By: Marc Lobliner, IFBB Pro

A recent state‑of‑the‑art review published in the Journal of Cardiac Failure (Kodur et al., 2025) shows that failing hearts naturally increase ketone oxidation as a survival mechanism for energy production. Small clinical trials have demonstrated that supplementing with ketones like beta-hydroxybutyrate (BHB) can improve heart function in patients with heart failure. The review highlights promising results for exogenous ketones in boosting cardiac output, stroke volume, and ejection fraction—metrics directly tied to heart performance.

Key Insights from the Review

Failing hearts suffer from an energy crisis. Normally, the heart burns glucose and fatty acids. But in heart failure, those pathways become inefficient. As a result, the heart shifts toward burning ketones, which are a more efficient and clean fuel.

The most accessible and impactful ketone for this purpose is beta-hydroxybutyrate (BHB). Studies now show that even in the most compromised hearts, infusions of BHB lead to immediate improvements in pumping capacity, oxygen use, and energy output.

These trials show that therapeutic ketosis—whether induced via diet or supplementation—can play a major role in improving cardiac performance.

Additional Clinical and Mechanistic Evidence

Acute Hemodynamic Boost
Research demonstrates that infusion of 3-OHB in heart failure patients led to a 40% increase in cardiac output, a 20 mL improvement in stroke volume, and an 8% increase in ejection fraction. This was achieved without a loss in cardiac efficiency or increased oxygen demand.

Ketones as Preferred Fuel
In failing hearts, up to 16% of the energy production (ATP) can come from ketones. This shift in metabolism suggests that the heart prefers ketones when under stress, and providing them exogenously makes a real difference in performance.

Anti-Inflammatory and Remodeling Effects
BHB has been shown to inhibit the NLRP3 inflammasome—a driver of chronic inflammation and tissue scarring in heart failure. By reducing inflammation, BHB may also limit myocardial fibrosis and support cardiac remodeling.

Endothelial and Vascular Support
Ketones have demonstrated an ability to support endothelial cell growth and blood vessel formation, which may improve circulation and nutrient delivery to the heart muscle itself.

Alignment with SGLT-2 Inhibitor Research
SGLT-2 inhibitors like empagliflozin, known for improving heart failure outcomes, also raise ketone levels. Many researchers believe this increase in circulating BHB is one of the reasons behind their success.