Patients should continue low fluid and salt intake
Doctors advised to prescribe once daily medications
Ramadan fasting can be safe for patients with heart failure, according to research presented today at the 29th Annual Conference of the Saudi Heart Association (SHA29), held 1 to 3 March in Riyadh, Saudi Arabia. Experts from the European Society of Cardiology (ESC) will present a special program.
More than one billion Muslims worldwide abstain from food, drink, and oral medications from dawn to sunset during the holy month of Ramadan. Patients with chronic illnesses are exempt but most elect to fast. The fasting period typically lasts 15 to 16 hours, and two meals are eaten during the night.
Symptoms of heart failure include shortness of breath, ankle swelling, and fatigue. Patients are advised to limit daily intake of fluid to less than two litres and sodium to less than 2500 mg. Medications include angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs), beta blockers, diuretics and digoxin.
"Patients with heart failure frequently ask their doctor if it is safe to fast but until now we didn't have any evidence on which to base our advice," said author Dr Rami Abazid, cardiologist, Prince Sultan Cardiac Centre, Qassim, Saudi Arabia.
This prospective observational study examined the effect of Ramadan fasting on symptoms of patients with chronic heart failure and reduced ejection fraction (less than 40%). The researchers assessed adherence to fluid and salt restrictions, medication use, and symptoms before, during, and after Ramadan.
The study included 249 outpatients from three heart failure clinics who had planned to fast during Ramadan in 2017. A total of 227 (91%) patients fasted for the duration of Ramadan. Of those, 209 (92%) had no changes or improved symptoms, while symptoms worsened in 18 (8%) patients. Hospitalisation and emergency department visits were more frequent in patients with worsening symptoms compared to those with stable or improved symptoms (39% versus 0%, p≤0.0001 and 50% versus 10%, p≤0.0001, respectively).
The study found that patients with worsening symptoms were less likely to have adhered to fluid and salt restrictions (39% versus 79%, p<0.0001) and were less adherent to heart failure drugs (67% versus 94%, p<0.0001) than those with stable or improved symptoms.
Dr Abazid said: "Patients who don't follow the fluid and salt recommendations during Ramadan report that it is because of the increase in socialising. When they visit friends the food has a normal or high salt content, and they drink a lot of fluids within a short period time, which can cause fluid shifts in the body."
Regarding non-adherence to medications, Dr Abazid said: "Some patients stop or reduce their use of diuretics because they are afraid of being thirsty during fasting hours. In addition, for medications that should be taken twice daily they either omit one dose or take both doses together."
Dr Abazid said: "Ramadan fasting is safe for most patients with chronic heart failure and reduced ejection fraction. My advice to patients is to adhere to fluid and salt restrictions, and do not omit any doses of drugs. For drugs with two daily doses, take them with as wide a gap as possible during non-fasting hours."
"If feasible, we advise doctors to shift patients to drugs with a single daily dose that can be taken during non-fasting hours," he continued. "This is possible for most heart failure medications."
The study excluded patients with an ejection fraction of 40% or more, recently diagnosed patients (less than three months), and patients with advanced heart failure (two emergency visits in the past three months, or three visits in the past six months). The results do not apply to these groups.
Dr Abazid concluded: "More research is needed to see if our results apply in colder climates."
Dr Mouaz Al-Mallah, head of scientific abstracts of SHA29 and head of Cardiac Imaging, King Abdul-Aziz Cardiac Centre, Riyadh, Saudi Arabia, said: "This important study provides preliminary evidence to guide doctors when advising their Muslim patients with heart failure who would like to fast. More research is needed to confirm these findings. It is important that patients adhere to their medications during fasting and ask their doctors to adjust the doses as needed, especially diuretics."
Professor Marco Roffi, course director of the ESC program in Riyadh and head of the Interventional Cardiology Unit, Geneva University Hospital, Geneva, Switzerland, said: "Medication, salt and fluid intake are the cornerstone of heart failure treatment and can be influenced by fasting during Ramadan. The authors of the study have to be commended for exploring the field and the results of their investigation are reassuring. However, more research is needed to define which patients with heart failure may safely fast during Ramadan and whether there are subgroups for whom Ramadan fasting may represent a health hazard."