Published on 22.03.2023
Depending on the stage of heart failure, nutrition can influence the development and progression of the disease in different ways: from over-nutrition in early, to malnutrition in advanced stages.
| Table 1: Characteristics of heart failure stages with possible dietary interventions | |||||
| NYHA HF severity | I | II | III | IV | |
| ACC/AHA stage | A | B | C | C | C/D |
| Cardiac | No structural heart disease but at high risk Compensated | Structural heart disease but no symptoms Compensated, beginning adaptation | Structural heart disease but no symptoms, preserved ejection fraction Compensated, adaptation | Known structural heart disease with symptoms, reduced ejection fraction Only partially compensated, remodelling | Marked HF-symptoms/signs, not compensated, markedly reduced ejection fraction, recurrent hospitalisation |
| Respiratory | No | No worsening of dyspnoea | Dyspnoea with activity | Dyspnoea with activity or at rest, dry hacking cough | Dyspnoea at rest, frequent dry hacking cough |
| Circulatory | No swelling of extremities | No (new) swelling of extremities | Beginning congestion. Increased swelling of extremities | Congestion. Increased swelling of extremities and abdomen | Increased discomfort/ swelling of extremities and abdomen |
| Physical activity | Not limited | Not limited | Slightly limited | Markedly limited | Only possible with discomfort |
| Frequently associated risk factors/diseases | Hypertension, dyslipidaemia, impaired fasting or post-prandial glucose regulation, obesity | Hypertension, dyslipidaemia, impaired fasting or post-prandial glucose regulation, obesity, arteriosclerosis | Hypertension, dyslipidaemia, impaired fasting or post-prandial glucose regulation, obesity, arteriosclerosis, coronary heart disease, diabetes | Frequent comorbidities (diabetes, COPD, renal failure, stroke, depression, anaemia) | Various comorbidities and polymedication |
| Sleep | Not impaired by risk | Not impaired by disease | Mostly unaffected by disease | Trouble sleeping | Increased trouble sleeping. Cannot lie flat |
| Mental | Unaffected | Unaffected | Mostly unaffected | Sadness, depression possible | New or worsening dizziness, confusion, depression |
| Weight | Increased fat mass, steady increase likely | Increased fat mass, steady increase likely | Over- or normal weight, low lean body mass likely | Unintended weight loss (lean body mass) or sudden weight gain (>1–1.5 kg/24h or 2.5 kg/week) possible | Cachexia, frailty, sarcopenia (BMI <20 kg/m2): unintended oedema-free weight loss (lean and fat body mass of 7.5% in 6–12 months) or sudden weight gain (>1–1.5 kg/24h or 2.5 kg/week) possible |
| Diet | Potentially unbalanced, hypercaloric diet likely, high intake of ultra-processed food | Potentially unbalanced, hypercaloric diet likely, high intake of ultra-processed food | Potentially unbalanced, hypercaloric diet likely, high intake of ultra-processed food | Higher probability of protein intake <0.8 g/kg/day micronutrient-deficiency possible, despite positive energy balance | Loss of appetite, protein-energy malnutrition, unbalanced/unstructured diet, decreased intake of iron and other micronutrients |
| Dietary intervention to consider | If BMI ≥30 kg/m2: Individualised (by dietician) calory restricted diets (continuous, intermittent fasting) with specific dietary/weight loss goals Consider pharmacotherapy or bariatric surgery if unsuccessful Mediterranean diet/DASH-diet Salt restriction if BP and intake is high and age ≥65y Avoid excessive alcohol intake | If BMI ≥30 kg/m2: Individualised (by dietician) calory restricted diets (continuous, intermittent fasting) with specific dietary/weight loss goals Consider pharmacotherapy or bariatric surgery if unsuccessful Mediterranean diet/DASH-diet Salt restriction if BP and intake is high and age ≥65y Avoid excessive alcohol intake | If BMI ≥30 kg/m2: Individualised (by dietician) dietary recommendations Avoid weight gain if BMI ≥30 kg/m2 Mediterranean diet/DASH-diet Prevent malnutrition | Avoid weight gain if BMI ≥30 kg/m2 Screen for malnutrition and micronutrient deficiency: supplementation if necessary Increase protein intake (to ≥1.1 g/kg/d) if intake <0.8 g/kg/day and/or BMI <20 kg/m2 Adapt fluid intake if necessary | Tailored (by dietician) nutrition plan and micronutrient supplementation, enteral/parenteral nutrition. IV-iron supplementation when anaemic or low ferritin concentration. Protein (to ≥1.1 g/kg/d), essential/branched-chained amino acid supplementation to prevent catabolism Adapt fluid intake if necessary |
| ACC, American College of Cardiology; AHA, American Heart Association; BMI, Body Mass Index; DASH, Dietary Approach to Stop Hypertension; HF, heart failure; NYHA, New York Heart Association functional classification | |||||
| Table 2: Heart nutritional recommendations by society guideline (adapted from [10]) | ||||
| Target | HFSA 2010 | ACC/AHA 2013ACC/AHA/HFSA 2017 | ESC 2021 | AND 2017 |
| Obesity | Provide specific weight loss diet instructions (B) | – | Consider weight loss if BMI 35–45 kg/m2 | Weight loss for stage B & C HF with obesity (Weak) |
| Cachexia | Provide caloric supplementation (C) | – | – | Provide ≥1.1 g/kg/d protein to prevent catabolism (Fair) |
| Salt (NaCl) | 5–7 g/d (or <5 g/d if refractory hypervolaemia) (C) | <7 g/d (class IIa, C) | Avoid intake >5 g/d | 5–7 g/d (Fair) |
| Fluid | <2 l/d for serum sodium, <130 mEq/l or diuretic resistance | 1.5–2 l/d for stage D HF, especially with hyponatraemia (class IIa) | 1.5–2 l/d may be considered in patients with severe HF/hyponatraemia | 1–2 l/d (Fair) |
| Energy | – | – | – | Recommend 22 kcal/kg or 24 kcal/kg malnourished or based on REE |
| Protein | – | – | – | Individualised, but ≥1.1 g/kg/d (Fair) |
| Thiamine/Vitamin D supplements | NA | NR | NA | NR (Weak) |
| Nutritional supplements | NR (B) | NR (class III, B) | NA | NR (Weak) |
| Folate, vitamin B6 & B12 supplements | Consider daily multivitamin and mineral supplementation for those on diuretic therapy and restricted diets (C) | NR | NA | NR (Weak) |
| Iron | Intravenous iron can be considered for documented deficiency | 2017 update: intravenous iron reasonable in NYHA II-III HF and iron deficiency (ferritin <100 ng/ml or 100 to 300 ng/ml if transferrin saturation <20%) (class IIb, B) | Intravenous ferric carboxymaltose for symptomatic HFrEF patients and iron deficiency (ferritin <100 ng/ml or 100–299 ng/ml if transferrin saturation <20%) (class IIa, A) | NR (Weak) |
| n-3 polyunsaturated fatty acid supplements | Reasonable as adjuvant therapy for HFrEF NYHA II-IV (B) | Reasonable as adjuvant therapy for HFrEF or HFpEF NYHA II-IV (class IIa, B) | – | NR (Weak) |
| ACC: American College of Cardiology; AHA: American Heart Association; AND: Academy of Nutrition and Dietetics; (B), (C), strength of evidence = B, C; BMI: Body Mass Index; ESC: European Society of Cardiology; HFpEF: heart failure with preserved ejection fraction; HFSA: Heart Failure Society of America; HFrEF: heart failure with reduced ejection fraction; NA: not addressed; NR: not recommended (for routine care); NYHA: New York Heart Association functional classification; REE: resting energy expenditure; (Weak), (Fair), strength of evidence = Weak, Fair; -, no (specific) recommendation | ||||
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