood is being pumped out of the left ventricle of the heart, less than 40% were randomly assigned to receive 300 mg per day of thiamine or placebo for 4 weeks. After a 6-week washout period (no treatment was received), each patient received the alternate treatment for an additional 4 weeks. Mean LVEF at baseline was 29.5%. Mean LVEF was significantly higher after thiamine treatment than after placebo (32.8% vs. 28.8%). (13)

 

Physical rehabilitation, exercise and chronic heart failure:

Cycling vs. cycling combined with calisthenics for heart failure: Researchers found benefits of physical rehabilitation in 134 patients (mean age 60 years, 94% male) with chronic heart failure (HF). The extent of heart failure among the patients, using the New York Heart Association Functional Classification system, was II (50%) and III (48%). For 6 to 16 weeks, study participants followed one of two exercise regimens: cycle ergometry (20 minutes 4-5 times per week at an intensity of 70%-80% of a predetermined peak heart rate) or cycle ergometry combined with calisthenics or body weight exercises (5 days/week with stationary running). Cycle ergometry warm up and cool down lasted for 1-3 min at 25 W. At the end of the study, improvement in resting catecholamines and hormones (such as epinephrine and norepinephrine) and heart rate variability were associated with a 13% increase in oxygen consumption (VO2) and a 17% increase in exercise duration. Compared to the cycle ergometry alone patients, the 54 patients on a combined exercise regimen achieved significantly better VO2 (2.7 vs 1.2 ml.kg.min-1). VO2 was also found to be linked to the duration of the program; after 16 weeks training VO2 was significantly higher than after 6 weeks (2.6 vs 0.3 ml.kg.min-1). No significant side effects were reported. (15)

Heart failure and afterload reduction using exercise: In a prospective randomized trial, the authors evaluated the effects of 6 months of exercise training in patients with stable chronic heart failure and moderate-to-severe left ventricular (LV) dysfunction in 73 men aged 70 years or younger. Patients were randomly assigned to 2 weeks of in-hospital ergometer exercise for 10 minutes 4 to 6 times per day, followed by 6 months of home-based ergometer exercise training for 20 minutes per day at 70% of peak oxygen uptake (n=36) or to no intervention (control group; n=37). Results indicated that aerobic endurance training leads 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. Cardiac output at rest and during sub-peak exercise remains almost unchanged. Long-term exercise training is associated with a reduction of total peripheral resistance (TPR) in the exercise training group vs an increase in the control group, p=0.003). Total peripheral resistance (TPR) is the amount of resistance to blood flow present in the vascular system of the body. These results suggest that in patients with stable chronic heart failure, regular physical exercise for 6 months is associated with a significant afterload reduction. This beneficial training effect leads to a small but significant improvement in LV stroke volume and reduction in cardiomegaly, enlargement of the heart seen in heart failure. (16)

 

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.

 

 

References:

1.Pittler M, Guo R, Ernst E. Hawthorn extract for treating chronic heart failure. Cochrane Database Syst Rev. 2008;CD005312. http://www.ncbi.nlm.nih.gov/pubmed/18254076

 

2.Zick SM, Vautaw BM, Gillespie B, Aaronson KD. Hawthorn Extract Randomized Blinded Chronic Heart Failure (HERB CHF) trial. Eur J Heart Fail. 2009 Oct;11(10):990-9. http://www.ncbi.nlm.nih.gov/pubmed/19789403

 

3.Dahmer S, Scott E. Health effects of hawthorn. Am Fam Physician. 2010 Feb 15;81(4):465-8. http://www.aafp.org/afp/2010/0215/p465.html

 

4.Holubarsch CJ, Colucci WS, Meinertz T, Gaus W, Tendera M. The efficacy and safety of Crataegus extract WS 1442 in patients with heart failure: the SPICE trial. Eur J Heart Fail. 2008 Dec;10(12):1255-63. http://eurjhf.oxfordjournals.org/content/10/12/1255.long

 

5.Weikl A, Assmus KD, et al. Crataegus Special Extract WS 1442. Assessment of objective effectiveness in patients with heart failure (NYHA II). German. Fortschr Med. 1996 Aug 30;114(24):291-6. http://www.ncbi.nlm.nih.gov/pubmed/8974970

 

6.Degenring FH, Suter A, Weber M, et al. A randomised double blind placebo controlled clinical trial of a standardised extract of fresh Crataegus berries (Crataegisan) in the treatment of patients with congestive heart failure NYHA II. Phytomedicine . 2003;10:363-369. http://www.ncbi.nlm.nih.gov/pubmed/12833999

 

7.Rosenfeldt F, Hilton D, Pepe S, Krum H. Systematic review of effect of coenzyme Q10 in physical exercise, hypertension and heart failure. Biofactors. 2003;18(1-4):91-100. http://www.ncbi.nlm.nih.gov/pubmed/14695924

 

8.Molyneux SL, Florkowski CM, George PM, et al. Coenzyme Q10. An independent predictor of mortality in chronic heart failure. J Am Coll Cardiol. 2008 Oct 28;52:1435-41. http://www.sciencedirect.com/science/article/pii/S0735109708027228

 

9.Langsjoen PH, Langsjoen PH, Folkers K. A six-year clinical study of therapy of cardiomyopathy with coenzyme Q10. Int J Tissue React. 1990;12(3):169-71. http://www.ncbi.nlm.nih.gov/pubmed/2276895

 

10.Langsjoen PH, Folkers K, Lyson K, Muratsu K, Lyson T, Langsjoen P. Effective and safe therapy with coenzyme Q10 for cardiomyopathy. Klin Wochenschr. 1988 Jul 1;66(13):583-90. http://www.ncbi.nlm.nih.gov/pubmed/3062263

 

11.Andrews R, Greenhaff P, Curtis S, et al. The effect of dietary creatine supplementation on skeletal muscle metabolism in congestive heart failure. Eur Heart J. 1998 Apr;19(4): 617-622. http://www.ncbi.nlm.nih.gov/pubmed/9597411

 

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