Coenzyme Q10 and Utility in Heart Failure: Just Another Supplement?

Heart failure affects 5.1 million people in the USA annually. It accounts for a frequent cause of hospitalizations and disability. Patients with congestive heart failure have lower plasma levels of CoQ10, which is an independent predictor of mortality in this patient population. It has been hypothesized that a deficiency of CoQ10 can play a role in the development and worsening of heart failure, and that oral supplementation can possibly improve symptoms and survival in these patients. Based on previous small studies and meta-analyses, the use of CoQ10 in heart failure suggested an improvement ejection fraction, stroke volume, cardiac output, and cardiac index with CoQ10 supplementation, however most of these small studies appeared to be underpowered to result in any significant data. The results of the recent Q-SYMBIO trial demonstrated an improvement in heart failure symptoms with a significant reduction in major adverse cardiovascular events and mortality.

Thiamine supplementation for the treatment of heart failure: a review of the literature.

A systematic review of the literature was performed by searching Pubmed and EMBASE databases using the terms "thiamine," "vitamin B1," "heart failure," "systolic dysfunction," "ventricular dysfunction," "cardiomyopathy," "ventricular failure," and "systolic failure." Relevant trials and articles were evaluated pertaining to thiamine deficiency in patients with heart failure (HF) and references were searched for further inclusion of articles. A total of 20 articles were reviewed and summarized in detail. While more research is needed to fully elucidate the clinical thiamine deficiency in HF patients, recent evidence has indicated that supplementing with thiamine in HF patients has the potential to improve left ventricular ejection fraction. Thiamine deficiency appears to be not uncommon in patients with HF, and supplementation with thiamine has been shown to improve cardiac function, urine output, weight loss, and signs and symptoms of HF. Therefore, this simple therapy should be tested in large-scale randomized clinical trial to further determine the effects of thiamine in HF patients.

Should we start prescribing omega-3 polyunsaturated fatty acids in chronic heart failure?

Chronic heart failure (HF) represents a significant health care burden. Over the past few decades, there have been considerable data supporting the benefits of omega-3 polyunsaturated fatty acids (PUFAs) on overall cardiovascular health. Reasons for the potential benefits of omega-3 PUFAs are multifactorial and not completely understood. It is likely that the culmination of multiple effects collectively help to prevent the development and slow the progression of chronic HF. A number of key epidemiologic and randomized trials have provided the basis of evidence in support of omega-3 PUFA supplementation in HF. This article reviews the benefits of omega-3 PUFAs and discusses the implications of recent trials. While the benefits seen in patients with chronic HF are modest at best, we believe the balance of evidence still favors the continuation of omega-3 PUFA supplementation in patients with chronic HF.

Omega-3 polyunsaturated fatty acids and cardiovascular diseases.

Omega-3 polyunsaturated fatty acid (omega-3 PUFA) therapy continues to show great promise in primary and, particularly in secondary prevention of cardiovascular (CV) diseases. The most compelling evidence for CV benefits of omega-3 PUFA comes from 4 controlled trials of nearly 40,000 participants randomized to receive eicosapentaenoic acid (EPA) with or without docosahexaenoic acid (DHA) in studies of patients in primary prevention, after myocardial infarction, and most recently, with heart failure (HF). We discuss the evidence from retrospective epidemiologic studies and from large randomized controlled trials showing the benefits of omega-3 PUFA, specifically EPA and DHA, in primary and secondary CV prevention and provide insight into potential mechanisms of these observed benefits. The target EPA + DHA consumption should be at least 500 mg/day for individuals without underlying overt CV disease and at least 800 to 1,000 mg/day for individuals with known coronary heart disease and HF. Further studies are needed to determine optimal dosing and the relative ratio of DHA and EPA omega-3 PUFA that provides maximal cardioprotection in those at risk of CV disease as well in the treatment of atherosclerotic, arrhythmic, and primary myocardial disorders.

New data on the clinical impact of exercise training, fish oils, and statins in heart failure.

Despite major advances in the field of cardiovascular (CV) diseases, heart failure (HF) continues to result in considerable CV morbidity and mortality and accounts for an increasing number of acute hospitalizations in adult patients. Recent major trials have focused on exercise training programs and the widely available nutraceutical omega-3 polyunsaturated fatty acids or fish oil and statins in patients with HF. In this article, we provide insight into the interpretation of the evidence base for these distinct interventions in HF and provide guidance for the clinical incorporation of exercise training and fish oil therapy for additional CV protection in chronic HF.

Fish oils produce anti-inflammatory effects and improve body weight in severe heart failure.

BACKGROUND: Fish oils have been shown to reduce production of tumor necrosis factor-alpha (TNF-alpha) in healthy subjects. We sought to evaluate the effects of fish oils on pro-inflammatory cytokines and body weight in patients with advanced heart failure. METHODS: Fourteen patients (New York Heart Association [NYHA] Class III to IV heart failure) were randomized in a double-blinded trial to active therapy with 8 g of n-3 fatty acids (Group A, n = 7) or placebo (Group B, n = 7) for 18 weeks. TNF-alpha and interleukin-1 (IL-1) production were measured by radioimmunoassay after endotoxin stimulation of peripheral blood mononuclear cells. RESULTS: Placebo-treated patients had a 44% increase in TNF-alpha (from 1.28 to 1.84 pg/ml; p = 0.07) but no significant change in IL-1 (from 0.68 to 0.78 pg/ml) production. n-3 fatty acids resulted in a 59% reduction in TNF-alpha (from 1.64 to 0.68 pg/ml; p = 0.02) and 39% decrease in IL-1 (from 1.98 to 1.21 pg/ml; p = 0.09) production. There was an inverse correlation between change in TNF-alpha production and change in percent body fat (r = -0.6; p = 0.02). CONCLUSIONS: Fish oils decrease TNF-alpha production in heart failure and improve body weight. Fish oil therapy may represent a novel therapeutic approach in late-stage heart failure characterized by cardiac cachexia.

Lunar Society and the discovery of digitalis.

William Withering was an established member of the renowned Lunar Society as well as an accomplished physician and botanist. Withering was an obsessive note taker and had a compulsion to observe and record. At the time when bleeding was the most common form of treatment for "dropsy", Withering's discovery of the foxglove and his detailed description of its medicinal purposes represented a major advance in the treatment of patients with heart failure. Withering's scrupulous account of the foxglove's potential for treating conditions of the heart was derived from dedicated study, experimentation, and deep concern for detail. The publication of "An Account of the Foxglove, and Some of its Medical Uses: with practical remarks on dropsy, and other diseases" marks a defining moment in the history of medicine.

Relation between left ventricular geometry and transmural dispersion of repolarization.

Studies have shown an association between left ventricular (LV) geometry and complex ventricular ectopic activity. Increased transmural dispersion of repolarization (TDR), which correlates to the interval from the peak to the end of the T wave (Tpe) on the surface electrocardiogram, is linked to ventricular tachyarrhythmias. The relation between LV geometry and TDR is unknown. The mean Tpe interval, measured from leads V(1) to V(3) of the surface electrocardiogram, was assessed in 300 patients (50% men) who had normal LV systolic function and QRS duration and were categorized into 3 equal groups, which were matched by age and gender, according to echocardiographically determined LV geometry (normal structure, concentric remodeling, and LV hypertrophy). The Tpe interval was corrected for the QT interval using Tpe/QTc and was compared among the 3 groups. Compared with those who had normal LV structure, the Tpe interval was significantly prolonged in those who had LV hypertrophy and significantly shortened in those who had concentric remodeling (p = <0.0001 for the 2 comparisons). Correcting for the QT interval using Tpe/QTc yielded similar results. Thus, TDR was increased in patients who had LV hypertrophy but decreased in concentric remodeling compared with those who had normal cardiac structure. Although LV hypertrophy represents a maladaptive geometric process that results in an unfavorable electrical substrate, concentric remodeling may represent a structural adaptation that has a more favorable electrical milieu.