Q: Dr. P, I was told that I have heart failure; what are the ramifications?
A: Simply put, heart failure is when the heart (a pump) is unable to meet the demands of the body. It means that tissues no longer get the oxygen needed, and back pressure results, producing edema in the lungs, liver, kidneys, digestive system, and other areas. In addition to the body's failing to properly circulate blood and oxygen, heart failure also impairs immune function.1,2 Finally, with heart failure, the body's detoxification processes are compromised, with altered perfusion to the kidneys and liver – two important organs of detoxification.3-6
Heart failure can be categorized as systolic, diastolic, or both. Systolic heart failure is when the heart cannot contract with adequate force to eject blood, while diastolic heart failure is when the heart muscle has impaired relaxation, preventing adequate blood from entering the heart prior to ejection. It is important to note that heart failure has different levels of severity designated by New York Heart Association (NYHA) Functional Classes (I–IV). Class I is when the person has no physical limitations. Class II means that a person is symptomatic on extra exertion. Class III is symptomatic on mild exertion, while Class IV is having symptoms at rest. A person's Functional Class determines the level of intervention needed.7
Q: What is the etiology of heart failure?
A: Heart failure has a variety of causes. Untreated hypertension, heart attacks, coronary disease, and valve disease are examples. Cardiomyopathy, a condition due to nutritional deficiencies, toxic exposures, hormonal problems, and sometimes unknown causes can also cause heart failure. Finally, infections, muscular disease and infiltrative conditions such amyloidosis can in rare cases cause heart failure.
Q: I have heart failure. Will my heart ever recover?
A: This depends on the severity of disease, but also whom you ask. I recall one of my patients, Wes, 68, who had diabetes, hypertension, and renal failure. Wes came looking for alternatives for the blood pressure drugs that he was taking: metoprolol, lisinopril, and hydrochlorothiazide. Despite the drugs, his blood pressure was poorly managed, with his systolic pressure still in the 180s. He had dyspnea on exertion, and while lying down (orthopnea). He had cyanosis in his fingernails and mouth, and edema in his abdomen and legs – all signs and symptoms consistent with heart failure. Based on his history and an exam Wes's Functional Class was between III and IV. For the short term, he needed extraction of the excess fluid; and for both the short and long term, natural approaches to improve his cardiac function.
After securing a blood sample, which later confirmed renal failure and NYHA Class III heart failure respectively; and, performing an ECG, (negative for MI,) we initiated short and long term plans. First, I encouraged Wes to stay on metoprolol and lisinopril for his high blood pressure, but changed the timing to between meals to improve bioavailability. I switched his thiazide diuretic to spironolactone (to help with fluid overload) and added digoxin (to improve cardiac contractility) and herbs and nutrients including hawthorn, CoQ10, L-carnitine, taurine, a multivitamin, and magnesium. Within 24 hours, Wes's shortness of breath resolved, his leg and abdominal edema improved, and his fingernail and mouth color returned to a healthy pink. Over the following 6 weeks, his blood pressure normalized, as did his blood tests. Then, over the remainder of the year, subsequent to improving his diet, walking daily, and staying on his natural medicines, Wes was able to get off his drugs, and he never again had a recurrence of heart failure symptoms. So when you ask if your heart can ever recover, although in medicine we are taught that the answer is no, in many cases (as with Wes), the answer is a resounding yes!
Q: What are the treatments for heart failure?
A: There are a wide range of treatment options, depending on the severity of disease. Generally, the goal is to reduce pressure caused by volume overload, decrease the risk/occurrence of life-threatening arrhythmias, and improve cardiac output. Of course, we want to find the cause and address it if possible; for example, stopping alcohol in the case of alcohol-induced cardiomyopathy.
Conventional approaches to treat heart failure include beta blockers to prevent/manage arrhythmias, diuretics to reduce volume overload and edema, ACE inhibitors and ARBs to decrease blood pressure, and potentially decrease the unfavorable enlargement of heart chambers, and digoxin for inotropic (improving contractile) effects. These drugs are excellent in addressing symptoms, and bringing a person out of life-threatening Class IV. They can be used orally or intravenously with other drugs, or with mechanical assists, if the situation warrants hospitalization or if a person becomes "hemodynamically unstable." Finally, transplantation is required if one's heart is damaged beyond a point when the condition cannot be managed by other means.8
Natural approaches for heart failure are numerous – some supported by the literature, some not. They can have similar effects to drugs in reducing blood pressure and occurrence of arrhythmias, and improving the heart's contractile force.9-11 However, many are unique in comparison with drugs in that they can be "nutritive" to the heart. For example: nutrients such as CoQ10, magnesium, and L-carnitine serve as necessary components of energy production at the cell level. By improving the energy production of heart cells, one can improve the output of the heart itself.12 Other approaches such as consuming an antioxidant-rich diet, taking antioxidants, and addressing heavy metal toxicity and chronic alcohol consumption are also important components of a comprehensive treatment plan. These interventions can reduce oxidative stress, and thereby affect "aging" often cited as the "cause" of diastolic heart failure. Finally, the importance of lifestyle modifications, including restricting sodium, tobacco cessation, and regular exercise, cannot be overstated.
Q: What are the benefits of the drugs, and what are the caveats?
A: Drugs are essential in addressing urgencies, wherein it is important to bring things under control quickly. They can reduce fluid rapidly and the occurrence of bad rhythms that put a person at risk of sudden death. There are caveats however. For example, diuretics that reduce volume overload in people with heart failure can also cause loss of important nutrients such as potassium, magnesium, calcium, and B vitamins – critical for healthy heart chemistry.13 So, although drugs are indispensable at times, it is essential to include nutritional approaches to mitigate the negative effects of drug therapy when it is necessary.
Q: Now that I have heart failure I am on several drugs. Must I continue them, and if so, how long?
A: The universal answer is, it depends! As in Wes's case, many who have heart failure and are also on a solid natural medicine plan, can discontinue (or reduce the dose of) medications as heart function improves. This considered, the last thing we want to do is throw someone who is stable and asymptomatic into Class IV (or worse) by quitting a conventional plan that was working. When someone is a candidate for drug withdraw, I typically taper the drugs over the course of several months, sometimes longer, and with concomitant use of multiple nutritional, herbal, and lifestyle supports. The monitoring of diagnostic tests, symptoms, and physical exam are also important to allow the medication withdrawal to be conducted safely and effectively. In cases where a person who is on drugs can't safely get off, natural approaches can still improve quality of life, and mitigate the unfavorable side effects of drugs.
Q: What tests should I be getting to monitor my condition?
A: Two diagnostic tests are critical for monitoring heart function: A BNP (B-type natriuretic peptide) and an echocardiogram (a heart ultrasound).14
First, the BNP is a blood test, the level of which rises as the heart fails. It serves as a useful confirmation of Functional Class, and can differentiate between (some) lung diseases and heart failure. BNP can also give an indication of the efficacy of a treatment. I routinely use BNP to assess the value of treatments in my patients with heart failure, particularly during the initial year. A normal BNP value is <100 pg/ml, but it is often elevated during initial phases of treatment. Once a person is stable, BNP should be followed every 6 or 12 months, depending on other risk factors or concomitant disease.
Second, an echocardiogram is one of the most valuable tests for assessment of heart structure and function. It provides information on valves, chamber size, wall thickness, contractility, relaxation, flow, pressures, volume ejected, and overall cardiac output. It is unique in that it can assess both systolic and diastolic failure. For the purposes of an initial assessment, I review all aspects of the echocardiogram, and for monitoring: I follow ejection fraction (EF; useful to assess and follow systolic dysfunction). And, I follow the E/A and E/E ratios that allow "grading" of any diastolic dysfunction. A normal EF is 60% or higher although some references cite normal as low as 40 (higher indicates better contractile function). Diastolic dysfunction is categorized as Grade I (mild) generally asymptomatic, to Grades III and IV (severe) with symptoms of heart failure.
Q: What are the questions that I need to ask my doctor at every visit?
A: Good communication with your doctor is perhaps the single most important factor to insure that you get what you need, with heart failure or any condition. Several things are important to ask:
- Medications, nutrients and herbal medicines: Should any be adjusted or discontinued; or should any new agents be started, and why?
- Lifestyle: Should diet, activity, or other practices that relate to your condition be modified?
- Monitoring: When should your next BNP occur? What is the actual level, and is it stable, improving or deteriorating? When should you have your next echocardiogram? What was your Ejection Fraction? And, if you have diastolic dysfunction, what Grade? Are these parameters stable, improving or deteriorating?
- New discoveries or possibilities for treatment: Can hormones or other agents be of value? Are there any new tests that should be considered that would alter my treatment course?
Q: What do I need to watch for if I have heart failure?
A: As with any heart condition, if you have shortness of breath at rest, chest pain, tightness, arm or jaw pain, a sustained rapid heart rate at rest, sustained dizziness, or a sense of doom, you should call 911. If you have known heart failure and are gaining weight; noticing a change to your breathing, urination, or appetite; your lips, mouth, or fingernails start to turn purple or blue; or your ankles, feet, or legs start to swell, it's time to call your doctor's office and communicate it.
Q: I've done some Internet research on natural approaches. What are your "go to" treatments in patients with heart failure?
A: First and foremost, it is critical to try and eliminate "causes." Alcohol, despite its growing popularity as "heart healthy," is cardiotoxic.15 A standard American (inflammatory) diet high in sodium and sugar, inactivity, obesity, heavy metal toxicity, high blood pressure, hormonal imbalances, and smoking (of any kind) are all potential contributors that should be addressed.
Although every person gets an individualized plan, I typically consider the following lifestyle and natural approaches for my patients with systolic heart failure:
- high-antioxidant plant-food rich diet, minimizing sodium and sucrose
- CoQ10: 60–300 mg daily
- L-carnitine: 1500–2000 mg daily
- taurine: 1000–1500 mg daily
- magnesium: 120–400 mg daily
- hawthorn: (standardized extract of Crataegus oxyacantha) 2000–3000 mg daily
- B complex (B50): 1 cap daily
- multimineral +/− potassium (if hypokalemic and not on potassium-sparing medications)
If the patient has diastolic dysfunction or coronary disease, I'll consider addition of:
- turmeric: 1000 mg daily of a standardized extract
- digestive enzymes daily with meals
- vitamin C 500-1000 mg daily with bioflavonoids
- fish oil of with approximately 1000 mg EPA daily.
Please bear in mind that the preceding list should not be considered a recipe for everyone with heart failure. Hawthorn can cause stomach upset. CoQ10 may interact with blood pressure medications. Multiminerals can produce hyperkalemia, while B vitamins can aggravate palpitations and anxiety. Therefore, it is prudent to consult with a knowledgeable physician to identify the "right" recipe for each person.
Q: What is the take-home message about heart failure and alternative approaches?
A: Regardless of NYHA class, those of us with heart failure can benefit from natural approaches. Heart failure not only causes physical limitations, but also can cause detoxification and immune dysfunction. It is important to make use of drug therapies when necessary, but also use nutritional and herbal approaches to mitigate the side effects of those very drugs. I've observed improvements in my patients with heart failure when using many nondrug therapies such as CoQ10, magnesium, L-carnitine, B-vitamins, and others. That said, the right recipe for each person varies, so it is prudent to make use of alternative therapies and medications under professional guidance.
Dr. Kasra Pournadeali is one of the country's authorities in naturopathic cardiology. He has been a provider for over 25 years, and practices at the Northwest Center for Optimal Health in Marysville, Washington. You can hear his talk show Sound Living Thursdays at 4 p.m. PT on Independent Public Radio at kser.org. Find out more about Dr. Pournadeali online at ncoh.net or facebook.com/naturalmedicinedoctors.