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Integrative Approach to Heart Failure

For additional information please review:
(a) Our four-hour DVD presentation on drug, nutritional, and device approaches to heart failure (Drug and Non-Drug Approaches to Heart Failure and Coronary Insufficiency)*.
(b) Our Bioenergetic Support for the Tired Heart Presentation*
(c) Reverse Heart Disease Now by Drs. Roberts and Sinatra, and The Sinatra Solution by Dr. Stephen Sinatra.
*Click Upcoming Lectures to view the above described presentations

Definition of Heart Failure: Cardiac pump dysfunction, impairing blood flow to our internal organs, with or without symptoms (fatigue, weakness, and shortness of breath), of any cause.

Causes of Congestive Heart Failure (CHF):

· Loss of heart muscle due to one or more heart attacks (ischemic cardiomyopathy), with or without additional transient impairment of pump function due to coronary insufficiency.

· Cardiac strain on the basis of overload pathophysiology:
A. Afterload strain due to sever 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 marked anemia or adrenaline (catecholamine) excess.

· 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 ADP back to ATP) such as Co-Enzyme Q10, carnitine, magnesium, taurine, and ADP precursors.

· Multiple cause CHF – Irrespective of the cause, all patients with CHF will experience bioenergetic insufficiency and a secondary auto-immune attack against the 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)..
· Endothelial function testing (peripheral endothelial dysfunction correlates with impaired myocardial bioenergetics and ineffective oxygen utilization)
· Serum ferritin, to exclude iron overload.
· Markers of inflammatory and oxidative stress (Boston Heart and NutrEval studies).
· Sleep apnea assessment (not uncommon in our patients with CHF).
· Provocative challenge testing to estimate 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, we will address it, 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, 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. While 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

· 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, which must to monitored 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 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) in the heart and vascular wall of angiotensin II, a powerful vasoconstrictive, inflammatory, and free radical generating peptide.
¨Cardioselective Beta Blockade (metoprolol or carvedilol) blocks maladaptive overstimulation of the heart and kidneys by the adrenal and autonomic nervous system hormone adrenaline.

· 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).
¨Allopurinol spares myocardial oxygen and blocks the generation of superoxide, while concomitantly protecting the kidneys.
¨Arginine and co-factors to encourage its conversion in to nitric oxide.

· 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.
¨ 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.

· 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:
A. Hawthorne Berry 600 mg twice a day is a helpful add-on therapy (standard care in Europe).
B. Terminalia arjuna can also be used (commonly used in Asia).

James C. Roberts MD FACC FAARFM
1/29/18