Table 2

Risk stratification for fasting in patients with cardiovascular conditions based on the IDF-DAR risk categories (reproduced based on10, with permission)

Risk levelModerate/low riskHigh riskVery high risk
AdviceMay be able to fast - listen to medical adviceShould not fastMust not fast
  • Stable hypertension

  • Stable angina*

  • Stable†, non-severe heart failure: LVEF >35%, HFpEF‡

  • Implantable loop recorder

  • Permanent pacemaker (single or dual chamber)

  • Mild/mild-moderate valvular disease

  • Supraventricular tachycardias/atrial fibrillation/non-sustained ventricular tachycardia

  • Mild/moderate pulmonary hypertension§

  • Poorly controlled hypertension (as defined by your specialist)

  • Recent acute coronary syndrome/myocardial infarction (<6 weeks)

  • Hypertrophic cardiomyopathy with obstruction¶

  • Severe valvular disease

  • Severe heart failure without advanced features

  • Poorly controlled arrhythmias (as defined by your specialist)

  • High risk of fatal arrhythmias (eg, inherited arrhythmic syndromes, arrhythmogenic cardiomyopathy)

  • Implantable cardioverter defibrillator±cardiac resynchronisation therapy

  • Advanced heart failure**

  • Severe pulmonary hypertension††

Patients with inherited cardiomyopathy, adult congenital heart disease, left ventricular assist device or heart transplantation should discuss fasting in Ramadan in their next routine appointment
  • *Episodes of angina are not occurring at rest or increasing significantly in frequency or severity.

  • †A difficult concept to define but the ESC guidelines define stability as no or mild heart failure symptoms and signs that have not changed recently for at least 1 month according to Ponikowski et al (2016).

  • ‡Diagnosed by a combination of symptoms, LVEF ≥45%–50%, Heart Failure Association score, natriuretic peptide levels±imaging (refer for specialist confirmation, if needed).

  • §Pulmonary artery systolic pressure >25 mm Hg without severe echocardiographic or right heart catheterisation features.

  • ¶With significant left ventricular outflow tract obstruction (>50 mm Hg).

  • **On optimal medical therapy, LVEF ≤35%, with class III–IV NYHA symptoms, ≥1 hospitalisation in the last 6 months due to decompensated heart failure and severely impaired functional capacity (eg, 6 min walk distance <300 m).

  • ††Defined as WHO/NYHA III–IV classification, right ventricular dysfunction and objective markers on right heart catheterisation, for example, SvO2 <60%.

  • ESC, European Society of Cardiology; HFpEF, heart failure with preserved ejection fraction; IDF-DAR, International Diabetes Federation and the Diabetes and Ramadan International Alliance; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.