Complementary and Alternative Medicines in the Management of Heart Failure

Coenzyme Q10 (CoQ10) is an antioxidant that naturally occurs in small amounts in organ meats, soybean oil and oily fish. In more recent studies, CoQ10 supplementation was associated with improvements in HF symptoms and a reduction in hospitalization and death. The beneficial effects of CoQ10 are not clear, and more studies are needed. It is important to note that CoQ10 may interact with blood pressure medicines and the blood thinner warfarin. The most common side effects are gastrointestinal.

D-Ribose is naturally occurring in many foods including red meat, poultry, fish, nuts and dairy. It has improved health factors and quality of life for patients with HF. There are no major harmful effects to the body and no major interactions with HF therapy. It is well tolerated and side effects include gastrointestinal upset, headaches and low blood sugar.

L-carnitine reduces oxidative stress and is naturally occurring in foods, with the highest concentrations in red meat. It provides health improvements in several factors related to HF including ejection fraction and HF symptoms. It appears to have no major harmful effects on the body. It is well tolerated and side effects, although infrequent, include gastrointestinal upset. It is likely safe for patients with HF.

Omega-3 polyunsaturated fatty acids (PUFA) are in fish, soybean oil and organ meats. In some studies, taking omega-3 fatty acid supplementation increased ejection fraction and decreased inflammation. It may lower the risk of HF and reduce recurrent HF hospitalization. They are generally safe and well tolerated with gastrointestinal symptoms being the most common side effect.

Although omega-3 PUFA supplementation does not seem to cause harm in people with HF, studies have shown an increased incidence of atrial fibrillation at higher doses. Omega-3 PUFA supplementation is recommended in the 2022 HF guidelines for those with moderate to severe HF to reduce death and hospitalizations for cardiac reasons. Supplementation at less than 4 grams per day can be added to other guideline-directed medical therapies and not as a replacement.  

Thiamine or vitamin B1 is a water-soluble B complex vitamin. It is not made by the body but occurs naturally in whole grains, beans and yeast. Thiamine deficiency is a known cause of HF. Thiamine supplementation is generally well tolerated with rare cases of skin rash.

Data from small, randomized studies suggest that thiamine supplementation in patients with chronic HF may increase ejection fraction; other studies have not shown any benefit. Thiamine supplementation in patients with HF and without clinically significant thiamine deficiency may not be helpful.

Vitamin C is naturally occurring in fruits and vegetables, particularly citrus fruits. It has been associated with a lower risk of HF in men without previous heart attack. There appears to be no major harmful outcomes and no major interactions for people with HF. 

Vitamin D is naturally occurring in fish, eggs and fortified dairy. It is generally well tolerated. Supplementation for HF has been variably associated with decreased inflammation and improved ejection fraction in some age groups. Improvement in death or functional capacity was not observed and impact on quality of life is conflicting. It does not appear to be harmful with routine supplementation.

Yoga and tai chi are safe and well-tolerated activities for people with HF. In some studies, yoga in combination with standard medical therapy for HF improved exercise tolerance and quality of life and reduced inflammation. In a small trial, tai chi improved exercise ability, adherence and self-confidence. It can also improve quality of life and mood as well as lower depression. Yoga and tai chi can be used along with traditional medical care to improve exercise tolerance and quality of life.

Bitter orange is a fruit-bearing tree native to Asia and has been used for gastrointestinal ailments. It contains many chemicals that can stimulate the nervous system. It can interact with some HF therapies, leading to an increase in blood pressure and heart rate up to five hours after ingestion. It may counteract the effect of blood pressure-lowering therapies and enhance the effect of stimulants, potentially making it harmful for people with HF.

Blue cohosh is a woodland perennial native to the eastern half of North America. It may cause increased heart rate, blood sugar and blood pressure as well as cause angina, which could be harmful to HF patients.

Devil’s claw is an herb, also known as wood spider. It may increase blood pressure and may interact with warfarin and cause a clotting issue, which could be harmful to those with HF.

Gossypol is found in the stem and seeds of cotton plants. It has been used as a male oral contraceptive and has some antimalarial properties. Gossypol depletes potassium in the body. This may lead to low potassium, which can lead to heart and circulation problems. For people on digoxin, it may also increase the digoxin levels, which can lead to gastrointestinal issues or cause serious heart issues, including slowing of the heart rate or, in extreme circumstances, death. It also may be harmful for people with HF.

Grapefruit juice interacts with many HF medicines including amiodarone, carvedilol, dofetilide and sotalol. It also interacts with statin medicines used to treat high cholesterol by reducing metabolism and increasing the absorption of the medicine. Because of these potential interactions, the consumption of grapefruit juice may be harmful to those with HF.

Khella is naturally occurring in dried, ripe fruit of the Khella plant. Khella has been shown to have negative effects on HF outcomes and may be harmful for those with HF. It may decrease the effect of some HF medications. Side effects include nausea, dizziness, constipation, lack of appetite, headache, itching, insomnia and liver problems.

Licorice can be found in black licorice, licorice flavored diet gum, cough mixtures and licorice teas. It has been found to cause harmful effects including sodium retention, high blood pressure, arrhythmias, high potassium and even cardiac arrest. Licorice is considered harmful for people with heart failure. The FDA advises against consuming more than 40-50 grams/day for more than two weeks. On the other hand, red licorice does not contain the same harmful ingredient and does not produce additional risk. 

Digitalis glycosides used in the medication digoxin are found in lily of the valley. All parts of the plants are considered toxic, including the roots and berries. These plants have a long history of medical use for those with mild heart failure and atrial fibrillation, particularly in Eastern medicine. Lily of the valley is considered harmful as acute accidental poisoning can occur. Symptoms of nausea, palpitations or visual disturbances could indicate toxicity. Because the effects can be increased with low potassium, these agents should not be combined with drugs that decrease potassium levels, such as diuretics and steroids, without careful monitoring of potassium levels.

Yellow oleander and common oleander are evergreen shrubs. All parts of the plant are toxic, including the leaves, flowers, twigs and stems. It may increase the risk of high potassium and are considered harmful. Side effects include heart rhythm problems, confusion, fatigue, poor appetite, nausea, vomiting, diarrhea, blurred vision and changes in color perception.

Strophanthus is an African perennial. All parts of the plant are toxic, but the highest concentration of toxins is in the seeds. Strophanthus may increase the risk of high potassium and are considered harmful for people with HF. Side effects include heart rhythm problems, confusion, fatigue, nausea, vomiting, diarrhea, blurred vision and changes in color perception.

Sources of naturally occurring vitamin E have been found in plant-based oils, nuts, seeds, fruits and vegetables. However, only moderate consumption should be encouraged given that doses in excess of 400 IU/d may increase the risk of HF.

Observational data suggest that low-to-moderate amounts of alcohol may be associated with a reduced risk of developing HF. The US Dietary Guidelines for Americans 2020-2025 defines moderate alcohol intake as two or less drinks per day for men and one or less drinks in a day for women.

Habitual consumption or abuse of alcohol is known to be a cause of cardiomyopathy and HF, even at lower doses if consumed habitually or excessively. Intake of more than 10 drinks per week is associated with increased new-onset atrial fibrillation in people with high blood pressure and enlargement of the left ventricle of the heart.

Some of the adverse effects of alcohol include flushing, confusion, lack of coordination, blackouts, drowsiness, nausea, vomiting and abdominal pain. Higher quantities of alcohol may lead to dependency, malnutrition, dementia and cancers. Alcohol should not be used during pregnancy and while breast-feeding.

Aloe vera is a gel from the leaves of aloe plants. It is generally used for softening dry skin. When ingested, it can act as a laxative. It may reduce potassium levels and increase the risk of digoxin poisoning. It is possibly unsafe for people with HF and during lactation and pregnancy if ingested.

Caffeine is a stimulant found in coffee, tea, soda and energy drinks. Caffeine increases blood pressure and the effect of diuretics. Caffeine can cause anxiety, diarrhea, upset stomach, headache, insomnia, muscular tremor, nausea and dependence with chronic use.

Studies are conflicting as to the benefits of caffeine. Some studies show that it is helpful, but others show no effect on HF. Moderate caffeine consumption is generally determined to be safe. However, the effects of caffeine vary widely between people. For some people, it may result in faster, abnormal heart rhythms. 

Guar gum is naturally occurring in the seed of the guar plant. It may aid in constipation and may decrease the amount of cholesterol and sugar absorbed in the stomach and intestines. There appears to be no harmful effects of its use, but it may decrease the absorption of some HF medications. It is generally well tolerated but gastrointestinal issues may occur with use. It is possibly safe during pregnancy and lactation, but studies are limited.

Hawthorn is naturally occurring in hawthorn leaves, flowers and berries. Studies are limited with hawthorn and HF. An interaction between hawthorn and digoxin is likely, and this combination should be avoided. However, most data suggest that it is safe in combination with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers. Information on the safety of taking this during pregnancy or lactation is insufficient.

The amino acid L-arginine is naturally occurring in red meat, poultry, fish and dairy. There is some risk with low blood pressure while taking L-arginine, but it is generally safe and well tolerated. However, studies have shown that initiation of L-arginine after heart attack was associated with increased risk of death in older patients. So administration of L-arginine should be avoided after a heart attack. Some evidence shows it is safe during pregnancy at doses lower than 12 g/day. Insufficient evidence exists around the safety during lactation.

Policosanol may be found in beeswax, wheat germ, rice bran and sugarcane. It appears it may improve cholesterol. In HF patients, it has been demonstrated to lower blood pressure and reduce the mass of the left ventricle in those with metabolic syndrome and an enlarged left ventricle hypertrophy. More studies are needed to determine the effectiveness of policosanol in people with HF.