14: Ramadan Kareem! Should your patient fast or not?

It is the first day of Ramadan, the holy blessed month observed by 1.8 billion Muslims around the world. This is a month with a mix of religious rituals, historical traditions, and family gatherings. It happens also to be an occasion for big meals, TV serials, and commercials! So I must say to all of you… Ramadan KareemBut when patients ask me “doctor, what should I do in Ramadan” I get a bit anxious. The answer to that question involves and mix of science and religious teachings. Even if you are a devout Muslim doctor, the answer won’t come easy as you need to be balancing from both the religious aspect, respecting the patient’s desire to fast, and the health aspect to avoid potential harm to your cardiac patient. And to make it worse, we don’t have enough randomized or observational studies to guide us on what to do exactly in different cardiac conditions. So most of the advice we gave to patients was based on our own personal views which is not exactly called “science”What we know is that fasting as a concept is useful. The benefits of intermittent fasting on cardiovascular health are proven and Ramadan fasting was shown to reduce systolic and diastolic BP and was even associated with improved anginal symptoms in patients with chronic ischemic coronary syndromes. But Ramadan fasting is different from intermittent fasting; there is no water and no medicines. There is always the risk of hypotension, dehydration, and thrombotic tendency during the long fasting hours, especially in the summertime and in frail elderly patients. Dehydration may increase the risk of arrhythmia like ventricular ectopics, and atrial fibrillation and is very risky in patients with long QT syndrome, Brugada syndrome, or patients taking digoxin or class I antiarrhythmic drugs. Also in one multi-center study, patients who undertook Ramadan fasting within 3 months of percutaneous coronary intervention had a higher incidence of significant cardiac events than those who did not undertake Ramadan fasting. Moreover, if fasting times are more than 12 hours, then twice daily dosed medications will be disrupted with a potential for overdosing and under-dosing. Patients receiving two times per day DOACs were noted to be more likely to change their anticoagulation administration and more likely to be admitted to the hospital as a consequence of their changes, for example, bleeding or stroke. And the habits in the middle east of food consumption after sunset breakfast “Iftar” are far from the essence of intermittent fasting. This meal can get heavy with lots of dates, sugary drinks, and full-loaded oriental sweets are made special in celebration of the holy month. This is a major disruption of blood sugar control in diabetic patients. And I would like to refer you to the nice scoring developed by Diabetes and Ramadan DAR group which guides patients and physicians on who can fast and who shouldn’t. You can also check the previous episode of cardio buzz where our nephrology expert provided guidance on fasting for renal patients.So who can fast Ramadan and who should not fast? There is a good consensus document from a group of British doctors in the NHS, published in Heart open journal last May. And I think it came on time. The link to the article is in the description. The eight authors scanned the literature for trials on fasting and cardiovascular disease and added their personal insights, and the work was supported by the British Islamic Medical Association. https://www.daralliance.org/daralliance/idf-dar-practical-guidelines-2021/https://heart.bmj.com/content/108/4/258