HFrEF patients can safely fast during Ramadan, but adherence to medication and diet is important
A study by Abazid et al presented at the Annual Conference of the Saudi Heart Association in Riyadh, Saudi Arabia on March 1-3, 2018 demonstrated that Islamic fasting is safe for patients with chronic heart failure with reduced ejection fraction (HFrEF). Although patients with chronic illnesses are exempt from fasting based on religious principles, most patients voluntarily choose to fast during Ramadan. The changes in dietary caloric intake and sleeping patterns may influence symptoms of HF, which has not been prospectively evaluated. This study therefore investigated the effect of Ramadan fasting on the symptoms of chronic HFrEF in 249 outpatients. Information on clinical assessment, diagnosis, emergency department visits and hospitalization during and in the month preceding Ramadan were obtained.
227 (91%) of the 249 patients enrolled, undertook the fast for the entire month. The vast majority (92%, 209 patients) remained hemodynamically stable, as 18 patients (8%) developed instability. The latter patients showed a lower NYHA functional class than the stable group (1.46±0.7 vs. 3.22±0.55, P <0.0001), although no intergroup differences were observed before Ramadan. Patients who became unstable showed significantly less adherence to medications (67% vs. 94%, P <0.0001) and to diet (39% vs. 79%, P <0.0001) than in those who remained stable. Moreover, the likelihood of demonstrating ischemic cardiomyopathy as an underlying etiology of HFrEF was lower in the unstable vs. stable patients (33% vs. 57%, p=0.046). Dependent t-test analysis including all patients showed that the NYHA classification before Ramadan was significantly higher than during Ramadan (2.19±0.9 vs. 1.6±0.8, t-value 8.5, P <0.0001).
These data suggest that Ramadan fasting is safe for most HFrEF patients. During this period, it is more difficult to maintain 8 to 12 hour dosing intervals for medications, which may cause variable therapeutic effects in patients, as a consequence of unpredictable pharmacodynamics of medications with shorter intervals. This study highlights the importance of patient education regarding diet/drug compliance to reduce the occurrence of decompensated HF during fasting. Also, the importance of a low-sodium and fluid-restricted diet should be emphasized. Physicians may consider alterations in drug regimens, for instance by changing to a once-daily dosing rather than a multiple-daily regimen.