Congestive Heart Failure: A Natural (Integrative) Approach

Heart failure (HF) is a syndrome of cardiac dysfunction in which the heart can no longer pump enough blood around the body to support its organs and systems. Identified risk factors for HF include conditions that damage the heart, such as hypertension, coronary heart disease, heart attack, chronic alcohol abuse, and diabetes. HF afflicts over 5 million persons in the United States, at a cost of over $30 billion yearly.

Myocardial Bioenergetics

The potential to therapeutically augment cardiac function and reduce morbidity and mortality in HF by specifically altering myocardial metabolism has tremendous appeal and growing support from the scientific literature. This approach, combined with therapeutic lifestyle strategies, addresses the root cause of the dysfunction and has the potential to bring about improved function and quality of life without side effects.

The “Awesome Foursome”

Dr Stephen Sinatra may be given credit for popularizing a metabolic therapy approach to HF in 1990s when he began using supplements in his cardiology practice to restore cardiac energy production. These agents will be featured here as primary therapeutic interventions that seek to address the unique needs of this crucial organ.

1) Coenzyme Q10

An antioxidant and critical component of cardiac energy production, CoQ10 is concentrated in healthy heart muscle and can become deficient in patients suffering from HF.  A study assessing CoQ10 supplementation (60-200 mg/day) over 1-6 months, found there was a 4% increase in ejection fraction (heart strength) using CoQ10 supplementation. The most definitive evidence, the Q-SYMBIO study, was a placebo-controlled, double-blind, randomized trial of patients with chronic HF. In this study, 420 HF patients were randomized to CoQ10 (100 mg TID) or placebo and followed for 2 years. However, the long-term, primary endpoint of major adverse cardiovascular events was reached by 26% of the placebo, vs only 15% of the CoQ10 group. In addition, cardiovascular mortality, all-cause mortality, and incidence of hospital stays for chronic HF were significantly lower in the CoQ10 treatment arm.

2) L-Carnitine

A 2000 study showed statistically significant improvements in mortality rate among HF patients supplemented with L-carnitine (2000 mg/day), compared to placebo. A 1988 study also found 2000 mg/day to have therapeutic benefit in HF. As L-carnitine is now known to have the potential to raise the blood levels of TMAO, I monitor this blood test when using TMAO as it may be problematic to raise TMAO blood concentrations.

3) D-Ribose

D-Ribose is a sugar used by the heart to produce energy (ATP). A 1992 study of stable but severe coronary artery disease patients found that supplementing these patients with D-ribose enabled them to increase their “ischemic threshold” and exercise longer with fewer symptoms.  It is usually used as 5 grams 2-3 times a day.

4) Magnesium

Magnesium is a crucial cofactor in many pathways involved with cardiac energy. Given that magnesium has effects on over 300 enzymatic processes and is the second most abundant intracellular cation (next to potassium) in the human body, the mineral certainly plays a significant role in human health beyond its impact on heart function.  A recent double-blind, placebo-controlled study also showed magnesium orotate supplementation over the course of 1 year to improve survival rate in severe HF patients by nearly 25%, while also significantly improving their symptoms and quality of life.

Additional therapies

Taurine is a sulfur-containing amino acid that may augment the role of conventional medications for HF. In a randomized study of placebo vs taurine supplementation in HF, at a dose of only 500 mg TID over 2 weeks, various aspects of exercise performance increased significantly in patients receiving the active supplement.

Berberine is a quaternary ammonium salt found in medicinal plants such as goldenseal, Oregon grape root, and coptis. In a study of 156 patients with CHF, in which all patients were given conventional medications for the disease, those who were also given 1.2-2 g of berberine per day experienced improvements in ejection fraction, exercise capacity, and dyspnea, as well as a decrease in the frequency of complex premature ventricular contractions (PVCs), compared to the placebo group.

Famotidine is the generic version of a popular antacid drug known as Pepcid AC. Several studies using 20-40 mg daily of famotidine improved symptoms and measurements of heart function in HF.

Astaxanthin is an antioxidant from nature. In a recent study in Japan, astaxanthin added to standard HF therapy improved the strength of the heart and also improved walking duration. 


Heart failure is a serious disorder that can cause great suffering and shorten life. There have been many advances in the drug therapy of HF. For those inclined, the natural therapies outlined here offer an integrated approach that may improve myocardial bioenergetics, left ventricular function, and quality of life even when added to standard therapies of HF.

Dr. Joel Kahn

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