Cardiac Patients and the Holy Month of Ramadan

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Cardiac Patients and the
Holy Month of Ramadan

Prof. Khalida Soomro

The month of Ramadan offers an opportunity to improve one’s life style with numerous benefits. Some of these benefits on cardiovascular system and body are as under:

  1. There is a significant impact on homocystein, and lipid profile, e.g higher HDL-C and lower cholesterol, triglycerides, LDL-C, VLDL-C levels, cholesterol/HDL and LDL/HDL ratios after Ramadan which reduces CHD risk up to 20% and decreases the related cardiovascular events. It seems that the effect of Ramadan fasting on serum lipid levels may be closely related to the dietary habits like there is a tendency for higher simple carbohydrate consumption during Ramadan].
  2. There is no significant change in FBS, fasting insulin and insulin-resistance (HOMA-IR) after Ramadan fasting, which may be explained by different food habits, amount of calorie intake, the number of fasting days, period of daily fasting. The circadian rhythms of nutrition-related biological variables shows some degree of changes during Ramadan, there might be concerns about amount of daily activities or circadian rhythm related hormones like cortisol which might affect FBS level 3. There may be significant increase in insulin sensitivity (1/HOMA IR) in subjects with the metabolic syndrome] and significant decrease in insulin and insulin resistance among men patients with type II diabetes after Ramadan fasting. The lack of improvement in HOMA-IR or FBS despite reduction in body weight may be due to decrease in total body water content instead of body fat content after Ramadan fasting, HbA1c levels decreases during the month.
  3. Body weight and BMI decreases significantly due to dietary pattern and other life style changes. It is assumed that weight loss during Ramadan contributes to the reduction in the hs- CRP which in routine and is a strong independent predictor of future MI and stroke. Apparently in healthy men and women the decrease of hs-CRP in Ramadan due to weight reduction may improve global risk prediction among those with high as well as low cholesterol levels. The changes in the meal schedule during Ramadan may beneficially affect inflammatory markers. Fasting has anti-inflammatory, antiplatelet, and mild anticoagulant.
    Weight changes during Ramadan are not long lasting, and patients gradually returned to pre-Ramadan status. Although Ramadan provides a chance to loose weight, structured and more consistent lifestyle modifications are still necessary in achieving weight loss.
  4. There is significant decrease in systolic blood pressure and no significant change in diastolic blood pressures after Ramadan fasting. Decrease in systolic BP is attributed to life style changes and the effect of control during Ramadan and the neutral effect of Ramadan on BP is attributed to the effect of weight f BP with long-acting anti-hypertensive. Though these benefits are short-lived, however, it could be maintained controlling food intake and changing lifestyle in favor of healthy living that practiced during Ramadan.

Fasting with pre-existing heart disease?

Fasting during Ramadan does not increase the burden of acute cardiac illness in general population at large. Neither has it seemed to increase hospitalizations for congestive heart failure. However, patients with volume overloaded de-compensated heart failure or those requiring large doses of diuretics are strongly advised not to fast, particularly when Ramadan falls in Summer, an adverse outcome could potentially be life-threatening, and a prospective study is warranted.

Patients with controlled hypertension can safely fast. However, patients with resistant hypertension should be advised not to fast until their blood pressure is reasonably controlled. Patients with recent myocardial infarction, unstable angina, recent cardiac intervention or cardiac surgery should avoid fasting. Physician advice should be individualized and patients are encouraged to seek medical advice before fasting in order to adjust their medications, it is required that the effects of fasting on stable patients with cardiac disease are minimal, and most patients with stable cardiac disease can fast. There is significant differences in the incidence of AMI and angina in Ramadan when compared with the other two periods. Patients with acute myocardial infarction, unstable angina, recent percutaneous cardiac intervention (PCI) or cardiac surgery are advised to avoid fasting. There are no effect on the clinical status of stable cardiac patients while fasting during Ramadan. However as most of the studies were conducted in the Gulf areas, patients living in North European countries, where the duration of daily fasting may be two to three hours longer, hence they might have slight variation on these effects.

It is said that people with mild hypertension can safely go for Ramadan fasting with once-only daily preparations. Blood pressure in treated hypertensive patients did not differ before and during Ramadan. Grade 2–3 hypertension is associated with moderate-to-very-high added cardiovascular risk, and combination therapy is recommended for effective blood pressure control in these patients. Taking antihypertensive medications twice daily (before fasting starts at dawn, and just after breaking fast in the evening) seems to be a suitable regimen for blood pressure control., if Ramadan falls in Summer time, the required period for fasting can last up to 18 hours and the pharmacokinetic and pharmacodynamic effects of longer fasting periods are unknown. Diuretics are better avoided during fasting, especially in hot climates, or should be administered in the early evening. Patients with difficult-to-control hypertension should be advised not to fast until their BP is reasonably controlled. Patients with hypertensive emergencies should be treated appropriately, including by intravenous medications.

Physician’s advice and management need to be individualized and patients encouraged to seek medical advice before fasting in order to adjust their medications, if necessary. Patients taking medications might wish to fast and therefore may not comply with their treatment. Doctors and pharmacists need to be aware of this possibility and offer such patients alternative treatments, e.g. once-daily formulations. Patient education should emphasize the need to maintain compliance with non-pharmacological and pharmacological measures. Fasting does not apply to Muslims whose health is at risk. The Qur’an states that fasting during illness should be avoided. It is entirely at the discretion of the treating physician to decide whether a patient is allowed to fast or not.