A summary of the existing literature and clinical guidance from the American Heart Association.

Complementary and alternative medicines (CAMs) are frequently used in the USA and are substantially less regulated than traditional pharmaceuti­cals. Because of the proliferation of evidence­-based therapies for heart failure, particularly with reduced ejection frac­tion (HFrEF), clinicians need to know the existing evidence for the efficacy of CAMs – to the extent that it exists – and the potential for adverse drug interactions between traditional and alternative therapies in patients with HF. This recent AHA scientific statement summarises the existing literature and provides guidance for clinicians caring for patients with HF.

Key points include the following:
• some evidence supports the efficacy of omega­-3 polyunsaturated fatty acids in HF, which has garnered a level IIb recommendation (i.e. ‘may be considered’) in HF guidelines. Yoga and tai chi may be useful adjuncts to standard medical therapy. There is no evidence of efficacy for thiamine, vitamin C or vitamin D aside from addressing documented deficiencies
• agents that can interact with traditional HF therapies or worsen HF include alcohol, excessive caffeine, gossypol, grapefruit juice (an intestinal CYP­450 3A4 inhibitor), hawthorn, L­-arginine, high­-dose vitamin E, liquorice and glycoside­-containing plant species like lily of the valley, oleander and ouabain
• few patients who use CAMs report this to their clinicians, perhaps in some cases to avoid criticism. The authors recommend that clinicians engage in constructive dialogue with patients around CAM use and collaborate with nontraditional practitioners
• the body of evidence for CAM in HF is sparse; randomised trials of commonly used agents would be informative to patient care.

Comment: Given the common use of CAMs, a structured approach to eliciting information about their use among patients with HF is warranted. I will be asking all of my patients about their use of supplements and alternative therapies as part of my review of their medications to ensure that they are not taking those that could result in adverse effects. A more robust evidence base about the benefits and risks of CAM would allow clinicians to provide clearer guidance to their patients.

FREDERICK A. MASOUDI, MD, MSPH, MACC, FAHA
Chief Science Officer and Vice President of Research and Analytics, Ascension Health; Clinical Professor of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA.

Chow SL, et al. Complementary and alternative medicines in the management of heart failure: a scientific statement from the American Heart Association. Circulation 2023; 147: e4–e30.

This summary is taken from the following Journal Watch title: Cardiology