Complementary medicines: Heart failure

Heart failure (HF), also referred to as congestive cardiac failure, is present in 1–2% of the Australian population.¹ It is the end result of a number of different pathophysiological processes in which there is loss or impairment of functioning myocardial cells.²

HF is predominantly a disease of the elderly, present in 10% or more of people aged over 75 years.¹

Three complementary medicine options for the treatment of HF are coenzyme Q10, hawthorn extract and omega-3 supplements.

Coenzyme Q10

What is it?

Coenzyme Q10 (CoQ10) is also known as ubiquinone, ubidecarenone or ubiquinol. It is a naturally occurring enzyme cofactor for mitochondrial energy production in body cells.

Population studies have suggested an association between low tissue levels of CoQ10 and heart failure.

Evidence for heart failure

A 2013 systematic review of 13 small RCTs (n = 395) evaluated the impact of CoQ10 supplementation on ejection fraction (EF) and New York Heart Association (NYHA) classification in heart failure. The reviewers concluded that CoQ10 may improve EF, but additional well-designed studies that include more diverse populations are needed.³

A 2014 Cochrane Review of seven small heterogeneous RCTs (n = 914) assessed the efficacy of CoQ10 supplementation in heart failure. The reviewers found no clear effect of CoQ10 on improvement of clinical status (using NYHA classification) or exercise capacity. The reviewers concluded there was no convincing evidence to support or refute the use of CoQ10 for heart failure.⁴

A 2014 RCT (n = 420) evaluated CoQ10 as adjunctive treatment in chronic heart failure. The authors concluded that 2 years of treatment with CoQ10 is safe, improves symptoms and reduces major adverse cardiovascular events.⁵

Hawthorn

What is it?

Hawthorn is a shrub of the rose family of plants. Hawthorn berries have traditionally been used, but extracts of the leaves and flowers are most commonly used in modern complementary medicine.

Hawthorn is currently used mainly to treat heart failure, but few studies have been published since 2008.

Evidence for heart failure

A 2008 Cochrane Review of 14 RCTs, with meta-analysis of 10 RCTs (n = 855) concluded that there is a significant benefit for symptoms and physiological outcomes when hawthorn extract is used as an adjunct to conventional treatment for chronic heart failure. Two forms of hawthorn extract (WS1442 and LI132) were used.⁶

A 2008 RCT (n = 2,681) concluded that taking 900 mg hawthorn extract WS1442 daily for 24 months in combination with conventional treatment did not significantly reduce cardiac mortality or time to first cardiac event. In a subgroup with less compromised left ventricular function, WS1442 reduced the incidence of sudden cardiac death.⁷

A 2008 RCT (n = 120) concluded that taking 900 mg hawthorn extract WS1442 daily for 6 months in combination with conventional treatment provides no symptomatic or functional benefit.⁸

Suggested counselling advice

The maximum benefit for heart failure can take up to 16 weeks of daily use.^6,9

Omega-3

What is it?

Omega-3s are polyunsaturated fatty acids found mainly in seafood and some plants. They are components of cell membranes and substrates for the synthesis of eicosanoids (e.g. prostaglandins, leukotrienes, thromboxanes). Most research has focused on docosahexanoic acid (DHA) and eicosopentanoic acid (EPA). Seafood is the main source of DHA and EPA.

Evidence for heart failure

The 2015 National Heart Foundation of Australia position statement states^10,11:

• Dietary fish intake is associated with lower rates of heart failure.
• There is some evidence for a modest benefit from omega-3 supplementation, in addition to standard therapy, in heart failure.

The American Heart Association currently recommends omega-3 supplementation for prevention of hospitalisation and death in patients with heart failure.¹²

Suggested counselling advice

Fish oil or other omega-3 supplements can take weeks to months of daily use to produce benefits. Maximum anti-inflammatory effect may take up to 3 months.^9,13

Fish oil supplements can cause gastrointestinal upset (e.g. nausea, diarrhoea) and a fishy aftertaste.^9,13

Learn more

For more evidence-based information about these and other complementary medicines – including clinical notes on adverse effects, contraindications and interactions, as well as full references – refer to the Australian Pharmaceutical Formulary and Handbook 24th edition (APF24). APF is available in print or digital formats. Digital APF is available at apf.psa.org.au (subscription required).

References

1. Sahle BW, Owen AJ, Mutowo MP, Krum H, Reid CM. Prevalence of heart failure in Australia: a systematic review. BMC Cardiovasc Disord 2016;16:32.
2. Kemp CD, Conte JV. The pathophysiology of heart failure. Cardiovasc Pathol 2012;21:365-71.
3. Fotino AD, Thompson-Paul AM, Bazzano LA. Effect of coenzyme Q10 supplementation on heart failure: a meta-analysis. Am J Clin Nutr 2013;97(2):268–75.
4. Madmani ME, Yusuf Solaiman A, Tamr Agha K, et al. Coenzyme Q10 for heart failure. Cochrane Database of Systematic Reviews 2014, Issue 6.
5. Mortensen SA, Rosenfeldt F, Kumar A, et al. The effect of coenzyme Q10 on morbidity and mortality in chronic heart failure: results from Q-SYMBIO: a randomized double-blind trial. JACC Heart Fail 2014;2(6):641–9.
6. Guo R, Pittler MH, Ernst E. Hawthorn extract for treating chronic heart failure. Cochrane Database of Systematic Reviews 2008, Issue 1.
7. Holubarsch CJF, Colucci WS, Meinertz T, et al. The efficacy and safety of Crataegus extract WS 1442 in patients with heart failure: the SPICE trial. Eur J Heart Fail 2008;10(12):1255–63.
8. Zick SM, Gillespie B, Aaronson KD. The effect of Crataegus oxycantha Special Extract WS 1442 on clinical progression in patients with mild to moderate symptoms of heart failure. Eur J Heart Fail 2008;10(6):587–93.
9. Gregory PJ. Natural medicines. 2017. At: https://naturalmedicines.therapeuticresearch.com
10. Nestel P, Clifton P, Colquhoun D, et al. Indications for omega-3 long chain polyunsaturated fatty acid in the prevention and treatment of cardiovascular disease. Heart Lung Circ 2015;24(8):769–79.
11. National Heart Foundation of Australia. Healthy hearts position statement. Fish and seafood. 2015. At: heartfoundation.org.au/for-professionals/food-and-nutrition/position-statements
12. Siscovick DS, Barringer TA, Fretts AM, et al. AHA science advisory. Omega-3 polyunsaturated fatty acid (fish oil) supplementation and the prevention of clinical cardiovascular disease. Circulation 2017;135(15):e867–84.
13. eTG complete. Melbourne: Therapeutic Guidelines; 2017.