The Right Diet for Heart Failure

Finding Morsels for Success

Corresponding Author

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• acute heart failure
• cardiovascular disease
• diet
• heart failure
• Mediterranean diet
• outcome

Based on the recent guidelines by the European Society of Cardiology, dietary recommendations for the management of heart failure restrict 3 items: fluids, salt, and alcohol (1). However, for those afflicted with heart failure, there is no clear recommendation on the specific types of foods that should be consumed in greater or lesser quantities to improve morbidity and mortality.

In this issue of JACC: Heart Failure, Miró et al. (2) report on the results of the MEDIT-AHF (Mediterranean DieT in Acute Heart Failure) study, an investigation into whether adherence to the traditional Mediterranean diet (3) has benefits extending to those with known heart failure. Miró et al. dichotomized participants into adherent and nonadherent with the Mediterranean diet based on a validated questionnaire used in the PREDIMED (Prevención con Dieta Mediterránea) trial (3) that consisted of 12 questions related to specific food consumption and 2 questions on food intake habits—specifically targeting higher intake of olive oil, vegetables, fruit, nuts, and fish; and lower intake of red meat, animal fats, and sugar-sweetened beverages (4). There are 2 noteworthy findings—adherence to a Mediterranean diet does not impact all-cause mortality, but may reduce the likelihood of hospitalization after an episode of acute heart failure.

As the authors of MEDIT-AHF point out in the discussion, there is biological plausibility for the Mediterranean diet tempering the clinical syndrome of heart failure, namely, that the consumption of foods high in polyphenol and monounsaturated fat content could increase plasma nitric oxide and also act as antioxidants and anti-inflammatory agents that could have led to a decrease in admissions for heart failure. Earlier work from the PREDIMED investigators found that adherence to the Mediterranean diet was associated with lower circulating heart failure clinical biomarkers including N-terminal pro–B-type natriuretic peptide, oxidized low-density lipoprotein cholesterol, and lipoprotein (a) (5).

The signal in MEDIT-AHF for improved survival among those who consumed fewer carbonated beverages should not be quickly passed over. In the recently reported PURE (Prospective Urban Rural Epidemiology) cohort study examining dietary patterns in 18 countries from 5 continents, diets consisting of fewer carbohydrates were associated with improved mortality (6), mirroring dietary behaviors seen in the Mediterranean diet.

A few other issues merit consideration. First, the participants in MEDIT-AHF were from an older (mean age 80 years), highly comorbid population. In this study population, the competing risk of death is arguably very high, and thus examining dietary patterns in this patient population is less likely to elicit a mortality benefit. The question then is whether a benefit could still be observed more upstream, in a younger population that is not afflicted with as many comorbidities. In other words, adherence to the Mediterranean diet in a younger heart failure population with fewer comorbidities may yield an all-cause or heart failure-related mortality benefit.

Second, although mortality benefit remains the gold standard outcome in cardiovascular studies, the finding of fewer heart failure admissions is not insignificant. In an elderly population afflicted with heart failure, reducing heart failure admissions so that further time is spent at home, or with family, may be associated with improved quality of life—a goal that should not be underestimated for this population. Results from the Palliative Care in Heart Failure trial showed that interdisciplinary palliative care interventions improved quality of life, as well anxiety and depression scores, among advanced heart failure patients at 6 months of follow-up (7). Broadening these interventions to include lifestyle modifications such as the traditional Mediterranean diet thus may offer greater benefit for elderly patients with heart failure who wish to focus on comfort, happiness, and remaining out of the hospital. A reduction in heart failure admissions is also cost saving. By 2030, the annual cost of treating heart failure in the United States, the majority of which is associated with hospitalization, is expected to increase from $30.7 billion at the present time to more than $69.7 billion (8). Thus, simple adjustments to an elderly patient’s diet to reduce heart failure admissions can potentially save the American health care system a large sum of money and should be promoted.

Finally, despite the lack of an overall mortality benefit in this study, MEDIT-AHF can offer guidance into how future studies exploring dietary interventions may be conducted, especially in highly comorbid populations such as those with clinical heart failure syndromes. As opposed to a cohort design, a sufficiently powered randomized controlled trial with adequate follow-up could shed more definitive light on whether a mortality benefit may result from adherence to a Mediterranean diet, as alluded to in other dietary studies in heart failure patients (9).

MEDIT-AHF is thought provoking. The results offer space for further investigation into simple dietary modifications to improve heart failure morbidity and mortality. It also pushes the medical community to consider heart failure outcomes that should not be discounted in any way, such as quality of life and health care costs. Although seemingly small morsels of success, these outcomes could have potentially large benefits.

• 2017 American College of Cardiology Foundation