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Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers.
Heart failure is a condition in which the heart has a structural or functional impairment. Heart failure can be acute, wherein the beginning signs and symptoms occur rapidly; or chronic, wherein the onset of signs and symptoms are gradual.1 In patients with heart failure, the heart is not efficiently circulating blood throughout the body, which can cause fluid to back-flow, leading to edema, where fluid leaks out from the blood vessels and into nearby tissues. There are many risk factors for heart failure, including coronary heart disease, hypertension, atherosclerotic cardiovascular disease, diabetes, a family history of heart disease, obesity, chronic pulmonary diseases, inflammation or chronic infection, and treatment with cardiotoxic agents.2
There are different types of heart failure, categorized by the percentage of blood that leaves the left ventricle. The left ventricle is responsible for pumping oxygen-rich blood to the rest of the body.3 Normal ejection fraction—measured as a percentage and meant to reflect how much blood the left ventricle pumps out with each contraction—is greater than 55%.4 The following are the 3 different types of heart failure:
- Heart Failure With Reduced Ejection Fraction (HFrEF): Also known as systolic heart failure or dilated cardiomyopathy. The ejection fraction for patients with HFrEF is less than 40%.This condition is especially prevalent in patients with coronary artery disease.5
- Heart Failure With Mid-Range Ejection Fraction (HFmrEF): Also known as borderline heart failure, where the ejection fraction is between 40% to 49%. HFmrEF shares symptoms and some risk factors with HFpEF, like hypertension and female sex at birth. Uncontrolled hypertension is the main cause of hospitalization. HFmrEF is a more recent addition to heart failure clinical practice guidelines.6
- Heart Failure With Preserved Ejection Fraction (HFpEF): The ejection fraction for patients with HFpEF is at least 50%. Patients with HFpEF are usually older adults and/or women with obesity, hypertension, and/or atrial fibrillation.2,5
Heart Failure Treatment
Before treatment, the provider will order laboratory tests including complete blood count, urinalysis, and blood glucose measurements. Some heart failure is caused by a specific heart condition that will need to be addressed and treated first.7
Treatment for symptomatic HFrEF include the following:7
- Angiotensin receptor-neprilysin inhibitor (ANRi): In patients with class II and III HFrEF, sacubitril-valsartan (Entresto®) is recommended
- Beta blocker: carvedilol (Coreg®), sustained-release metoprolol succinate (Toprol-XL®), or bisoprolol
- Mineralocorticoid receptor antagonist: In patients with class II through IV HFrEF, eplerenone (Inspra®) or spironolactone (Aldactone®)
- Sodium glucose cotransporter 2 inhibitors (SGLT2 inhibitor): In patients with symptomatic chronic HFrEF, dapagliflozin (Farxiga®), empagliflozin (Jardiance®), and sotagliflozin (Inpefa®)
- Isosorbide and hydralazine: Recommended for Black patients with class II through IV HFrEF.
- Diuretic: loop diuretics or thiazide diuretics can be used as needed for fluid build-up
Treatment recommendations for symptomatic HRmrEF include diuretics as needed for fluid build-up; SGLT2 inhibitor therapy, specifically empagliflozin; an angiotensin-converting enzyme inhibitor (sacubitril-valsartan), or an angiotensin (II) receptor blocker; and a mineralocorticoid receptor antagonist.7
Treatment recommendations for HFpEF include diuretics as needed for fluid build-up; SGLT2 inhibitors, specifically empagliflozin; sacubitril-valsartan; an angiotensin (II) receptor blocker; and a mineralocorticoid receptor antagonist. Other medications may be added if specific conditions develop.7
Mechanism of Action of SGLT2 inhibitors
Sodium-glucose-cotransporter 2 inhibitors (SGLT2i), like dapagliflozin, canagliflozin (Invokana®), sotagliflozin, and empagliflozin, are oral medications that increase glucose excretion in the urine. These medications work by inhibiting the SGLT2 enzymes in the kidneys that cause glucose reabsorption. They were recently approved for use in patients with heart failure. Adverse events include urinary tract infections and increased urination.8
Use of SGLT-2 Inhibitors in Patients With Heart Failure
These medications were originally studied to evaluate their cardiovascular safety in patients with type 2 diabetes and cardiovascular risk factors or atherosclerotic cardiovascular disease. Studies showed an unexpected improvement in patients with diabetes as well as a decrease in major cardiovascular events and hospitalizations within 2 to 3 months in the patients with atherosclerotic cardiovascular disease.8
SGLT2 inhibitors were added to heart failure guidelines in 2022. Dapagliflozin and empagliflozin have shown benefits in patients with HFrEF, HFpEF, and HFmrEF with or without diabetes.7 SGLT2 inhibitors were found to prevent heart failure hospitalization by up to 30%. They also improved blood pressure and reduced adverse renal outcomes. The exact mechanism of how these medications improve the heart remains unclear.8
SGLT2 inhibitors including canagliflozin (Invokana®), dapagliflozin, empagliflozin, and sotagliflozin are recommended as first-line treatment for hyperglycemia in patients with type 2 diabetes with heart failure or at high risk for heart failure. In these patients, they are associated with a reduction in major adverse cardiovascular events, like hospitalizations for heart failure and cardiovascular death and all-cause mortality.7 They have also been shown to reduce the incidence of heart failure in patients with diabetes with varied cardiovascular risk factors.5
Frequently Asked Questions
Will the use of SGLT2 inhibitors improve my heart failure?
SGLT2 inhibitors improve survival, mortality, and hospitalizations in patients with HFrEF, HFmrEF, and HFpEF. They have been associated with preventing the development of symptomatic heart failure.7
Will SGLT2 inhibitors affect my blood sugar?
While uncommon, there is a risk of developing hypoglycemia, which is increased if you are also taking sulfonylureas, meglitinides, or insulin.9 If there are signs of hypoglycemia, like shakiness or dizziness, the patient should sit or lie down, and eat or drink 15 to 20 grams of carbohydrates quickly. For adults, this can be 3 to 4 glucose tablets, 4 ounces of juice or nondiet soda, 1 tablespoon of sugar, or 6 to 8 hard candies. If the patient feels like they may faint, they should call 911.10
What are the side effects of SGLT2 inhibitors?
The most common side effects associated with SGLT2 inhibitors include urinary tract infection and female genital mycotic infections. If you have a history of Fournier gangrene, recurrent fungal genital/urinary tract infection, are pregnant or breastfeeding, or heavily drink, discuss with your provider before taking this medication.9
Can I take SGLT2 inhibitors with my other medications for heart failure?
SGLT2 Inhibitors are safe and recommended to use with other medications for heart failure. However, if you are taking other medications for other conditions, such as diabetes, speak with your provider to make sure the medication does not interact with other medications.7,9
Click here for PDF.
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Nearly 25 years ago, the American Heart Association (AHA) and the American Stroke Association developed the Get With The Guidelines (GWTG) series1,2 to increase the consistent implementation of guidelines-based care in hospitals for patients with cardiovascular disease (CVD) and stroke.1-3
The GWTG suite of programs aims to improve patient care and outcomes through resources such as provider education, quality improvement measures, and patient registries, with an overarching goal of reducing death and disability associated with CVD and stroke.4,5
For updates on the current status and achievements of the GWTG series, Cardiology Advisor interviewed AHA volunteer Gregg Fonarow, MD, FAHA, interim chief of the division of cardiology and the Eliot Corday Chair in Cardiovascular Medicine and Science at the University of California, Los Angeles (UCLA). Dr Fonarow is also director of the Ahmanson-UCLA Cardiomyopathy Center and co-director of the UCLA Preventative Cardiology Program.
How did the GWTG series come about? Why was there a need to create such a program in the various areas of focus, such as stroke and atrial fibrillation?
Dr Fonarow: In 1999, AHA volunteers identified a need to establish a mechanism by which hospitals could stay up to date with the latest clinical guidelines and recommendations to improve cardiovascular care quality and clinical outcomes. The AHA had set an ambitious goal to reduce death and disability due to CVD by 25% by 2010.1 With that goal in mind, AHA created the very first GWTG module for coronary artery disease, beginning with a regional pilot program. Based on this initial success, GWTG expanded nationally in 2001 and then launched additional modules.6
"
All GWTG [Get With the Guidelines] modules are associated with significant improvements in multiple processes of care strongly linked to improved outcomes.
This performance-improvement, registry-based approach would allow sites to evaluate their patient population against the most recent guideline-directed medical therapies, engage in collaborative learning, and share best practices. In addition to the technical support for the effort, AHA introduced the role of Quality Improvement consultants. Every GWTG hospital is provided a skilled quality consultant to assist as they use the registry to report on performance, identify opportunities for process improvement, and support their facility accreditation and certification with data from the registry. Sites also have the opportunity to be recognized by the AHA for their consistent performance.
GWTG is now available for atrial fibrillation, coronary artery disease including chest pain, heart failure, stroke, and resuscitation to support cardiac arrest care.2
Since the program’s inception, what have been some of the most significant achievements in terms of improved processes and outcomes at participating hospitals?
Dr Fonarow: All GWTG modules are associated with significant improvements in multiple processes of care strongly linked to improved outcomes. The AHA’s 2010 Strategic Goal was able to be met 3 years early, in 2007, in part based on GWTG.6
Currently, more than 2,600 US hospitals participate in one or more GWTG program module. That means nearly 80% of the American population has access to the program. Plus, since the creation of the program, more than 13 million US patient records have been entered into the registry.2
A few of the most significant achievements include:
- Demonstrating that participation in GWTG could reduce and even eliminate race/ethnicity- and sex-based disparities in the use of guideline recommended therapies. Equitable care provision during hospitalization has been achieved for most of the achievement measures targeted in GWTG modules.7,3
- Learning that recognition, along with targeted quality improvement efforts, can drive adherence with the most recent clinical trial evidence and guidelines. An example was the development of the Target: Stroke program. The primary goal of this initiative was to reduce the door-to-needle times, as time to treatment is strongly associated with stroke outcomes. In just the first year of Target: Stroke, participating hospitals reduced the time from 80 minutes pre-intervention to 68 minutes, and patients experienced substantially improved clinical outcomes.8 In subsequent phases of the project, we have seen continued improvement and have now added Target: Stroke Advanced Therapy to evaluate and monitor interventional treatment.
- Integrating Target: Type 2 Diabetes in the Get With The Guidelines - Stroke, CAD, and HF modules, so we are caring across diagnoses.
- Targeted implementation of the April 2022 Heart Failure guidelines in a pilot program that utilized Get With The Guidelines – Heart Failure. The emphasis was on the provision of quadruple therapy, which has increased the provision of guideline-directed medical therapies with participating sites from 14% to 49%. More importantly, the impacted patients had improvement in their LVEF [left ventricular ejection fraction]– moving from 9% at baseline to 55%.9
- Emphasizing systems of care for ST elevation myocardial infarction (STEMI). The GWTG-Coronary Artery Disease module meets the needs to measure and improve care from first medical contact – ie EMS or referring hospital – to reperfusion at the receiving center. Cohorts (eg, regions, states, and health systems) can use a Get With The Guidelines – Super User account to create data reports that drive performance as a group.
What are the key factors driving the success of the GWTG programs?
Dr Fonarow: Understanding quality measurement is critical to improving patient care and making the certification process simple. Participating hospitals take their efforts a step further to ensure teams are using current guideline-directed treatments, setting best in class goals, and using peer benchmarks to compare performance. The integration of the most current guidelines is a key benefit to sites.
Each participating hospital and health system works with a program consultant to implement, interpret data, identify areas for improvement, and articulate recommendations internally. It’s like having a consultant for the organization’s quality improvement objectives – and a significant reason these programs are so successful.
Also, the GWTG registry tool collects data from participating hospitals, allowing health care leaders and researchers to examine trends and continue bringing current evidence-based guidance to care delivery at hospitals across the country.
What are examples of situations in which deviation from the guidelines may be necessary – for example, due to access issues, limited resources, or patient-specific scenarios?
Dr Fonarow: As with any therapy, there are contraindications to some treatments, and collecting information on contraindications is actually built into the registry. Sites are provided the opportunity to document the reason why a patient was excluded from the treatment and can use that information to evaluate overall treatment and considerations for process improvement. And of course, the final decision on treatment resides with the patient and their caregivers. They can decide against a treatment, and GWTG allows for that documentation.
What areas are targeted for further development, and what are some of the program goals for the future?
Dr Fonarow: Until recently, the biggest gap in reaching all hospitals pertained to the small or rural hospital. These sites were less likely to join the quality improvement program due to resource limitations and low volumes of patients. However, the data shows these residents are at 30% higher risk of stroke, 40% more likely to develop heart disease, and live an average of 3 years fewer than urban counterparts.10 Yet, when rural hospitals did participate in GWTG, care quality improved, and in many cases performance rivaled that of urban hospitals. The AHA has now launched the Rural Community Network, which is open to all rural hospitals to join GWTG. This program aims to help close those gaps. More than 350 new hospitals have signed up so far.
As newer therapies are discovered, tested, proven to provide patient-centered outcomes, and are integrated into the national guidelines, these therapies can be rapidly integrated into GWTG. The program aims to further enhance these processes, so that each patient receives the best evidence-based care at the right time, at the right dose, equitably, reliably, every time. This is aligned with the AHA’s goal of advancing cardiovascular health for all, including identifying and removing barriers to health care access and quality.
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April was Stress Awareness Month, the perfect excuse to get stress under control. Although cardiologists may recognize the undeniable link between stress and heart health, they’re far from immune to its harmful effects. Mindfulness is a promising way for physicians and patients to find relief.
Mindfulness is an ancient practice gaining steady traction in modern medicine. This cost-effective intervention improves quality of life and reduces health care costs and hospitalizations.1 In addition, mindfulness interventions don’t interfere with existing treatment plans but may enhance their efficacy.
Although mindfulness can be packaged into different formats (meditation, yoga, or as part of cognitive behavioral therapy), the basic principle involves actively focusing on the present to relax the body and mind.
The time has come for overstressed physicians to teach by example through practicing mindfulness. If you’re still not convinced, here’s the evidence.
Taking control of the heart-mind connection
The relationship between stress and cardiovascular health is complex. When the body perceives a threat or experiences stress, it triggers a cascade of physiological responses, including the release of stress hormones such as cortisol and epinephrine. These hormones spike heart rates, raise blood pressure, elevate blood sugar, and boost inflammation.
Chronic stress, characterized by persistent activation of the body's stress responses, can assault the cardiovascular system over time. Research has established a clear link between chronic stress and an increased risk for hypertension, heart disease, and stroke. Moreover, stress worsens existing cardiovascular conditions, making management and treatment more challenging.
The impact of stress on heart health is well-established. Although mindfulness has become a popular buzzword in health and wellness spaces, it’s not necessarily a common practice. Fortunately, basic mindfulness exercises can be done anywhere, anytime. All you need is a few minutes in a quiet space.
To practice mindful meditation, follow these steps:
- Sit down, close your eyes, and practice deep, slow breathing.
- Consciously relax each muscle group, starting with the lower body.
- As you work your way up, shrug your shoulders and roll your head in different directions.
- Choose a calming word and say it quietly with each exhalation, like “peace.”
- Continue for 5 to 10 minutes. As your thoughts wander, refocus back on meditating.2
Group mindfulness programs can increase accountability for regular practice. Making a conscious effort to focus on the present and clear your mind can turn almost any steady-state activity into a mindfulness exercise, including walking, swimming, and bike riding.2 Participating in mind-body activities helps harness the benefits of mindfulness while providing the added benefit of some physical exercise, through tai chi and yoga, for example.
Is mindfulness worth it?
While most physicians agree that their patients would benefit from mindfulness practices, carving out time for mindfulness isn’t always a priority for doctors themselves. Knowing in real numbers how mindfulness can impact health helps build a case for it.
Numerous studies have demonstrated that calming the mind calms the body. A 2013 review of 9 studies published in the AHA journal Hypertension found meditation reduces systolic blood pressure by 4.7 mm Hg and diastolic by 3.2 mm Hg.2 In another study, 5 minutes of daily meditation positively affected heart rate variability. This measure of heart attack and stroke in those without cardiovascular disease showed improvements within just 10 days of consistent meditation practice.2
In another meta-analysis, which included 16 studies and 1,476 adults, mindfulness-based interventions significantly improved psychological distress, enhancing self-awareness, attention, and emotional regulation.3 This review observed more drastic impacts on blood pressure, with an average 14 mm Hg reduction in systolic and a 5 mm Hg decrease in diastolic readings for participants in mindfulness-based intervention versus control groups.
Most recently, a 2024 meta-analysis of 12 randomized controlled trials confirmed that structured mindfulness-based intervention programs effectively reduce blood pressure in participants with prehypertension and hypertension.4 These benefits were more pronounced in men. The researchers noted, “In addition, the results also support previous studies which showed that MBIs [mindfulness-based interventions] can lower blood pressure in patients with other diseases, such as breast cancer survivors, coronary heart disease, and diabetic patients.”
By promoting relaxation responses, mindfulness modulates stress hormone levels, counteracting the harmful physical effects of chronic stress. It targets emotional distress, helping prevent disease and slow disease progression.
In a systematic review of mindfulness interventions for patients with heart failure, researchers concluded that practicing mindfulness is “beneficial for patients with heart failure in reducing depression and anxiety and enhancing health-related quality of life in the short term.”1 Some studies noted improvements in physical symptoms like fatigue, unsteadiness, dizziness, and breathlessness. In 1 of the studies reviewed, researchers observed sustained positive effects on depression and anxiety lasting 3 months and 6 months after the completion of mindfulness programs.
Although the long-term effects aren’t always documented in studies, there’s no downside to practicing mindfulness, and the potential for ongoing benefits makes developing a mindfulness habit worthwhile.
Why cardiologists need mindfulness
Physicians, as caregivers entrusted with the health and well-being of others, often find themselves navigating high-pressure environments fraught with stressors. From demanding workloads and long hours to the emotional toll of patient care, the medical profession is inherently predisposed to stress and burnout.
Studies show physician burnout is at an all-time high, and cardiologists are no exception. One survey of almost 6,000 cardiologists found that 42% of cardiologists feel burned out, and 83% have symptoms of colloquial depression.5 While 16.9% of cardiologists surveyed reported having a mental illness, only 34.2% attempted to get help. The top cited barriers stopping cardiologists from seeking mental health support included privacy concerns (34.5%), time constraints (30.8%), shame (29.5%), and fears about how it would impact their professional advancement (28.6%).
Although mindfulness isn’t a sufficient replacement for mental health treatment, it’s a practical option with the potential to improve cardiologists’ everyday lives. By integrating mindfulness practices into their daily routines, physicians can develop a greater self-awareness, emotional regulation, and compassion for patients.
Prioritizing self-care and stress management sets a positive example for patients and colleagues, reinforcing the importance of holistic health practices. Cardiologists can lead the way in championing initiatives that promote a culture of well-being and mindfulness among others.
Stress Awareness Month isn’t just for patients. Cardiologists can harness the power of mindfulness and other stress management strategies to improve their lives. By learning and doing mindful meditation, cardiologists promote the highest level of heart health care for themselves and others.
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Caffeinated energy drinks sold at popular chain restaurants have become the focus of increasing attention recently since wrongful death lawsuits were filed attributing 2 cardiac-related deaths to the consumption of Charged Lemonade from Panera Bread: In September 2022, a 21-year-old woman with long QT syndrome (LQTS) died from cardiac arrhythmia due to LQTS after consuming an unspecified amount of the drink, and a 46-year-old man died in October 2023 from cardiac arrest due to hypertensive disease after drinking 3 cups of the beverage.1,2
The lawsuits filed by the families of these individuals allege that the caffeine content of the drinks was not properly advertised and that consumers were not warned about the associated risks.3
Cardiovascular Effects of Energy Drinks
Paul Leis, DO, assistant professor of medicine in the division of cardiology at the Icahn School of Medicine at Mount Sinai in New York, believes that many cardiologists are aware that highly caffeinated energy drinks are on the market but may be “unaware of how much caffeine they contain and whether they exceed the recommended daily limit of 400 mg as outlined by the FDA,” he said.4 “Also, some patients may have multiple of these drinks per day, which can be harmful.”
"
Providers other than cardiologists should be educated and informed of the risks associated with these drinks as well, as they may also be involved in the care of at-risk individuals.
Various studies have linked the consumption of energy drinks to a wide range of cardiovascular side effects, including increased blood pressure, cardiac arrhythmias, prolonged QT interval, cardiac arrest, coronary disease, heart failure, and aortic dissection.5
According to Helga Van Herle, MD, cardiologist and associate professor of clinical medicine with Keck Medicine of the University of Southern California in Los Angeles, the consumption of drinks with high caffeine content can be especially risky for individuals with pre-existing cardiac conditions such as rhythm disturbances, as well as those with caffeine sensitivity and those taking medications with the potential to cause side effects such a heart palpitations or tachycardia. “For example, prescription stimulants or stimulant-like medications for conditions including ADHD, narcolepsy, and other sleep-related issues commonly have palpitations or tachycardia as a side effect, and high levels of caffeine intake have the potential to exacerbate these symptoms.”
Although the caffeine content of beverages can vary substantially depending on a range of factors, the approximate amount of caffeine found in commonly consumed drinks are as follows:
- 80 to 100 mg in an 8-ounce cup of coffee
- 40 to 250 mg in an 8-ounce energy drink
- 30 to 50 mg in an 8-ounce cup of green or black tea
- 30 to 40 mg in a 12-ounce caffeinated soft drink4
The large Charged Lemonade from Panera Bread contains approximately 390 mg of caffeine, and the large size of the recently launched Sparkd’ Energy drink from Dunkin’ contains an estimated 192 mg of caffeine.6,7
“I think issues arise when someone significantly exceeds the recommended limit, typically as an acute ingestion rather than habitual use, as with most coffee drinkers,” said Catherine Benziger, MD, MPH, director of research at Essentia Health Heart and Vascular Center in Duluth, Minnesota, and member of the American College of Cardiology’s Prevention of Cardiovascular Disease Council. “Drinking 2 or more high-energy caffeinated drinks can put the consumer well over the daily recommended caffeine limit and at risk for heart-related events.”
Dr Van Herle noted that, along with caffeine, energy drinks often contain other substances intended to increase energy, such as guarana, ginseng, and ephedra, which may have proarrhythmic effects.8
Clinical Recommendations
In general, Dr Benziger recommends that patients not exceed the recommended limit of under 400 mg of caffeine per day. This would equate to “approximately 4 cups of coffee, and the caffeinated drinks at Panera and Dunkin’ would also fall within this range but only if you drink just one,” she said. She pointed out that other products also contain various amounts of caffeine, such as ice cream, chocolate, foods containing coffee, and caffeine pills. While many of these products can typically be safely consumed within reasonable limits, using them “in combination can greatly exceed the recommended daily limit and put people at risk for a variety of heart issues such as increased heart rate, increase blood pressure and abnormal heart rhythms, such as supraventricular tachycardia.”
Dr Leis recommends that patients with known cardiac disease, especially arrhythmias, avoid consuming energy drinks to reduce the risk of associated complications. “In particular, for arrhythmias such as atrial fibrillation, the high caffeine content from these drinks could potentially put patients who have rate-controlled atrial fibrillation into an uncontrolled ventricular rate and lead to potential complications,” he explained.8
Additionally, patients with hypertension who consume high amounts of caffeine can experience increased blood pressure due to adrenergic stimulation, he said. “For those who have had a myocardial infarction or have established coronary artery disease, increased heart rate and blood pressure resulting from these energy drinks could potentially cause symptomatic angina from the increased demand on the heart.”
In addition, Dr Benziger noted that people may use caffeine to compensate for inadequate sleep, and depending on the individual, may benefit from improved sleep habits including earlier bedtimes and less screen time in the evening so they can reduce their reliance on caffeine. For other patients, undiagnosed sleep apnea may be causing excessive tiredness.
“We know poor sleep is associated with cardiovascular disease and heart attacks, and the American Heart Association Life's Essential 8 recommends 7 to 9 hours of sleep per night for adults,” she said.9 “If people are using caffeine because they are often tired and not getting good-quality sleep, I recommend they talk to a doctor about it.”
Public Health Measures Needed
Along with steps that consumers can take to reduce caffeine intake, several safety measures are needed on the public health level as well. “We need to have full transparency on the caffeine content of energy drinks so people will know how much caffeine they are getting and whether they are over the recommended level,” Dr Leis stated. Currently, the FDA does not regulate energy drinks and does not require sellers to list the caffeine content of beverages.10,11
"Another thing I would really like to see is some sort of warning label that perhaps certain populations should avoid these drinks, including but not limited to those with known cardiac conditions and those who are pregnant or breastfeeding—if we start off with at least those 2 groups, I think we would be headed in the right direction,” he suggested.
Dr Van Herle also points to the need for labels listing the other energy-boosting ingredients contained in these drinks to allow patients to make more informed decisions.
Transparency about ingredients and caffeine levels of energy drinks is “particularly important for children, who are often attracted to these drinks because they're popular or their friends are using them or they are for sale at their schools,” Dr Benziger emphasized. She cautioned that young children are especially susceptible to the effects of caffeine and said pediatricians advise that children under 12 years avoid caffeine consumption, that all children and teens avoid the consumption of energy drinks, and that those ages 12 to 18 years limit caffeine intake to 100 mg at most.12
“Providers other than cardiologists should be educated and informed of the risks associated with these drinks as well, as they may also be involved in the care of at-risk individuals,” Dr Van Herle added.
Future Research
Numerous questions warrant attention in future research regarding highly caffeinated beverages. According to Dr Van Herle, “There are several things health providers need to better understand, including how highly caffeinated beverages affect individuals with specific cardiac conditions—especially those at risk for lethal arrhythmias; how these beverages interact with prescription medications that can potentiate an individual’s risk of a heart arrhythmia; and whether individuals in different age groups are more or less at risk of cardiac issues that may stem from consumption of these drinks, especially since much of the marketing is geared towards a younger age group.”13
Dr Leis would like to see research examining the incidence of arrhythmias among individuals with daily consumption of highly caffeinated energy drinks to gauge whether rates are higher in this group compared to individuals with less frequent consumption. Such data could inform recommendations regarding the risk of developing arrhythmias among individuals who frequently consume these beverages.
There is an ongoing need for further research regarding safe levels of caffeine intake and which populations are at risk for acute caffeine toxicity, Dr Benziger stated. She also cited an urgent need for data on the use of energy drinks among adolescents, as nearly one-third of those aged 12 to 17 years reportedly consume these products on a regular basis.14 “This is not my area of expertise as I'm an adult cardiologist, but I think that any behavior that starts in adolescence may track into adulthood and could lead to chronic diseases or poor health habits in the future.”
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