New AHA Statement on Complementary Medicine in Heart Failure

There are some benefits and potentially serious risks associated with complementary and alternative medicines (CAM) patients with heart failure (HF) may use to manage symptoms, the American Heart Association (AHA) says in a new scientific statement on the topic.

For example, yoga and tai chi can be helpful for people HF, and omega-3 polyunsaturated fatty acids may also have benefits. However, there are safety concerns with other commonly used over-the-counter (OTC) CAM therapies, including vitamin D, blue cohosh, and Lily of the Valley, the writing group says.

It's estimated that roughly 1 in 3 patients with HF use CAM. But often patients don't report their CAM use to their clinician and clinicians may not routinely ask about CAM use or have the resources to evaluate CAM therapies, writing group chair Sheryl L. Chow, PharmD, told theheart.org | Medscape Cardiology.

Dr Sheryl L. Chow

"This represents a major public health problem given that consumers are frequently purchasing these potentially dangerous and minimally regulated products without the knowledge or advice from a healthcare professional," said Chow, with Western University of Health Sciences, Pomona, California, and University of California Irvine.

The 27-page statement was published online December 8 in Circulation.

CAM Use Common in HF

The statement defines CAM as medical practices, supplements, and approaches that do not conform to the standards of conventional, evidence-based practice guidelines. CAM products are available without prescriptions or medical guidance at pharmacies, health food stores, and online retailers.

"These agents are largely unregulated by the FDA and manufacturers do not need to demonstrate efficacy or safety. It is important that both healthcare professionals and consumers improve communication with respect to OTC therapies and are educated about potential efficacy and risk of harm so that shared and informed decision-making can occur," Chow said.

The writing group reviewed research published before November 2021 on CAM among people with HF.

Omega-3 polyunsaturated fatty acids (PUFAs), such as fish oil, have the strongest evidence among CAM agents for clinical benefit in HF and may be used safely by patients in moderation and in consultation with their healthcare team, the writing group says.

Research has shown that omega-3 PUFAs are associated with a lower risk of developing HF as well as improvements left ventricular systolic function in those with existing HF, they point out.

However, two clinical trials found a higher incidence of atrial fibrillation with high-dose omega-3 PUFA administration. "This risk appears to be dose-related and increased when exceeding 2 g/d of fish oil," the writing group says.

Research suggests that yoga and tai chi, when added to standard HF treatment, may help improve exercise tolerance and quality of life and decrease blood pressure.

Inconclusive or Potentially Harmful CAM Therapies

Other CAM therapies for HF have been shown as ineffective based on current data, have mixed findings, or appear to be harmful. The writing highlights the following examples:

Overall evidence regarding the value of vitamin D supplementation in patients with HF remains "inconclusive" and may be harmful when taken with HF medications such as digoxin, calcium channel blockers, and diuretics.
Routine thiamine supplementation in patients with HF and without clinically significant thiamine deficiency may not be efficacious and should be avoided.
Research on alcohol varies, with some data showing that drinking low-to-moderate amounts (one to two drinks per day) may help prevent HF, while habitual drinking or consuming higher amounts is known to contribute to HF.
The literature is mixed on vitamin E. It may have some benefit in reducing the risk of HF with preserved ejection fraction but has also been associated with an increased risk of HF hospitalization.
Coenzyme Q10 (Co-Q10), commonly taken as a dietary supplement, may help improve HF class, symptoms, and quality of life, but it also may interact with antihypertensive and anticoagulant medication. Co-Q10 remains of "uncertain" value in HF at this time. Large-scale randomized controlled trials are needed before any definitive conclusion can be reached.
Hawthorn, a flowering shrub, has been shown in some studies to increase exercise tolerance and improve HF symptoms such as fatigue. Yet it also has the potential to worsen HF, and there is conflicting research about whether it interacts with digoxin.
The herbal supplement blue cohosh, from the root of a flowering plant found in hardwood forests, could cause tachycardia, high blood pressure, chest pain, and increased blood glucose. It may also decrease the effect of medications taken to treat high blood pressure and type 2 diabetes, they note.
Lily of the Valley, the root, stems, and flower of which are used in supplements, has long been used in mild HF because it contains active chemicals similar to digoxin. But when taken with digoxin, it could lead to hypokalemia.

In an AHA news release, Chow says, "Overall, more quality research and well-powered randomized controlled trials are needed to better understand the risks and benefits" of CAM therapies for HF.

"This scientific statement provides critical information to healthcare professionals who treat people with heart failure and may be used as a resource for consumers about the potential benefit and harm associated with complementary and alternative medicine products," Chow adds.

The writing group encourages healthcare professionals to routinely ask their HF patients about their use of CAM therapies. They also say pharmacists should be included in the multidisciplinary healthcare team to provide consultations about the use of CAM therapies for HF patients.

The scientific statement does not include cannabis or traditional Chinese medicine, which have also been used in HF.

In 2020, the AHA published a separate scientific statement on the use of medical marijuana and recreational cannabis on cardiovascular health, as reported previously by theheart.org | Medscape Cardiology.

The scientific statement on CAM for HF was prepared by the volunteer writing group on behalf of the AHA Clinical Pharmacology Committee and Heart Failure and Transplantation Committee of the Council on Clinical Cardiology; the Council on Epidemiology and Prevention; and the Council on Cardiovascular and Stroke Nursing.

Circulation. Published online December 8, 2022. Abstract

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