As promised… here is a little tweetorial on my case presentation on plant based nutrition and cardiac reverse remodeling! 
To be noted: I know nutrition can be wildly controversial. Plant based nutrition happens to be the dietary intervention that has worked in my practice, and I do recognize there are many different ways to be healthful and help our patients. This happens to be one of them 🙂
48 year old male with a past medical history of CAD s/p STEMI 2016, PCI to LAD, repeat instent thrombosis 2017 (on DAPT) HFrEF (30%) s/p primary prevention ICD, presented to establish care in Aug 2018.
Patient was NYHA Class II, had already been optimized on maximally tolerated standardized guideline directed medical therapy for HFrEF for 2 years (beta-blocker, angiotensin-converting enzyme inhibitor, mineralcorticoid receptor antagonist)
Medical Hx
The patient was euvolemic and well compensated at presentation in our clinic. We made NO changes to his already optimized medications/doses. The patient elected to start a whole food plant based diet. He followed up with us in 6 months.
After 6 months of a plant based diet, some impressive changes
And… changes in TTE *Reminder: this patient had already been optimized for 2 yrs on GDMT before presenting to our clinic. We made NO changes in medications. The ONLY change in 6 months was dietary intervention with a plant based diet.
Most importantly: patients symptoms and QOL have improved drastically. He completed >11 minutes of Bruce Protocol, and states he has had no anginal symptoms since dietary change.
We know that activation of neurohormonal & sympathetic systems can potentiate remodeling of the myocardium, leading to abnormal cardiac geometry and progressive dilatation, and assoc with increased cardiovascular events, hospitalizations of HF, worsening symptoms, and death.
Standardized GDMT have improved CV outcomes and mortality and have also demonstrate the ability to affect a variable degree of cardiac reverse remodeling. But despite optimized GDMT, a subset of chronic HFrEF patients do not demonstrate appreciable CRR.
Which suggests additional mechanisms contribute to chronic HF, possibly inflammatory pathways. Well recognized data demonstrates that elevated proinflammatory cytokines including TNF-α, IL-1, IL-6, are closely correlated with chronic HF.
What could be the potential mechanism by which plant based nutrition aids in CRR? Nutritional factors are major contributors to HF precursors including hypertension, OSA/OHS, obesity, dyslipidemia, insulin resistance/T2DM, and systemic inflammation.
A plant based diet has been found in numerous studies to reduce CV risk factors such as T2DM, HTN, HLD, and obesity which contribute to HF incidence.
On a molecular level: ROS induce myocyte hypertrophy, aortic stiffness, apoptosis, & interstitial fibrosis, potentially contributing to the progression of HF may reduce myocardial contractility.
An inverse relationship between anti-oxidant uptake & heart failure has been described. And plant-based diets are rich in anti-oxidants and reduce ROS.
Plant-based diets are assoc w/ decreased serum concentrations of the inflammatory biomarkers, C-reactive protein, soluble intercellular adhesion molecule-1, and interleukin-6.
A plant based diet naturally decreases intake of trans fat and saturated fat, which may be beneficial in reducing inflammation as seen in several studies:
N=42 HF patients
Higher saturated and trans fat intake -> higher systemic inflammation & proinflammatory cytokine levels (tnf-α)
J Card Fail. 2005 Oct; 11(8):613-8
Higher saturated and trans fat intake -> higher systemic inflammation & proinflammatory cytokine levels (tnf-α)
J Card Fail. 2005 Oct; 11(8):613-8
N=86 ambulatory patients w/ HF
Elevated plasma trans fatty acids were strongly associated with elevated markers of systemic inflammation: interleukin (IL) 1beta, IL-6, TNF α, monocyte chemoattractant protein, & elevated BNP
Am J Clin Nutr. 2004 Dec; 80(6):1521-5
Elevated plasma trans fatty acids were strongly associated with elevated markers of systemic inflammation: interleukin (IL) 1beta, IL-6, TNF α, monocyte chemoattractant protein, & elevated BNP
Am J Clin Nutr. 2004 Dec; 80(6):1521-5
Additionally - oxidized LDL-C is cytotoxic to endothelial cells, promotes chemotaxis of monocytes & T-cells, which leads to endovascular inflammation and atherogenesis, attenuates the response of endothelial cells to nitric oxide.
A plant-based diet may lead to a decrease in total LDL-C and LDL-C particles that are more resistant to oxidation.
There are countless more mechanisms and reasons why a plant based diet may be beneficial in heart failure and CRR, but no RCT has been conducted as of yet. So we are doing it @PPirlamarla_MD @AVishnevsky_MD @RJAjr Stay tuned 🙂
