Background The impact of ketone supplementation, low carbohydrate diets (LCDs) and ketogenic diets (KDs) on heart failure (HF) outcomes is largely unknown. This systematic review and meta-analysis investigated how these dietary changes impacted cardiac function and HF outcomes. Method A systematic search of MEDLINE, Embase, CINAHL and Web of Science was performed; last search on 19 November 2025. Randomised controlled trials (RCTs) and observational studies in humans receiving ketone supplementation, LCD and KD interventions were included. Studies were eligible if they reported at least one cardiac function/HF measure. Risk of bias was performed using RoB2 and ROBINS-I (Risk Of Bias In Non-randomised Studies of Interventions). Treatment effects were pooled, mean differences and 95% CIs calculated. Subgroup analysis was performed and heterogeneity was assessed. Results 14 studies were included in this systematic review. A meta-analysis was performed on six RCTs. Ketone supplementation increased left ventricular ejection fraction by 3.12% (95% CI 0.95% to 5.30%, p<0.01), with greater improvement in patients with HF with reduced ejection fraction (HFrEF); 4.25% (95% CI 1.99% to 6.51%, p<0.001). In patients with HFrEF, ketone supplementation increased peak systolic annular velocity (0.60% (95% CI 0.17% to 1.02%, p<0.01)) and cardiac output (1.24 L/min (95% CI 0.24 to 2.24, p<0.05)), compared with controls. Due to small cohorts and different treatment durations, assessment of certainty was low to high. Meta-analysis could not be performed on LCD or KD studies, due to low study numbers. Conclusions Ketone supplementation significantly improved cardiac function compared with controls, especially in people with HFrEF. More research is needed to determine how low carbohydrate and ketogenic diets affect HF outcomes. PROSPERO registration number CRD42024615367.

Background: Evidence supporting dietary interventions for heart failure (HF) prevention remains limited. The Dietary Approaches to Stop Hypertension (DASH) diet has been proposed as a cardioprotective dietary pattern, but population-level evidence linking DASH adherence to HF risk is sparse. Aim: To examine the association between adherence to the DASH diet—characterised by high intake of vegetables, fruits and whole grains, and lower consumption of sodium and red and processed meat—with combined risk of HF incidence and death due to HF, as well as its risk factors, namely hypertension and type 2 diabetes mellitus (T2DM). Methods: A prospective cohort analysis was conducted using UK Biobank participants free of HF at baseline (2006–2010), with follow-up to 2024. Dietary intake was assessed using ≥2 instances of 24-hour recall. DASH scores were derived and categorised into quintiles. Fine-Gray competing risks Cox models estimated adjusted HRs (aHRs) and 95% CIs for a primary composite outcome of incident HF or HF-related death, adjusting for sociodemographic factors, deprivation, obesity, smoking, hypertension and T2DM and accounting for all-cause mortality. Secondary outcomes were incident hypertension and T2DM. Results: Among 124 777 participants (mean age 56.1±7.8 years; 56% female; 7% with diabetes; 36% with hypertension), followed for a mean of 12 years, 2931 HF events and 441 HF-related deaths occurred. Compared with the lowest DASH adherence quintile, the highest quintile had a lower risk of HF after adjustment for sociodemographic factors (aHR 0.79, 95% CI 0.70 to 0.89, p<0.001) and comorbidities (aHR 0.89, 95% CI 0.79 to 1.00, p<0.05). Greater DASH adherence was associated with reduced risk of hypertension (aHR 0.91, 95% CI 0.86 to 0.96, p<0.001) and T2DM (aHR 0.82, 95% CI 0.75 to 0.90, p<0.001). Conclusions: Greater adherence to the DASH diet was associated with lower combined risk of HF and death due to HF, as well as hypertension and T2DM, supporting the role of a DASH diet in HF prevention.

Background and Objectives: There is limited evidence supporting the incorporation of dietary patterns into heart failure (HF) management. The Dietary Approaches to Stop Hypertension (DASH) diet is linked to cardiovascular disease prevention, but evidence correlating DASH adherence to HF risk is sparse. This study is the first prospective investigation into the relationship between the DASH diet, incident HF and its associated risk factors—hypertension and diabetes mellitus (DM)—in Australian women. Materials and Methods: Survey data (2001–2022) from the Australian Longitudinal Study on Women’s Health (ALSWH) was analysed, where DASH diet scores were calculated from food frequency questionnaire (FFQ) responses and categorised into quintiles. Multivariable logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association between DASH adherence and incident HF. Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% CIs for secondary endpoints, hypertension and DM, and dietary exposure was modelled as a time-varying covariate. Results: 10 594 women (mean age 52.5 ± 1.45 years) participated and, at 21-year follow-up, there were 136 (1.3%) cases of HF, 2182 (20.6%) and 994 (5.7%) cases of hypertension and DM, respectively. After adjustment for covariates (including age and socioeconomic factors), no association was found between the highest DASH quintile and incident HF [OR 0.73, 95% CI: 0.37–1.43; p = 0.20]. However, adjusted HRs for hypertension and DM—0.73 (95% CI: 0.63–0.84; p < 0.001) and 0.65 (95% CI: 0.53–0.81; p < 0.001), respectively—indicated significant associations. Conclusions: In Australian women, DASH diet adherence was associated with a significantly lower risk of hypertension and DM, both of which are HF risk factors. The finding of no direct statistically significant association between the DASH diet and incident HF might reflect the small incidence of HF in our cohort.

Background: Dietary interventions in heart failure (HF) remain limited, with current guidance focused largely on sodium restriction. Ketone metabolism has emerged as a potential therapeutic target in HF, with ketone supplementation shown to improve cardiac function. However, there are currently no studies investigating factors affecting adherence to a ketogenic diet (KD) in HF. Aim: To explore the factors influencing adherence to a KD in patients with HF to inform future dietary interventions. Method: This qualitative study was embedded within the KETO-HF pilot randomised controlled trial, in which participants with HF with reduced ejection fraction undertook a 4-month KD. Consenting participants were invited to complete semi-structured interviews. Interviews were audio-recorded, deidentified and transcribed verbatim. Data were analysed using thematic analysis with a mixed inductive–deductive strategy. Results: Fifteen participants were interviewed. Facilitators of adherence were: (1) personal motivation and self-regulation; (2) improved well-being; (3) interpersonal support and; (4) adaptive strategies and improved nutritional literacy. Barriers included: (1) early-phase physiological and psychological challenges; (2) social and cultural friction; (3) competing family and work demands and; (4) limited availability of suitable foods, particularly difficulty managing social situations and dining out. Conclusions: Adherence to a KD in people with HF is shaped by a combination of individual and social factors. These findings highlight the need for improved education, support, and increased food options to optimise implementation of dietary ketosis in HF.