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Health Protocols

Heart Failure

Dietary and Lifestyle Consideration

Cessation of Tobacco and Excessive Alcohol Use

Intake of more than 7–8 alcoholic drinks per day for more than five years may increase the risk of cardiovascular dysfunction that can lead to heart failure. Patients with a history of alcohol overconsumption are encouraged to abstain from drinking.3 However, light-to-moderate drinking (up to one drink daily for women and two drinks daily for men) may be associated with a reduced risk of heart failure compared with those who abstain from drinking.32,183,184

Smoking is a major risk factor for many medical conditions, including cardiovascular diseases. Stopping smoking was shown to provide benefits for patients with congestive heart failure similar to benefits offered by primary drugs.33,185 Several other studies found people who quit smoking have a lower risk of cardiovascular disease.186

The DASH Diet and Mediterranean Diet

The DASH (Dietary Approaches to Stop Hypertension) eating plan, which is rich in fruits, vegetables, whole grains, and low-fat dairy products, has been shown to lower systolic blood pressure by 8‒14 mmHg187,188 and is often recommended for people with heart failure.189,190 The Mediterranean diet, which is similar to the DASH diet in emphasizing fruits, vegetables, and whole grains, is also a healthy dietary pattern for those with heart failure.189

Specifically restricting dietary sodium intake remains controversial in the context of heart failure.191-194 However, both the DASH and Mediterranean dietary patterns generally do not contain large amounts of sodium relative to the typical Western diet. Until large, randomized, controlled trials can address the question of whether specifically restricting dietary sodium is optimal for heart failure patients, adhering to a diet rich in unprocessed plant-based foods is a good option.195

Monitor Micronutrient Sufficiency

Deficiencies in micronutrients, such as potassium, calcium, magnesium, and zinc play an important role in the progression of heart failure. These nutrients help maintain the proper relaxation and contraction of heart muscle cells. A comprehensive literature review suggests micronutrients improve health outcomes in heart failure patients, including symptoms, work capacity of the heart, and left ventricular ejection fraction.196

In a recent multi-center, longitudinal study, 246 heart failure patients were asked to fill out four-day food diaries. Analysis of these diaries revealed micronutrient deficiency to be a strong, independent predictor of one-year hospitalization or death rates, particularly in patients with comorbid depressive symptoms. The most common dietary deficiencies were calcium, folate, magnesium, zinc, and vitamins C, D, E, and K. These results suggest promoting a varied diet may prevent micronutrient deficiencies, and diet quality plays a role in heart failure outcomes.197

The frequency of malnutrition increases with degree of heart failure severity, ranging from an estimated 22% in NYHA class II patients to 63% in class III patients.31 Micronutrient insufficiency is of particular concern among patients on certain heart failure medications. Further research is needed to document the effects of micronutrients on quality of life and heart failure patient survival.

Potassium and zinc. Diuretic use is associated with electrolyte depletion. Potassium is essential for normal heart rhythm and function. Conversely, ACE inhibitors and ARBs decrease the excretion of potassium and may lead to elevated potassium levels. ACE inhibitors, ARBs, and thiazide increase urinary excretion of zinc.31

Magnesium. Loop diuretics increase renal excretion of magnesium and other essential minerals.31 In a study of 68 patients admitted to the hospital for heart failure, 38% presented with low magnesium levels at admission and 72% had excessive urinary magnesium loss.198 Several clinical trials have investigated the use of magnesium in heart failure patients. A recent analysis of 40 trials including over one million participants concluded that increasing dietary magnesium intake lowered risk of stroke, diabetes, heart failure, and mortality.199

B-vitamins. Chronic therapy with diuretics, which are administered to many patients with heart failure, may prevent the reabsorption of thiamine and increase its urinary excretion, contributing to thiamine deficiency. A study in 25 patients with heart failure found that furosemide use at 80 mg or more per day was associated with a 98% prevalence of thiamine deficiency.31 Deficiencies of several vitamins, including riboflavin, pyridoxine, folic acid, and B12 have also been documented in heart failure patients. Riboflavin, B12, and folic acid play a role in homocysteine metabolism. Homocysteine is an amino acid that can cause damage to the inner lining of blood vessels (the endothelium), and elevated homocysteine levels have been associated with a poor prognosis in heart failure patients.200,201


Exercise training is a valuable addition to other heart failure interventions. Regular exercise that provokes mild-to-moderate shortness of breath is beneficial, and best undertaken in a structured, medically-supervised program.202,203 In clinically stable patients able to participate, cardiac rehabilitation improves heart-related quality of life, functional capacity, endothelial function, and reduces hospitalizations and mortality.47 Exercise training is considered suitable for most heart failure patients in NYHA class I‒III. 204

Published studies evaluating the efficacy of exercise training in heart failure patients report improvements in skeletal muscle oxygen utilization, diastolic function, symptoms and quality of life measures; increased exercise capacity, muscle strength and endurance; and reductions in inflammatory cytokines (eg, TNF-α and IL-6), NYHA functional class, hospital stays and mortality.205

In addition to formal structured exercise programs that may include aerobic and resistance exercise components, lifestyle approaches that emphasize activities such as brisk walking, taking stairs, gardening, and house work are also considered valuable.204

Regular physical activity can also help maintain a healthy weight, which in turn promotes optimal cardiovascular health.

Maintain Healthy Blood Sugar Levels

Diabetes and insulin resistance are major risk factors for heart failure. Diabetes not only increases risk of heart failure, but also worsens the outcome of patients with existing heart failure.3 The diabetic heart is more susceptible to ischemic (low oxygen) injury, myocardial infarction, and oxidative damage.206 Strategies for maintaining blood sugar control are reviewed in Life Extension’s Diabetes and Glucose Control protocol.

For those with diabetes and heart failure, the choice of diabetes medication may be complex. Metformin is often the first-line drug of choice for managing blood sugar in diabetics without overt heart disease. It was historically contraindicated in patients with heart failure due to concerns over increased risk of lactic acidosis. However, accumulating evidence suggests the risk of lactic acidosis may not be as pronounced as once thought. In fact, studies suggest metformin may reduce heart failure risk in diabetic patients and improve two-year survival rates in those with heart failure.207,208 Metformin is now commonly prescribed to diabetics with heart failure.209

Emerging evidence increasingly favors another class of diabetes medication, SGLT-2 inhibitors, in the management of diabetes in people with heart failure. These drugs work by increasing the amount of glucose excreted into the urine by the kidneys. SGLT-2 inhibitors may be a reasonable choice for add-on therapy in heart failure patients whose diabetes cannot be controlled by metformin and diet alone.209,210 However, additional randomized controlled trials are needed to establish the ideal medication strategy to maintain glucose control in people with heart failure.

Reduce Stress

Reducing stress levels may also promote optimal heart health. Anxiety is a serious mood disorder that affects many heart failure patients. Feeling anxious can make the heart beat faster, which in turn increases breathing rates and blood pressure levels. This can exacerbate heart failure, as the heart is already struggling to meet the body’s demand for oxygen-rich blood. In addition, stress may affect lifestyle behaviors that influence heart disease, such as alcohol consumption, overeating, smoking, and physical inactivity.211

In one review of six prospective cohort studies, there was a significant association between hospitalization and anxiety.212 Further research is needed to determine if anxiety can help predict a cardiac event or hospitalization in those with chronic heart failure. Research on meditation (focused mental practices that improve concentration and mindfulness) suggests a benefit on cardiovascular risk, especially in addition to tradition treatments.213 However, randomized trials with large cohorts are needed to clarify the role this method of stress reduction plays in cardiac health.