Ramadan is an ideal platform to target year long lifestyle modification, to ensure that whatever health care benefits have been gained during this month, are perpetuated.
Patients with stable Coronary Artery Disease (CAD) can observe fasting during Ramadan without anticipating any major adverse cardiac events while those with unstable disease or recent/pending revascularization should largely refrain from fasting. Previous studies have shown that neither has there been an increase in the incidences of acute myocardial infarction nor has there been an increase in the number of patients hospitalized due to heart failure, during Ramadan.
A fairly small group of patients with cardiac conditions should be advised to refrain from fasting during Ramadan. These include patients with acute cardiac illnesses like Acute Myocardial Infarction (AMI) and Acute Coronary Syndrome (ACS). Patients with uncontrolled HTN requiring multiple dosages during the daytime should be counseled against fasting. Patients with severe congestive heart failure (CHF) requiring high doses of diuretics should also refrain from fasting.
Patients are encouraged to seek medical advice 1 or 2 months before Ramadan in order to adjust their medications if needed. Drugs given thrice daily can be usually changed to single sustained doses.
Most medications prescribed for stable cardiac conditions are taken once or twice daily and people can divide the regimen at dawn and after breaking the fast in the evening. Usually, the regiment includes aspirin, statin the anti-lipid medicine, beta-blockers and other medicines to control risk factors like high blood pressure and diabetes mellitus.
Diuretics are not the first choice as a new antihypertensive for a fasting patient. Diuretics dosing, whether for the purpose of CHF or as antihypertensive, may need to be adjusted down during fasting, especially loop diuretics with prolonged fasting during hot seasons. Dehydration and electrolyte imbalance that is often encountered with diuretics should be avoided particularly in cardiac patients where this can lead to serious cardiac dysrhythmias.
Effect of fasting on patients with hypertension
Many factors may theoretically influence the blood pressure(BP) during Ramadan. These include feeding patterns, sleep changes, and changes in the timing of intake of medication,
People with mild hypertension can safely undertake Ramadan fasting with once-only daily medicine dose of blood pressure medication. 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. Those patients who are stable with two times drug regimen can take antihypertensive medications twice daily (before fasting starts at dawn, and just after breaking fast in the evening) in order to keep their blood pressure under control. Diuretics (e.g. hydrochlorothiazide, natrilix, and Lasix) are better avoided during fasting, especially in hot climates.
Patients with difficult-to-control hypertension should be advised not to fast until their blood pressure is reasonably controlled.
Effect of Ramadan on patients with known pre-existing heart disease
The effects of fasting during Ramadan on stable patients with cardiac diseases are minimal, and that patients with stable cardiac illness are able to fast during Ramadan, provided they comply with the recommended dietary and medication regiments. However, as stated earlier, those patients with unstable heart conditions should completely avoid fasting.
Effect of fasting on patients with heart failure
Fasting during Ramadan does not seem to increase hospitalizations for congestive heart failure (CHF). However, patients should still seek the advice of their cardiologists before the start of Ramadan, in order to adjust their medication and check their dosage, especially diuretic requirements and checking electrolytes and renal function test. Patients using a low dose of a diuretic are better advised to use it in the evening. Patients who have unstable heart failure and maintain their clinical condition with a high dose of diuretics like furosemide are better refrain from fasting especially in very hot summer season.
Lifestyle modification for cardiac patients
Fasting Ramadan is a radical change in lifestyle for the period of a lunar month, and lifestyle change has a significant impact on the cardiovascular system. Moderate eating, physical exercise, engaging in spiritual activities, and abstention from forbidden foods and drinks. Weight loss occurs during Ramadan fasting, and if maintained can be beneficial to patients, so they should be encouraged to preserve it, particularly if the patient suffers from metabolic syndrome, HTN, diabetes, and obesity.
Physical activity is also markedly restricted during Ramadan, and this should be modified. Exercise can be conveniently done after the evening meal or before the morning meal. Aerobic exercise such as walking or cycling are preferred and must include the physical exertion involved in the prayers, especially the Tarawih prayers.
Many public health authorities have used the start of Ramadan as a spur to encourage smoking cessation, using several lines of reasoning. Smokers can be motivated by the fact that if they abstain from smoking during the daytime, then they could easily abstain later as well.
Dr. Zubair Ali Memon
Aster Speciality Clinic, International City