By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.

What is Cardiomyopathy?

Cardiomyopathy is a condition where heart muscle tissue becomes damaged, diseased, enlarged, or stretched out and thinned (dilated), and thus weakened. It is common, though lesser known, type of heart disease. Typically, heart disease involves inflammation and plaque build-up in the coronary arteries that supply the around-the-clock pumping action of the heart muscle with essential oxygen and nutrients. As this destructive process advances, the plaque may grow in size to choke off blood flow, or a piece of plaque may break off and also block blood flow. When a part of the heart muscle becomes oxygen-deprived, a heart attack can develop, sooner or later, and with or without symptoms.

Causes of Cardiomyopathy

Cardiomyopathy occurs as a consequence of heart attacks, chronic hypertension (high blood pressure), valvular disease, or some genetic glitch. Nutritional deficiencies, alcoholism, and infections may also trigger cardiomyopathy.

Whatever the cause, a weakened heart muscle can’t generate enough energy to sustain strong and healthy pumping action − contracting (pushing blood out into the body) and relaxing (refilling the heart chambers with blood).

Compromised pumping results in a variety of deficits that can severely affect quality of life. While early-stage cardiomyopathy may not produce any symptoms at all, as the condition progresses the common symptoms of heart failure (also called congestive heart failure) start showing up: shortness of breath with minimal exertion, fatigue, cough, and pain and fluid buildup (edema) in the legs and ankles. Fluid can also accumulate in the lungs and cause a serious congestion of blood in the heart.

Causes and consequences of cardiomyopathy are so varied that no single intervention can consistently be relied upon. The condition often leads to progressive failure and a high incidence of mortality: 20 percent after one year, and 70-80 percent after eight years for patients who develop outright heart failure. Cardiomyopathy is the third leading cause of heart failure after coronary artery disease and hypertension. Among women, heart failure is the leading cause of death over the age of 65.

Treatment for Cardiomyopathy

Conventional treatments for cardiomyopathy include drug therapy, defibrillators, and in the most serious cases of full-blown heart failure, heart transplantation. Lifestyle changes revolve around alcohol restriction, weight loss, exercise, smoking cessation, lowering stress, and an anti-inflammatory, low-sodium diet.

As an integrative cardiologist, I have used all these strategies in my clinical practice. However, I have taken an additional step that has made a significant difference in the quality of life of my patients and, I’m convinced, their longevity as well.

That added step is perhaps the most simple of all: targeted nutritional supplements that directly address the energy deficit of the heart muscle.

The specific supplements are co-enzyme Q10 (CoQI0), L-carnitine, magnesium, and D-ribose. I call them my “awesome foursome.”

In brief, the awesome foursome feed, protect, and facilitate the activity of the mitochondria, energy-producing structures within the trillions of cells in the body, including the hard-working heart muscle cells. Through a complex biochemical process, adenosine triphosphate (ATP) is produced inside the mitochondria. ATP is the fuel that powers cellular functions, just like gasoline runs the engine of a car. Patients with cardiomyopathy and heart failure suffer from ATP deficiency. Their hearts are energy-starved.

The awesome foursome helps significantly to rectify this situation. Moreover, they do not interfere with other treatment strategies. To the contrary, they support any comprehensive treatment approach. No prescription is needed; you can purchase them at a health food store.

My Supplement Recommendations:


CoQ10 is a vitamin-like substance and a central ingredient in the enzymatic process that produces ATP. It also has powerful antioxidant properties, and helps protect the mitochondria from oxidative damage. It is my favorite supplement because its efficacy is so superb.

As we age, our body’s natural supply of CoQ10 diminishes. In addition, the use of certain medication, namely cholesterol-lowering statin drugs often prescribed by doctors for cardiomyopathy and heart failure patients, depletes the body’s own CoQ10 production.

Multiple studies, beginning more than thirty years ago, have shown that CoQ10 supplementation significantly benefits patients with cardiomyopathy and heart failure. Every heart patient, I believe, benefits big time.

  • Dosage: 300-600 milligrams in divided doses daily with food. Use soft-gels for best absorption.


Molecules of this important amino acid provide a critical transportation service in energy production. They carry fatty acids into the mitochondria, a needed raw material for making ATP. They also carry wastes out.

Studies show that supplementation increases longevity, improves blood pressure, rhythm disorders, and signs and symptoms of heart failure.

  • Dosage: 1-2 grams once or twice a day, best taken on an empty stomach.


This VIP mineral is typically deficient in adults because it is stripped away in most processed foods. Whole grains, figs, and green, leafy vegetables are good sources of magnesium, but most people don’t eat enough of these healthy food sources. Moreover, stress depletes the body of magnesium.

Magnesium is essential for some 300 or so enzymatic activities in the body, cellular energy production among them. It is usually depleted in heart patients. Inside cells, it is most concentrated in the mitochondria. Nature designed it that way for a reason, so better make sure you have enough in your body. Magnesium also helps keep muscles and blood vessels relaxed, a factor that makes it beneficial as a natural remedy against high blood pressure.

  • Dosage: 400-800 milligrams daily in divided dosages. The best forms of magnesium are malate, citrate, and glycinate. Start low and increase dosage gradually. Too much magnesium all at once can temporarily cause loose stool. I don’t recommend magnesium oxide, a common form used in many supplements. It is not well absorbed.


As a building block of ATP, D-ribose can rapidly restore depleted energy in sick hearts.

Every cell in the human body makes some of this simple sugar molecule but only slowly and to varying degrees, depending on the tissue. Heart tissue, for instance, can only make enough to manage day-to-day needs in a normal situation. Unfortunately, these cells lack the metabolic ability to make D-ribose quickly when stressed, as occurs with heart disease when the blood supply to the heart is compromised. When oxygen and nutrient deficits become chronic, tissues can never make enough D-ribose and cellular energy suffers. D-ribose is the only compound generated by the human body to replenish the diminished ATP energy stores.

Certain drugs, known as inotropic agents, are utilized in cardiology to make the heart beat stronger for patients. However, they place considerable strain on the heart and long-term treatment with these agents can further drain energy reserves.

Here is where D-ribose can come to the rescue. Research shows that supplementation reduces the energy drain without any negative impact on the activity of the drug.

  • Dosage: in the capsule form, take 15 grams daily in divided doses; if taken as a powder, a teaspoon three times a day. Either way, take it with meals.

The “awesome foursome” help nurture, “fertilize,” and support the mitochondria. Together they act like a sparkplug, stoking the mitochondrial production of ATP. They can recharge your heart like nothing else I know.

I suspect these four nutraceuticals were a prime reason why my re-admission rate for heart failure patients at the hospitals I served was practically nil. I was able to improve the quality of life of my patients and keep them out of the hospital! That’s what medicine should be all about – making healthier patients.


© 2015 HeartMD Institute. All rights reserved.

Leave a Reply


  1. jackie

    on September 18, 2015 at 11:10 pm

    In your article on what causes cardiomyopathy, you name as causes “heart attacks, chronic hypertension, valvular disease, genetic glitches, nutritional deficiencies, alcoholism, and infections”. It may help to warn those of us who have had anthracycline chemotherapy to mention Adriamycin (doxorubicin) as a potential cause of cardiomyopathy as well. Many people have no idea about the cardiotoxicity until years afterward.

    I am wondering if you’ve heard that in studies on mice with diminished MI-induced LV function, therapeutic dosage of Paxil (paroxetine) inhibited GRK2 and enabled improvement of LV function ( Among ssris studied, only Paxil had that effect. Do you know of human studies of Paxil on GRK2?

  2. Elizabeth Kenoyer

    on December 19, 2015 at 10:04 pm

    I must take Coumadin due to prosthetic heart valves caused by meningitis. Can I still take Acetyl Carnitine, AlphaLipoicAcid and PHosphatidylserine?

    Elizabeth Kenoyer

  3. Judy Lesnick

    on December 24, 2016 at 12:25 am

    Can D-ribose be taken by those who have a defibrillator?

  4. Leticia S

    on May 16, 2017 at 1:44 pm

    Dr. Sinatra, I came across your website while researching info on treatment for cardiomyopathy in patients with Duchenne muscular dystrophy. My youngest son who is 16-years-old, has DMD and, though his heart is still in very good condition, the doctors want to put him on Lisinopril for preventive purposes. Due to the side-effects (cough, low bp), I am hesitant to start the meds. I read your info on the “awesome foursome” and am wondering if this would be a good alternative to try. We are already (since November 2016) giving him coq10 and fish oil, along with vitamin D3. He also takes Topamax for seizures. From what I have read, clinical trials for the efficacy of Lisinopril in DMD patients are still being conducted and won’t be complete until December 2017. Your opinion would be most helpful in deciding treatment.

  5. HeartMD Editor

    on May 23, 2017 at 9:08 pm

    Dr. Sinatra says, “Sorry, but I do not have any clinical experience with DMD and Linisopril. I like the the Q10,Omega 3 and some Vitamin D. I might hold off on Carnitine and D- Ribose, though, unless his heart weakens or the DMD gets worse with progressive weakness. I can understand why your MD is suggesting an ace inhibitor like lisinopril – if you are uncertain about the drug, waiting till the clinical is over may give you more information as well as security.”

  6. Jerry Z.

    on June 15, 2017 at 11:05 am

    Dr. Sinatra, a bit over 15 years ago at age 52, half my heart was attacked by a virus causing the infractions on half my heart to drop below 35%; currently, they are between 25% -28% depending on how much and how well my exercise program is in force. I proved the more I exercise the better my infractions that are recorded during a test. I currently take 10mg fosinopril, 12.5 mg x2 carvedilol, and eplerenone 12.5mg, plus the baby aspirin COQ10 200mg x2 and a vitamin D. The medication impedes my ability to work out and increase my infractions; also, my BP dips to below 100 sometimes during the day, my ankles retain water (more so if I do not exercise), and have a lot of phlegm which causes me to expectorate more than usual. Do you have any suggestions for alternative medications or workout programs to help me maintain an active lifestyle? (I have rejected implanting a defibrillator)

  7. HeartMD Editor

    on June 22, 2017 at 2:42 pm

    Dear Jerry,
    I would recommend that you consult with one of the cardiologists on Dr. Sinatra’s Top Docs List. They can better help you decide what alternative medications, supplements, and lifestyle changes can be integrated into your routine to help you maintain your activity level. You can see the list here.

  8. Gary Z.

    on July 12, 2017 at 10:37 pm

    Hello dr.

    I plan on beginning this regimen this weekend. If effective How long before I can expect results? I have hypertrophic cardiomyopathy, and have only had noticeable symptoms for the last 2-3 yrs. I am a 56 yr old male.

  9. Gary Zohn

    on July 13, 2017 at 11:09 am

    Hello dr.

    I plan on beginning this regimen this weekend. If effective How long before I can expect results? I have hypertrophic cardiomyopathy, and have only had noticeable symptoms for the last 2-3 yrs. I am a 56 yr old male.

  10. HeartMD Editor

    on July 17, 2017 at 12:28 pm

    Dear Gary, the supplement program listed above is to address heart failure resulting from cardiomyopathy. If you do not have evidence of heart failure, only hypertrophic cardiomyopathy, and you were Dr. Sinatra’s patient, he would instead recommend low-dose Coenzyme Q10 (approximately 50 mg) and 200-400mg magnesium for adjunctive support. Please discuss this with your cardiologist before going forward.

  11. Ana

    on September 3, 2017 at 7:03 am

    Good morning, I’m happy to find this website! My question is whether these four elements are equally beneficial for dogs with heart disease?

  12. Eileen

    on October 16, 2017 at 3:54 pm

    This has been so helpful. I take the supplements recommended and could not be happier with the results.

  13. HeartMD Editor

    on October 19, 2017 at 11:09 am

    Hi Eileen,

    We are so happy that you have benefited from Dr. Sinatra’s recommendations!

    And thank you for sharing your success with all our readers – it is an inspiration.

  14. Keri A.

    on November 18, 2017 at 3:27 pm

    Is it ok to take CoQ10 with Topral XL? I am a HCM patient who would like to start on CoQ10 but I do currently take Topral for palpitations. From what I understand from an earlier comment, Dr. Sinatra recommends the CoQ10 and Magnesium supplements for those with HCM alone and no signs of heart failure, correct?

  15. HeartMD Editor

    on November 28, 2017 at 1:03 pm

    Hi Keri,

    Dr. Sinatra has had many patients who’ve taken CoQ10 in addition to beta blockers.

    Please discuss taking it with your doctor.

  16. Russ E.

    on June 28, 2018 at 10:03 am

    Dr sinatra; i went on your awesome foursome after having 12 heart attacks, was told by a friend about it. Anyways here i sit after a month and a half of having following your recommendations with my 13th heart attack under my belt but now this time i had swelling in my feet and ankles wake up gasping for air. Hospital stay for four days with three more prescriptions added to my list . Should i keep going on your foursome or not, what are your thoughts, best regards Russ from canada

  17. HeartMD Editor

    on July 11, 2018 at 3:55 pm

    Hi Russ,
    Very sorry to hear about your condition. Many of Dr. Sinatra’s heart patients (including those with heart failure), realized significant benefits from taking targeted supplements. Dr. Sinatra discusses his Metabolic Cardiology approach in detail here and here. Discuss this material with your doctor and see if this is something you could consider.

  18. bhuvnendra S.

    on November 11, 2018 at 3:15 am

    Hello Doctor,
    My wife is suffering from HCM for last 17 years. Doctors told that now she is having HOCM. I came across a article where they have mentioned that CU ( copper supplement ) reverse the condition of hypertrophic cardiomyopathy. What is your view on this. Below is the link.
    Can I start CU supplement along with the suppliments which you have suggested ?

  19. amr yehia sallam

    on January 1, 2019 at 8:11 am

    1 comment

    Add a comment as amr yehia

    amr yehia1 day ago – Shared publicly

    Dear Dr Sinatra , I’m 46 years old Egyptian journalist writing in the field of medical sciences in one of the biggest newspaper in the middle East. I’m an x athlete , my body index in the area of over weight not obesity up and down 5 to 10 kilogram each year, I was diagnosed with hypertension years ago and I’m on ACE drugs. I’m not diabetic my lipid profile is always on the boarder line or higher a bit I don’t like taking statin drugs they cause me muscle ache. No heart attack history , my lab tests shows good kidney function and liver enzymes too. I have a slightly bright liver. my echo showed grade 1 diastolic dysfunction. lately I felt that my heart working harder and beating fast with some chest discomfort, although I’m taking supplements like fish oil , serrapaptase and nattokinase. etc. my Cardiologist told me that the ECG and Echo showed Hypertrophy cardiomyopathy (septal ).my old record ECG seemed to be normal tell 2013 it seems I got it after that , because of uncontrolled hypertension because I was on and off the medication and the stress of the job. they asked me to do MRI of heart muscle to get more details, but I couldn’t make it , my heart valves are okay , My EF 65 % . they added a beta blocker medication to rest the heart muscle , but it affected my sex drive and erection . what can you advice me with ? I’m taking Nattokinase and serrapaptase supplement , fish oil , liver support supplement , l carnitine , I feel some discomfort when I exercise, i’m playing soccer( is it recommended ???!!!) . do you think D ribose and magnesium will add much benefits to my case or what do think. can you give me a strategy were I can follow, because I believe on you thanks for your support


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