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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... ARE THER

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

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)

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

• 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/m 2

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

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

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

• 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

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

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 EF<35% sodium intake >2800

mg/d associated with 3-fold higher rate of HF readmissions

Arcand et al Am J Clin Nutr 2011;93:332-337

• 232 patients EF<40% sodium intake >3000

mg/d associated with increase in

death/hospitalization

Son et al J Clin Nurs 2011;20:3029-38

Effects of Nutritional Intervention

Colin Ramirez et al Nutrition 2004:(20)890-5

↑Na+, ↓Fluids, High Dose Diuretics

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

Dual response to sodium restriction

Gupta et al Circulation 2012;126:479-485

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!

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