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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