A Supplement That Strengthens Your Heart and Lungs

One of the natural supplements gaining popularity over the past 20 years is creatine. It is known best for its use to boost athletic performance. It could be far more valuable for people with major heart and lung disease. Continue reading

Anthem Blue Cross Announces New Wireless Remote Monitoring Program to Help California Members with Congestive Heart Failure

Anthem Blue Cross today announced the launch of an innovative, wireless remote monitoring program to help members with congestive heart failure (CHF) to better monitor and manage this potentially fatal condition.

According to the Centers for Disease Control and Prevention, more than five million Americans have CHF. Increasing prevalence, hospitalizations, and deaths have made CHF a major chronic condition in the United States, with annual costs of nearly $40 billion.

Through this innovative program, Anthem Blue Cross is utilizing wireless remote monitoring technology to provide real-time information to help those with CHF  Continue reading

Natural Medicines in the Clinical Management of Heart Failure

T
THIS IS IS AN IN-DEPTH REVIEW SUITABLE FOR MEDICAL PRACTITIONERS
Heart failure can be a bit tricky. Early symptoms are often so subtle they go undetected. By the time symptoms are noticed, there can be significant cardiac damage. By the time they are diagnosed, many patients have already lost up to 50% of their cardiac function.12316 As a result, survival time after diagnosis of heart failure is relatively short…an average of 1.7 years for men and 3.2 years for women.12317

The sooner heart failure is detected, the better. Suspect heart failure in patients with poorly-controlled or long-standing hypertension, valvular disease, or coronary artery disease. An echocardiogram can give an early indication of heart failure even in patients who don’t have symptoms. The diagnosis can often be confirmed with further testing, such as an exercise test.12316

Heart failure develops with a snowball effect. Symptoms beget more symptoms. When the heart starts to fail, the body tries to compensate. As cardiac output decreases, the adrenergic system kicks in and norepinephrine levels increase. At first, the increased adrenergic stimulation helps maintain cardiac output. Over time the adrenergic stimulation starts to work against the heart. Norepinephrine increases arterial pressure. Eventually the heart must contract more forcefully to overcome increased arterial pressure. The increased norepinephrine also stimulates production of renin in the kidney. Renin is important in the conversion of angiotensinogen to angiotensin I. And angiotensin I is converted by angiotensin-converting enzyme (ACE) to angiotensin II. Angiotensin II further increases arterial pressure and causes structural changes in the heart. The structural changes are known as “cardiac remodeling.” Ultimately, these effects put additional stress on the heart, increase cardiac cell death, and cause disease progression.12318

Many of the treatments used for heart failure target these processes…and ultimately slow the snowball effect. The goal of treatment is to slow the progression of the disease.

Commonly Used Conventional and Natural Medicines for Heart Failure*
Renin-Angiotensin-Aldosterone System (RAAS) Blockers
Angiotensin-Converting Enzyme (ACE) Inhibitors
Conventional Medicines
Benazepril (Lotensin)
Captopril (Capoten)
Enalapril (Vasotec)
Fosinopril (Monopril)
Lisinopril (Zestril / Prinivil)
Moexipril (Univasc)
Perindopril (Aceon)
Quinapril (Accupril)
Ramipril (Altace)
Trandolapril (Mavik)
Natural Medicines
L-arginine
Pomegranate (Punica granatum)
Angiotensin II Receptor Blockers (ARBs)
Conventional Medicines
Candesartan (Atacand)
Eprosartan (Teveten)
Irbesartan (Avapro)
Losartan (Cozaar)
Olmesartan (Benicar)
Telmisartan (Micardis)
Valsartan (Diovan)
Aldosterone Blockers
Conventional Medicines
Spironolactone (Aldactone)
Adrenergic System Blockers
Beta-blockers
Conventional Medicines
Atenolol (Tenormin)
Bisoprolol (Zebeta)
Carvedilol (Coreg)
Metoprolol (Toprol XL)
Propranolol (Inderal)
Diuretics
Conventional Medicines
Eplerenone (Inspra)
Furosemide (Lasix)
Hydrochlorothiazide (Microzide)
Spironolactone (Aldactone)
Natural Medicines
Corn silk (Zea mays)
Dandelion (Taraxacum officinale)
Stinging nettle (Urtica dioica)
Cardiac Positive Inotropes
Cardiac Glycosides
Conventional Medicines
Digoxin (Lanoxin)
Natural Medicines
Digitalis (Digitalis purpurea)
Hawthorn (Crataegus monogyna)
Oleander (Nerium oleander)
Pheasant’s eye (Adonis vernalis)
Squill (Urginea indica)
Star of Bethlehem (Ornithogalum umbellatum)
Others
Natural Medicines
Carnitine
Creatine
Propionyl-L-carnitine
Terminalia (Terminalia arjuna)
Vasodilators
Conventional Medicines
Hydralazine (Apresoline)
Hydralazine + Isosorbide dinitrate (BiDil)
Isosorbide dinitrate (Isordil)
Miscellaneous
Natural Medicines
Coenzyme Q-10
L-arginine
Magnesium
Taurine
Thiamine (Vitamin B1)
*Note: Many natural products are tried for heart failure, but very few have reliable evidence that they work. Inclusion in this list does NOT imply that these products are effective for heart failure.

Only a few conventional treatments are actually proven to slow disease progression and improve survival. They fall into two categories: 1.) renin-angiotensin-aldosterone system (RAAS) blockers; and 2.) adrenergic system blockers.

To read more about heart failure guidelines see Pharmacist’s Letter / Prescriber’s Letter Detail-Document #180109.

Renin-Angiotensin-Aldosterone System (RAAS) Blockers return to top
The RAAS blockers include three classes of drugs:

  • Angiotensin-converting enzyme (ACE) inhibitors
  • Angiotensin II receptor blockers (ARBs)
  • Spironolactone and eplerenone (Inspra)

People used to think ACE inhibitors (e.g., Monopril, Vasotec, etc) worked because they cause vasodilation and decrease arterial pressure. We now know that ACE inhibitors do more. They block production of angiotensin II, and that helps prevent cardiac remodeling. Treatment with ACE inhibitors improves symptoms and can decrease death rate by up to 23%.12318

An angiotensin II receptor blocker (e.g., Atacand, Avapro, Cozaar, Diovan, etc) can be substituted for patients who can’t tolerate an ACE inhibitor. There’s growing evidence that these drugs also improve survival.12320

Spironolactone (Aldactone) is a potassium-sparing diuretic. It causes diuresis, but works in a unique way that also seems to interrupt one of the “snowball effects” of heart failure. Spironolactone blocks aldosterone. Aldosterone levels increase in patients with heart failure, which leads to fluid retention, fluid overload, and worsening of symptoms. Adding spironolactone to heart failure patients already on an ACE inhibitor and other diuretics can reduce symptoms and mortality by about 30%.12321

An alternative to spironolactone is the newer drug eplerenone (Inspra). It works like spironolactone, but is more selective for aldosterone receptors…and therefore causes fewer side effects.

To read more about eplerenone see Pharmacist’s Letter / Prescriber’s Letter Detail-Document #191104.

Practice Pearl
Watch for hyperkalemia in patients who get spironolactone or eplerenone…especially when they are combined with an ACE inhibitor, ARB, or another drug that increases potassium. Inappropriate monitoring of patients on spironolactone has been linked to increased hospitalizations and death due to hyperkalemia.12322

Several natural medicines are promoted and used for cardiovascular conditions such as heart failure. Some of these products affect the renin-angiotensin-aldosterone system.

L-arginine is one of the best known natural medicines used for cardiovascular disease. The most common explanation for its cardiovascular benefits has to do with L-arginine’s affect on nitric oxide. L-arginine is a substrate for the enzyme nitric oxide synthase (NOS). The enzyme converts L-arginine to nitric oxide. This leads to vasodilation, improved coronary endothelial function, and increased coronary blood flow.110,116,1362,1363,3330

In addition to increasing nitric oxide, there is some evidence that L-arginine decreases the activity of the angiotensin-converting enzyme (ACE).7820 Theoretically, this could have benefits in interrupting the snowball effect of congestive heart failure.

Despite these promising pharmacological effects, the clinical benefits of L-arginine are limited. When L-arginine is added to conventional treatment, heart failure patients seem to have improved kidney function and increase fluid elimination.3596 Some patients also have improved functional status, exercise tolerance, and quality of life, but these benefits have not been found consistently in clinical trials.3595,6028,7813,8014

L-arginine seems promising, but there’s not much known about it’s long-term benefits…or if L-arginine can improve ultimate outcomes. For now, don’t recommend it for most patients. But if patients decide to try it, don’t worry too much, L-arginine is usually safe for most patients. Advise patients who use L-arginine that high doses are usually needed… 6-20 grams per day. Explain that adding L-arginine might cause a decrease in blood pressure. This could lead to hypotension in some patients, especially if they are taking other antihypertensives.

Pomegranate (Punica granatum) doesn’t sound all that appetizing to many of us. But pomegranate juice is now becoming a popular healthy drink. Products like POM Wonderful are being promoted by the fact that pomegranate juice has lots of polyphenols that work as antioxidants. There are more of these healthy polyphenols in pomegranate juice than in green tea, orange juice, or red wine.

But the evidence for cardiovascular benefits in humans is still just ramping up. There is preliminary evidence that it can decrease angiotensin-converting enzyme (ACE) activity. Some evidence also suggests that drinking pomegranate juice 50 mL/day might help decrease blood pressure by about 5% in patients with hypertension.8310

Since pomegranate juice decreases ACE, there is potential for its use in heart failure. But so far this hasn’t been studied. If heart failure patients want to drink the juice, no problem. There’s no question that it’s a healthy drink. Just advise them not to rely on it for improved heart failure symptoms.

Question #1
ACE inhibitors
View brands containing:
L-arginine
Question #2
Which of the following drugs is L-arginine most likely to interact with? (HINT: click here to go to the L-arginine monograph; then scroll down to the Interactions with Drugs section)
View brands containing:
Pomegranate
Green tea
Orange juice
Red wine

Adrenergic System Blockers return to top
The second category of drugs includes those that target the adrenergic system, beta-blockers.

Beta-blockers are now considered essential in heart failure. We used to think beta-blockers would worsen heart failure, so clinicians weren’t using them. Now there’s proof that at least some beta-blockers (Coreg, Toprol XL, Zebeta) can save lives. Beta-blockers block the adrenergic system that revs up in patients with heart failure and can often lead to serious arrhythmias. Adding a beta-blocker can reduce mortality by up to 34%.12318

Most patients should be started on an ACE inhibitor, even when they are asymptomatic. Beta-blockers should be added for improved prevention of disease progression and improved survival benefits.12319 But don’t add beta-blockers in “decompensated” patients…those with pulmonary edema, etc. Beta-blockers can initially worsen these symptoms.

Question #3
Which of the following primarily affects the renin-angiotensin-aldosterone system?

Diuretics return to top
A lot of patients with heart failure need a diuretic to reduce fluid retention…furosemide (Lasix), hydrochlorothiazide (Microzide), etc.

Some patients also turn to natural medicines to help with fluid retention. Several natural medicines are reported to have diuretic effects. Dandelion (Taraxacum officinale) is one of the most common herbal diuretics recommended for edema. Others include corn silk (Zea mays) and stinging nettle (Urtica dioica).

While tradition suggests that these herbs have diuretic properties, there is no reliable evidence that they reduce edema in patients with heart failure. Advise patients not to use them.

Thiamine and magnesium are sometimes recommended for heart failure patients who take conventional diuretics. That’s because diuretics can deplete levels of these nutrients.

Thiamine (vitamin B1) deficiency can worsen heart failure.1284,1285,1286,10507 This deficiency is most common in the elderly.10506 Elderly patients taking loop diuretics who continue to have symptoms despite adequate treatment might benefit from thiamine supplements.1284,1286,10508 Consider adding thiamine in these patients… 50-200 mg per day.

Magnesium deficiency is particularly concerning in heart failure patients who are also taking digoxin. Low magnesium levels can increase the risk of digoxin toxicity.9613,9614 Consider checking magnesium levels in elderly patients who have been taking diuretics chronically. Also, make sure magnesium levels are checked in heart failure patients who have had arrhythmias…low magnesium levels could be a contributing factor. Add a magnesium supplement for patients who are deficient… 20-130 mg daily.6430

View brands containing:
Dandelion
Corn silk
Stinging nettle
Thiamine
Magnesium
Question #4
Thiamine is sometimes recommended for heart failure patients because:

Cardiac Positive Inotropes return to top
Digoxin (Lanoxin) is a good example of a natural medicine that is no longer an “alternative medicine.” Digoxin is a cardiac glycoside derived from the Digitalis purpurea plant…also known as foxglove. Digoxin can increase intracellular calcium in cardiac cells. This increases contractility and cardiac output. Digoxin is typically added as symptoms progress, but it does not reduce mortality.

Practice Pearl
Help make sure patients who get digoxin get an appropriate dose. There is some concern that doses that are too high might INCREASE mortality in women. Usually doses of 0.125 mg/day are adequate. Serum levels should be maintained between 0.5-1.0 ng/mL.

To read more about gender difference related to digoxin see Pharmacist’s Letter / Prescriber’s Letter Detail-Document #181203.

Several other plants contain cardiac glycosides…oleander, pheasant’s eye, squill, star of Bethlehem and others. Anecdotally, they may help,15331,15332 but none of these have been studied in clinical trials…and none are appropriate for self-treatment of heart failure. Due to the lack of stringent manufacturing standards, these herbal products would likely contain an inconsistent amount of the active cardiac glycosides and produce inconsistent results. Fortunately, formulations of these plants are almost never found in supplements sold on store shelves.

Carnitine seems to have a positive inotropic effect, but it’s much different than the cardiac glycosides. Carnitine is an amino acid-like cofactor in skeletal muscles and the heart. It is involved in generating energy within the cells. Carnitine helps move long-chain fatty acids into mitochondria where they are converted to energy.

Patients with heart failure and other cardiovascular conditions seem to have decreased levels of this cofactor in heart tissue.1572 Some researchers think carnitine levels might be a disease marker for heart failure…lower levels usually indicate more severe heart failure.12323

The clinical evidence looks promising. Carnitine seems to improve symptoms, ejection fraction, and exercise tolerance. Carnitine seems to increase ejection fraction by up to 14% and exercise tolerance by as much as 21% in some patients.1575,1582,1583,3626 In some patients carnitine also seems to decrease cardiac remodeling.1575

There’s even some preliminary evidence that carnitine might slow the disease process and improve survival.3625

The body of evidence supporting carnitine is growing, but it’s still fairly preliminary. There’s not enough support to recommend it across the board. But it might be worth a try in patients who are not improving on standard therapy. Some clinicians are using 1.5-2 grams, usually divided and given 2-3 times daily. Two different formulations are being used…L-carnitine and propionyl-L-carnitine. Both have been used in studies, but there’s some speculation that propionyl-L-carnitine might deliver carnitine to the cells more efficiently.1439

Tell patients who take carnitine that it might take 2 weeks to a month for significant symptom improvement. Maximum improvement can take up to 6 months.

Creatine is a very popular sports supplement. Athletes often use it to bulk up or improve athletic performance. Now some people are using it in patients with heart failure…to improve exercise tolerance. There’s some evidence that it can help improve strength and endurance in heart failure patients.4562,4563

But there are safety concerns with creatine and some unanswered questions. Creatine is probably not a good choice for patients with heart failure. Taking creatine requires drinking extra fluids to prevent dehydration and cramping. Fluid overload is a problem with heart failure patients. So increasing fluid intake is usually avoided. Also, people with heart failure are prone to renal disease. There is some concern that creatine might contribute to worsening renal function.184,2118 Advise heart failure patients to avoid creatine.

Hawthorn (Crataegus monogyna) is an herb with a long history of use in Europe. Many clinicians in Europe consider hawthorn a preferred alternative to digoxin. Hawthorn seems to have many of the same benefits as digoxin. It increases cardiac output and exercise tolerance and reduces symptoms. Specific extracts of hawthorn (Crataegutt and Faros 300) seem to be helpful in the early stages of heart failure.8279,8280,10144,11449 But it might not offer much benefit in patients with more severe disease.

Hawthorn contains constituents that increase heart contraction and coronary blood flow, and cause vasodilation.406,10144,11450 Some people claim that hawthorn is actually better than digoxin. They say it’s less likely to induce arrhythmias, safer in renal dysfunction, and better tolerated overall. But there’s no solid evidence this is true.

You can think of hawthorn as a “milder digoxin.” It’s not appropriate for self-treatment. If you consider using it for your patients, hawthorn should only be considered early on in the disease, when symptoms aren’t too severe and BEFORE patients require digoxin. There’s no benefit to adding it in patients already taking digoxin. Doses of hawthorn extract are typically 200-500 mg three times daily. Keep in mind that it can take 6-8 weeks before there is maximal benefit. Tell patients that as symptoms get worse, they’ll eventually need to be switched to digoxin.

You might see patients trying another herb for heart failure…terminalia (Terminalia arjuna), also known as arjuna. There is some evidence it can improve heart function and decrease symptoms.2504 Some researchers think it might increase heart rate and cardiac output. Terminalia looks promising, but don’t recommend it yet. More evidence is needed about long-term safety and effectiveness.

THANKS TO THE NATURAL DATABASE.COM FOR THIS INFORMATION

View brands containing:
Digitalis
View brands containing:
Oleander
Pheasant’s eye
Squill
Star Of Bethlehem
Carnitine
Question #5
Which of the following is most similar to digoxin?
View brands containing:
L-carnitine
Propionyl-L-carnitine
Question #6
Which of the following is TRUE regarding carnitine?
View brands containing:
Creatine
Hawthorn
Question #7
Which of the following is TRUE about creatine?
View brands containing:
Terminalia

Vasodilators return to top
The vasodilators hydralazine (Apresoline) and isosorbide dinitrate (Isordil) were commonly used for heart failure many years ago…before we started using ACE inhibitors and beta-blockers. Now they are making a comeback…especially for African Americans. There are concerns that ACE inhibitors and beta-blockers don’t work as well for blacks as for whites. Black patients with moderate to severe heart failure, who get hydralazine plus isosorbide dinitrate (BiDil) along with standard treatment, seem to have improved survival.

To read more about using hydralazine plus isosorbide dinitrate for heart failure see Pharmacist’s Letter / Prescriber’s Letter Detail-Document #210105.

Question #8
A heart failure patient who is taking digoxin wants to use hawthorn. What should you tell him?

Miscellaneous return to top
Coenzyme Q-10 is one of the most talked about supplements used for heart failure and many other conditions. The theory about how it works makes some sense. Coenzyme Q-10 is a vitamin-like cofactor found mostly in cellular structures called mitochondria. Coenzyme Q-10 has an important role in the biochemical process that results in production of adenosine triphosphate (ATP). ATP is used by cells as a fuel to produce energy. Inhibition of ATP production can cause cell death and tissue damage. Coenzyme Q-10 levels are low in some patients with heart failure. Researchers think that replacing coenzyme Q-10 might improve cellular energy production and prevent cell death in people with heart failure. Coenzyme Q-10 also has antioxidant effects and can prevent oxidative damage.12321

There is a lot of controversy about the effectiveness of coenzyme Q-10. Many cardiologists are skeptical. The reason is that some research findings are inconsistent. Early clinical studies are mostly positive. But recent studies are more negative. Most studies show that coenzyme Q-10 does NOT improve ejection fraction or exercise tolerance.5090,6037,6038

But coenzyme Q-10 does seem to consistently improve SYMPTOMS…dyspnea, edema, etc. There’s even some evidence that coenzyme Q-10 can improve quality of life and reduce hospital admission rates.6407,6408,6409,8909,12170

There isn’t enough strong evidence to recommend coenzyme Q-10 for all heart failure patients. But coenzyme Q-10 might be worth a try in some patients with heart failure, especially those with persistent symptoms. Consider adding it in patients who still have symptoms despite adequate treatment with conventional meds. Most clinicians use 100-200 mg, divided, and given 2-3 times daily.

Practice Pearl
Be careful in patients taking warfarin (Coumadin). Coenzyme Q-10 is chemically similar to vitamin K and might decrease the effectiveness of warfarin.2128,6048,6199

There’s a good chance patients will ask about taurine. Taurine is an amino acid that is actually increased in the left ventricle of heart failure patients.9900 Researchers are finding that giving taurine supplements can help some patients. Taurine can improve cardiac output and decrease symptoms of heart failure when used for up to a year.5248,5271,5306,8221

Researchers are still trying to figure out exactly how taurine works. But it seems to help regulate calcium movement in cardiac muscle cells. There is also evidence that it might have antioxidant effects, lower adrenergic stimulation, and decrease blood pressure.3467,8219,8221,8222 Each of these effects could help heart failure patients.

Most studies have been small and preliminary. As more evidence develops, taurine may become an important option for heart failure patients. But for now, there isn’t enough evidence to recommend it.

View brands containing:
Coenzyme Q-10
Question #9
Which of the following is most appropriate for a heart failure patient who continues to have symptoms despite adequate treatment with conventional medicines?
Question #10
Which of the following has preliminary evidence suggesting that it might improve survival in patients with heart failure?
View brands containing:
Taurine

The Bottom Line return to top
The thought of using natural medicines for heart failure makes some clinicians cringe. Heart failure is a serious condition. It requires serious, proven therapies.

It’s true; natural medicines are NOT appropriate as primary treatment of heart failure. But some natural medicines may end up with a place in therapy…as adjunctive treatments.

There are a surprising number of beneficial natural medicines for heart failure. Several could be worth considering as add-on therapy in select patients…coenzyme Q-10, carnitine, and L-arginine.

There is growing evidence that some natural medicines may have a real role in therapy. But they are no substitute for standard treatments. Make sure patients are not attempting to self-treat heart failure. Ensure they are getting treatments proven to improve survival…ACE inhibitors, beta-blockers, etc. Patients adding on natural meds as adjunctive treatment should be monitored closely for signs of improvement or deterioration. These patients should also be watched for potential interactions.

Recommendation Chart for Natural Medicines Used for Heart Failure *
Safety/Effective Likely
Safe
Possibly
Safe
Insufficient
Evidence
Possibly
Unsafe
Likely
Unsafe
Unsafe
Effective
Magnesium
(for deficiency)
Thiamine
(for deficiency)
Likely
Effective
Digitalis
Possibly
Effective
Coenzyme Q-10
L-arginine
L-carnitine
Propionyl-L-carnitine
Hawthorn
Taurine
Terminalia
Creatine
(but not advised in CHF)
Insufficient
Evidence
Corn silk
Dandelion
Pomegranate
Stinging nettle
Oleander
Pheasant’s eye
Squill
Star Of Bethlehem
Possibly
Ineffective
Likely
Ineffective
Ineffective
KEY:
Consider recommending this product.
Don’t recommend using this product.
Recommend against using this product.
* These proposed recommendations are based solely on the Safety and Effectiveness Ratings contained in Natural Medicines Comprehensive Database. This assumes use of high-quality, uncontaminated products and the use of typical doses. Keep in mind that some products are never appropriate for some patients due to concomitant disease states, potential drug interactions, or other clinical factors. Use your clinical judgment before recommending any product.
References return to top
110 Lerman A, Burnett JC Jr, Higano ST, et al. Long-term L-arginine improves small-vessel coronary endothelial function in humans. Circulation 1998;97:2123-8.
116 Adams MR, McCredie R, Jessup W, et al. Oral L-arginine improves endothelium-dependent dilatation and reduces monocyte adhesion to endothelial cells in young men with coronary artery disease. Atherosclerosis 1997;129:261-9.
184 Koshy KM, Griswold E, Schneeberger EE. Interstitial nephritis in a patient taking creatine. N Engl J Med 1999;340:814-5.
406 Upton R, ed. Hawthorn Leaf with Flower: Analytical, quality control, and therapeutic monograph. Santa Cruz, CA: American Herbal Pharmacopoeia 1999:1-29.
1284 Shimon I, Almog S, Vered Z, et al. Improved left ventricular function after thiamine supplementation in patients with congestive heart failure receiving long-term furosemide therapy. Am J Med 1995;98:485-90.
1285 Pfitzenmeyer P, Guilland JC, d’Athis P, et al. Thiamine status of elderly patients with cardiac failure including the effects of supplementattion. Int J Vitam Nutr Res 1994;64:113-8.
1286 Seligmann H, Halkin H, Rauchfleisch S, et al. Thiamine deficiency in patients with congestive heart failure receiving long-term furosemide therapy: a pilot study. Am J Med 1991;91:151-5.
1362 Creager MA, Gallagher SJ, Girerd XJ, et al. L-arginine improves endothelium-dependent vasodilation in hypercholesterolemic humans. J Clin Invest 1992;90:1248-53.
1363 Clarkson P, Adams MR, Powe AJ, et al. Oral L-arginine improves endothelium-dependent dilation in hypercholesterolemic young adults. J Clin Invest 1996;97:1989-94.
1439 Siliprandi N, Di Lisa F, Menabo R. Propionyl-L-carnitine: biochemical significance and possible role in cardiac metabolism. Cardiovasc Drugs Ther 1991;5 Suppl 1:11-5.
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1575 Anand I, Chandrashekhan Y, De Giuli F, et al. Acute and chronic effects of propionyl-L-carnitine on the hemodynamics, exercise capacity, and hormones in patients with congestive heart failure. Cardiovasc Drugs Ther 1998;12:291-9.
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2118 Pritchard NR, Kalra PA. Renal dysfunction accompanying oral creatine supplements. Lancet 1998;351:1252-3.
2128 Spigset O. Reduced effect of warfarin caused by ubidecarenone. Lancet 1994;334:1372-3.
2504 Bharani A, Ganguly A, Bhargava KD. Salutary effect of Terminalia Arjuna in patients with severe refractory heart failure. Int J Cardiol 1995;49:191-9.
3330 Tenebaum A, Fisman EZ, Motro M. L-arginine: Rediscovery in progress. Cardiology 1998;90:153-5.
3467 Niittynen L, Nurminen ML, Korpela R, et al. Role of arginine, taurine, and homocysteine in cardiovascular diseases. Ann Med 1999;31:318-26.
3595 Rector TS, Bank AJ, Mullen KA, et al. Randomized, double-blind, placebo-controlled study of supplemental oral L-arginine in patients with heart failure. Circulation 1996;93:2135-41.
3596 Watanabe G, Tomiyama H, Doba N. Effects of oral administration of L-arginine on renal function in patients with heart failure. J Hypertens 2000;18:229-34.
3625 Rizos I. Three-year survival of patients with heart failure caused by dilated cardiomyopathy and L-carnitine administration. Am Heart J 2000;139:S120-3.
3626 Ghidini O, Azzurro M, Vita G, Sartori G. Evaluation of the therapeutic efficacy of L-carnitine in congestive heart failure. Int J Clin Pharmacol Ther Toxicol 1988;26:217-20.
4562 Andrews R, Greenhaff P, Curtis S, et al. The effect of dietary creatine supplementation on skeletal muscle metabolism in congestive heart failure. Eur Heart J 1998;19:617-22.
4563 Gordon A, Hultman E, Kaijser L, et al. Creatine supplementation in chronic heart failure increases skeletal muscle creatine phosphate and muscle performance. Cardiovasc Res 1995;30:413-8.
5090 Khatta M, Alexander BS, Krichten CM, et al. The effect of coenzyme Q10 in patients with congestive heart failure. Ann Intern Med 2000;132:636-40.
5248 Azuma J, Sawamura A, Awata N. Usefulness of taurine in chronic congestive heart failure andits prospective application. Jpn Circ J 1992;56:95-9.
5271 Azuma J, Sawamura A, Awata N, et al. Therapeutic effect of taurine in congestive heart failure: a double-blind crossover trial. Clin Cardiol 1985;8:276-82.
5306 Azuma J, Hasegawa H, Sawamura A, et al. Therapy of congestive heart failure with orally administered taurine. Clin Ther 1983;5:398-408.
6028 Hambrecht R, Hilbrich L, Erbs S, et al. Correction of endothelial dysfunction in chronic heart failure: additional effects of exercise training and oral L-arginine supplementation. J Am Coll Cardiol 2000;35:706-13.
6037 Watson PS, Scalia GM, Galbraith A, et al. Lack of effect of coenzyme Q on left ventricular function in patients with congestive heart failure. J Am Coll Cardiol 1999;33:1549-52.
6038 Permanetter B, Rossy W, Klein G, et al. Ubiquinone (coenzyme Q10) in the long-term treatment of idiopathic dilated cardiomyopathy. Eur Heart J 1992;13:1528-33.
6048 Heck AM, DeWitt BA, Lukes AL. Potential interactions between alternative therapies and warfarin. Am J Health Syst Pharm 2000;57:1221-7.
6199 Landbo C, Almdal TP. [Interaction between warfarin and coenzyme Q10]. [Article in Danish]. Ugeskr Laeger 1998;160:3226-7.
6407 Morisco C, Trimarco B, Condorelli M. Effect of coenzyme Q10 therapy in patients with congestive heart failure: A long-term, multicenter, randomized study. Clin Investig 1993;71:S134-6.
6408 Hofman-Bang C, Rehnqvist N, Swedberg K, et al. Coenzyme Q10 as an adjunctive treatment of congestive heart failure. J Card Fail 1995;1:101-7.
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Imaging Techniques Can Identify Plaques Likely to Cause Heart Attacks

NEW YORK –  Imaging techniques can help identify the types of vulnerable plaque that are most likely to cause adverse cardiac events before they occur, say researchers.

This finding comes from a clinical trial called Providing Regional Observations to Study Predictors of Events in the Coronary Tree (PROSPECT), which is the first prospective natural history study of atherosclerosis using multi-modality imaging to characterize the coronary tree.

A presentation on the study was made at the 21st annual Transcatheter Cardiovascular Therapeutics (TCT) scientific symposium, sponsored by the Cardiovascular Research Foundation (CRF).

“As a result of the PROSPECT trial, we are closer to being able to predict-and therefore prevent – sudden, unexpected adverse cardiac events,” said principal investigator Dr. Gregg W. Stone, immediate past chairman of CRF, professor of medicine at Columbia University Hospital and Director of Cardiovascular Research and Education at the Center for Interventional Vascular Therapy at NewYork-Presbyterian Hospital/Columbia University Medical Center.

During the multi-centre trial, 700 patients with acute coronary syndromes (ACS) were studied using three-vessel multimodality intra-coronary imaging-angiography, intravascular ultrasound (IVUS), and virtual histology.

The purpose was to quantify the clinical event rate due to atherosclerotic progression, and to identify those lesions that place patients at risk for unexpected adverse cardiovascular events-sudden death, cardiac arrest, heart attacks and unstable or progressive angina.

The study revealed that most untreated plaques that cause unexpected heart attacks are not mild lesions, as previously thought, but actually have a large plaque burden and a small lumen area. These are characteristics that were invisible to the coronary angiogram but easily identifiable by IVUS.

Only about half of new cardiac events due to non-culprit lesions exemplified the classic notion of vulnerable plaque (rapid lesion progression of non flow limiting lesions), while half were attributable to unrecognized and untreated severe disease with minimal change over time.

Perhaps most importantly, for the first time it was demonstrated that characterization of the underlying plaque composition (with virtual histology) was able to significantly improve the ability to predict future adverse events beyond other more standard imaging techniques.

“These results mean that using a combination of imaging modalities, including IVUS to identify lesions with a large plaque burden and/or small lumen area, and virtual histology to identify a large necrotic core without a visible cap (a thin cap fibroatheroma) identifies the lesions that are at especially high risk of causing future adverse cardiovascular events,” Dr. Stone said.

Introducing – CoQ10

Other Names: Coenzyme Q10, Co Q10, Ubiquinone, Vitamin Q

CoQ10 is a naturally-occuring compound found in every cell in the body. CoQ10’s alternate name, ubiquinone, comes from the word ubiquitous, which means “found everywhere.”

CoQ10 plays a key role in producing energy in the mitochondria, the part of a cell responsible for the production of energy in the form of ATP.

Why People Use CoQ10

  • Heart failure
  • Cardiomyopathy
  • Heart Attack Prevention and Recovery
  • High Blood Pressure
  • Diabetes
  • Gum Disease
  • Kidney Failure
  • Migraine
  • Counteract Prescription Drug Effects
  • Parkinson’s disease
  • Weight loss

What is the Evidence For CoQ10?

  • Heart failure
    People with heart failure have been found to have lower levels of CoQ10 in heart muscle cells. Double-blind research suggests that CoQ10 may reduce symptoms related to heart failure, such as shortness of breath, difficulty sleeping, and swelling. CoQ10 is thought to increase energy production in the heart muscle, increasing the strength of the pumping action. Recent human studies, however, haven’t supported this.

In one study, 641 people with congestive heart failure were randomized to receive either CoQ10 (2 mg per kg body weight) or a placebo plus standard treatment. People who took the CoQ10 had a significant reduction in symptom severity and fewer hospitalizations.

In another study, 32 patients with end-stage heart failure awaiting heart transplantation received either 60 mg of CoQ10 or a placebo for 3 months. Patients who took the CoQ10 experienced a significant improvement in functional status, clinical symptoms, and quality of life, however there were no changes in echocardiogram (heart ultrasound) or in objective markers.

A study randomized 55 patients with congestive heart failure to receive either 200 mg per day of CoQ10 or a placebo in addition to standard treatment. Although serum levels of CoQ10 increased in patients receiving CoQ10, CoQ10 didn’t affect ejection fraction, peak oxygen consumption, or exercise duration.

A longer-term study investigated the use of 100 mg of CoQ10 or a placebo in addition to standard treatment in 79 patients with stable chronic congestive heart failure. The results indicated that CoQ10 only slightly improved maximal exercise capacity and quality of life compared with the placebo.

  • Cardiomyopathy

Several small trials have found CoQ10 may be helpful for certain types of cardiomyopathy.

  • Parkinson’s disease

Lower levels of CoQ10 have also been observed in people with Parkinson’s disease. Preliminary research has found that increasing CoQ10 may increase levels of the neurotransmitter dopamine, which is thought to be lowered in people with Parkinson’s disease. It has also been suggested that CoQ10 might protect brain cells from damage by free radicals.

A small, randomized controlled trial examined the use of 360 mg CoQ10 or a placebo in 28 treated and stable Parkinson’s disease patients. After 4 weeks, CoQ10 provided a mild but significant significant mild improvement in early Parkinson‘s symptoms and significantly improved performance in visual function.

A larger 16 month trial funded by the National Institutes of Health explored the use of CoQ10 (300, 600 or 1200 mg/day) or a placebo in 80 patients with early stage Parkinson’s disease. The results suggested that CoQ10, especially at the 1200 mg per day dose, had a significant reduction in disability compared to those who took a placebo.

  • CoQ10 and Statin Drugs

Some research suggests that statin drugs, or HMG-CoA reductase inhibitors, a class of drugs used to lower cholesterol, may interfere with the body’s production of CoQ10. However, research on the use of CoQ10 supplements in people taking statins is still inconclusive, and it is not routinely recommended in combination with statin therapy.

  • Diabetes
    In a 12-week randomized controlled trial, 74 people with type 2 diabetes were randomized to receive either 100 mg CoQ10 twice daily, 200 mg per day of fenofibrate (a lipid regulating drug), both or neither for 12 weeks. CoQ10 supplementation significantly improved blood pressure and glycemic control. However, two studies found that CoQ10 supplementation failed to find any effect on glycemic control.
  • Gum disease
    A small study looked at the topical application of CoQ10 to the periodontal pocket. Ten male periodontitis patients with 30 periodontal pockets were selected. During the first 3 weeks, the patients applied topical CoQ10. There was significant improvement in symptoms.

Dosage

A typical CoQ10 dosage is 30 to 90 mg per day, taken in divided doses, but the recommended amount can be as high as 200 mg per day.

CoQ10 is fat-soluble, so it is better absorbed when taken with a meal that contains oil or fat.

The clinical effect is not immediate and may take up to eight weeks.

Safety

Consult your doctor before trying CoQ10, especially if you have heart disease, kidney failure, or cancer.

Side effects of CoQ10 may include diarrhea and rash.

CoQ10 is used in combination with standard treatment, not to replace it.

CoQ10 may lower blood sugar levels, so people with diabetes should not use CoQ10 unless under a doctor’s supervision. CoQ10 may also lower blood pressure.

The safety of Co q10 in pregnant or nursing women or children has not been established.

PLEASE SEE THE POST ON “POLICOSANOL” FOR LOWERING CHOLESTEROL

 

Resynchronization Cuts Down Risk of Heart Failures

CHICAGO A therapy called cardiac ‘resynchronization’ reduced risk of heart failures by 41 percent, says an international study.

“This shows, for the first time, that the onset of heart failure symptoms and hospitalization for heart failure can be delayed with pacing therapy,” said David Wilber, director of the Cardiovascular Institute at Loyola University (Chicago) Stritch School of Medicine.

Cardiac resynchronization therapy (CRT) is an innovative new therapy that can relieve congestive heart failure (CHF) symptoms, by improving the coordination of its contractions.

It is done with the help of electrical impulses delivered by a device implanted in the upper chest, that help synchronize contractions of the left ventricle, the heart’s main pumping chamber.

The study included 1,820 patients from 110 centers in the US, Canada and Europe. All patients in the trial had been diagnosed with early stage, mild heart failure (Class 1 and Class 2 on the New York Heart Association classification system), according to a Loyola release.

For instance, Loyola heart failure patient Rosemary Jakubowski of Elmwood Park said before she received cardiac resynchronization, she had experienced significant fatigue. “I always had that dragging feeling,” she said.

Since receiving resynchronization, Jakubowski has been taking kickboxing and swim aerobics classes, without fatigue. “I’m 100 percent better — complete satisfaction,” she said. “It’s like I’m a new person.”

The Food and Drug Administration has approved cardiac resynchronization for patients with Class 3 (moderate) and Class 4 (severe) heart failure. Such patients experience marked limitations in physical activity or are unable to do any physical activity at all without discomfort.

“With this study, we have shown that certain patients with early-stage, mild heart failure also can benefit from cardiac resynchronization,” Wilber said.

These findings were published in the New England Journal of Medicine.