Diet/nutrition in the prevention and treatment of heart failure - Khôi Minh Lê

Diet/Nutrition in the Prevention 
and Treatment of Heart Failure 
Khôi Minh Lê, MD, FACC, FSCAI 
Co-Director Cardiac Cath Lab 
Eisenhower Medical Center 
Rancho Mirage, California 
Proportion of population living with 
heart failure 
Ponikowski et al. ESC Heart Failure 
2014;1:4-25 
H Single 
centre 
PREVENTION OF HEART FAILURE 
ARE THERE RISK FACTORS FOR HEART 
FAILURE THAT MIGHT BE MODIFIED BY 
DIET? 
Obesity and Heart Failure Risk 
Kenchaiah et al N Engl J Med 
2002;347:305-13 
Obesity and heart failure risk 
• Obesity, overweight, and abdominal adiposity 
increase risk of HF 
• 2016 Meta-analysis of 28 prospective studies 
• RR for 5 unit increment in BMI 
– 1.41 heart failure incidence 
– 1.26 heart failure mortality 
Aune et al. Circulation 2016 Feb 
16;133(7):639-49 
Hypertension and Heart Failure Risk 
SPRINT Research Group 
The SPRINT Research Group. N 
Engl J Med 2015;373:2103-2116 
What’s different in Southeast Asia? 
Lam ESC Heart Failure 2015;2:46-9 
Recommended diets for obesity and 
hypertension 
DASH and Mediterranean Diets 
DASH diet associated with decreased 
Heart Failure (HF) 
• 36 019 Swedish women ages 48-83 
• Greater compliance with DASH diet associated 
with 37% lower rate of HF hospitalization or 
death 
Levitan et al Arch Intern Med 
2009;169:851-7 
Healthy lifestyle including 
Mediterranean diet reduces risk of HF 
• Swedish study of 33966 men and 30713 
women between 45 to 83 years old 
• Healthy lifestyle reduced HF risk 
– Nonsmoker 
– Physically active 
– BMI 18.5-25 kg/m2 
– Diet (modified Mediterranean) 
• Men RR 0.82 (0.74,0.91) 
• Women RR 0.83 (0.74,0.94) 
Larsson et al Circ Heart Fail 
2016;9:e002855 
Contribution of major lifestyle risk 
factors to HF 
• US study of 4490 men and women age ≥65 
years followed >20 years 
• Physical activity, modest alcohol intake, 
avoiding obesity, and not smoking associated 
with lower risk of HF 
• No protective dietary pattern (including DASH) 
identified although ↑Na+ associated with 
trend to ↓HF risk. 
Del Gobbo et al JACC Heart Failure 
2015;3:520-8 
Decreased HF with dietary pattern 
• 24008 middle-aged participants of the 
European Prospective Investigation into 
Cancer and Nutrition (EPIC)- Potsdam 
(Germany) 
• Traditional Greek Mediterranean diet score 
not significantly associated with HF risk 
• Low meat, high fish, and moderate alcohol 
intake inversely associated with HF risk 
Wirth et al European Journal of Clinical 
Nutrition 2016;70:1015-21. 
THE CASE FOR FRUITS AND 
VEGETABLES 
Fruit and vegetable intake associated 
with lower risk of HF 
• Sweden: 34319 women followed for 12.9 yr showed 
lowest risk of HF (RR 0.80) associated with ≥5 servings/d 
(Rautianen et al European Journal of Heart Failure 2015;17:20-6) 
• Finland: 38075 women and men aged 25-74 yr, followed 14.1 
yr reported association between vegetables (RR 0.70) and HF 
but not fruit 
(Wang et al Circ Heart Failure 2011;4:607-12) 
• US Physicians’ Health Study 20900 men followed 22.4 yr 
showed ↓HF risk with ≥4 servings/d 
(Djousse et al JAMA 2009;302:394-400) 
Which fruits and vegetables? 
Rautianen et al European Journal of 
Heart Failure 2015;17:20-6 
Most protective 
Apples, pears, berries, green leafy vegetables 
No association 
Bananas, citrus, tomatoes, peppers, root and cruciferous 
vegetables 
Nutrient Protection? 
• Plasma vitamin C 
– EPIC-Norfolk study of 20299 women and men 
– Pfister et al Am Heart J 2011:162:246-253 
• Serum β-carotene 
– Swedish study of 2321 men followed 29 years 
– Ingelsson et al JACC 2005;46:2054-2060 
• Total dietary antioxidant intake 
– Swedish study of 33713 women followed 11.3 years 
– Rautianen et al Am J Med 2013;126:494-500 
↓Heart Failure 
Risk 
But only if BMI < 25 kg/m2 
But only with CAD 
Petrone et al Eur J Heart Fail 
2014;12:1372-6 
Djoussé Circulation 
2007;115(1):34-9 
↑Heart Failure 
Risk 
Date of download: 10/7/2016 Copyright © The American College of Cardiology. All rights reserved. 
Linear relationship between sodium intake and 
mortality 
Cook et al. JACC 2016;68:1609-17 
Possible Explanations for Protective 
Effect of Diet 
• Direct effect on development of HF 
• Reductions in 
– Hypertension 
– Obesity 
– Myocardial infarction 
– Hyperglycemia/diabetes 
– Atrial fibrillation 
DIET/NUTRITION IN THE 
TREATMENT OF HEART FAILURE 
Patient Education and Interventions 
DASH and Mediterranean 
US Women’s Health Initiative 
• Compliance with healthy diets modestly 
associated with lower HF mortality 
– DASH statistically significant benefit 
– Mediterranean trend to benefit 
• Diet score components, vegetables, nuts, and 
whole grain intake inversely associated with 
HF mortality 
Levitan et al Circ Heart Fail 2013;6:1109-11 
Nutritional Supplements for HF 
• n-3 polyunsaturated fatty acids 
• Vitamin C 
• Vitamin D 
• Thiamine 
• Magnesium 
• Coenzyme Q10 
Evidence limited; mostly small studies and/or with 
surrogate outcomes 
Diet and Heart Failure 
Can we apply preventive principles to 
treatment? 
Associated with reduced risk of developing HF: 
• Weight loss with goal of normal BMI 
• Sodium restriction 
Utility in treating HF? 
DIET/NUTRITION IN THE 
TREATMENT OF HEART FAILURE 
The Obesity Paradox and Cardiac Cachexia 
Obesity Paradox in Chronic Heart 
Failure 
• Meta-analysis of 6 
studies including 22807 
patients with chronic 
heart failure 
• Highest mortality seen 
in underweight patients 
• Overweight patients did 
better than normal 
weight 
0
0.2
0.4
0.6
0.8
1
1.2
1.4
CV Mortality (RR) by BMI 
Sharma et al Am J Cardiol 2015 
Obesity Paradox in Acute Heart Failure 
Shah et al JACC 2014;63:778-75 
Mortality at 30 Days Mortality at 1 Year 
Normal BMI 
Normal BMI 
Obese Obese 
The Obesity Paradox is a 
Global Phenomenon 
Shah et al JACC 2014;63:778-75 
Cardiac Cachexia 
• Protein-calorie malnutrition with muscle 
wasting and peripheral edema 
• Mechanisms 
– Malabsorption due to intestinal edema, hepatic 
congestion 
– Cytokine-mediated anorexia 
– ↓food intake due to dyspnea, fatigue 
SODIUM RESTRICTION IN ACUTE 
AND CHRONIC HEART FAILURE 
Gupta et al Circulation 2012;126:479-485 
Global Consensus for Sodium Restriction 
Observational studies favoring sodium 
restriction 
• 123 patients EF2800 
mg/d associated with 3-fold higher rate of HF 
readmissions 
Arcand et al. Am J Clin Nutr 2011;93:332-337 
• 232 patients EF3000 
mg/d associated with increase in 
death/hospitalization 
Son et al. J Clin Nurs 2011;20:3029-38 
Effects of Nutritional Intervention 
• Sodium (2000-2400 
mg/d) and fluid (1.5 
L/d) restriction vs. 
standard care in 65 
patients with HF 
• Improved NYHA 
functional class with 
dietary intervention 
0
10
20
30
40
50
60
70
Intervention Standard
Colin Ramirez et al. Nutrition 
2004:(20)890-5 
↑Na+, ↓Fluids, High Dose Diuretics 
An Improved Paradigm? 
• Several studies by same authors at a single 
center 
• Moderate-to-high sodium intake combined 
with fluid restriction and high doses of 
furosemide reduced mortality, 
hospitalizations, and laboratory results (BNP, 
BUN, Cr) 
• These results have not been confirmed by 
other investigators 
Licata et al Am Heart J 2003;145:459-66 
Paterna et al JACC 2005;45:1997-2003 
Parrinello et al J Card Fail 2009;15:864-73 
Doukky et al. JACC HF 2016;4:24-35 
Dietary sodium restriction 
Detrimental outcomes in heart failure? 
Observational study with many limitations relying on patient self-reporting to 
estimate dietary sodium. 
<2500 mg/d 
≥2500 mg/d 
Dichotomous correlation 
• Dietary sodium <3000 mg/d 
– Increased hospital visits, readmissions, and mortality 
in NYHA class I, II 
– Better outcomes in NYHA class III, IV 
• Possible explanation? 
– Negative effects of sodium restriction in euvolemic 
patients leading to R-A-A-S activation 
– Beneficial effects of volume contraction in fluid-
overloaded patients 
Lennie et al. J Card Fail 2011;17:325-330 
Dual response to sodium restriction 
Gupta et al Circulation 2012;126:479-485 
Guideline adjustments 
2013 ACC/AHA Heart Failure Guidelines 
– Stage A, B <1.5 g/d 
– Stage C, D <3.0 g/d 
– (US average 3.7 g/d) 
2016 ESC Heart failure guidelines 
Yancy et al JACC 2013;62:e147-239 
Diet/nutrition and Heart Failure 
Prevention ≠ Treatment 
• DASH/Mediterranean diet 
– Probably beneficial for prevention and treatment 
– Evidence base is limited, mostly observational 
• Weight reduction and sodium restriction 
– Reduce risk of developing heart failure 
– Impact on patients with heart failure unclear 
• Lifestyle counseling is fundamental to the care of 
heart failure patients 
• We need more evidence to guide us and them! 
44