One of the five pillars of Islam is the fasting in the month of Ramadan. During this month Muslims observe a complete fast which means no food, water or smoking from dawn to sunset. This can be taxing for patients with heart diseases. Although the Holy Quran exempts sick persons from the duty of fasting, but still millions of people with a background of heart disease observe fasting during this month.
Let us see how different category of patients should be advised regarding their management during this month.
Hypertension (High Blood Pressure);
Hypertension is a very common medical problem in the community with a prevalence of 25-35%. Patients with hypertension are often on multiple drugs. It is advisable to ensure before the beginning of the holy month that the BP is reasonably well controlled. There are several combination tablets which can be taken once or twice a day. These medicines can be conveniently taken early morning before the start of fasting and after breaking the fast after sunset. Patients on diuretics (Water pills) should not be taking a high dose and take it preferably in the evening. Studies have shown that fasting is otherwise safe during the month of Ramadan. Salt restriction should be abided with even during summer. All other restrictions like over eating, taking pickles, chutney's etc need to continue.
Patients with uncontrolled hypertension should strictly refrain from going on fast during this month.
Chronic heart failure:
Patients with chronic heart failure, those with poor functioning of the heart, low ejection fraction (<35%) especially those with shortness of breath on exertion should avoid fasting on medical grounds. However those patients who are well controlled and nearly symptom free may observe Ramadan but be careful. They should avoid over eating after breaking the fast but have frequent small helpings till morning. The diuretic (drugs like Lasix, dytor etc) should be taken instead of morning in the evening so that proper hydration can be maintained. Any increase in symptoms should be reported to the treating doctor and not to increase the dose of medicines especially water pills.
Angina and old Myocardial infarction;
Stable patients who are able to continue their normal activities can observe fast if they want. They should however reduce their physical activities during this month. Weight gain can be restrained by reducing the calories during the hours between dusk and dawn. Should avoid taking sublingual angina medicine like sorbitrate, during day time because it can lead to low BP and giddiness and syncope because of no fluid intake which contracts the blood volume. They should take rest and get over the chest pain if it is effort related.
Patients with recent unstable angina or a recent heart attack should refrain from observing fast on strict medical grounds.
Previous Angioplasty (Stenting) or Bypass Surgery;
Stable patients who have had these procedures done more than 1 year ago and are able to perform their routine activities can observe fast as long as they take all their medicines between dusk and dawn. Once again strenuous activities should be avoided during the day especially in summer because it can lead to dehydration which can produce blockage of stents or grafts.
Anticoagulant dependent patients:
Patients on warfarin / Acitrom to keep their blood thin need to be careful. If they are doing well and have been on these medicines chronically and have a stable INR of 2 -3 can observe fast. It is always advisable to get a blood test to evaluate the prothrombin Time (INR) before the start of the month of Ramadan to ensure that it is therapeutic range. Care should be taken to have a good fluid intake in the permitted hours. During the day time especially in hot summer month's undue exertion should be avoided to prevent contraction of blood volume leading to blood clotting. The vegetable and fruit content should be kept uniform during the month so that drug food interactions are minimized.
The decision of undertaking the one month fast is entirely the subject's prerogative in case he or she is a heart patient. Quran exempts sick people from observing fasting. The treating doctor should always be consulted for guidance before undertaking the fast whenever in doubt.
Prof Upendra Kaul is Executive Director and Dean Cardiology Fortis Escorts Heart Institute and Fortis Vasant Kunj, New Delhi