In the initial stages of CHF, natural measures designed to address the underlying cause (e.g., hypertension) or improve the metabolic functions of the myocardium (described later, as well as measures described in Chapter 145) are often effective. In later stages, however, medical treatment involving the use of diuretics and angiotensin-converting enzyme (ACE) inhibitors, digitalis glycosides, or both, is indicated in most cases. The measures described here can be used as adjunctive therapy in these more severe cases. The New York Heart Association (NYHA) staging system for CHF can be used in an effort to better identify likely respondents to natural therapy alone (Table 158-1). In general, excellent clinical results can be expected in stages I and II with the use of the natural measures described below.

STAGE	SYMPTOMS
Stage I	Patient is symptom-free at rest and with treatment.
Stage II	Patient experiences impaired heart function with moderate physical effort. Shortness of breath with exertion is common. There are no symptoms at rest.
Stage III	Even minor physical exertion results in shortness of breath and fatigue. There are no symptoms at rest.
Stage IV	Symptoms such as shortness of breath and signs such as lower extremity edema are present when the patient is at rest.

Nutritional Supplements

The natural approach focuses on improving myocardial energy production, as CHF is always characterized by a state of energy depletion. This impaired energy production is often the result of nutrient or coenzyme deficiency (e.g., magnesium, thiamine, coenzyme Q₁₀ [CoQ₁₀], carnitine). The dietary recommendations given in Chapter 174 are appropriate for most patients with CHF, especially if the CHF is due to long-term hypertension. Of particular importance is a diet low in sodium and high in potassium. A high intake of sodium greatly exacerbates the hemodynamic aspects of CHF. Sodium intake should be restricted to below 1.8 g daily. Furthermore, the dietary intake of several nutrients is usually well below recommended levels in patients with CHF.¹ Most notably low are magnesium, calcium, zinc, copper, manganese, thiamine, riboflavin, and folic acid. A high-potency multivitamin/multimineral formula is critical in these patients, especially if they are taking a diuretic.

In addition to providing benefits of its own in CHF, magnesium supplementation prevents the magnesium depletion caused by the conventional drug therapy for CHF (i.e., digitalis, diuretics, and vasodilators such as beta blockers and calcium channel blockers). Magnesium supplementation has even been shown to produce positive effects in CHF patients receiving conventional drug therapy even if serum magnesium levels are normal.³ However, magnesium supplementation is not indicated in patients with renal failure, as this condition predisposes them to hypermagnesemia—a significant risk factor for mortality.⁴ ACE inhibitors appear to produce a magnesium-sparing effect in patients on furosemide.⁵ Typical dosages are 200 to 300 mg one to three times per day of magnesium in the citrate form. Oral magnesium can be effective in raising white blood cell magnesium and potassium levels.⁶ It is highly important to monitor serum magnesium levels so as to prevent hypermagnesemia in patients with renal impairment as well as those on digoxin. Magnesium significantly reduces the frequency and complexity of ventricular arrhythmias in digoxin-treated patients with CHF even without the presence of digoxin toxicity, but too much magnesium may interfere with digoxin.⁷

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