Complementary and Alternative Medicines in Heart Failure Management

Coenzyme Q10 (CoQ10) is an antioxidant found in organ meats, soybean oil and oily fish. Studies show that CoQ10 supplements may improve heart failure symptoms and reduce hospital stays and death. However, the benefits of CoQ10 are not clear, and more research is needed. CoQ10 may interact with blood pressure medications and the blood thinner warfarin. The most common side effects are stomach-related.

D-Ribose is found in foods including red meat, poultry, fish, nuts and dairy. It improves health factors and quality of life for patients with heart failure. It doesn’t have major harmful effects or interactions with heart failure therapy. It is well tolerated. Side effects include stomach upset, headaches and low blood sugar.

L-carnitine is found mostly in red meat. It reduces oxidative stress and improves ejection fraction and heart failure symptoms. It appears to have no major harmful effects on the body. It is well tolerated, with occasional stomach upset. It is likely safe for patients with heart failure.

Omega-3 polyunsaturated fatty acids (PUFA) are in fish, soybean oil and organ meats. Some studies show that taking omega-3 fatty acid supplements can improve heart function and reduce inflammation. They might lower the risk of heart failure and reduce hospital visits. They are generally safe, with stomach issues being the most common side effect.

Omega-3 PUFA supplements don’t seem to harm people with heart failure. However, higher doses can increase the risk of atrial fibrillation. The 2022 heart failure guidelines recommend omega-3 PUFA for those with moderate to severe heart failure to reduce death and hospital stays. Supplements under 4 grams per day can be added to other treatments, but should not replace them.   

Thiamine, or vitamin B1, is found in whole grains, beans and yeast. Vitamin B1 deficiency can cause heart failure. Vitamin B1 supplements are usually well tolerated, with rare cases of skin rash. Routine screening for thiamine deficiency may be helpful in patients who use a diuretic or are malnourished.

Small clinical studies have shown that thiamine supplements may improve left ventricular ejection fraction and symptoms in patients with chronic heart failure, especially those with a deficiency. However, other studies have shown no big benefit. Thiamine supplements may be most useful in patients with heart failure who have documented or suspected deficiency, rather than as routine treatment.

Vitamin C is in fruits and vegetables, especially citrus. It may lower the risk of heart failure in men without a previous heart attack. There are no major harmful effects or interactions for people with heart failure. 

Vitamin D is in fish, eggs and fortified dairy. It is generally well tolerated. Taking vitamin D for HF has shown mixed results. There has been some associated with decreased inflammation and improved ejection fraction in some age groups. It hasn’t been shown to improve survival or the ability to function. Its impact on quality of life is unclear. Routine use doesn’t seem to be harmful.

Yoga and tai chi are safe and well-tolerated in people with heart failure. In some studies, yoga, combined with standard medical therapy, was shown to: 

• Improve exercise tolerance
• Improve quality of life
• Reduce inflammation

In a small trial, tai chi lowered depression and improved:

• Exercise ability
• Adherence
• Self-confidence
• Quality of life
• Mood 

Both can be used with traditional medical care to improve exercise tolerance and quality of life.

Bitter orange is a fruit from Asia. It has been used for stomach issues. It has chemicals that can stimulate the nervous system. It can interact with some heart failure treatments, raising blood pressure and heart rate for up to five hours after taking it. This can make it harmful for people with heart failure.

Blue cohosh is a plant from eastern North America. It may cause an increase in heart rate, blood sugar and blood pressure.  Blue cohosh can also cause chest pain, which can be harmful to heart failure patients.

Devil’s claw is an herb, also known as wood spider. It can raise blood pressure and interact with warfarin, and cause clotting issues. This can be harmful to people with heart failure.

Ginkgo biloba is found in ginkgo tree leaves. Studies on its interaction with heart failure treatment are limited. It can interact negatively with warfarin and can increase the chance of bleeding. Other side effects include:

• Headaches
• Dizziness
• Palpitations
• Stomach issues
• Bleeding disorders 
• Skin rash

Gossypol is found in cotton plants. It has been used as a male oral contraceptive and treat and prevent malaria. It depletes potassium, which can cause heart and circulation problems. For people on digoxin, it can increase the digoxin levels. This can lead to stomach issues or serious heart problems, including slow heart rate or even death. It may be harmful for people with heart failure.

Grapefruit juice interacts with many heart failure medications, including:

• Amiodarone
• Carvedilol
• Dofetilide
• Sotalol

Grapefruit juice also affects statin medications used to treat high cholesterol. It reduces metabolism and increases the absorption of the medicine. These interactions can make grapefruit juice harmful for people with heart failure.

Khella is found in the dried, ripe fruit of the Khella plant. It can negatively affect heart failure outcomes and may be harmful for those with heart failure. It can reduce the effect of some HF medications. Side effects include:

• Nausea
• Dizziness
• Constipation
• Lack of appetite
• Headache
• Itching
• Insomnia
• Liver problems

Licorice can be found in black licorice, licorice-flavored diet gum, cough mixtures and licorice teas. It can cause harmful effects, including:

• Sodium retention
• High blood pressure
• Arrhythmias
• High potassium
• Cardiac arrest

Licorice is harmful for people with heart failure. The FDA advises against consuming more than 40-50 grams per day for more than two weeks. Red licorice does not contain the same harmful ingredient and does not pose a risk.

Digitalis glycosides in digoxin are found in lily of the valley. All parts of the plants are toxic, including the roots and berries. It has been used for mild heart failure and atrial fibrillation, especially in Eastern medicine. Lily of the valley can cause poisoning. Symptoms include:

• Nausea
• Palpitations
• Vision problems

Its effects can be increased with low potassium. So, it shouldn’t be combined with drugs that lower potassium, such as diuretics and steroids, without carefully monitoring potassium levels.

Yellow oleander and common oleander are evergreen shrubs. All parts of the plant are toxic. It can increase the risk of high potassium. Side effects include:

• Heart rhythm problems
• Confusion
• Fatigue
• Poor appetite
• Nausea 
• Vomiting
• Diarrhea 
• Blurred vision
• Changes in color perception

Strophanthus is an African plant. All parts are toxic, especially the seeds. It can increase the risk of high potassium and is harmful for people with heart failure. Side effects include:

• Heart rhythm problems
• Confusion
• Fatigue
• Nausea 
• Vomiting
• Diarrhea
• Blurred vision
• Changes in color perception

Vitamin E is found in plant-based oils, nuts, seeds, fruits and vegetables. It should be taken in moderation. More than 400 IU per day can increase the risk of heart failure.

Observational data suggest that low-to-moderate amounts of alcohol may lower the risk of developing heart failure. The U.S. Dietary Guidelines for Americans 2020-2025 defines moderate alcohol intake as two or less drinks per day for men and one or less drinks per day for women.

Regular drinking or alcohol abuse can cause cardiomyopathy and heart failure, even at lower amounts. Drinking more than 10 drinks per week can lead to new-onset atrial fibrillation in people with high blood pressure. It can also lead to an enlargement of the left ventricle of the heart.

Alcohol can cause: 

• Flushing
• Confusion
• Lack of coordination
• Blackouts
• Drowsiness
• Nausea
• Vomiting
• Abdominal pain 

Drinking a lot of alcohol may lead to dependency, malnutrition, dementia and cancers. Don’t drink alcohol if you are pregnant or breast-feeding.

Aloe vera is a gel from the leaves of aloe plants. It is generally used to soften dry skin. When eaten, it can act as a laxative. It may lower potassium levels and increase the risk of digoxin poisoning. If eaten, it might be unsafe for women during pregnancy or while breastfeeding or for people with heart failure. 

Caffeine is a stimulant found in coffee, tea, soda and energy drinks. It increases blood pressure and the effect of diuretics. With long-term use, caffeine can cause:

• Anxiety
• Diarrhea
• Upset stomach
• Headache
• Insomnia
• Muscular tremor
• Nausea
• Dependence

Studies disagree on the benefits of caffeine. Some show it’s helpful, but others show no effect on heart failure. Moderate caffeine consumption is usually safe, but the effects vary widely. For some people, it may cause faster, abnormal heart rhythms. 

Guar gum come from the seed of the guar plant. It can help with constipation. It may also decrease the amount of cholesterol and sugar absorbed in the stomach and intestines. It generally has no harmful effects, but it might reduce the absorption of some heart failure medications. It’s usually well tolerated, but can cause stomach issues. It seems safe during pregnancy and while breastfeeding, but studies are limited.

Hawthorn found in hawthorn leaves, flowers and berries. Studies on hawthorn and heart failure are limited. It may interact with digoxin, so it should be avoided. It does seem safe if used with angiotensin-converting enzyme (ACE) inhibitors and beta-blockers. There isn’t enough information on the safety of taking hawthorn during pregnancy or while breastfeeding.

The amino acid L-arginine is found in red meat, poultry, fish and dairy. It can lower blood pressure, but it is generally safe. However, starting L-arginine after a heart attack may increase the risk of death in older patients. So, L-arginine should be avoided after a heart attack. It seems safe during pregnancy at doses below 12 grams per day. There’s not enough evidence on its safety while breastfeeding.

Policosanol is found in beeswax, wheat germ, rice bran and sugarcane. It appears it may improve cholesterol. In heart failure patients, it can lower blood pressure and reduce the size of the left ventricle in those with metabolic syndrome and an enlarged left ventricle hypertrophy. More studies are needed to confirm its effectiveness.