What is Heart Failure?

Before we discuss the role of ketones during heart failure, let’s define what heart failure is. Heart failure occurs when the heart becomes weak and pumps less blood than necessary to deliver adequate amounts of oxygen and nutrients to the body’s cells.  Heart failure is a progressive condition; to compensate for reduced flow from a weak heart pump, the heart becomes enlarged as it stretches to increase contractions in order to supply the blood that the body demands.  As the heart cells contract harder to increase blood flow, the cells become larger and, therefore, the muscle mass of the heart increases (A.K.A. myocardial hypertrophy).  Resting heart rate also increases, in order to pump blood faster into the body.  These mechanisms help for a time, but as the heart grows weaker, the blood supply from the heart becomes inadequate for the body’s demand.

Symptoms

Symptoms of heart failure include shortness of breath, fatigue, rapid heartbeat, swollen legs, chest pain, dizziness,and loss of appetite. Heart failure may result from an energy-starved heart, due to an unstable fuel supply.  Therefore, nutrition-related areas have been researched to determine the best way to provide energy for a weakened heart.

Can Ketones During Heart Failure Help?

Typically, a healthy adult heart is flexible in the fuel sources they can utilize for energy, often using fatty acids, glucose, and lactate.  Ketones or ketone bodies, when accessible, are a preferred source of energy for the heart, especially one that is failing.^[1] Ketogenic diets consumed for 3-15 weeks have been shown to reduce cardiac muscle hypertrophy, improve cardiac structure and function, and increase ejection fraction (the amount of blood pumped out of the heart per beat) in rats with heart failure.^[1]  Mouse studies have demonstrated that a ketogenic diet protects against heart failure^[2] and associated cardiomyopathy.^[3] A heart failure study in pigs demonstrated that a drug that shifted fuel metabolism in the heart, from glucose to ketone body utilization, improved the energy status and structure of the heart.^[4] Moreover, a human study demonstrated that the hearts of patients with heart failure utilize a substantial amount of ketone bodies (beta-hydroxybutyrate and acetoacetate) for fuel, possibly due to the fact that ketone bodies have been shown to be a more energetically efficient fuel source.^[5]

Beta-hydroxybutyrate dehydrogenase (BDH1) is an enzyme that catalyzes the interconversion of the ketones beta-hydroxybutyrate and acetoacetate, in order to be used for fuel. BDH1 has been implicated as an early biomarker for heart failure, as the heart may start to transition to utilize ketone bodies for fuel.^[6] Providing ketone bodies via a keto diet or ketone supplementation may provide more fuel for the heart, as it may become more primed to utilize ketones over other fuel sources.  In other words, increasing levels of ketones now means you won’t have to worry about using ketones during heart failure because you’ll be preventing it. In addition to providing an efficient fuel source, ketone bodies have been shown to increase blood flow in the hearts of healthy humans, which will allow for more nutrients to reach and energize the heart.^[7]

To conclude, research indicates that it would be worth discussing the possibility of implementing the ketogenic diet into your lifestyle with your doctor, if you or a loved-one struggles with heart failure. Currently, the American Heart Association considers heart failure incurable, and treatments to reduce some of the symptoms include prescription medications, eating less salt, limiting fluid intake, and/or surgically implanting a pacemaker.  A combination of treatments may be utilized in hopes of providing the best care to strengthen the heart and reduce symptoms.

References:

1. Zhang, Y., Taufalele, P. V., Lin, K. D., Cochran, J. D., Cassier, T., & Abel, E. D. (2017). Ketogenic Diet Rescues Heart Failure Induced by Loss of the Mitochondrial Pyruvate Carrier 1.

2. Nakamura, M., Odanovic, N., Dohi, S., Zhai, P., & Sadoshima, J. (2017). Ketogenic Diet is Cardioprotective Against Pressure-overload-induced Heart Failure.

3. McCommis, K. S., Gierasch, C. M., Kovacs, A., Weinheimer, C. J., Koves, T. R., Muoio, D. M., & Finck, B. N. (2017). Cardiac Deletion of the Mitochondrial Pyruvate Carrier Results in Dilated Cardiomyopathy with Preservation of Fatty Acid Catabolism.

4. Santos-Gallego, C. G., Ibanez, J. A. R., San Antonio, R., Ishikawa, K., Watanabe, S., Botija, M. B. P., … & Badimon, J. (2018). EMPAGLIFLOZIN INDUCES A MYOCARDIAL METABOLIC SHIFT FROM GLUCOSE CONSUMPTION TO KETONE METABOLISM THAT MITIGATES ADVERSE CARDIAC REMODELING AND IMPROVES MYOCARDIAL CONTRACTILITY. Journal of the American College of Cardiology, 71(11), A674.

5. Voros, G., Ector, J., Garweg, C., Droogne, W., Van Cleemput, J., Janssens, S., & Vermeersch, P. (2017). Increased Cardiac Uptake of Ketone Bodies and Free Fatty Acids in Human Heart Failure and Hypertrophic Left Ventricular Remodeling.

6. Major, J. L., Dewan, A., Salih, M., Leddy, J. J., & Tuana, B. S. (2017). E2F6 impairs glycolysis and activates BDH1 expression prior to dilated cardiomyopathy. PloS one, 12(1), e0170066.

7. Gormsen, L. C., Svart, M., Thomsen, H. H., Søndergaard, E., Vendelbo, M. H., Christensen, N., … & Jessen, N. (2017). Ketone Body Infusion With 3‐Hydroxybutyrate Reduces Myocardial Glucose Uptake and Increases Blood Flow in Humans: A Positron Emission Tomography Study. Journal of the American Heart Association, 6(3), e005066.