Micronutrients in Chronic Heart Failure

Relationship between BMI and prognosis of chronic heart failure outpatients in Vietnam: a single-center study

Background

Insufficient data exists regarding the relationship between body mass index (BMI) and the prognosis of chronic heart failure (CHF) specifically within low- and middle-income Asian countries. The objective of this study was to evaluate the impact of BMI on adverse outcomes of ambulatory patients with CHF in Vietnam.

Methods

Between 2018 and 2020, we prospectively enrolled consecutive outpatients with clinically stable CHF in an observational cohort, single-center study. The participants were stratified according to Asian-specific BMI thresholds. The relationships between BMI and adverse outcomes (all-cause death and all-cause hospitalization) were analyzed by Kaplan-Meier survival curves and Cox proportional-hazards model.

Results

Among 320 participants (age 63.5 ± 13.3 years, 57.9% male), the median BMI was 21.4 kg/m2 (IQR 19.5-23.6), and 10.9% were underweight (BMI <18.50 kg/m2). Over a median follow-up time of 32 months, the cumulative incidence of all-cause mortality and hospitalization were 5.6% and 19.1%, respectively. After multivariable adjustment, underweight patients had a significantly higher risk of all-cause mortality than patients with normal BMI (adjusted hazard ratios = 3.03 [95% CI: 1.07-8.55]). Lower BMI remained significantly associated with a worse prognosis when analyzed as a continuous variable (adjusted hazard ratios = 1.27 [95% CI: 1.03-1.55] per 1 kg/m2 decrease for all-cause mortality). However, BMI was not found to be significantly associated with the risk of all-cause hospitalization (p > 0.05).

Conclusion

In ambulatory patients with CHF in Vietnam, lower BMI, especially underweight status (BMI < 18.5 kg/m2), was associated with a higher risk of all-cause mortality. These findings suggest that BMI should be considered for use in risk classification, and underweight patients should be managed by a team consisting of cardiologists, nutritionists, and geriatricians.

Interconnection between Cardiac Cachexia and Heart Failure—Protective Role of Cardiac Obesity

Cachexia may be caused by congestive heart failure, and it is then called cardiac cachexia, which leads to increased morbidity and mortality. Cardiac cachexia also worsens skeletal muscle degradation. Cardiac cachexia is the loss of edema-free muscle mass with or without affecting fat tissue. It is mainly caused by a loss of balance between protein synthesis and degradation, or it may result from intestinal malabsorption. The loss of balance in protein synthesis and degradation may be the consequence of altered endocrine mediators such as insulin, insulin-like growth factor 1, leptin, ghrelin, melanocortin, growth hormone and neuropeptide Y. In contrast to many other health problems, fat accumulation in the heart is protective in this condition. Fat in the heart can be divided into epicardial, myocardial and cardiac steatosis. In this review, we describe and discuss these topics, pointing out the interconnection between heart failure and cardiac cachexia and the protective role of cardiac obesity. We also set the basis for possible screening methods that may allow for a timely diagnosis of cardiac cachexia, since there is still no cure for this condition. Several therapeutic procedures are discussed including exercise, nutritional proposals, myostatin antibodies, ghrelin, anabolic steroids, anti-inflammatory substances, beta-adrenergic agonists, medroxyprogesterone acetate, megestrol acetate, cannabinoids, statins, thalidomide, proteasome inhibitors and pentoxifylline. However, to this date, there is no cure for cachexia.

Lack of Association between Inadequate Micronutrient Intake and Prognosis in Outpatients with Heart Failure

Inadequate nutrient intake can lead to worse outcomes in patients with heart failure (HF). This prospective cohort study aimed to assess the prevalence of inadequate micronutrient intake and their association with prognosis in 121 adult and elderly outpatients with HF. Habitual micronutrient intake was evaluated using 24-h dietary recalls (minimum 2 and maximum 6). Participants were grouped into moderate (n = 67) and high (n = 54) micronutrient deficiency groups, according to the individual assessment of each micronutrient intake. Patients' sociodemographic, clinical, and anthropometric data and clinical outcomes (hospitalization and mortality) within 24 months were collected. Overall and event-free survival rates were calculated using Kaplan-Meier estimates, and curves were compared using the log-rank test. The death risk rate (hazard ratio (HR)) was calculated using Cox's univariate model. The rate of inadequate intake was 100% for vitamins B1 and D and above 80% for vitamins B2, B9, and E, calcium, magnesium, and copper. No differences in overall survival and event-free survival were observed between groups of HF outpatients with moderate and high micronutrient deficiencies (HR = 0.94 (CI = 0.36-2.48), p = 0.91, and HR = 1.63 (CI = 0.68-3.92), p = 0.26, respectively), as well as when the inadequacy of each micronutrient intake was evaluated alone (all p > 0.05). In conclusion, a high prevalence of inadequate micronutrient intake was observed in outpatients with HF. Inadequate micronutrient intake was not associated with hospitalization and mortality in this group of patients.

Metabolic Therapy of Heart Failure: Is There a Future for B Vitamins?

Heart failure (HF) is a plague of the aging population in industrialized countries that continues to cause many deaths despite intensive research into more effective treatments. Although the therapeutic arsenal to face heart failure has been expanding, the relatively short life expectancy of HF patients is pushing towards novel therapeutic strategies. Heart failure is associated with drastic metabolic disorders, including severe myocardial mitochondrial dysfunction and systemic nutrient deprivation secondary to severe cardiac dysfunction. To date, no effective therapy has been developed to restore the cardiac energy metabolism of the failing myocardium, mainly due to the metabolic complexity and intertwining of the involved processes. Recent years have witnessed a growing scientific interest in natural molecules that play a pivotal role in energy metabolism with promising therapeutic effects against heart failure. Among these molecules, B vitamins are a class of water soluble vitamins that are directly involved in energy metabolism and are of particular interest since they are intimately linked to energy metabolism and HF patients are often B vitamin deficient. This review aims at assessing the value of B vitamin supplementation in the treatment of heart failure.

Role of Coenzyme Q10 in Health and Disease: An Update on the Last 10 Years (2010-2020)

The present review focuses on preclinical and clinical studies conducted in the last decade that contribute to increasing knowledge on Coenzyme Q₁₀'s role in health and disease. Classical antioxidant and bioenergetic functions of the coenzyme have been taken into consideration, as well as novel mechanisms of action involving the redox-regulated activation of molecular pathways associated with anti-inflammatory activities. Cardiovascular research and fertility remain major fields of application of Coenzyme Q₁₀, although novel applications, in particular in relation to topical application, are gaining considerable interest. In this respect, bioavailability represents a major challenge and the innovation in formulation aspects is gaining critical importance.

CoenzymeQ in cellular redox regulation and clinical heart failure

Coenzyme Q (CoQ) is ubiquitously embedded in lipid bilayers of various cellular organelles. As a redox cycler, CoQ shuttles electrons between mitochondrial complexes and extramitochondrial reductases and oxidases. In this way, CoQ is crucial for maintaining the mitochondrial function, ATP synthesis, and redox homeostasis. Cardiomyocytes have a high metabolic rate and rely heavily on mitochondria to provide energy. CoQ levels, in both plasma and the heart, correlate with heart failure in patients, indicating that CoQ is critical for cardiac function. Moreover, CoQ supplementation in clinics showed promising results for treating heart failure. This review provides a comprehensive view of CoQ metabolism and its interaction with redox enzymes and reactive species. We summarize the clinical trials and applications of CoQ in heart failure and discuss the caveats and future directions to improve CoQ therapeutics.

Biomarkers of Zinc and Copper Status and Associated Factors in Outpatients with Ischemic and Non-Ischemic Heart Failure

Background: Few studies have explored the impact of ischemic and non-ischemic etiologies of heart failure and other factors associated with heart failure on zinc and copper status. This study examined zinc and copper status in 80 outpatients with ischemic (n = 36) and non-ischemic (n = 44) heart failure and associations with biodemographic, clinical, biochemical, and nutritional parameters.Materials: Biomarkers of plasma zinc and copper, copper-zinc ratio, 24-h urinary zinc excretion, ceruloplasmin, and dietary intake of zinc and copper were assessed. Plasma zinc and copper and urinary zinc were measured by inductively coupled plasma mass spectrometry (ICP-MS).Results: Patients with ischemic heart failure showed lower dietary zinc intake and higher dietary copper intake (both p = 0.02). Zinc and copper in plasma, copper-zinc ratio, ceruloplasmin, and 24-h urinary zinc excretion showed no statistical differences between the groups (all p ≥ 0.05). An inverse association was found between age (β =-0.001; p = 0.005) and the use of diuretics (β = -0.047; p = 0.013) and plasma zinc. Copper levels in plasma (β = 0.001; p < 0.001), and albumin (β = 0.090; p<0.001) were directly associated with plasma zinc. A positive association was found between ceruloplasmin (β = 0.011; p < 0.001), gamma-glutamyl transferase (β = 0.001; p < 0.001), albumin (β = 0.077; p = 0.001), and high-sensitivity c-reactive protein (β = 0.001; p = 0.024) and plasma copper.Conclusion: Zinc and copper biomarkers in clinically stable patients with heart failure did not seem to be responsive to the differences in zinc and copper intake observed in this study, regardless of heart failure etiology. The predictors of plasma zinc and copper levels related to oxidative stress and inflammation should be monitored in heart failure clinical practice.

Importance of the Corrected Calcium Level in Patients With Acute Heart Failure Requiring Intensive Care

Background: Serum calcium (Ca) concentrations in the acute phase of acute heart failure (AHF) have not been not sufficiently investigated. Methods and Results: This study enrolled 1,291 AHF patients and divided them into 3 groups based on original and corrected Ca concentrations: (1) hypocalcemia (both original and corrected Ca ≤8.7 mg/dL; n=651); (2) pseudo-hypocalcemia (original and corrected Ca ≤8.7 and >8.7 mg/dL, respectively; n=300); and (3) normal/hypercalcemia (both original and corrected Ca >8.7 mg/dL; n=340). AHF patients were also divided into 2 groups based on corrected Ca concentrations: (1) corrected hypocalcemia (corrected Ca ≤8.7 mg/dL; n=651); and (2) corrected normal/hypercalcemia (corrected Ca >8.7 mg/dL; n=640). Of the 951 patients with original hypocalcemia (≤8.7 mg/dL), 300 (31.5%) were classified as corrected normal/hypercalcemia after correction of Ca concentrations by serum albumin. The prognoses in the pseudo-hypocalcemia, low albumin, and corrected normal/hypercalcemia groups, including all-cause death within 730 days, were significantly poorer than in the other groups. Multivariate Cox regression analysis showed that classification into the pseudo-hypocalcemia, hypoalbumin, and corrected normal/hypercalcemia groups independently predicted 730-day all-cause death (hazard ratios [95% confidence intervals] of 1.497 [1.153-1.943], 2.392 [1.664-3.437], and 1.294 [1.009-1.659], respectively). Conclusions: Corrected normal/hypercalcemia was an independent predictor of prognosis because this group included patients with pseudo-hypocalcemia, which was affected by the serum albumin concentration.

Folic acid affects cardiometabolic, oxidative stress, and immunohistochemical parameters in monocrotaline-induced rat heart failure

Heart failure (HF) is one of the major cardiovascular causes of death worldwide. In this study, we explored the effects of folic acid (FA) on cardiometabolic, oxidative stress biomarker changes, and the activity of proliferation marker Ki67 in monocrotaline-induced HF. The research was conducted during a 4 week period using five experimental groups (eight animals per group): blank solution exposed controls (C1: 1 mL/kg physiological saline, 1 day; C2: 1 mL/kg physiological saline, 28 days), monocrotaline (MCT) induced HF (50 mg/kg MCT), FA (5 mg·kg^-1·day^-1 FA), and MCT+FA (50 mg/kg MCT, 5 mg·kg^-1·day^-1 FA). Superoxide dismutase and glutathione peroxidase activities together with total glutathione and parameters of oxidative damage of proteins were determined in cardiac tissue as well as cardiometabolic parameters in plasma or serum. The total glutathionylation was determined by Western blot and proliferation marker Ki67 was assessed by immunohistochemistry. The right ventricular (RV) wall hypertrophy and Ki67 positivity, accompanied by a significant increase of troponin T, has been shown in MCT-induced HF. The antioxidant effect of FA was reflected through superoxide dismutase activity, reduced Ki67 positivity in the RV wall, and a slightly decreased total glutathionylation level.

Association of meal and snack patterns with micronutrient intakes among Greek children and adolescents: data from the Hellenic National Nutrition and Health Survey

BACKGROUND

The present study aimed to examine how different meal and snack patterns are associated with micronutrient intakes and diet quality among a nationally representative sample of Greek children and adolescents aged 1-19 years from the cross-sectional Hellenic National Nutrition and Health Survey (n = 598).

METHODS

Meal and snack patterns were derived using 24-h dietary recalls. Mean adequacy ratio (MAR) was used as an overall measure of diet quality. Multiple linear regression adjusted for covariates was conducted to examine associations between eating patterns, nutrient intakes and MAR.

RESULTS

Four most frequently reported eating schemes were identified including breakfast (B), lunch (L), dinner (D) and two snacks (S) (20.9%); B, L, D and 1S (16.2%); B, L, D and 3S (10.8%); and B, L and D (7.9%). Based on these schemes, the daily consumption of all main meals from the majority of the sample was highlighted. In children and adolescents aged 4-19 years, increasing snack frequency was positively associated with intakes of vitamin D, vitamin K, riboflavin, niacin, pantothenic acid, folate, magnesium, copper and selenium. An inverse association was recorded for vitamin E, vitamin B₆ , calcium and iron. Among children aged 1-3 years, only niacin and copper were significantly associated with number of snacks, with the group of 'B-L-D-2S' presenting the highest intake. As for the overall diet quality, among all participants, there was no significant association of MAR with the type of meal and snack pattern, and thus the snack frequency.

CONCLUSIONS

Snacking behaviour is a common practice among children and adolescents. Modifying current snack foods with nutrient-rich choices could lead to an improvement of their diet's nutritional quality.

Benefits of multiple micronutrient supplementation in heart failure: A comprehensive review

BACKGROUND

Multiple micronutrient supplementation has been suggested to have a role on health outcomes in patients with heart failure (HF), but the evidence is inconclusive.

OBJECTIVE

To elucidate the role of multiple micronutrient supplementation in heart failure we performed a comprehensive review of the literature.

METHODS AND RESULTS

The search in databases included PUBMED (until June 2018) to detect randomized controlled trials (RCTs) and meta-analyzes that investigated the impact of micronutrient supplementation in HF.

RESULTS

With more than 2357 titles and abstracts reviewed, we included only the studies suitable for the final review. Whether alone or in combination, micronutrients have been found to improve the health outcomes of patients with HF by improving symptoms, work capacity and left ventricular ejection fraction (LVEF), thus increasing the quality of life in these patients.

CONCLUSION

Future studies are needed to document the effects of multiple micronutrient associations in order to include them in nutritional guidelines to increase survival and to improve quality of life in patients with heart failure.

The Modulating Effects of Cardiac Resynchronization Therapy on Myocardial Metabolism in Heart Failure

Heart failure (HF) is associated with changes in cardiac substrate utilization and energy metabolism, including a decline in high-energy phosphate content, mitochondrial dysfunction, and phosphotransfer enzyme deficiency. A shift toward glucose metabolism was noted in the end stage of HF in animals, although HF in humans may not be associated with a shift toward predominant glucose utilization. Deficiencies of micronutrients are well-established causes of cardiomyopathy. Correction of these deficits can improve heart function. The genes governing the energy metabolism were predominantly underexpressed in nonischemic cardiomyopathy and hypertrophic cardiomyopathy but were overexpressed in ischemic cardiomyopathy. Cardiac resynchronization therapy (CRT) has been proven to increase cardiac efficiency without increasing myocardial oxygen consumption. Altered myocardial metabolism is normalized by CRT to improve ventricular function.

Cardiac Cachexia: Perspectives for Prevention and Treatment

Cachexia is a prevalent pathological condition associated with chronic heart failure. Its occurrence predicts increased morbidity and mortality independent of important clinical variables such as age, ventricular function, or heart failure functional class. The clinical consequences of cachexia are dependent on both weight loss and systemic inflammation, which accompany cachexia development. Skeletal muscle wasting is an important component of cachexia; it often precedes cachexia development and predicts poor outcome in heart failure. Cachexia clinically affects several organs and systems. It is a multifactorial condition where underlying pathophysiological mechanisms are not completely understood making it difficult to develop specific prevention and treatment therapies. Preventive strategies have largely focused on muscle mass preservation. Different treatment options have been described, mostly in small clinical studies or experimental settings. These include nutritional support, neurohormonal blockade, reducing intestinal bacterial translocation, anemia and iron deficiency treatment, appetite stimulants, immunomodulatory agents, anabolic hormones, and physical exercise regimens. Currently, nonpharmacological therapy such as nutritional support and physical exercise are considered central to cachexia prevention and treatment.

Role of micronutrients in congestive heart failure: A systematic review of randomized controlled trials

OBJECTIVES

To assess the effect of micronutrients on health outcomes in patients with heart failure.

MATERIALS AND METHODS

Only randomized controlled trials testing the effectiveness of different micronutrients either singly or combined versus placebo in heart failure patients were included. We conducted a search in different databases such as Medline from PubMed, Embase and Scopus from Elsevier, and Google Scholar. The keywords used in the search were "Heart Failure" and its cognates, "Micronutrient," "Minerals," and names of individual micronutrients.

RESULTS

Out of 3288 titles and abstracts reviewed, only 11 trials comprising 529 individuals were found to be appropriate to be included in the final review. It was found that micronutrients, either single or combined, improved the health outcomes of heart failure patients by improving exercise tolerance, functional capacity, left ventricular function, flow-dependent dilation, and inflammatory milieu, thereby improving the quality of life of health failure patients. Certain micronutrients also normalized endothelial dysfunction.

CONCLUSION

Overall, this systematic review found sufficient evidence to support a large-scale trial on micronutrient supplementation in patients with heart failure.

Nutritional Deficiency in Patients with Heart Failure

Heart failure (HF) is the main cause of mortality and morbidity in Western countries. Although evidence-based treatments have substantially improved outcomes, prognosis remains poor with high costs for health care systems. In patients with HF, poor dietary behaviors are associated with unsatisfactory quality of life and adverse outcome. The HF guidelines have not recommended a specific nutritional strategy. Despite the role of micronutrient deficiency, it has been extensively studied, and data about the efficacy of supplementation therapy in HF are not supported by large randomized trials and there is limited evidence regarding the outcomes. The aim of the present review is to analyze the state-of-the-art of nutritional deficiencies in HF, focusing on the physiological role and the prognostic impact of micronutrient supplementation.

Diastolic Left Ventricular Function in Relation to Circulating Metabolic Biomarkers in a General Population

Background

The metabolic signature associated with subclinical diastolic left ventricular (LV) dysfunction in the population remains ill defined.

Methods and Results

In 711 randomly recruited Flemish (50.8% women; mean age, 50.8 years), we assessed echocardiographic Doppler indexes of diastolic LV function in relation to 44 circulating metabolites determined by nuclear magnetic resonance spectroscopy. In multivariable‐adjusted regression analysis with Bonferroni correction of significance levels applied, peak a’ decreased (P≤0.048) and e’/a’ increased (P≤0.044) with circulating tyrosine, high‐density lipoprotein apolipoproteins, glucose+glutamine, and an unidentified molecule. Effect sizes expressed per 1‐SD increment in the metabolite ranged from −0.277 to −0.203 cm/s for peak a’ and from +0.047 to +0.054 for e’/a’. In addition, peak a’ decreased (P≤0.031) with glucose+2‐aminobutyrate (−0.261 cm/s) and glucose+2‐phosphoglycerate (−0.209 cm/s). In partial least square discriminant analysis (PLS‐DA), metabolites associated with normal diastolic LV function (n=538) included glucose+glutamine, glucose+2‐aminobutyrate, and glucose+2‐phosphoglycerate, whereas those siding with abnormal function encompassed 4‐aminobutyrate, 4‐hydroxybutyrate, creatinine, and phosphocholine. In receiver operating characteristics plots, adding 3 latent factors identified by PLS‐DA to prohormone brain natriuretic peptide increased (P<0.0001) the area under the curve from 0.64 (95% CI, 0.58–0.68) to 0.73 (0.68–0.78).

Conclusions

In a general population, circulating metabolites indicative of energy substrate utilization and protection against oxidative stress differentiated normal from abnormal diastolic LV function. These findings improve our understanding of the pathophysiology underlying deterioration of diastolic LV function and potentially point to new targets for prevention and treatment of this condition.

Changes in dietary intake and nutritional status associated with a significant reduction in sodium intake in patients with heart failure. A sub-analysis of the SODIUM-HF pilot study

BACKGROUND & AIMS

Concerns have been raised about the impact of dietary sodium restriction on the overall dietary intake and nutritional status in patients with heart failure (HF). The objective of this study was to evaluate the association between a significant reduction in sodium intake and dietary changes and nutritional status in patients with chronic HF.

METHODS

This is a secondary analysis of 38 patients enrolled in a pilot study of dietary sodium reduction. Patients were classified into two groups according to a level of sodium reduction achieved (≥25% [n = 21 patients] and <25% [n = 14 patients]) at 6 months. Between group changes in energy, nutrient intake, weight loss, and hand grip strength from baseline to 6 months were compared.

RESULTS

Patients had a median age of 65 years, 51% were male, median body mass index was 30.7 kg/m² and median ejection fraction was 39%. Over 6 months, the group with ≥25% sodium reduction exhibited a greater increase in folate intake [median change 50 mcg/day (25th-75th percentiles: -101, 167) vs. -31 mcg/day (25th-75th percentiles: -221, 51), p = 0.04 between groups] and a larger reduction in calcium intake [median change -262 (25th-75th percentiles: -585, -9) vs. 91 (25th-75th percentiles: -114, 210), p = 0.01 between groups], and were more likely to meet the parameters of the DASH diet compared to the <25% sodium reduction group. No significant differences between groups were seen for caloric intake and other relevant nutrients and no significant weight loss was found in either group.

CONCLUSIONS

Dietary sodium reduction may be achieved without compromising overall dietary intake and nutritional status in patients with HF when an individualized and comprehensive dietary approached is used.

CLINICAL TRIAL IDENTIFIER

Clinicaltrials.gov identifier: NCT01480401.

Immunohistochemical determination of the extracellular matrix modulation in a rat model of choline-deprived myocardium: the effects of carnitine

Choline has been identified as an essential nutrient with crucial role in many vital biological functions. Recent studies have demonstrated that heart dysfunction can develop in the setting of choline deprivation even in the absence of underlying heart disease. Matrix metalloproteinases (MMPs) are responsible for extracellular matrix degradation, and the dysregulation of MMP-2 and MMP-9 has been involved in the pathogenesis of various cardiovascular disorders. The aim of the study was to investigate the role of MMPs and their inhibitors (TIMPs), in the pathogenesis of choline deficiency-induced cardiomyopathy, and the way they are affected by carnitine supplementation. Male Wistar Albino adult rats were divided into four groups and received standard or choline-deficient diet with or without L-carnitine in drinking water (0.15% w/v) for 1 month. Heart tissue immunohistochemistry for MMP-2, MMP-9, TIMP-1, and TIMP-2 was performed. Choline deficiency was associated with suppressed immunohistochemical expression of MMP-2 and an increased expression of TIMP-2 compared to control, while it had no impact on TIMP-1. MMP-9 expression was decreased without, however, reaching statistical significance. Carnitine did not affect MMP-2, MMP-9, TIMP-1 or TIMP-2 expression. The pattern of TIMP and MMP modulation observed in a choline deficiency setting appears to promote fibrosis. Carnitine, although shown to suppress fibrosis, does not seem to affect MMP-2, MMP-9, TIMP-1 or TIMP-2 expression. Further studies will be required to identify the mechanism underlying the beneficial effects of carnitine.

The importance of assessing nutritional status in elderly patients with heart failure

Heart failure (HF) is a syndrome characterized by high morbidity and mortality, despite advances in medical and device therapy that have significantly improved survival. The outcome of HF in elderly patients results from a combination of biological, functional, psychological, and environmental factors, one of which is nutritional status. Malnutrition, as well as HF, is frequently present with aging. Early detection might lead to earlier intervention. It is our goal to review the importance of nutritional status in elderly patients with HF, as well as tools for assessing it. We also propose a simple decision algorithm for the nutritional assessment of elderly patients with HF.

The effect of coenzyme Q10 on morbidity and mortality in chronic heart failure: results from Q-SYMBIO: a randomized double-blind trial

OBJECTIVES

This randomized controlled multicenter trial evaluated coenzyme Q10 (CoQ10) as adjunctive treatment in chronic heart failure (HF).

BACKGROUND

CoQ10 is an essential cofactor for energy production and is also a powerful antioxidant. A low level of myocardial CoQ10 is related to the severity of HF. Previous randomized controlled trials of CoQ10 in HF were underpowered to address major clinical endpoints.

METHODS

Patients with moderate to severe HF were randomly assigned in a 2-year prospective trial to either CoQ10 100 mg 3 times daily or placebo, in addition to standard therapy. The primary short-term endpoints at 16 weeks were changes in New York Heart Association (NYHA) functional classification, 6-min walk test, and levels of N-terminal pro-B type natriuretic peptide. The primary long-term endpoint at 2 years was composite major adverse cardiovascular events as determined by a time to first event analysis.

RESULTS

A total of 420 patients were enrolled. There were no significant changes in short-term endpoints. The primary long-term endpoint was reached by 15% of the patients in the CoQ10 group versus 26% in the placebo group (hazard ratio: 0.50; 95% confidence interval: 0.32 to 0.80; p = 0.003) by intention-to-treat analysis. The following secondary endpoints were significantly lower in the CoQ10 group compared with the placebo group: cardiovascular mortality (9% vs. 16%, p = 0.026), all-cause mortality (10% vs. 18%, p = 0.018), and incidence of hospital stays for HF (p = 0.033). In addition, a significant improvement of NYHA class was found in the CoQ10 group after 2 years (p = 0.028).

CONCLUSIONS

Long-term CoQ10 treatment of patients with chronic HF is safe, improves symptoms, and reduces major adverse cardiovascular events. (Coenzyme Q10 as adjunctive treatment of chronic heart failure: a randomised, double-blind, multicentre trial with focus on SYMptoms, BIomarker status [Brain-Natriuretic Peptide (BNP)], and long-term Outcome [hospitalisations/mortality]; ISRCTN94506234).

Polypharmacy in heart failure: drugs to use and avoid

Polypharmacy, the use of 4 or more medications, is universal in patients with heart failure (HF). Evidence-based combination therapy is prescribed in patients with HF with reduced ejection fraction (HFrEF). Additionally, treatment of the high prevalence of comorbidities presents many therapeutic dilemmas. The use of nonprescription medications is common, adding further complexity to the medication therapy regimens of patients with HF. An approach for combining evidence-based therapies in patients with HFrEF is presented. Strategies for optimizing the management of common comorbidities in patients with HF are reviewed. Both prescription and nonprescription medications to avoid or use with caution are highlighted.

What should we tell patients with heart failure about sodium restriction and how should we counsel them?

This article is a review of current evidence regarding the recommended level of dietary sodium, involvement of family members in adoption of a low sodium diet, and evidence-based strategies to increase patient and family member willingness and ability to a follow a low sodium diet. The available evidence suggests that recommending a 2.5 to 3 g sodium diet will meet nutritional needs and decrease risk of hospitalizations. The best strategy identified for patient success is to fully involve both patients and family members in jointly reducing sodium intake. Motivational interviewing techniques should be used before counseling begins to guide patients and family members toward realization of the need to follow a low sodium diet. Successful counseling starts with determining perceptions, barriers, and individual characteristics that impede adherence. This information is incorporated into theory-based teaching strategies to promote behavior change and successful adoption of a low sodium diet.

New Approaches to Treating Cardiac Cachexia in the Older Patient

Congestive heart failure (CHF) is a leading cause of morbidity and mortality in the elderly, accounting for more hospitalizations than any other condition. Advanced stages of congestive heart failure can be associated with serious complications such as cardiac cachexia (defined here as unintentional weight loss of more than 6% in 6 months). Cardiac cachexia and the associated progressive weight loss are sometimes overlooked by older patients, their families and care providers. A delay in the diagnosis can result in further loss of vital organ tissue, progressive weakness, fall-related injuries and even long-term care institutionalization and/or death. During the past several years, researchers have begun to broaden their understanding of this common, morbid and often fatal condition, and these findings will help to characterize the features that assist in its diagnosis, minimize its exacerbation, delay the progressive decline, and educate clinicians about the potential management options.

Selenium attenuates adriamycin-induced cardiac dysfunction via restoring expression of ATP-sensitive potassium channels in rats

The possible mechanism of adriamycin (ADR) and/or selenium (Se) deficiency-induced cardiac dysfunction, and cardioprotective effects of Se against ADR-induced cardiac toxicity were investigated in this study. Cardiac function was evaluated by plasma brain natriuretic peptide level and echocardiographic and hemodynamic parameters. Cardiac glutathione peroxidase (GPx) activity was assessed spectrophotometrically. Expression of ATP-sensitive potassium channels (KATP) subunits-SUR2A and Kir6.2-were examined by real-time PCR and Western blotting. The results showed that cardiac function and cardiac GPx activity decreased remarkably after administration of ADR or Se deficiency; more dramatic impairment of cardiac function and cardiac GPx activity were observed after co-administration of ADR and Se deficiency. Mechanically, it is novel for us to find down-regulation of KATP subunits gene expression in cardiac tissue after administration of ADR or Se deficiency, and more significant inhibition of cardiac KATP gene expression was identified after co-administration of ADR and Se deficiency. Furthermore, cardiac toxicity of ADR was found alleviated by Se supplementation, accompanied by restoring of cardiac GPx activity and cardiac KATP gene expression. These results indicate that decreased expression of cardiac KATP is involved in adriamycin and/or Se deficiency-induced cardiac dysfunction; Se deficiency exacerbates adriamycin-induced cardiac dysfunction by future inhibition of KATP expression; Se supplementation seems to protect against adriamycin-induced cardiac dysfunction via restoring KATP expression, showing potential clinical application in cancer chemotherapy.