Heart Failure
Manual of Clinical Nutrition Management III- 44 Copyright © 2013 Compass Group, Inc.
demonstrates that this level of alcohol consumption is not harmful to heart failure patients (Grade II) (3).
Patients who have alcoholism should avoid alcohol and seek alcohol rehabilitation.
Thiamin: Individuals who take more than 80 mg/day of loop diuretics, such as furosemide, have increased
urinary excretion of thiamin and may develop clinically significant thiamine deficiency. Thiamin deficiency
causes high-output cardiac failure (beriberi) and may exacerbate cardiac function in patients who have heart
failure (10). The patient should consume at least the Dietary Reference Intake (DRI) for thiamin through food
or supplements (Grade III) (3). Food sources high in thiamin include fortified cereals, bran, bread, and meats.
Folate: Heart failure patients should consume at least the DRI for folate through food or a combination of
vitamin B 6 , vitamin B 12 , and folate supplementation. Folate supplementation given with other vitamins and
minerals has beneficial clinical outcomes for patients who have heart failure (Grade II) (3).
Vitamin B 12 : A multivitamin and mineral supplement containing vitamin B 12 or a combination of vitamin B 6 ,
vitamin B 12 , and folate is recommended for heart failure patients. Vitamin B 12 supplementation (200 to 500
mcg/day) provided with other vitamins and minerals has beneficial clinical outcomes for heart failure
patients (Grade II) (3).
Minerals: Dietary minerals, including potassium, magnesium, and calcium, may be depleted due to diuretic
therapy. Food sources of these minerals include low-fat dairy products, fruits, vegetables, and whole grain
products. Heart failure patients should consume at least the DRI for these minerals from food sources or
supplements and should place a special emphasis on their magnesium intake (Grade II) (3). Low levels of
magnesium may be present in patients who have heart failure and can result in irregular heart rhythms (Grade
II) (3). The recommended potassium intake is 2 to 6 g/day, unless the patient has renal impairment or receives
a potassium-sparing diuretic such as spironolactone. The need for additional magnesium requirements in
heart failure patients is being evaluated (3).
Herbal supplements and over-the-counter dietary supplements: Heart failure patients should be
carefully evaluated for their use of herbal supplements and over-the-counter dietary supplements. The most
commonly used supplements used by heart failure patients include L-arginine, carnitine, coenzyme Q10, and
hawthorn (3). Limited evidence is available regarding clinical heart failure outcomes and the use of these
supplements (Grade III; except coenzyme Q10, grade II) (3). The risks and harms of taking supplements in different disease
states and with various medications should be thoroughly examined (3). For example, patients who take
warfarin (Coumadin) should be aware that coenzyme Q10 is chemically similar to vitamin K and can decrease
the effectiveness of warfarin (3). Hawthorn should be used cautiously in patients who take beta-blockers and
calcium channel blockers, as hawthorn may decrease blood pressure (3). In addition, hawthorn in
combination with digoxin can increase digoxin levels and increase the risk of side effects. Hawthorn in
combination with nitrates, which increase blood flow, may cause or worsen dizziness and lightheadedness (3).
Lastly, ephedra (ma huang), ephedrine, or its metabolites should be avoided due to an increased risk for
mortality and morbidity in heart failure patients (1). The clinician should use additional resources in
conjunction with evidence analysis documents for information regarding the potential side effects of these
supplements (3). Refer to Section II: “Food and Medication Interactions” and “Herb and Medication
Interactions” as needed.
Caffeine: Some studies have demonstrated that caffeine increases the heart rate and blood pressure and
causes dysrhythmias. More research is needed to assess the effect of caffeine on specific conditions. The
effects of caffeine intake on heart failure outcomes have not been studied. In addition, the latest guidelines
for blood pressure management do not address limiting caffeine as a recommended modifiable lifestyle factor
to reduce blood pressure (8). Because information is limited, it is recommended that heart failure patients use
caffeine in moderation and do not exceed 300 mg/day.
*The Academy of Nutrition and Dietetics has assigned grades, ranging from Grade I (good/strong) to Grade V (insufficient evidence), to
evidence and conclusion statements. The grading system is described in Section III: Clinical Nutrition Management A Reference Guide,
page III-1.
References
- Adams KF, Lindenfield J, Committee Members of the Heart Failure Society of America. Heart Failure Society of America 2006
Comprehensive Heart Failure Practice Guideline. J Card Fail. 2006;12:e1-e122. - Heart failure. In: Nutrition Care Manual. Academy of Nutrition and Dietetics; Updated annually. Available at:
http://www.nutritioncaremanual.org. Accessed February 7, 2013.