How can nutrition help patients with cardiac diseases

V. Biourge DVM PhD Dipl ACVN&ECVCNHealth and Nutrition Scientific Director

R&D, Royal Canin SAS, Aimargues, France

Thanks to D. Elliott, DVM PhD Dip ACVIM&CVN

Courtesy of V Chetboul

Nutrition and cardiac disease

• « Let food be thy medicine »Hippocrates (460-377 BC)

• Nutrition and cardiac disease Strong evidences in human medicine. Little support in veterinary medicine.

• Poor palatibility of the historical diet.• Na content as the main emphasis.

Importance of Nutrition• Anorexia will not support recovery.• Importance of a complete and balanced diet to support animal

maintenance.• Essential role of nutrients for normal cardiac function

– Taurine, Carnitine, n-3 fatty acids, antioxidants, …

Research & Development Confidential information - Mars Inc

Nutrition and cardiac disease

Role of nutrition in cardiac disease:• Provide nutrients and

energy requirements.• Pharmacological actions

of nutrients.• Slow progression of

heart failure.• Extend a symptom-free

quality of life.

Energy

• Adapt energy to body weight and BCS

• Overweight cardiac patients cardiac workload and risk of

congestive heart failure. Exercise intolerance. Weight reduction improves

respiratory function

• Disproportional weight loss Patients with more advance disease. Predominate loss of lean body mass Cardiac cahexia: 54% of DCM cases

LM Freeman

LM Freeman

Cardiac Cachexia

Royal Canin, Canine Clinical Encyclopedia, 2004

Cardiac Cachexia

• Pathophysiology Anorexia Metabolic alterations (cytokines) Increased energy expenditure Poor tissue perfusion

• Exacerbate weakness and exercise intolerance

• Catabolism of cardiac muscle may contribute to progression

• Associated with immune system dysfunction

Royal Canin, Canine Clinical Encyclopedia, 2004

Cytokine dysregulation

• Dogs with heart failure have increased levels of TNF

• TNF correlates with severity of cardiac cachexia

• IL-I inversely correlates with survival

0

5

10

15

20

25

30

-2 -1 0 1 2 3

Change in IL-1 (ng/ml)

Sur

viva

l (m

onth

s)

Freeman et al, 1994Freeman et al, 1998

R = -0.52P = 0.02

Changes in IL-1 and Survival in 21 Dogs with DCM

Anorexia

• Causes of anorexia include Fatigue or dyspnea Medication toxicity Poor diet palatability Early management may help to

reduce the risks of anorexia and cachexia

• Prevalence 33% of CHF dogs had only fair or

poor appetite. 84% of dogs experience anorexia

during disease. Dogs with DCM ate only 72-84%

of expected caloric intake. Important reason influencing

euthanasia decision.0

500

1000

1500

2000

2500

Week 2 Week 4 Week 6

kcal

/day

Actual calorie intake Expected calorie intake

Food Intake in 21 dogs with DCM

Freeman et al, 1994Freeman et al, 1998

Promoting Food Intake

• Target: 70 -95 Kcal/kg0,75

• Highly palatable, energy dense foods Protein, Fat, Sodium

• Warm foods prior to feeding• Texture

Dry Vs Moist

• Assisted feeding• Tube feeding

Protein

• Some cardiac diets are severely protein restricted to reduce “metabolic stress” No evidence to support this

theory• Protein restriction may

contribute to Muscle loss and weakness Cardiac cachexia Exercise intolerance Poor quality of life

• Provide cardiac patients with adequate dietary protein– Dogs: > 50 g/1000 Kcal ME– Cats: 60-70 g/1000 Kcal ME

Series10

1

2

3

4

5

6

7 Royal Canin cardiac

Hills h/d can

Hills h/d Dry

Purina CV can

Pro

tein

(g/

100

kcal

)

AAFCO

Royal Canin, Canine Clinical Encyclopedia, 2004

Taurine

Essential a.a. in cats• Beta -amino sulfonic acid

H+3 N - CH2 - CH2 - SO-

3

• Not a part of proteins

• [Taurine] in cells very high

• Role: Intracellular osmolality Calcium concentration Transmembrane ion fluxes Positive inotrope

Pion et al, 1987

250-500 mg/1000 kcal

Taurine

Research & Development Confidential information - Mars Inc

Low level of synthesis Obligate losses

Taurine

• Taurine deficiency reported in dogs with DCM– American Cocker Spaniel– Portuguese Water Dog– Low or poorly available Met+Cys

• Certain lamb based diets• Vegetarian diets• Severely protein restricted diets

• Cardiac diets should contain supplemental taurine– 250-500 mg/1000 Kcal ME

Kittleson 1997; Freeman 2000, Torres 2000, Sanderson 2001

Carnitine

• Present in highest concentrations in the heart and skeletal muscles.

• Facilitates the transport of long chain fatty acids (LCFA) into the mitochondria– Normal heart obtains 60% of its

energy from fatty acid oxidation• Carnitine deficiency reported in

Boxers, Doberman Pinchers, American Cocker Spaniels

• Patients often have normal plasma [carnitine] with low intramyocardial levels– ?Membrane transporter defect

• Improvement within weeks of supplementation

• Carnitine may help improve myocardial energy production

• 50-100 mg/kg PO TID

L-arginine

• Essential amino acid for dogs and cats

• Precursor of nitric oxide (endothelium-derived relaxation factor)

• nitric oxide endothelial dysfunction peripheral blood flow exercise intolerance

• Arginine supplementation in humans with CHF has been reported to

– Increase endothelial nitric oxide levels– Improve endothelium-dependent vasodilation– Improve cardiac output– Increase renal function– Improve exercise tolerance– Decrease dyspnea

• Cardiac diets should have adequate arginine

– NRC RA = 0,88 g/1000Kcal– Cardiac diets = 3-5,6 g/1000 Kcal

Wang et al, 1997

Fat

• Very good source of energy9 Kcal/g Vs. 4 for Prot – CHO

• Essential components for life: phospholipids, sterols, ecosanoïds, …

• Source of essential fatty acids.-3 and -6 fatty acids

• Fish oils have been shown to decrease TNF and IL-1 in human patients Inhibition of pro-inflammatory

arachadonic acid metabolites Direct inhibition on gene transcription

Dogs 7%Cats 0%

EPA DHA0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

2

Healthy (n = 5)

Heart Failure (n = 5)

Con

cent

rati

on (

%)

-3 Polyunsaturated Fatty Acids

Dogs with heart failure have low concentrations of EPA (c20:5n-3) and DHA (c22:6n-3)

*

** P < 0.05

Freeman 1998

-50

150

350

550

750

950

1150

1350

1550

1750

1950

EPA DHA

% B

asel

ine

Cha

nge

Placebo

Supplemented

* P < 0.05

*

*

Fish oil supplementation – Increases EPA and DHA in

dogs with DCM– Decreases arachidonic acid

-3 Polyunsaturated Fatty Acids

• Supplementation with fish oils– Reduced IL-1 and TNF in

dogs with DCM– Improved cachexia and

anorexia – Reduced arrhythmogenesis

• cytokines is associated with a lower risk of cardiac cachexia and increased survival of cardiac patients

Freeman 1998

-3 Polyunsaturated Fatty Acids

Sodium

• Sodium restriction Reduce fluid retention Minimize congestion

• When should we institute sodium restriction?

• What level of restriction should we implement?

Pathogenesis of Na Retention in Heart Disease

Dietary sodium

Research & Development Confidential information - Mars Inc

Dietary sodium

Research & Development Confidential information - Mars Inc

Royal Canin, Canine Clinical Encyclopedia, 2004

Sodium

Rush et al, 2000

-0,8

-0,6

-0,4

-0,2

0

0,2

0,4

0,6

cm

LS (0.4g/1000kcal)

MS (0.7g/1000Kcal)

• * = P<0.05 • LA = standard left atrial dimension• maxLA = maximum left atrial dimension;• LVIDd/s = left ventricular internal dimension in diastole / systole

*

*

**

Sodium

• Activation of RAA system occurs early in cardiac disease– Increases ventricular preload and

afterload– Cardiotoxic effects

• May be exacerbated by sodium restriction

• Severe restriction in association with ACE-inhibitor therapy in early cardiac disease could hasten progression

Pedersen 1995

Potassium

Hypokalemia Hyperkalemia

Diuretics e.g.furosemide

Anorexia

ACE-Inhibitors

High K+ diets

Muscle weakness ArrhythmogenesisDigitalis toxicity

Cardiac arrest

NRC RA = 1,1 g/1000 kcalCardiac diets = 1,8 – 2,0 g/1000 kcal

Potassium

• 60% of dogs on low sodium/potassium diet, furosemide, digoxin and captopril developed hyperkalemia

• Cardiac patients should receive a normal dietary K content 1-1,5 g/1000 Kcal

• Monitor serum potassium concentrations

Roudebush 1994 Mark E Peterson, 2011

Magnesium

• Involved in – Carbohydrate and fatty

acid metabolism– Protein and nucleic acid

synthesis– Energy conversion – Cardiac and smooth

muscle contractility• Cardiac drugs (i.e. loop

diuretics, digoxin) are associated with magnesium depletion

Magnesium

• 50% of Cavalier King Charles Spaniels with heart failure were magnesium deficient

• Hypomagnesemia is associated with– Hypertension, coronary artery

disease– Congestive heart failure – Cardiac arrhythmias, decreased

cardiac contractility– Muscle weakness

• Cardiac patients should receive diets with adequate magnesium concentrations

Pedersen et al 1998

NRC RA = 100 mg/1000 kcalCardiac diets = 100 – 320 mg/Mcal

B-Vitamins

• B-vitamins are water soluble– Diuresis

• Cats with cardiomyopathy have decreased concentrations of vitamin B6 and B12

• B12 correlates correlates with left atrial size– Involved in pathogenesis

or promotion of heart disease in cats?

0500

10001500200025003000350040004500

pmol

/ml

B6 B12

HealthyHCM

*P < 0.05

*

*

Plasma Concentrations of Vitamins B6 and B12 in 27 Cats with

Cardiomyopathy compared with 29 Healthy Cats

McMichael et al 2000

Oxidative Stress

Freeman et al, 1999

Heart failure class

% o

f co

ntro

l

MDAVit EVit C

I II III IV

Oxidative Stress and Antioxidant Concentrations in 18 Dogs With DCM

**

* *

* P < 0.05

Vitamin E; r = -0.51, p = 0.03

0

50

100

150

200

250

Antioxidants

• Free radicals– Cytotoxic– Negative inotropes

• Free radical injury implicated in development and progression of – Coronary artery

disease– Myocardial infarction– Cardiomyopathy

How Can Nutrition Help?

High palatability & Maintain appetite &energy density avoid cachexia

“Normal” protein Restriction may contributecontent to cachexia and muscle loss

Taurine Beneficial in DCM?

L-arginine Improved endotheliumdependent vasodilatation

Carnitine Improve myocyte energy production

w-3 PUFA Reduced inflammatory cytokines, anorexia

Reduced arrhythmogenesis

How Can Nutrition Help?

Moderate potassium Avoids hypo & hyperkalaemiacontent Compatible with therapy

Staged sodium Reduced sodium andrestriction water retention

Magnesium Avoids deficiency

Antioxidants Combat oxidative stress

B vitamins Avoids deficiency

If you want to know more …

Obrigado …

www.ivis.org