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UTube Presentations available:
Nutritional Approaches to Heart Failure and Post-Heart Attack Outcome
Bioenergetic Support in Heart Failure and Coronary Insufficiency
Integrative Approach to Heart Failure
For additional information please review a) the heartfixer.com website, b) our YouTube heart failure-related presentations (Drug and Device Approaches, Nutritional Approaches to Heart Failure and Post-MI Outcome, and Bioenergetic Support for the Tired Heat), c) Reverse Heart Disease Now by Drs. Roberts and Sinatra, and d) The Sinatra Solution by Dr. Stephen Sinatra.
Definition: Cardiac pump dysfunction, impairing blood flow to our internal organs, with or without symptoms (fatigue, weakness, and shortness of breath), of any cause.
Causes:
·
Loss of heart muscle due to one or more heart attacks (ischemic cardiomyopathy),
with or without additional reversible pump function impairment due to coronary
insufficiency.
·
Cardiac strain on the basis of overload pathophysiology:
A. Afterload strain due to severe hypertension or aortic stenosis (narrowed
aortic valve).
B. Preload strain due to a leaky aortic or mitral valve or to excessive blood
recirculation due to a cardiac shunt lesion (hole in the heart) or dialysis
access placement.
C. Overuse strain, due to an elevated heart rate (Atrial Fib) or marked anemia.
·
Cardiomyopathy, a loss of heart muscle cells or cellular dysfunction due to:
A. An auto-immune response to viral infection or any other form of prior myocyte
damage.
B. Toxins, such as mercury, cobalt, and cadmium.
C. Chemotherapy for malignancy.
·
Bioenergetic strain, the loss of co-factors required to generate biochemical
energy (to recycle AMP and ADP back to ATP) such as Co-Enzyme Q10, carnitine,
magnesium, taurine, and AMP precursors.
·
Multiple cause CHF (Congestive Heart Failure) – Irrespective of the cause, all
patients with CHF will experience bioenergetic insufficiency and a secondary
auto-immune attack against the heart muscle (myocardium).
Imaging: Cardiac catheterization, echo, or nuclear imaging, alone or in
combination, to grade pump dysfunction and quantitate secondary pulmonary
hypertension or valvular insufficiency.
Laboratory assessment:
·
BNP (B-Natriuretic peptide), a treatment responsive lab marker of CHF severity.
·
Kidney chemistries (many of our drug therapies for CHF strain kidney function).
·
EndoPAT Endothelial function testing (peripheral endothelial dysfunction
correlates with impaired myocardial bioenergetics).
·
Serum ferritin, to exclude iron overload (causes myocardial oxidative damage).
·
Markers of inflammatory and oxidative stress (Cleveland Heart and NutrEval
studies).
·
Sleep apnea assessment (not uncommon in our patients with CHF).
·
Provocative challenge testing to estimate soft tissue heavy metal burden.
·
Anabolic assessment (Testosterone in men and DHEA-s and IGF-1 in both genders).
Therapeutic Approach (at this point we have determined the cause(s) of your CHF,
graded its severity, and screened your for aggravating metabolic factors). If a
specific driving force has been identified, it will be addressed, in an effort
to prevent further damage. The following steps are or value irrespective of the
cause(s) of your CHF:
·
Bioenergetic support: Co-Enzyme Q10, carnitine, taurine, magnesium, and related
nutritional supports have been shown to improve pump function and reduce
symptoms, mortality, and hospitalization. Ribose assists with ATP energy
recycling, and arginine with endothelial tone. Nutritional testing will provide
us with specifics; listed below is a general nutritional guide:
¨Co-Enzyme
Q10 200-400 mg/day (aiming for a level
³
2.5).
¨Carnitor
330 mg tid or Carnitine 500 mg bid (tid is three times a day and bid is twice a
day).
¨Ribose
5 grams tid
¨Taurine
1000 mg bid
¨Magnesium
glycinate 100-200 mg bid
¨NMN
(Nicotinamide Mononucleotide) 1500 mg, Resveratrol 1000 mg daily, +/- Quercetin
500 mg daily to increase the NAD+/SIRT mitochondrial biogenesis/energy
generation pathway.
·
Fluid volume control: Loop diuretic therapy, furosemide or torsemide, every
morning or every other morning. If necessary, metolazone (zaroxylyn) can be
taken 30²
prior to the loop diuretic to enhance its effect. These agents predictably
waste potassium, magnesium, thiamine, and other B vitamins (we can monitor for
this and supplement accordingly).
·
Neuroendocrine blockade – Biochemical “whips” elaborated by the kidneys, adrenal
glands, and nervous system in a maladaptive attempt to increase cardiac
performance will progressively damage the heart (a “secondary insult”) and must
be blocked:
¨Spironolactone
blocks the receptor for aldosterone, an adrenal hormone that leads to myocardial
stiffness, magnesium and potassium loss, and salt and water retention by the
kidneys.
¨Angiotensin
Converting Enzyme Inhibitors (ACEI) block the generation in the circulation and
(quinapril and ramipril only) in the heart and vascular wall of angiotensin II,
a powerful vasoconstrictive, inflammatory, and free radical generating peptide,
concomitantly inhibiting the degradation of bradykinin, a beneficial,
endothelial supporting molecule.
¨Angiotensin
Receptor Blockers (ARBs) do not block the generation of angiotensin II, but
prevent it from acting on its receptor, thus negating its activity. ARBs are
used primarily when ACEI is not tolerated (on the basis of cough).
¨Cardioselective
Beta Blockade (metoprolol or carvedilol) blocks maladaptive overstimulation of
the heart and kidneys by the adrenal and autonomic nervous system hormone
adrenaline. Nebivolol directly blocks the generation of superoxide free radical
and can also be used in CHF.
¨EntrestoÒ
combines an ARB (valsartan) with Sacubitril, an agent that blunts degradation of
BNP. While we use BNP as an index of CHF severity, the heart generates this
molecule in an attempt to help itself. Increasing BNP expression with EntrestoÒ
thus improves CHF symptoms.
·
Afterload reduction – Hydralazine dilates arteries, decreasing the work the
heart must do to pump blood forward. Hydralazine, like Nebivolol and
Allopurinol, also also lowers superoxide free radical generation (superoxide
destroys nitric oxide and inhibits cardiac performance).
·
Endothelial support – Peripheral endothelial dysfunction (low EndoPAT score)
correlates with a low nitric oxide to superoxide ratio within the myocardium,
with consequent impaired contractile efficiency (less heart function per oxygen
molecule utilized). Arginine and co-factors to encourage its conversion in to
nitric oxide can rebalance this biochemistry.
¨Allopurinol
spares myocardial oxygen demand and blocks superoxide generation, concomitantly
improving endothelial function and protecting the kidneys (from uric acid toxicity and oxidative
stress).
·
Immune modulation – The immune system’s response to heart failure is overzealous
and maladaptive and must be attenuated without compromising overall immune
defense function.
¨ Pentoxifylline
blunts generation of TNF-alpha and the overblown Th1 immune response that
characterizes CHF and atherosclerosis, and has been shown to be effective in CHF
of any cause.
¨
Statins waste Co-Enzyme Q10 and by this mechanism are a negative, but they also
blunt intracellular free radical generation and down regulate the Th1 immune
response, a plus.
¨
Famotidine (pepcid) blocks the myocardial histamine receptor, which in CHF is up
regulated.
¨
Berberine lowers inflammation and improves functional status and outcome in CHF.
¨
Vitamin D, Co-Q10, fish oil, and other nutritionals also have immune modulating
benefits.
¨
Weight loss helps on multiple fronts and will attenuate maladaptive immune
stimulation.
¨
A compounded immune modulator is available for my personal patients.
·
Khavinson peptides bioregulators provides cardiac, vascular, and (specific to
other organs) growth factors and have used extensively in Russia and Eastern
Europe in the treatment of CHF.
· Ouabain (Stropanthus) improves contractile without increasing oxygen, and thus is of value in heart failure and coronary insufficiency. Ouabain assist with rate control in atrial fibrillation.
·
Rapamycin 3-6 mg every two weeks may be helpful in cardiomyopathic states
associated with diabesity and/or impaired energy generation.
· Device therapies utilize physics to improve cardiac biochemistry and function:
¨
Dual chamber pacing restores synchronicity to cardiac contraction in patients
with conduction delays, improving ejection fraction and cardiac performance.
¨
Implanted defibrillator placement provides a back stop with respect to severe
arrhythmia.
¨
EECP may improve functional status in some patients with CHF.
·
Botanical support:
¨
Hawthorne Berry 600 mg twice a day is a helpful add-on therapy (standard care in
Europe).
¨Terminalia
arjuna may help with CHF (commonly used in Asia).
James C. Roberts MD FACC FAARFM 12/23/23
The Basic Concept of Bioenergetic Support - Supplementation with Co-Enzyme Q10, Carnitine, Ribose, and related agents involved in the generation of human energy, or better stated, the conversion of chemical energy stored in food into the biochemical energy that fuels all useful chemical reactions carried out by the body. Bioenergetic Support is the "heart" of nutritional medicine. Rather than memorizing what to take and at what dose, it makes more sense to understand the role that each substance plays in human energy metabolism. For more information and dosing instruction you can review the Nutritional Approaches to Heart Failure and post-Heart Attack DVD or the Bioenergetic Support DVD, or read Reverse Heart Disease Now . For more information on this site click Bioenergetic Support.
Co-Enzyme Q10 and Carnitine Deficiency - Co-Q and Carnitine levels fall as the severity of heart disease rises.
Co-Enzyme Q10 Overview - Co-Enzyme Q10 is a fat-soluble vitamin critical to multiple aspects of our physiology.
Co-Enzyme Q10 in CHF - Several studies demonstrating benefit of Co-Q10 supplementation in CHF are presented.
Co-Enzyme Q10 in Coronary Insufficiency - This section abstracts studies demonstrating that coronary insufficiency is associated with CoQ10 deficiency, that CoQ10 works by improving the efficiency of energy metabolism, and that CoQ supplementation is therapeutic in coronary insufficiency, relieving symptoms and improving functional capacity
Co-Enzyme Q10 in Heart Attack - Clinical studies demonstrate that CoQ10 supplementation, with of without other antioxidants, improves outcome and reduces mortality following heart attack.
Co-Enzyme Q10 in Open Heart Surgery - CoQ10 supplementation improves outcome and decreases costs in open heart surgery.
Co-Enzyme Q10 and Statin Therapy - Statin therapy wastes CoQ10, causing cardiac dysfunction and myalgia that respond to CoQ10.
Carnitine Overview - Carnitine is CoQ10's right hand man, of value in all cardiac conditions associated with ATP deficiency.
Carnitine in Cardiomyopathy and CHF - Carnitine is critical to energy metabolism, the heart under strain is low in Carnitine, so it stands to reason that Carnitine supplementation would be of value in CHF and Cardiomyopathy. Let's take a look at a few of the studies:
Carnitine in Coronary Insufficiency - Carnitine prolongs aerobic metabolism, lessens symptoms, & improves functional capacity in CADz.
Carnitine in Heart Attack - This section reviews several studies demonstrating benefits of carnitine in acute heart attack.
Ribose in Energy Metabolism - Ribose accelerates the recovery of cellular ATP (energy) in the oxygen deprived or strained heart.
Ribose in CHF - Ribose improves diastolic function and quality of life in patients with congestive heart failure.
Ribose in Coronary Insufficiency - Ribose allows you to do more with less angina
Ribose in Open Heart Surgery - Ribose accelerates functional recovery following open heart surgery