Cardiovascular Disease- How to Reverse Heart Disease

Introduction:

The research evidence here describes many effective non-pharmacological heart disease treatments, and reviews possibilities of how to reverse heart disease from coronary artery disease. In Preventive Health Advisor, coronary heart disease (CHD), coronary artery disease (CAD) are terms that will be used interchangeably to represent the disease characterized by atherosclerosis or thrombosis within the arteries of the heart. Atherosclerosis of these arteries result from plaque accumulation within the artery walls leading to compromise of blood flow and oxygen supply to the heart. According to the Centers of Disease Control as of 2010, the leading cause of death in the United States is heart disease and coronary artery disease makes up the largest proportion of these deaths. Coronary heart disease commonly causes symptoms of angina, shortness of breath, palpitations, lightheadedness, and heart attack (myocardial infarction). Although coronary heart disease cannot be cured completely, it can be managed by modification of risk factors for the disease. This is accomplished by improving important lifestyle habits and reinforcing these with education to impact the disease course. If a diagnosis of coronary heart disease has already become established, medication and medical procedures are often necessary to treat it. Standard-of-care medications for coronary heart disease includes lipid lowering drugs, nitrates, antiplatelet medications, beta blockers, angiotensin-converting enzyme inhibitors, and calcium channel blockers. There are many dietary, lifestyle, and Integrative Medicine options for prevention, improvement, and in some cases, reversal of coronary heart disease. This information includes data showing how to reverse heart disease from coronary artery disease.

 

Cause of Atherosclerosis:

Atherosclerosis is the primary disease process of the coronary arteries leading to coronary heart disease. Atherosclerosis was described by a world renowned Cardiologist, William C. Roberts, MD as the leading cause of heart attacks, stroke, and peripheral vascular disease. This author claimed that cholesterol intake causes atherosclerosis. Roberts is a highly regarded cardiologist with five decades of relevant experience, has over 1300 scientific publications, a dozen cardiology textbooks, and has been editor in chief of the American Journal of Cardiology for 25 years. According to this author, the evidence which supports that cholesterol causes atherosclerosis include a higher frequency of atherosclerotic events in populations with relatively high cholesterol levels compared with populations with relatively low cholesterol levels. Atherosclerosis is easily produced in herbivores (rabbits, monkeys) by feeding them a high-cholesterol (egg yolks) or high-saturated-fat (animal fat) diet. Lowering total cholesterol and low-density lipoprotein (LDL) cholesterol levels decreases first and repeat atherosclerotic events and decreases plaque size. Furthermore, societies with a high frequency of hypertension or a high frequency of cigarette smoking but low cholesterol levels rarely get atherosclerosis. Therefore, to decrease the risk of atherosclerotic events, Roberts recommends that LDL cholesterol needs to be <100 mg/dL and ideally <70 mg/dL. Total cholesterol should be <150 mg/dL, and the high-density lipoprotein (HDL) cholesterol >20 mg/dL. The low HDL goal is rationalized by the author that levels below 20 are not dangerous if LDL and total cholesterol is also low. (80)

 

Ideal cardiovascular health:

The American Heart Association (AHA) developed a construct of “ideal cardiovascular health,” targeting 7 behaviors that raise the likelihood of not having to face cardiovascular disease or stroke. These metrics established by the American Heart Association were applied by Artero, EG et al in The Aerobics Center Longitudinal Study to reduce the risk of cardiovascular mortality. They include 4 core behaviors—no smoking, a normal body mass index (BMI), engaging in physical activity, and eating healthfully—and meeting at least 3 of the following criteria: cholesterol lower than 200 mg/dL, blood pressure lower than 120/80 mm Hg, not having diabetes, or being free of heart disease. To assess the effects of meeting these targets on risk of death from cardiovascular disease, Artero and colleagues looked at data from the Aerobics Longitudinal Study, conducted in 11,993 patients between Oct. 9, 1987 and March 3, 1999. The authors found that those who met 3-4 of AHA’s “Simple Seven” heart-health criteria had a 55% lower risk of cardiovascular mortality than those who met no more than 2 of those practices over about 11 years. It was 63% lower for those who fulfilled five to seven of the ideal criteria compared with those with the lowest scores However, the overall prevalence of ideal cardiovascular health was extremely low in this middle-aged cohort, with only 0.2% of patients meeting all 7 criteria. (79)

 

Risk factor modifications to prevent or improve coronary heart disease:

According to the American Heart Association (AHA), the key to the prevention of coronary heart disease (CHD)or improvement of the CHD course is the emphasis of the following goals for cardiovascular disease risk reduction (82): 1) evidence-based dietary changes; 2) cardiopulmonary exercise; 3) achieving healthy bodyweight; 4) favorable lipid panel; 5) maintaining normal blood pressure; 6) avoidance of smoking; and 7) keeping blood glucose levels within normal range. (82)

 

Heart Health Risk Assessment Tool:

Heart Health Risk Assessment, “My Life Check,” is a free screening tool designed to determine risk of heart disease. This simple tool evaluates 7 simple achievements used to improve heart health. The tool will be a quick assessment of heart health by entering blood pressure, cholesterol, fasting blood sugar, activity level, fruit/vegetable intake, body weight, and smoking. This takes about 2 minutes to complete. It has been determined that a greater achievement in heart health in these 7 simple guidelines results in a lower lifetime occurrence of heart disease including heart failure (114).

 

 

American Heart Association (AHA) Scientific Statement, Diet and Lifestyle Recommendations for Cardiovascular disease (Revision 2006 by Lichtenstein, AH et al) (82):

Diet recommendations by the AHA:

• Eat a healthful diet the majority of the time including vegetables, fruits, whole grains, fat-free or low fat dairy, beans, lean meat, poultry, and oily fish at least twice weekly. Limit total cholesterol to 300 mg per day for healthy adults and for patients with LDL cholesterol under 100 mg/dl. Limit cholesterol to 200 mg per day for patients with coronary artery disease.
• Total fat intake limited to under 25–35 percent of total calories per day.
• Saturated fat intake limited to under 7 percent of total calories per day.
• Trans fat intake should be under 1 percent of total calories per day.
• Other fat in the diet should come from monounsaturated or polyunsaturated oils from unsalted nuts, seeds, oily fish, and vegetable oil such as canola or olive oil.

 

Maintain a healthy bodyweight:

Maintain a healthy bodyweight with a body mass index (BMI) between 18.5-24.9 kg/m². The AHA defines overweight as 25-29.9 kg/m², and obesity as greater than or equal to 30 kg/m². BMI can be calculated from the basic formula: [Weight (lb) / (Inches of height)²] x 703. BMI may also be calculated using a commonly available BMI calculator such as that available here: http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm from the NIH National Heart, Lung and Blood Institute. Please see weight loss in Preventive Health Advisor.

 

Achieve lipid profile goals:

Achieve LDL, HDL, triglyceride and total cholesterol goals. The Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol has established that the following lipid profile is optimal (as cited in Lichtenstein, 2006): LDL optimal under 100 mg/dl, near optimal 100-129 mg/dL, borderline high 130-159 mg/dL, high 160-189 mg/dL, and very high over 190 mg/dL. No specific goals for HDL and triglycerides exist but HDL under 40 mg/dL for men and under 50 mg/dL for women as wells a s a triglyceride level of over 150 mg/dL are all associated with metabolic syndrome. For more information about treatment of elevated cholesterol levels, please see the hyperlipidemia section of Preventive Health Advisor.

 

Blood pressure goal:

Focus on achieving normal blood pressure. According to the AHA, the lifetime risk of hypertension is about 90% and any elevation above a normal blood pressure of 120 systolic over 80 diastolic increases risk of coronary heart disease even if elevated into pre-hypertensive levels. For more information, please see the hypertension section of Preventive Health Advisor.

 

Blood glucose levels:

Strive to keep blood glucose in normal range. According to the AHA, normal fasting blood glucose is less than or equal to 100 mg/dL and a fasting blood glucose of greater than or equal to 126 is diagnostic of diabetes. Weight loss, exercise, and avoidance of concentrated sweets can greatly improve control of glucose and insulin resistance. For more information, please see the diabetes mellitus section of Preventive Health Advisor.

 

Exercise goals:

Maintain a physically active lifestyle. Regular activity promotes cardiovascular fitness. For further information about benefits of aerobic exercise or resistance training, please see these sections of Preventive Health Advisor.

 

Smoking:

Counsel patients to quit smoking. Please see the section on smoking cessation in Preventive Health Advisor.

 

Importance of reducing dietary fat intake and coronary artery disease:

Reducing dietary fat, LDL reduction, and arterial diameter: Fourteen patients with slightly elevated levels of low-density lipoproteins (LDL) and confirmed coronary atherosclerosis were treated with pharmacologic and nonpharmacologic interventions for 2 years. The subjects were evaluated by coronary angiogram before and after the 2 year University of California Davis Coronary Artery Disease Regression Program. During the study intervention, dietary fat intake was decreased by 58% and intensive risk factor reduction was implemented. LDL levels dropped from 120 mg/dL to 104 mg/dL (p = 0.05). After 24 months, there was a net increase in arterial diameter (regression) of 0.05 mm to 2.81 mm (p = 0.01). While there was no significant change in the average diameter of discrete stenosis (abnormal narrowing in a blood vessel), 1 of 8 mild lesions < or = 20% regressed, while 4 progressed. The intervention resulted in regression of more severe lesions (> 50% initial stenosis), but does not appear to prevent progression of mild lesions (< 20%). These findings suggest that in patients with only mild elevation of lipids, the modification of risk factors improves the biology of the most severe lesions. (81)

For more information: Please see hyperlipidemia in Preventive Health Advisor.

 

Importance of homocysteine levels and risk of heart attack:

A statistically significant positive association between elevated homocysteine (Hcy), an amino acid, and risk of heart attack (myocardial infarction) and stroke has been found in a cohort study of 7,983 individuals. It was estimated that each 1 mmol/L increase in plasma Hcy concentrations were associated with a 6%–7% increase in the risk of stroke. Additionally, participants with total Hcy levels above 18.6 micromol/L were at significantly increased risk for heart attack (odds ratio [OR]=2.43) and stroke (OR=2.53). Those with hypertension also faired worse. (67)

 

Evidence-based diet and exercise programs for coronary artery disease:

The Pritikin Program evidence-based benefits:

A study using 67 patients with metabolic syndrome to investigate the effects of Pritikin therapy for 12-15 days showed improvement in most heart disease risk factors, including body mass index (3% reduction), blood pressure, glucose and LDL cholesterol (10%-15% reduction), and triglycerides (36% reduction). Additionally, 37% of subjects no longer met the criteria for metabolic syndrome as determined by the National Cholesterol Education Program. However, HDL cholesterol decreased by 3%. (33)

The Centers for Medicare and Medicaid Services review of published data on the Pritikin intensive cardiac rehabilitation programs found that it effectively slowed or reversed progression of coronary heart disease and reduce the need for coronary artery bypass grafts (CABG) and percutaneous interventions. Other benefits identified included reduced LDL cholesterol levels, body weight, blood pressure, rates of angioplasty procedures and the need for cholesterol, blood pressure, and diabetes medications. (34)

The Pritikin Program was found to lower total cholesterol, lower LDL cholesterol, lower blood pressure, provide better control of insulin levels (control type 2 diabetes), decrease in the circulating levels of compounds that increases the risk of heart disease and blood vessel damage, reduction in the risk of heart disease, hypertension, type 2 diabetes, breast cancer, colon cancer, and prostate cancers. (35)

 

Pritikin Diet characteristics (33,34,35):

• Diet plus exercise counseling for three to four weeks.
• Very low fat, less than 10% of calories compared to 35% in the normal American diet.
• Eat low sodium and avoid salty foods.
• High fiber with at least five ½-cup servings of whole grains daily (wheat, oats, and brown rice or starch vegetables such as potatoes, and dried beans and peas.
• Refined grain products (white flour, regular pasta, white rice) are limited to two servings daily.
• At least four 1-cup servings of raw vegetables daily or ½-cup servings of cooked vegetables. Dark green, leafy, and orange or yellow vegetables are preferred
• At least three servings of fruit, one of which can be fruit juice.
• Two servings daily of calcium-rich foods such as nonfat milk, nonfat yogurt or fortified and enriched soymilk.
• No more than one caffeinated drinks daily. Instead drink water, low-sodium vegetable juices, grain-based coffee substitutes or caffeine-free teas.
• No more than four alcoholic drinks per week for women and no more than seven for men, with red wine preferred over beer or distilled spirits.
• No more than seven egg whites per week.
• no more than 2 ounces (about 1/4 cup of nuts) daily.
• Moderate amounts of fish, nonfat dairy, and lean meat with no more than one 3.5 cooked serving of animal protein per day with fish and shellfish are preferred. Lean poultry should optimally be limited to once a week and lean beef to once a month.
• Adapted to vegetarians by replacing animal protein with protein from soy products, beans, or lentils.
• Avoid fried foods, dressing with fat, and fatty sauces, animal fats, processed meat, dairy products not made with non-rat milk, egg yolks, salty snacks, cakes, cookies, and similar high-calorie choices.
• Eat frequently with three meals a day plus two snacks.
• Artificial sweeteners such as Splenda are okay.
• Exercise component of the Pritikin Program: The exercise component includes 45 minutes of moderate exercise daily such as walking.

 

Insurance approval for the Pritikin Program:

Medicare may approve coverage for the Pritikin Program for qualifying individuals with a history or risk of cardiovascular events. The program has been approved for coverage under Part B of Medicare. Medicare will reimburse eligible beneficiaries for up to 72 one-hour ICR sessions, up to 6 sessions per day, at the Pritikin Longevity Center & Spa.

 

The Dean Ornish Program for Reversing Heart Disease (36):

The Ornish program evidence-based benefits:

• The study used 3,780 patients and found that the average patient lost 13.3 pounds in the first 12 weeks and 15.9 pounds after 1 year.
• Significant reductions in systolic blood pressure (BP), diastolic BP, total cholesterol, triglycerides, and LDL-cholesterol after 12 weeks were still significant after 1 year.
• Exercise capacity increased by 18% after 12 weeks and 24% after one year.
• Reductions in depression were still significant after 1 year.
• Hemoglobin A1C in diabetics continued to decrease after one year.
• 5% of patients reported improvement in severity of angina (chest pain) after 1 year.
• Ornish Program characteristics: The Ornish program teaches a plant-based, meatless diet, meditation, and regular exercise with adherence to the program between 85 to 90% after one year in hospitals and clinics that have offered it.

 

Insurance approval for the Ornish Program:

Medicare Part B covers The Dean Ornish Program for Reversing Heart Disease, under a new benefit category, Intensive Cardiac Rehabilitation (ICR). Eligibility includes acute myocardial infarction within the preceding 12 months, a coronary artery bypass surgery, current stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or coronary stenting, a heart or heart-lung transplant, or other cardiac conditions as specified through a national coverage determination. (36)

 

The Therapeutic Lifestyle Changes Diet for coronary heart disease (37,38):

The Therapeutic Lifestyle Changes Diet characteristics:

• Consistent with the American Heart Association’s 2006 Diet and Lifestyle Recommendations which can reduce the risk of cardiovascular disease.
• The diet consists of cutting back sharply on saturated fat, which may elevate LDL cholesterol levels and increase the risk of heart attack and stroke. Intake of saturated fat is kept below 7% of the total calorie intake. Total fat intake should consist of 25-35% of daily total calories.
• Daily cholesterol intake should be kept below 200 milligrams.
• Sodium intake is limited to 2400 mg per day. Calorie intake should be kept to a level needed for maintaining healthy weight and reduce blood cholesterol level. (38)

 

Therapeutic Lifestyle Changes Diet plus exercise:

The effect of adding 30 minutes of daily exercise at 50-75% of age-predicted maximum heart rate, to a Therapeutic Lifestyle Changes Diet (TLC) for 6 months was examined by Welty, FK et al. The authors of the study randomized participants with high-normal or stage 1 hypertension to either a treatment diet rich in fruit, vegetables, low-fat dairy products, reduced saturated/total fat or a control diet low in fruit, vegetables, and dairy products with fat content typical of the average US diet. A TLC diet with the addition of exercise assisted 89% of participants to reach an LDL cholesterol goal of under 130 mg/dL without lowering HDL levels or needing to add or increase lipid lowering therapy. The authors emphasized that exercise and weight loss should be encouraged with the TLC diet to achieve the LDL goal. Mean total cholesterol, LDL cholesterol and triglycerides decreased by 9.2% (p=0.08), 9.3% (p<0.018), and 18.8% (p<0.05), respectively; mean HDL cholesterol increased 2.6% (p=0.41). Women had a 12.3% reduction in LDL cholesterol and an 11.4% increase in HDL cholesterol compared with a 7.9% reduction in LDL cholesterol and no change in HDL cholesterol in men. Additionally, systolic and diastolic blood pressure (BP) decreased 9% (p<0.001) and 13%, respectively (p <0.0001). These BP reductions were two-fold greater than in the Diet and Systolic Hypertension study (DASH) The addition of exercise also achieved a 50% reduction in angina. (37)

 

Specific evidence-based dietary modifications for coronary heart disease:

Nut consumption and risk of coronary events:

Studies have shown that consumption of almond and walnuts, instead of more traditional fats, is linked to an 8% to 12% reduction in LDL (bad) cholesterol.  Macadamias and hazelnuts have been shown to be at least as beneficial as fats in commonly recommended diets. Other studies have reported that frequent consumption of nuts were linked with a 30% to 50% decreased risk of coronary heart disease. Additionally, the Dietary Approaches to Stop Hypertension (DASH) diet recommends regular consumption of nuts with seeds and dried beans (4-5 servings per week) as part of a diet to control hypertension. (43)

There is consistent evidence from epidemiologic and clinical studies that tree nuts and peanuts reduce the risk of developing coronary heart disease (CHD) and also have beneficial effects on CHD risk factors (including oxidation, inflammation, and vascular reactivity). Collectively, the data from the four most recent U.S. studies estimates that Americans who eat five or more servings of nuts per week have a 35% reduced risk of coronary heart disease. Nuts lower total and LDL cholesterol to a greater extent than expected based on their favorable fatty acid profile and also appear to contain other bioactive compounds with cholesterol-lowering properties. Including nuts and peanuts in a healthy diet may decrease the risk of CHD. (44)

 

Amount of fruit and vegetable intake by weight to lower risk of ischemic heart disease:

A literature review of studies examining the relationship between consumption of fruit and vegetables (including nuts) and the risk of ischemic heart disease (IHD) was conducted. The only controlled intervention study ever performed resulted in a negative result. However, eight published cohort studies resulted in an overall reduction in the risk of developing IHD of approximately 20%. It has also been shown that the risk reduction is associated with the quantity consumed, but the benefit appeared to be only up to 800 grams of fruits and vegetables according to this review. Therefore, the maximum benefit of fruits and vegetables in ischemic heart disease was determined to be 800 grams per day by this study. The study however does not mention that other health benefits may be obtained such as cancer prevention and reduction in risk for other diseases with a higher consumption of fruits and vegetables. (48)

 

Vegetarian diet and cardiovascular disease:

A meta-analysis consisting of 7 studies with a total of 124,706 participants from the UK, Germany, USA, Netherlands and Japan was conducted to investigate cardiovascular disease mortality and cancer incidence among vegetarians and non-vegetarians. All-cause mortality, mortality from circulatory diseases, and mortality from cerebrovascular diseases in vegetarians were lower when compared to non-vegetarians by 9%, 16%, and 12%, respectively. Researchers also found a statistically reduced rate for vegetarians in terms of ischemic heart disease mortality (29%) and cancer incidence (18%). This study suggests vegetarians have a mortality advantage compared to non-vegetarians. (50)

 

Whole grain consumption and risk of cardiovascular disease:

This meta-analysis examined evidence on whole grain intake and cardiovascular disease (CVD). Seven prospective cohort studies with measures of dietary whole grains and cardiovascular outcomes were identified. Researchers found that greater whole grain intake (average 2.5 servings per day vs. 0.2 servings per day) was associated with a 21% lower risk of CVD events. The findings were similar for both men and women and CVD events including heart disease, stroke, and fatal CVD events. The authors’ concluded that evidence from prospective cohort studies showed that as dietary whole grains consumption increases events associated with cardiovascular disease decrease. (45)

 

Soy protein and reduced risk of coronary artery disease:

The Food and Drug Administration (FDA) has approved a statement on food labels that soy protein may reduce the risk of coronary artery disease by lowering cholesterol levels when included in a diet low in saturated fat and cholesterol. (42)

 

Purple potatoes and risk of hypertension:

Eighteen overweight and hypertensive men and women consumed 6-8 small microwaved purple potatoes twice a day, or no potatoes, for four weeks; then switch to the opposite regimen for another four weeks.  The researchers monitored the volunteer’s blood pressure during the same period and found that the average diastolic blood pressure dropped by 4.3% and the average systolic dropped by 3.5%. None of the study participants gained weight during the study period. The study authors conclude, “purple potatoes are an effective hypotensive agent and lower the risk of heart disease and stroke in hypertensive subjects without weight gain.” (49)

See hypertension in Preventive Health Advisor for further information.

 

Beta-carotene in food vs. supplements and heart disease:

Intake of vegetables containing beta carotene was associated with a lower risk of cardiovascular mortality and with a lower risk for all causes of death but no benefit was seen with taking beta-carotene supplements. Greenberg ER et al tested beta carotene levels in subjects prior to being randomized to take beta carotene supplements. Subjects with an intial beta carotene level of 0.34-0.52 umol/L had a 43% less risk of death from cardiovascular disease when compared to subjects with the lowest intial beta carotene levels of under 0.21 umol/L. Those subjects with an intitial beta carotene level of over 0.52 umol/L had a lower risk of death from all causes. There was no reduced risk of disease or mortality benefit in subjects who took beta carotene supplements in pill form. (68)

Beta-carotene supplements are not advised among healthy individuals, unless they suffer from or are at risk of vitamin A deficiency. Beta-carotene supplementation results in a greater increase of beta-carotene blood concentration than beta-carotene rich foods. A 20 mg/d supplement of beta-carotene can result in blood concentrations high enough to increase a patient’s risk of lung cancer, while the same quantity obtained from foods was not associated with lung cancer risk. Additionally, 30 mg/d of beta-carotene supplement was associated with blood concentrations 5 times greater than that of 29 mg/d of beta-carotene from carrots. (70)

The consumption of 5 or more daily servings of fruits and vegetables is recommended by “National Cancer Institute’s Five-A-Day for a Better Health program” and “Canada’s Food Guide for Healthy Eating.” Eating a variety of 5 fruits and vegetables per day provides the individual with about 5.2 to 6 mg/day of food based beta-carotene. This allows plasma carotenoid levels to rise above a range represented in studies which were associated with a lower risk of coronary heart disease and all-cause mortality compared to those with a lower food based carotenoid levels.

The Beta-Carotene and Retinol Efficacy Trial (CARET), showed that among 18,314 men and women who smoked heavily or were exposed to asbestos, daily intake of 30 mg (100,000 IU) of beta-carotene and 25,000 IU vitamin A failed to decrease the risk of heart disease. The study was stopped early because it showed that beta-carotene/vitamin A takers who were heavy smokers, ex-smokers or asbestos workers were showing a 28% increased risk of lung cancer in smokers (versus placebo) and a 17% more likely chance of dying, mostly of lung cancer or heart disease.  Results of a 6-year follow-up of study participants showed that compared to the placebo or no intervention group, participants who had taken the intervention had a 12% and 8% increase in relative risk of lung cancer and all-cause mortality among the intervention group, respectively. Researchers also found that after the intervention was stopped relative risk of cardiovascular disease mortality dropped and there was no difference in risk between the two groups. Finally, they found that women were more affected by the supplements with a larger relative risk of cardiovascular disease mortality (1.44 versus 0.93; P = .03), and all-cause mortality (1.37 versus 0.98; P = .001) than males. (100)

According to Martini et al in the University of Minnesota Cancer Prevention Research Unit Feeding Studies, an intake of 5 mg per day of beta carotene was required to establish beta carotene levels to a plasma level of 0.37 umol/L. When food based beta carotene was consumed in the form of about 1.5 cups of carrots, and about 0.9 cups of spinach which equated to just over 42 mg of beta-carotene per day, levels increased to 0.83 umol/L. (69)

Beta-carotene in foods: For a breakdown of concentration of beta-carotene in foods, please see: Nutritive Value of Foods, United States Department of Agriculture, Agricultural Research Service, Home and Garden Bulletin Number 72. This may be accessed at (102): https://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR25/nutrlist/sr25w321.pdf and http://www.nal.usda.gov/fnic/foodcomp/Data/HG72/hg72_2002.pdf

A meta-analysis that included 78 randomized clinical trials was conducted to determine the relationship of oral antioxidant supplementation (beta-carotene, vitamin A, vitamin C, vitamin E, and selenium) and mortality. Mean duration of supplementation was 3 years. When all of the trials were combined, and the analysis that is typically used when similarity is present was conducted (fixed-effect model), antioxidant use did slightly increase mortality. When the trials with low risks of bias were considered, the patients consuming the antioxidants had a 4% higher risk of death compared to those taking placebo or no intervention (relative risk [RR]=1.04). The increased risk of mortality was significantly associated with use of beta-carotene (death rate: 13.8% on supplement vs 11.1% on placebo; RR=1.05) and vitamin E (12.0% vs 10.3%; RR=1.03) and possibly vitamin A, though the relationship was not significant with a 14.0% death rate among those taking vitamin A compared to a 13.6% death rate among placebo subjects. The current evidence does not support the use of these antioxidant supplements in the general population or in patients with various diseases. (101)

The studies mentioned thus far on beta-carotene suggest a lower risk of mortality stems from beta carotene intake from food sources but not beta-carotene supplements. The benefit may also come from other substances in the vegetable food source and not necessarily the beta carotene itself.

For the prevention of cancer or cardiovascular disease, the U.S. Preventive Services Task Force (USPSTF) recommends against the use of beta-carotene supplements, alone or in combination. According to the USPSTF, there is insufficient evidence to recommend for or against the use of vitamins A, C, or E supplements or multivitamins with folic acid or antioxidant combinations for the prevention of cancer or cardiovascular disease. (72)

 

Vitamin D and cardiovascular-related and all-cause mortality:

Sun and colleagues evaluated the associations between both dietary and supplemental vitamin D and cardiovascular disease risk. Researchers evaluated data on 74,272 women and 44,592 men who were initially heart disease and cancer-free from the Nurses’ Health Study (1984-2006) and the Health Professionals Follow-Up Study (1986-2006). After about a 20 year follow-up period, 9,886 cases of coronary heart disease and stroke were documented.  The researchers found a 16% reduction in heart disease among men who met the Dietary Reference Intake (DRI) of vitamin D of at least 600 IU per day, as compared to men with daily intakes of less than 100 IU. The researchers found that men who consumed larger amounts of vitamin D had a decreased risk of heart disease. There was no association between vitamin D intake and heart disease risk for women. (75)

In a study on adult men, Michaëlsson K et al found that a vitamin D concentration of 24 to 34 ng/ml (60 to 85 nmol/L) approximately translates to a vitamin D dose of 2000 IU/d and corresponded to the lowest cardiovascular-related and all-cause mortality (103). Overall mortality was increased by 50–60% among subjects in the lowest 10% and highest 5% of the vitamin D level curve distribution, whereas cardiovascular mortality was increased only in the bottom 10%. Vieth reported that the ideal level of vitamin D intake for adults should be 50 mg (2000 IU) per day (104). Bosomworth NJ conducted a review of multiple studies, and determined that 500-1500 IU/d of vitamin D reduced all-cause mortality (105). After Sun Q, et al followed 74,272 women and 44,592 men over 20 years, 9,886 cases of coronary heart disease and stroke occurred, and a 16% reduction in heart disease was seen among men with an intake of 600 IU or more per day of vitamin D, compared with those with an intake of 100 IU (106).

For more information, please see vitamin D section of Preventive Health Advisor.

 

Vitamin D and hypertension:

Goel RK found that subjects taking 33,000 IU of vitamin D every 2 weeks for 3 months plus standard therapy were noted to have a reduction in systolic blood pressure (BP) of 7.5 mm Hg compared to a 3.6 mmHg reduction in the standard therapy group, but diastolic BP in both groups increased by 2.1 mmHg and 1.3 mmHg, respectively. (107).

A double-blind randomized controlled trial of 148 women with a mean age of 74 years tested 1200 mg calcium plus 800 IU vitamin D3 and found that systolic blood pressure (SBP) decreased by 9.3% and heart rate by 5.4% compared with 1200 mg/day of calcium alone. 81% in the vitamin D3 and calcium group compared with 47% in the calcium group showed a decrease in SBP of 5 mm Hg or more. (108)

Vitamin D and cardiovascular disease: Maintain favorable levels of vitamin D in all patients with any risk factors for cardiovascular disease. Vitamin D is not established as a direct cause of cardiovascular disease, but vitamin D deficiency is associated with a higher incidence of hypertension, hyperlipidemia, coronary artery disease, stroke, chronic kidney disease, and diabetes mellitus type 2 (113). A retrospective analysis showed that patients with diabetes mellitus have a very low 25-hydroxy vitamin D level, and also found that high levels of triglycerides, LDL cholesterol, and HbA1C had a consistent association with vitamin D deficiency in type 2 diabetes patients (112).

For more information, please see vitamin D section of Preventive Health Advisor.

 

Wine consumption and cardiovascular risk:

Moderate red wine consumption has been associated with decreased cardiovascular risk, reduced mortality, improved cholesterol profile, improved bone density in older adults, and reduced risk of cancer esophageal and gastric cancer. Multiple studies have shown that red wine is more beneficial in reducing the risks of coronary artery disease (CAD) and mortality in general when compared with other alcoholic beverages such as spirits, beer and white wine. HDL cholesterol have been found to be increase with red wine consumption in numerous studies. (55)

A study done in Copenhagen, Denmark followed 6051 men and 7234 women between 30 and 70 years old. The relative risk of cardiovascular and cerebrovascular mortality was significantly less for those who had a low to moderate intake of wine. It was found that beer intake did not change mortality risk much and that drinking spirits increased mortality. (56)

A parallel four-armed intervention studied the relationship between cardiovascular disease (CVD) and wine drinkers. Sixty-nine men and women aged 38-74 years old were randomized to either 1: red wine (males: 300 ml/day, 38.3 g alcohol/day, female subjects: 200 ml/day, 25.5 g alcohol/day), 2: water + red grape extract tablets (wine-equivalent dose), 3: water + red grape extract tablets (half dose), or 4: water + placebo tablets. At the end of the 4-week study period, results showed that drinking red wine in moderation increased HDL cholesterol by 11–16% and decreased fibrinogen (a protein that plays a key role in blood clotting) by 8–15% compared with drinking water with or without red fermented grape extract. The findings suggest that it is the alcohol component of red wine that is causing these beneficial effects. In conclusion, moderate alcohol consumption in the form of red wine and other beverages is associated with beneficial changes in blood lipids and fibrinogen that may help to reduce the risk of CVD. (57)

The relation between red wine (polyphenolic extracts) and risk factors associated with cardiovascular disease was examined in this European project FAIR CT 97 3261. Results from a study of 40 healthy volunteers in Barcelona showed a significant increase in HDL cholesterol levels and a decreased oxidation of LDL cholesterol after red wine consumption (30 g alcohol daily for 4 weeks) as compared to the same amount of alcohol given as spirit such as vodka, whiskey, gin, tequila, and rum. Additionally, according to the authors, a meta-analysis indicated a significant negative relationship between moderate wine drinking of 150-300 ml daily and the risk of cardiovascular events. In conclusion, moderate wine consumption is linked with prevention of cardiovascular disease. (58)

The effects of dealcoholized red wine (DRW) and regular red wine (RW) on risk factors associated with cardiovascular disease (CVD) in 45 hypercholesterolemic (high cholesterol level) postmenopausal women were analyzed. Participants were randomized to 400 mL/day of either water, DRW or RW for 6 weeks on a controlled diet following a 4-week washout. At the end of the study period, concentrations of fasting lipids, lipoproteins, insulin and glucose were unaffected by DRW intake. However, chronic consumption of RW significantly decreased LDL (“bad”) cholesterol concentrations by 8% and increased HDL (“good”) cholesterol concentrations by 17%.  In summary, regular consumption of red wine reduces CVD risk by improving fasting LDL and HDL levels in hypercholesterolemic postmenopausal women. (59)

Drinking alcohol has a positive protective effect on cardiovascular disease. Men who consumed light-to-moderate amounts of alcohol at 3–4 or 5–7 days per week had decreased risks of myocardial infarction and ischemic stroke compared with men who consumed alcohol less than once per week. Moderate alcohol drinking decreases the risk of cardiovascular disease by about 25%, which is linked to a decrease in the total cardiovascular disease burden in Australia of 4.7%. In Australia, 34% of the total number of deaths in 2008 were from cardiovascular disease and in 2003, it was18% of the overall burden of disease (coronary heart disease and stroke contributed over 80% of this burden). Alcohol consumption decreases the risk of cardiovascular disease. (60)

 

Chocolate consumption and risk of coronary artery disease:

Researchers studied the effects of total chocolate intake on coronary heart disease (CHD) in 4,970 men and women, ages 25 to 93 years, looking at the frequency of dark chocolate consumption and assessing for the onset of CHD.  The researchers found evidence suggesting an inverse association between frequency of chocolate consumption and coronary heart disease: specifically, consumption of chocolate 1-4 times per week was associated with a 26% lower risk of CHD and consumption of chocolate more than five times a week was associated with 57% lower risk of CHD, as compared to those subjects who did not consume chocolate. Additionally, consumption of non-chocolate candy was associated with a 49% higher risk of CHD comparing 5 or more times per week vs. none per week. (39)

A large study on chocolate consumption suggests that chocolate might help maintain healthy arteries. Researchers analyzed data from food frequency questionnaires of 2217 subjects. Healthy arteries were assessed by rate of calcified atherosclerotic plaque in the coronary arteries (CAC) (measured by cardiac computer tomography). Using non-eaters of chocolate as a baseline, the researchers concluded that those who ate 1-3 servings per month had a 6% reduced CAC. For 1/week chocolate eaters, a 22% reduction was observed, and consuming chocolate at least 2 times per week was associated with a 32% reduced CAC. (40)

In a study, 15 healthy adults under the age of 50 and 19 healthy adults over the age of 50 drank a specially made flavonol-rich cocoa every day for four to six days. Flavonols naturally occur in plants and possess antioxidant characteristics. Blood pressure and peripheral arterial responses were recorded. The results showed blood vessel function improved among both younger and older adults after the cocoa phase. However, improvements were more significant in the older group. (41)

 

Caffeine consumption and cardiovascular disease risk:

In a population study researchers found that consumption of coffee, green tea and oolong tea and total caffeine intake was linked to a reduced risk of death from cardiovascular disease (CVD). Participants included 76,979 adults followed for 1,010,787 person years, all of whom were ages 40 to 79 and free of stroke, heart disease, and cancer at the start of the study. Researchers determined that compared to non-coffee drinkers, men consuming 1-6 cups/week, 1-2 cups/day and ≥ 3 cups/day had a protective effect from coffee with a 22%, 33%, and 55% less rate of stroke occurrence than the control population. The multivariate hazard ratio,(HR), (or ratio of hazard rates from coffee drinkers to non coffee drinkers) was 0.78 (range 0.50 to 1.20), 0.67 (range 0.47 to 0.96) and 0.45 (range 0.17 to 0.87) respectively for strokes among men (p = 0.009). Compared with non-tea drinkers, women consuming 1-6 cups/week, 1-2 cups/day, 3-5 cups/day and ≥ 6 cups/day had a 66%, 72%, 61%, and 58% reduced rate of coronary heart disease compared to non-tea drinkers. Multivariable hazard ratios were 0.34 (0.06-1.75), 0.28 (0.07-1.11), 0.39 (0.18-0.85) and 0.42 (0.17-0.88) respectively(p = 0.038 for trend). Men drinking ≥ 1 cups/day of oolong tea benefited from a 61% reduced rate of CVD (the HR was 0.39, with range of 0.17-0.88) when compared to non-tea drinkers, (p = 0.049 for trend). Individuals in the second highest quintile of total caffeine intake had a total CVD risk reduction of 38% in men and 22% in women. (53)

According to James J. E. , caffeine, through its daily consumption from a variety of sources (coffee, teas, soft drinks, chocolate and medicines), may have an impact on cardiovascular risk. This fact is related to the evidence found the scientific literature about the ability of caffeine to increase resting blood pressure (BP) in adults by about 4/2 mmHg. However, this increase in BP could be responsible for premature deaths of about 14% for coronary heart disease and 20% for stroke. (54)

 

Green tea and cardiovascular disease:

Consuming green tea is associated with a reduced risk of death from heart disease as well as from all-cause mortality. Researchers followed 40,530 Japanese adults up to 11 years. The results indicated that individuals who consumed the most green tea had lower death rates from cardiovascular disease (CVD) compared to subjects who consumed the least green tea (less than 1 cup/day). Women who drank ≥ 5 cups/day of green tea had a 31% lower risk of dying from CVD and a 23% lower risk of mortality from all causes than women who drank <1 cup/day. Those who drank 1 to 2 cups/day or 3 to 4 cups/day green tea had a 2% and 18% reduced risk of all cause mortality, respectively. Corresponding risk reductions in CVD were 16% and 31%. The protective effects of green tea was stronger in women than in men. In men who drank ≥ 5 cups/day green tea their all-cause mortality rate fell by 12%. Men who drank 1 to 2 cups/day or 3 to 4 cups/day green tea had a 7% and 5% reduced risk of all cause-mortality, respectively. Green tea consumption was not associated with a reduction in cancer mortality. (51)

A Japanese insurance database was used to study the relationship between green tea consumption and all-cause and disease-specific mortality. The population-based study included data on 40,530 Japanese adults aged 40 to 79 years. At baseline in 1994, all subjects were free of stroke, coronary heart disease, and cancer. All-cause mortality was assessed over 11 years’ follow-up and mortality from cardiovascular disease and cancer over 7 years’ follow-up. Especially for women, greater consumption of green tea was associated with lower all-cause mortality and mortality from cardiovascular disease. On multivariate analysis, hazard ratios for all-cause mortality were 0.93 for men who drank 1 to 2 cups of green tea per day, 0.95 for 3 to 4 cups per day, and 0.88 for more than 5 cups per day (compared to less than 1 cup per day). For women, the hazard ratios were 0.98, 0.82, and 0.77, respectively. Green tea consumption had an even stronger inverse association with cardiovascular disease: for women, hazard ratios were 0.84 at 1 to 2 cups per day, 0.69 at 3 to 4 cups per day, and 0.69 at 5 or more cups per day. This study suggests that all cause and cardiovascular disease mortality are lower among subjects with higher consumption of green tea. Drinking green tea was noted in this study to have no apparent protective effect against cancer mortality. (52)

 

Aerobic exercise for cardiovascular disease prevention and treatment:

Seek approval by primary physician prior to starting an exercise program. Aerobic exercise generally consists of mild to moderate intensity activity with rhythmic contraction of major muscle groups over an extended period of time. Examples include fast walking, jogging, cycling, Zumba, cross country skiing, and swimming. For the  physician or fitness professional, the following source is the most credible reference for initiation of exercise in patients: Walter R. Thompson, American College of Sports Medicine, Neil F. Gordon, Linda S. Pescatello. ACSM’s Guidelines for Exercise Testing and Prescription. Lippincott Williams & Wilkins, Feb 1, 2009. (26)

 

Benefits of aerobic exercise:

The data provided below illustrates many benefits of aerobic exercise in cardiopulmonary (heart and lung) conditioning, improved pumping efficiency of the heart, improved circulatory system (83), weight control (84), cholesterol reduction (84,27), triglyceride lowering (84), lowering of blood pressure (30), lower rate of smoking (29),  and control of diabetes (89,90).

 

Aerobic exercise results in reduction of cardiac mortality and all-cause mortality (29).

According to the World Health Organization: According to the World Health Organization, regular exercise is recommended for not only all healthy individuals, but also those suffering from obesity, diabetes, hypertension, atherosclerotic cardiovascular disease and cancer. (92)

 

Starting exercise in apparently healthy adults:

According to the American College of Sports Medicine (ACSM) and the American Heart Association (AHA): Older adults need moderate-intensity (between 5-6 on a 10-point scale) aerobic endurance activity for a minimum of 30 min which can be achieved in short 10 minute sessions on five days each week or vigorous-intensity aerobic, (rated a 7-8 on a 10-point scale) activity for a minimum of 20 min on 3 days each week.  Adults should also perform muscle-training exercises 2-3 days each week using a variety of exercises (8-10 exercises involving the major muscle groups). For each exercise, 10-15 repetitions are recommended to improve strength. Additionally, older adults at risk of falling should do flexibility exercises at least 2 or 3 days each week to maintain or improve balance. (27)

Amount of activity according to the World Health Organization: The most benefit from physical activity is achieved with at least 2.5 hours of aerobic exercise of moderate intensity per week, which can be accumulated in 10-minute periods. At least 2 days/week vigorous intensity aerobic exercise and resistance exercises for muscle strengthening are recommended. Increased intensity, frequency and duration of exercise is associated with increased added health benefits. (92)

 

American College of Sports Medicine (ACSM) Cardiorespiratory Training Guidelines:

Main components of an exercise session per ACSM include warm-up, conditioning stimulus, and cool down. Warm-up before the session and cool down after the session of exercise consists of 5-15 minutes of activity at 50% training intensity of the conditioning stimulus. One should be easily able to hold conversation at 50% intensity.

 

Aerobic exercise intensity:

Aerobic exercise intensity may be done continuously or intermittently during the day 3-5 days per week initially for 30 minutes per day at moderate intensity to start and increase duration and intensity as tolerated.

 

Determining Intensity according to the ACSM:

• Estimate the maximum heart rate (MHR) in beats per minute by calculating 220 – age.
• Determine resting heart rate while counting pulse in beats per minute by feeling the radial artery of the wrist after lying down comfortable for more than 10 minutes.
• Take MHR and subtract resting heart rate (RHR) to calculate heart rate reserve (HRR). MHR – RHR = HRR.
• Calculate training intensity (TI) by multiplying HRR by desired training intensity generally between 40% and 85% and add back the RHR. TI = HRR x TI + RHR.
• For beginners start at 40% to 50% for intensity.
• Once advanced enough by progressive training, the optimum cardiovascular training zone per the ACSM is seen at 75% to 85% training intensity.

 

Training progression according to the ACSM consists of these 3 stages:

• Initial stage: Beginners on week 1 – 4, start exercising 3 – 4 times per week at 40 – 50% TI and by 4 weeks 60 – 70% TI for 15 minutes duration per session at week 1 and ending at 30 minutes per session at week 4.
• Improvement stage: Progress further as endurance develops after 4 weeks. On week 5 – 24, exercise 3 – 5 times per week at 60 – 70% TI and by 24  weeks 70 – 85% TI for 25 – 30 minutes duration per session at week 1 and ending at 35 – 40 minutes per session at week 24.
• Maintenance stage: After 24 weeks, maintenance should consist of exercise 3 – 5 times per week at 70 – 85% TI for 30 – 45 minutes per session.

 

Power walking:

This exercise is generally an effective initial aerobic activity for beginners. Start walking at a normal pace and continue to increase the walking speed over 10 minutes to reach a heart rate of 110 – 120 beats per minute resulting in mild perspiration. Then follow the guidelines in a. and b. above.

 

Use of fat compared to use of carbohydrates for energy:

An intensity under 25% of maximum oxygen consumption will result is much less aerobic conditioning benefit but still utilize fat oxidation as the body’s main source of energy. Aerobic exercise intensity of 25% to 65% of oxygen consumption will increase the amount of aerobic oxidative energy production by both carbohydrates and fat. However, fat burning potential is greatest in moderate intensity aerobic exercise done at a rate of 65% of the maximum oxygen consumption. This intensity maximizes aerobic oxidative energy production for the body (85).

 

Starting exercise in chronically ill patients:

Exercise guidance in patients with serious illnesses and for those with specific medical problems: The most respected credible source available for exercise prescription is Thompson et al, American College of Sports Medicine’s (ACSM’s) Guidelines for Exercise Testing and Prescription (26). This source should be consulted for advice when recommending exercise to patients with specific serious illnesses. Another valuable source is Gauer, RL and O’Connor, FG with Department of Family Medicine Uniformed Services University of the Health Sciences, “How To Write An Exercise Prescription.” (31) This can be accessed at: http://www.move.va.gov/download/Resources/CHPPM_How_To_Write_And_Exercise_Prescription.pdf

 

Risk of exercise exceeds the benefits in the following medical conditions:

In patients suffering from a recent heart attack, unstable angina, ventricular arrhythmias, any tear in the inner layer of the aorta, aortic aneurysm, congestive heart failure, severe aortic stenosis, inflammation of the heart muscle or pericardium, pericarditis, pulmonary embolism, intracardiac thrombi, blockage of the main artery of the lung or one of its branches, and acute infection should not exercise since the risks of exercise exceed the benefits. Again, if any of these health conditions are present in an individual a health provider prior should be consulted before any exercise and the physician should refer to the ACSM’s guidelines for exercise testing and prescription (26):

 

The following medical conditions may increase the risk of complications during exercise:

In the following medical conditions, exercise may increase the risk of complications may still be beneficial. These conditions include untreated or uncontrolled high blood pressure, moderate aortic stenosis, severe narrowing of the left ventricle of the heart just below the aortic valve, mitral stenosis, atrial arrythmias, swelling of a blood vessel in the heart that occurs after a heart attack, ventricular bigeminy or trigeminy, frequent premature ventricular contractions, deterioration of the heart muscle, metabolic disease (diabetes, thyroid disease, etc) or electrolyte abnormality, chronic or recurrent infectious disease such as malaria and hepatitis, neuromuscular, musculoskeletal or rheumatoid diseases made worse by exercise, or complicated pregnancy. If any of these health conditions are present, the physician should refer to the ACSM’s guidelines for exercise testing and prescription. (26)

 

Risk of sudden cardiac death and approach to patients with ventricular arrhythmias prior to exercise:

Arrhythmias (abnormal heart rhythm) may cause symptoms of transient palpitations, chest pressure/pain, lightheadedness and shortness of breath. All arrhythmias require Cardiology for evaluation and treatment. Prior to exercise, from a prevention perspective for any patient with a history of ventricular arrhythmia, frequent premature ventricular contractions (PVCs) or any type of heart disease, it is important that a patient have risk for SCD determined. Hospitalized patients for cardiac or other reasons may have an arrhythmia or frequent PVCs seen on telemetry and not receive follow up. In this case a patient may have the primary physician help the patient obtain hospital records or the patient may obtain this on their own by signing consent in the medical records department.

The American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee (ACC/AHA/ESC) published guidelines for prevention of sudden cardiac death (SCD) in patients with ventricular arrythmias. About 50% of all deaths related to coronary heart disease (CHD) occur suddenly within 1 hour after a cardiac event and 300,000 to 350,000 SCDs occur in the U.S. annually. SCD may follow symptoms of ventricular arrhythmia, as a cardiac arrest, or without any symptoms at all (32)

Any patient with syncope, palpitations, history of arrhythmia with or without a history of heart disease should be referred to Cardiology prior to any consideration for exercise or rigorous physical activity. Cigarette smoking is an independent risk factor for SCD whether or not coronary heart disease is present (32). When using diuretics, or in patients with history of arrhythmia, reduce the risk of arrhythmias by maintaining the potassium level over 4.0 mg/dL and the magnesium level over 2.0 mg/dL.

The SCD of young athletes is rare, but an electrocardiogram (EKG) is indicated prior to competitive sports in young patients which may reveal abnormalities and help define a risk of ventricular arrythmias. An echocardiogram may be considered prior to participation in competitive sports if concern exists or if an EKG is abnorml. (32)

 

Exercise cardiac stress testing referral:

Stress testing should be conducted in patients with suspected or known coronary artery disease, typical and atypical angina or have had prior heart attack. In healthy people, without symptoms, those with multiple heart risk factors (high cholesterol, high blood pressure, family history, obese, diabetes mellitus) or concurrent chronic diseases or those in a high-risk occupation for example pilots, firefighters, law enforcement officers, and transit operators should undergo exercise stress testing. Stress testing is also recommend for men over age 40 and women over age 50 who have been inactive but plan to start vigorous exercise. Evaluation of exercise capacity in patients with heart disease involving one or more of the valves of the heart (patient’s whose heart valve does not open fully), those with heart rhythm disorders, and those with pacemakers is also necessary. (31)

 

Clinical cardiopulmonary exercise testing:

Cardiopulmonary exercise testing is done using a treadmill or cycle ergometer. A basic 6 minute walk test may be used to determine baseline exercise capacity before and after medications, surgery, and pulmonary or cardiac rehab programs. These tests may be used as a basic evaluation of exercise capacity, safety and guidelines in patients with coronary heart disease, shortness of breath with/without exertion, lung/heart transplantation, poor exercise tolerance, lung resection, pulmonary hypertension, chronic bronchitis, asthma, interstitial lung disease, heart failure, COPD, cystic fibrosis, peripheral vascular disease, fibromyalgia, advanced age, patients with pulmonary vascular disorders, and for predicting mortality in cardiac patients.

 

Clinical cardiopulmonary exercise testing:

• This testing may provide valuable diagnostic data for a patient’s poor exercise capacity, assist evaluation of disease conditions, and safely evaluate the patient’s ability to start and continue an exercise program.
• Monitors uptake of oxygen, EKG, blood pressure, ventilation, and perceived exertion using a treadmill or cycle ergometer (86).
• A motivated patient interested in improving their health status despite chronic disease conditions will greatly benefit from a referral for cardiopulmonary exercise testing.
• Exercise testing will be able to evaluate a patient’s response to exercise while taking medications. An example includes medications such as beta blockers, including labetalol, which decrease heart rate and blood pressure during rest and exercise. Beta blockers will also increase baseline exercise capacity in patients with pre-existing angina and will either decrease exercise capacity or have no effect in those patients without angina. (31)
• The 6 minute walk test is a simple test using an area for the patient to walk such as a hallway to determine the distance traveled in 6 minutes. The patient is instructed to walk as far as possible at their desired intensity without jogging. The items required include a timer, cones to mark turnarounds, lap counter, and safety equipment such as defibrillator, crash cart, emergency personnel, oxygen, and chair in the walking area. However, thousands of subjects in several studies have previously performed the test without adverse events. It is contraindicated in those with myocardial infarction or unstable angina within the past month, heart rate over 120 and blood pressure of 180/100. (86,87)

 

Exercise and Asthma According to the National Heart, Lung, and Blood Institute (NHLBI):

Exercise induced asthma or bronchospasm (EIB): In adults and children with asthma, taking inhaled short and long acting beta2-agonists (such as albuterol, salmeterol, formoterol) before vigorous activity or exercise may prevent EIB, exercise induced asthma, in about 80% of patients. The benefits of treatment may last for 2-3 hours for short  action beta agonist or up to 12 hours if long action beta agonists are used. Additionally, a warm-up period prior to exercise is associated with a lessen degree of EIB. In cold weather, a mask or scarf over the mouth may lessen the effects of cold-induced EIB. Children suffering from EIB should not be excluded from sports and other activities but teachers and coaches should be notified that the child suffers from EIB and may need inhaled medication prior to participation. If symptoms of EIB occur during usual non-vigorous play activities, this may an sign of poorly managed or persistent asthma and long-term treatment may be necessary. Appropriate long-term management may reduce EIB. (93)

 

Medication effect upon exercise:

According to Gauer, RL and O’Connor, FG with Department of Family Medicine Uniformed Services University of the Health Sciences, “How To Write An Exercise Prescription.” Accessed 3/8/2013. (31)

 

Beta Blockers and exercise:

Examples include Lopressor and Toprol XL( metoprolol), Coreg (carvedilol), Tenormin (atenolol), and Bystolic (bisoprolol). Beta blockers reduce heart rate and blood pressure during both rest and exercise. Beta blockers will increase baseline exercise capacity in patients with pre-existing angina and will either decrease or have no affect on those patients without angina.

 

Calcium channel blockers and exercise:

Examples include Adalat and Procardia (nifedipine), Cardizem (dilitiazem), and Calan (verapamil). These drugs will increase baseline exercise capacity in patients with pre-existing angina and have no effect on those patients without angina. During rest and exercise, nifedipine increases heart rate and decreases blood pressure. Dilitiazem and verapamil decrease both heart rate and blood pressure during rest and exercise.

 

Nitrate medications or nitroglycerin and exercise:

These medications increase heart rate and blood pressure during rest and exercise. They will increase baseline exercise capacity in patients with pre-existing angina and have no effect on those patients without angina. In patients with CHF, nitrates will increase or have no affect on baseline exercise capacity.

 

Diuretics and exercise:

These medications increase the production of urine but do not effect exercise capacity except potentially in patients with congestive heart failure by relieving edema in the lungs. Heart rate during rest and exercise is not affected. Blood pressure may decrease or remain unaffected with the use of diuretics. They may lower hydration status.

 

Bronchodilators and exercise:

Methylxanthines such as theophylline, sympathomimetic agents (such as ephedra, pseudoephedrine, amphetamines and methamphetamines), cromolyn sodium, and corticosteroids such as prednisone or methylprednisolone increase exercise capacity in patients with limited bronchospasm. During rest and exercise, methylxanthines and sympathomimetic agents (albuterol) increase or have no effect on heart rate and blood pressure. Sympathomimetic agents may also increase blood pressure during rest and exercise. Cromolyn sodium and corticosteroids have no effect on either heart rate or blood pressure during rest and exercise.

 

Hyperlipidemic agents and exercise:

These medications with the exception of clofibrate and nicotinic acid (also known as niacin), have no effect on heart rate or blood pressure. In patients with prior heart attack, clofibrate and dextrothyroxine may increase arrhythmias and angina. If you are taking dextrothyroxine, it is advisable to discontinue it because it was pulled from the market due to cardiac adverse effects. During rest and exercise, dextrothyroxine may increase heart rate and blood pressure and worsen myocardial ischemia. Probucol is a cholesterol lowering agent which decreases LDL but it is advisable to discontinue since it may also lower HDL. Blood pressure is decreased by use of nicotinic acid (Niacin) and use of probucol may decrease heart rate (QT interval lengthens). During rest and exercise, nicotine increases blood pressure and either increases or has no effect on heart rate.

 

Antihistamines and exercise:

Benadryl (diphenhydramine), Claritin (loratadine), and  Zyrtec (cetirizine) which are commonly used to treat an allergic reaction have no effect on heart rate and blood pressure during rest and exercise. They also have no effect on exercise capacity. Cold medicine with sympathomimetic agents may increase heart rate or blood pressure during rest and exercise.

 

Levothyroxine (or brand name Synthroid) and exercise:

This thyroid hormone replacement medication increases heart rate and blood pressure during rest and exercise. It has no effect on exercise capacity except if a patient has angina, it may become worse.

 

Alcohol and exercise:

Alcohol has no effect on heart rate but chronic use of alcohol increases blood pressure during rest and exercise. Alcohol has no effect on exercise capacity.

 

Hypoglycemic (blood sugar lowering agents) and exercise:

These medications include insulin and oral agents which have no effect on heart rate and blood pressure during rest and exercise. They also have no effect on exercise capacity.

 

Evidence-based benefits of aerobic exercise:

Aerobic exercise, weight loss and cholesterol control: A study done by Barnard, et al. compared 51 to 64 year old subjects from an exercise group that did a consistent exercise program for at least 10 years, a diet plus exercise group who did a consistent diet and exercise program for at least 10 years, and a sedentary group with poor diet. Based on this used as a comparison, if someone began to exercise 5 days per week for one hour in their 50s for 10 years without a change in diet, they should expect to decrease their body mass index about 11.5 kg/m^2, reduce total cholesterol by about 11 points, and reduce their triglycerides by about 105 mg/dl. There was no large benefit in LDL and HDL cholesterol seen in the group which consumed a poor diet. If someone began to exercise 4-6 days per week for one hour in their 50s for 10 years with eating a low fat, high fiber and complex carbohydrates diet along with exercise they would attain the following average benefit. A decrease in their body mass index about 16.5 kg/m^2, reduce total cholesterol by about 33 points, reduce LDL cholesterol by about 20 points, and reduce their triglycerides by about 109 mg/dl. There was no large benefit in HDL cholesterol was seen in this study.(84)

 

Aerobic exercise safely increases endurance in heart failure patients:

Researchers from the European Heart Failure Training Group found benefits of physical rehabilitation in 134 patients (mean age 60 years, 94% male) with chronic heart failure (HF). The extent of heart failure among the patients, using the New York Heart Association Functional Classification system, was II (50%) and III (48%). For 6 to 16 weeks, study participants followed one of two exercise regimens: cycle ergometry (20 minutes 4-5 times per week at an intensity of 70%-80% of a predetermined peak heart rate) or cycle ergomertry combined with calisthenics or body weight exercises (5 days/week with stationary running). Cycle ergomertry warm up and cool down lasted for 1-3 min at 25 W. At the end of the study, improvement in resting catecholamines and hormones (such as epinephrine and norepinephrine) and heart rate variability were associated with a 13% increase in oxygen consumption (VO2) and a 17% increase in exercise duration. Compared to the cycle ergometry alone patients, the 54 patients on a combined exercise regimen achieved significantly better VO2 (2.7 vs 1.2 ml.kg.min-1). VO2 was also found to be linked to the duration of the program; after 16 weeks training VO2 was significantly higher than after 6 weeks (2.6 vs 0.3 ml.kg.min-1). No significant side effects were reported. (88)

 

Aerobic exercise reduces mortality:

Aerobic exercise done along with or without a cardiac rehab program reduces mortality in coronary artery disease. A systematic review and meta-analysis of randomized controlled trials by Taylor et al found that exercise based cardiac rehabilitation reduces all cause and cardiac mortality and improves a number of cardiac risk factors in patients with coronary heart disease according to a meta-analysis of 48 randomized controlled trials (RCTs) (8940 patients, mean age 55 y). Intervention duration ranged from 0.25–30 months and follow up was between 6–72 months. Patients who received exercise-based cardiac rehab had a significant reduction in all-cause mortality of 20% and cardiac mortality of 26% than did patients who received usual care. Groups did not differ for rates of non-fatal heart attack (odds ratio [OR]= 0.79), coronary artery bypass grafting (OR=0.87), or percutaneous coronary intervention (OR=0.81). Cardiac rehabilitation was associated with significant reductions in total cholesterol of 0.37 mmol/L and triglyceride concentrations by 0.23 mmol/L; no significant differences were seen in low ‘bad’ or high-density ‘good’ lipoprotein concentrations. Systolic blood pressure was significantly reduced by 3.2 mm Hg. A significant 36% reduction in patient smoking was reported with cardiac rehabilitation. (29)

Silberman and colleagues reported the results of an analysis of patients (n=2974) participating in an intensive cardiac rehabilitation program. The authors reported significant improvements in body mass index (BMI), triglycerides, low density lipoprotein cholesterol, total cholesterol, hemoglobin A1c, systolic blood pressure, diastolic blood pressure, depression, hostility, exercise, and functional capacity at 12 weeks and 1 year. (28)

 

Aerobic exercise, diabetes, blood pressure, cholesterol and blood pressure:

Aerobic exercise improved long term blood glucose control, insulin sensitivity, blood pressure, cholesterol, and risk of coronary artery disease in patients with and without diabetes mellitus.

Individual with type 2 diabetics can improve multiple health parameters associated with Diabetes Mellitus through regular exercise. A brisk half-an-hour walk every day can significantly reduce (improve) HbA1c (glycated hemoglobin test indicating how well diabetes is being controlled ), blood pressure, blood lipids and coronary heart disease risk. Exercise regimens should be monitored and tailored to the individual to avoid over-exertion. General practitioner should continually encourage their patient to engage in physical activity, with the aim of improving insulin resistance. (89)

Low intensity aerobic exercise of longer duration resulted in more sustained improvement in insulin sensitivity than higher intensity for a shorter time period. Patients with type 2 diabetes mellitus (T2DM) were examined to determine whether exercise programs differing in duration and intensity had different effects on insulin sensitivity (oral glucose tolerance test, ISI) following a 12-week exercise program. Inactive T2DM patients (age 51.2 ± 1.3 years) were assigned to 5 sessions/week and 240 kcal/session of either a low-intensity (50% VO(2peak), n = 27) or a high-intensity exercise group (75% VO(2peak), n = 28). Insulin sensitivity (ISI) increased in both groups 16-24 h after the final exercise session. The interesting fact is that only the low-intensity group had elevated ISI 15 days after the end of training despite each group burning about the same amount of calories per session. The low intensity group spent about 56 minutes per session and the high intensity group about 34 minutes per session. These findings suggest that in T2DM patients, improvements in insulin sensitivity may rely more on exercise duration than exercise intensity. (90)

According to the American College of Sports Medicine and the American Heart Association (AHA), moderate-intensity aerobic activity, preferably every day of the week, for a minimum of 30 minutes per day is recommended to improve and maintain cholesterol levels in adults. (27)

 

Aerobic exercise and risk of disability:

Aerobic exercise may reduce the risk of disability and mortality of older adults into their 80s. Nine lifelong cross-country skiers, with a mean age of 81 years and a history of aerobic exercise and participation in endurance events throughout their lives, where examined to determine whole body aerobic capacity and myocellular markers of oxidative metabolism. A cycle test was used to measure aerobic capacity (VO2 max) and a resting vastus lateralis muscle biopsy was used to measure oxidative enzymes associated with muscle health. Six age-matched, healthy, untrained men were used as a comparison. Results indicated that the athletes had a higher absolute [2.6 vs. 1.6 L•min(-1)] and relative [38 vs. 21 ml•kg(-1)•min(-1)] aerobic capacity, heart rate [160 vs. 146 b•min(-1)], and final workload (182 vs. 131 watts). Among athletes, muscle oxidative enzymes were 54% (citrate synthase) and 42% (βHAD) higher. In summary, compared to their counterparts, the lifelong athletes had better cardiovascular and skeletal muscle health that was associated with lower risk for disability and mortality. (91)

 

Aspirin and coronary artery disease mortality:

22,507 cancer-free postmenopausal women provided information on aspirin and NSAID use. Aspirin use was found to decrease the risk of mortality from coronary artery disease by 25% and reduced the risk of all-cause mortality by 18%. (78)

 

Aspirin for prevention of cardiovascular disease and stroke according to the U.S. Preventive Services Task Force (USPSTF) (99):

• Ideal dose of aspirin: According to the USPSTF, the ideal dose of aspirin is not known, but a dose of 75 mg per day appears as effective as higher doses and may have less risk of gastrointestinal bleeding.
• The USPSTF recommendation for prevention of cardiovascular disease in men:
• Men younger than 45 years: For myocardial infarction prevention in men younger than 45 years the USPSTF recommends against the use of aspirin since the benefit for prevention of cardiovascular events are small.
• Men age 45 to 79 years: The USPSTF strongly recommends the use of aspirin when the potential benefit due to a reduction in myocardial infarctions is more beneficial than the potential harm due to gastrointestinal hemorrhage.
• The USPSTF recommendation for prevention of cardiovascular disease for the elderly: Men and Women 80 years of age and older: According to the USPSTF, there is insufficient evidence to determine the risk verses benefit of taking aspirin by men and women over 79 years of age for the prevention of cardiovascular disease.
• Aspirin and prevention of ischemic stroke in women: Cardiovascular events were not reduced in women by aspirin and therefore they are not believed to benefit from aspirin for heart disease but women do benefit from aspirin in the prevention of ischemic stroke.
• Women age 55 to 79 years: The USPSTF strongly recommends aspirin when the potential benefit due to a reduction in ischemic strokes (which occur when an artery to the brain is blocked) is more beneficial than the potential harm due greater gastrointestinal hemorrhage.
• Women 55 years old or younger: The USPSTF recommends against the use of aspirin for stroke prevention since the benefit for prevention of ischemic stroke is small.

 

Omega-3 fatty acids and coronary heart disease:

American Heart Association (AHA) fish, fish oil, and oil intake recommendation is as follows. The American Heart Association (AHA) recommends that all adults eat fish (particularly fatty fish) at least two times per week. The AHA also recommends eating plant-derived omega-3 fatty acids. Tofu and other forms of soybeans; walnuts and flaxseeds and their oils. For patients with coronary heart disease (CDH) it is recommended they consume about 1 gram of two kinds of omega-3 fatty acids shown to be cardio-protective, EPA and DHA (found in especially oily species like mackerel, lake trout, herring, sardines, albacore tuna, and salmon). Patients needing triglyceride lowering, should consult a physician and the AHA recommends a daily intake of 2-4 grams of EPA+DHA in capsule form. (1)

 

Omega-3 fish oil benefits in myocardial infarction and mortality:

A review of 14 randomized clinical trials reported that fish oil is associated with a reduction in total mortality and sudden death, but no significant reductions in nonfatal heart attacks were reported. Trials that included supplementation with the plant based alpha-linolenic acid (ALA) showed a possible benefit in reducing sudden death and nonfatal heart attack, but the results were not conclusive. (2)

A 3.5-year study including 11,324 myocardial infarction (MI) survivors with an MI occurring within 3 months) showed that fish oil supplementation at a dose of 1 gram daily, but not vitamin E at a dose of 300 mg daily, significantly reduced the total rate of all-cause death, nonfatal MI, and nonfatal stroke. (3)

Fish oil supplementation (docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA) was associated with a significant reduction in deaths from cardiac causes, but it was not beneficial in terms of arrhythmic events (problems with rate or rhythm of the heartbeat) or all-cause mortality. Twelve randomized controlled trials (RCTs) were included in the review (n=32,779). Supplementation with fish oil was associated with a significant 20% decrease in death from cardiac causes. (4)

According to the American Heart Association (AHA) individuals without coronary heart disease (CHD) should eat fish (especially oily fish) at least 2 times a week and consume a diet rich in alpha-linolenic acid such as flaxseed, canola, and soybean oils. Individuals diagnosed with CHD should consume 1g daily of omega-3 fatty acid (EPA+DHA) preferably from oily fish. EPA+DHA supplements may be considered under doctor supervision. Among individuals looking to lower triglyceride levels, 2-4 grams of EPA+DHA daily is recommended under doctor supervision. (5)

A systematic review of the literature on the effects of omega-3 fatty acids (n-3 FAs) (consumed as fish or fish oils rich in eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA] or as alpha-linolenic acid [ALA]) on cardiovascular disease outcomes was conducted. The authors concluded that the evidence suggests that increased consumption of n-3 FAs from fish or fish-oil supplements, but not plant derived ALA, reduces the rates of all-cause mortality, heart attack, cardiac and sudden death, and possibly stroke. The evidence for the benefits of fish oil is stronger in secondary (14 trials included)- than in primary-prevention settings (1 trial included). (6)

In a randomized controlled trial, 11,324 patients with pre-existing coronary heart disease (CHD) were randomly allocated to either 300 mg vitamin E, 850 mg omega-3 fatty acid ethyl esters (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]), both, or no treatment and followed for 3.5 years. In the end, a 15% reduction in mortality, nonfatal heart attack (myocardial infarction), and nonfatal stroke was seen in participants taking 850 mg omega-3 fatty acid alone. Compared to the no treatment group, participants taking omega-3 fatty acid after 6-months experienced a 2.5% increase in HDL (“good”) cholesterol and a 4% reduction in triglycerides, a type of fat in the bloodstream and fat tissue that can contribute to the hardening and narrowing of arteries. As a group, those taking this dietary supplementation experienced a 20% reduction in all-cause mortality and a 45% reduction in sudden death. The results indicate that in patients who have CHD, omega-3 fatty acid supplements, but not vitamin E, significantly reduce mortality. (7)

A randomized controlled trial by Burr et al. examined the relationship between diet and secondary prevention of myocardial infarction (MI) or heart attack in 2033 men recovered from MI. The men were advised to reduce fat intake, increase fatty fish consumption, and increase fiber intake from cereal. Results showed that patients who had had a myocardial infarction had a 29% reduction in mortality over 2 years by eating three fish meals a week. By contrast, patients who were randomized to high-fiber and low-fat diets did not have a significant reduction in mortality. Authors conclude that intake of fatty fish two or three time per week may decrease mortality among men recovered from MI. (8)

Kromhout and colleagues looked at the relationship between fish consumption and coronary heart disease (CHD) in 852 middle-aged men. Dietary information was collected in 1960 and a 20-year follow-up established that 78 men had died from CHD. Researchers found an inverse association between fish intake and CHD mortality. CHD mortality was more than 50% lower among the men who consumed at least 30 grams of fish per day than among those who did not eat fish. In conclusion, eating fish once or twice a week may lower risk of CHD. (10)

 

Fish oil vs. mustard oil for coronary artery disease:

A 12-month, randomized, placebo-controlled trial examined the effects of fish oil versus mustard oil in 360 patients with suspected acute myocardial infarction (AMI), heart attack. Treatments were administered to all patients approximately 18 hours after symptoms of an acute MI. Patients in group A (n = 122) received fish oil 1.08 g/day orally, group B (n = 120) received mustard oil 2.9 g/day orally, and 118 patients received placebo. Results indicated a reduction in total cardiac events in patients treated with fish oil or mustard oil compared with placebo (24.5% and 28% vs 34.7%; p < 0.01). Nonfatal infarctions also occurred less frequently in patients treated with fish oil or mustard oil compared with placebo (13% and 15% vs 25.4%; p < 0.05); however, total cardiac deaths were not reduced in patients treated with mustard oil or fish oil. When compared with the placebo group, patients treated with fish oil or mustard oil showed a reduction in total angina pectoris (chest pain), cardiac arrhythmias (irregular heartbeat), and left ventricular enlargement. Diene conjugates (signal deterioration of lipids/fats) were reduced in both treatment groups, indicating antioxidant activity. (9)

 

Omega-3 fish oil adverse reactions and interactions:

• A total of 10 studies were reviewed by Villani AM et al to determine potential serious adverse effects of fish oil at a dose of under 1.86 grams per day (21 It was found that there were no serious adverse effects reported in 994 adults over 59 years of age and other non-serious adverse effects were not significantly different from placebo (98).
• Fish oil has been reported to affect platelet aggregation, reduce vitamin K dependent factors which may be associated with an increased anticoagulation (reduce blood clotting) effect. Consumption should be avoided when taking anticoagulants like aspirin, warfarin, or ticlopidine because of the potential increased risk of bleeding (97).
• A case of a 67-year old woman taking warfarin (1.5 mg/day), an increase in her fish oil intake from 1 g/day to 2 g/day was associated with an increase in time for blood to clot as measured by the international normalized ratio (INR) which went from 2.8 to 4.3 within 1month, and decreased to 1.6 after the fish oil dose was reduced (94).
• An intake of 6 grams per day of docosahexaenoic acid (DHA) found no significant difference found in blood coagulation, platelet function, or thrombotic parameters including prothrombin time, activated partial thromboplastin time, antithrombin-III levels, and platelet aggregation (96).
• Fish oil may contain harmful contaminants such as heavy metals including mercury, dioxins, and polychlorinated biphenyls (PCBs). This risk can be reduced by purchasing fish oil that has undergone a purification process specified on the label (approved by the FDA, EPA, or US Pharmacopeia) (95).

 

High-dose calcium supplementation and cardiovascular disease:

High-dose calcium supplementation and cardiovascular mortality:

High-dose calcium supplementation was associated with greater cardiovascular (CV) mortality and all-cause mortality in women according to this prospective cohort study of 61,433 women born between 1914 and 1948. Compared with dietary calcium intakes of 600 to 1000 mg daily, daily intakes of over1400 mg were associated with significantly higher rates of death from all causes (40% increased risk), CV disease (49% increased risk), and ischemic heart disease (2 times higher risk), but not from stroke. Among the 6% of participant women using calcium supplements (500 mg), those who were also consuming >1,400 mg/d in their diet had a 2.5-times higher risk of all-cause death than women with similar total intakes not taking a supplement. (11)

 

High calcium intake and risk of cardiovascular disease:

An analysis of 388,229 individuals aged 50 to 71 years found that high calcium intake was associated with an increased risk of cardiovascular disease (CVD) mortality in men, but not women. At study enrollment, 51% of men and 72% of women were taking some form of calcium. The study found that compared to men not taking calcium, men with calcium intake of 1000 mg/day had an elevated risk of total CVD death (20% increased risk) and heart disease death (19% increased risk) but not cerebrovascular disease. In women, there was no association between calcium supplementation and death from cardiovascular disease or cerebrovascular disease. (12)

 

Calcium supplements and risk of cardiovascular events:

Calcium supplements increased the risk of cardiovascular events, especially heart attacks, in older women. A re-analysis of data from the Women’s Health Initiative Calcium/Vitamin D Supplementation Study found that among the almost 16,718 women not taking personal supplements at the time of randomization, being randomized to new supplement use (1g calcium and 400 IU vitamin D daily) was associated with a statistically significant increase in risk of cardiovascular events (heart attack, stroke) ranging from 13%-22%. Among women already taking supplements at the start of the study, no such increase in events was seen. A meta-analysis of 3 placebo-controlled trials found that compared to placebo, calcium and vitamin D increased the risk of heart attack by 21%, stroke by 20%, and heart attack or stoke by 16%. (13)

 

Coenzyme Q10 and acute myocardial infarction:

Treatment with coenzyme Q10 (120 mg per day) for 28 days in 73 patients (Q10 group) with acute myocardial infarction (AMI) resulted in a significant reduction in cardiac events (heart death and nonfatal heart attack) with use of coenzyme Q10. Compared to placebo, Q10 reduced cardiac events (15% vs 30.9%), chest pain that occurs when the heart is not getting enough blood (9.5 vs 28.1), irregular heartbeat (9.5% vs. 25.3%), and poor left ventricular function (8.2% vs. 22.5%).  (14)

 

Coenzyme Q10 levels and coronary artery disease:

Yalcin et al. indicated that a relation between low plasma coenzyme Q10 (CoQ10) concentration and coronary artery disease (CAD) exists. In this study, levels of plasma CoQ10 and the ratios of CoQ10 to plasma lipids in 64 patients with CAD and 34 healthy individuals were analyzed. CoQ10 concentrations in patients with CAD and healthy individuals were found to be 0.41 and 0.77 micromol/l, respectively (p < 0.01). Additionally, compared to healthy individuals, patients with CAD had a significantly lower ratio of CoQ10 to low density lipoprotein (LDL) (p < 0.01). (15)

 

Coenzyme Q10 treatment of hyperlipidemia and hypertension:

Both hyperlipidemia and hypertension are risk factors for coronary artery disease which have been treated with some success using coenzyme Q10 supplementation. For further information, please see hyperlipidemia, hypertension, or coenzyme Q10 sections of Preventive Health Advisor.

 

Treatment of endothelial function:

Endothelial function is the ability of blood vessels to respond to the body’s blood flow requirements. The endothelium is the inner lining of blood vessels. Endothelial dysfunction occurs after a substance acts upon the endothelium of blood vessels to cause an imbalance of contraction and dilation. Endothelial dysfunction is associated with atherosclerosis, diabetes, hypertension, and cardiovascular disease. Dysfunction in this lining is characterized by inflammation, reduced dilation of the blood vessels and an increased tendency to form clots. Thus, endothelial function is important for cardiovascular health.

 

Coenzyme Q10 for patients with endothelial dysfunction:

A meta-analysis examining the results of five randomized controlled trials, including 194 subjects, found that supplemental coenzyme Q10 (CoQ10) resulted in a clinically significant, 1.7% increase in flow-dependent endothelial-mediated dilation. These findings suggest CoQ10 supplementation is associated with significant endothelia function improvement and provides evidence for use in patients with endothelial dysfunction. (17)

 

Lycopene supplementation for endothelial dysfunction:

Researchers evaluated the effect of lycopene supplementation in endothelial function by measurement of blood flow in the fingertips following compression of the upper arm with an inflatable cuff. The study included 126 healthy men an average of 34 years old and an average body mass index of 24 kg/m2 in a randomized, placebo-controlled study. The subjects received lycopene at 6mg (n = 41), 15mg (n=37), or placebo (n = 38) daily for 8 weeks. The study found that lycopene reduced markers of oxidative stress and endothelial dysfunction. The group receiving 15 mg per day of lycopene had significantly increased plasma superoxide dismutase activity and reduced lymphocyte DNA comet tail length, which is a measurement of DNA damage. The group consuming 15 mg of lycopene also had a 23% improvement in endothelial function. The higher-dose lycopene group also showed a significant decrease in C-reactive protein (CRP), a marker of inflammation, systolic blood pressure, sICAM-1 and sVCAM-1 (markers of inflammation associated with plaque formation in the blood vessels). (18)

 

Creatine phosphate for myocardial protection:

Creatine phosphate (CP) for myocardial protection in surgery: administered to patients before undergoing coronary artery surgery had beneficial effects on the heart. Patients received either CP (n=20) or standard cardioplegic solution (control group, n=20). Three days before surgery, those in the CP group received 6 g of CP daily in two 20-min IV sessions. During surgery, standard cardioplegic solution enriched in CP (10 mmol/l) was given. After surgery 4.0 g/day of CP was administered in 2 IV injections for 2 days. Results show improved heart function after bypass surgery in patients administered CP. Ventricular arrhythmias (abnormal rapid heart rhythms) during and after surgery improved with CP. CP treatment also significantly reduced use of inotropic drugs (used to strength the heart) and damage seen in the heart muscle. (19)

 

Benefits of creatine phosphate (CP) in surgery:

Creatine phosphate (CP) for myocardial protection in surgery The use of creatine phosphate in individuals undergoing coronary artery (heart) surgery was examined in 50 patients who were administered either creatine phosphate or placebo. Findings show a reduction in arrhythmias and in patients with weakened systolic function, blood circulation results were similar when creatine phosphate was administered. Creatine did not affect the heart muscle or the level of enzymes produced when the heart is damaged. (20)

 

Allicor and risk of ischemic heart disease:

Allicor, a long-acting garlic drug, reduced the risk of ischemic heart disease (IHD), a condition where the heart muscle doesn’t get enough oxygen, in a year-long study that included 167 participants without IHD and with high levels of lipids/fats in the blood. After 1-year of allicor treatment, the 10-year absolute risk of IHD was reduced by10.7%, and the 10 year risk of both acute myocardial infarction, and sudden death were reduced 22.7%. A reduction in total cholesterol and LDL cholesterol for men ( by 27.9 and 22.5 mg/dl, respectively) and women (by 11.4 and 10.8 mg/dl, respectively) was also reported. Allicor used by women was also reported to prevent age-related cardiovascular risk. (21)

 

L-propionylcarnitine and ischemia:

According to researchers supplementation with L-propionylcarnitine (LPC, important for energy production in cells) may be beneficial to individuals suffering from ischemia. Men (n=31) with left coronary artery disease were administered either 15 mg/kg of LPC or placebo and then underwent pacing stress tests. After LPC administration, oxygen demand and supply to the heart remain unchanged. However, heart ischemia (restriction of blood supply) was reduced and the amount of blood being pumped out of the left ventricle of the heart increased by 18%. Additionally, recovery of heart function after pacing increased among those taking LPC. In conclusion, LPC has an anti-schemia effect. (22)

 

L-carnitine and angina:

L-carnitine may help treat angina: L-carnitine (important for energy production in cells) supplementation might be good for managing chest pain or discomfort (angina) according to a double-blind, placebo-controlled study of 44 men with stable angina. Carnitine plays a role in the cell production of energy. The results of this study, which randomly administered 1 g L-carnitine or placebo to participants, showed that daily use of L-carnitine may increase exercise tolerance. At the end of this 4-week study, compared to placebo, L-carnitine participants experience an increase in exercise work load and work needed to exacerbate their angina. Additionally 22.7% and 9.1% of L-carnitine and placebo participants, respectively, became free of angina. L-carnitine had no effect on blood pressure or heart-rate. (23)

Individuals with angina (chest pain/discomfort cause by heart problems) may benefit from use of propionyl-L-carnitine (important for energy production in cells). For 6 weeks researchers gave patients with 2 or more angina attacks per week either 500 mg L-propionylcarnitine (n=37) or placebo (n=37). Compared to placebo, L-propionylcarnitine increased the time to 0.1 mV ST-segment depression, which measures ischaemia (restriction in blood supply to tissues), and exercise duration improved by 5%. Heart rate, blood pressure and maximum exercise were not affected. (24)

 

Broccoli sprouts and ischemia:

Broccoli sprouts may protect against ischemia. Akhlaghi et al. administered a regular (control) diet or a diet mixed with 2% dried broccoli sprouts to rats for 10 days. At the end of the study period, the hearts of the rats were subjected to a decrease in the blood supply to tissues (ischemia) for 20 min and reperfusion (return of blood supply) for 2 hours, and evaluated for cell death, oxidative damage, and Nrf2-regulated phase 2 enzyme activities. In rats fed broccoli sprouts, markers of necrosis (premature cell death) and apoptosis (programmed cell death) was decreased by 78-86%, and indices of oxidative stress decreased by 82-116%. The results indicate that a diet with broccoli sprouts can protect the heart against oxidative stress and cell death caused by ischemia-reperfusion. (46)

 

Kiwi fruit and cardiovascular disease:

Consuming kiwi fruit, rich in vitamins C and E and polyphenols, may be beneficial in cardiovascular disease. A randomized cross-over study found that eating 2-3 kiwi fruit per day for 28 days significantly reduced platelet activation response to collagen and adenosine diphosphate (ADP) by 18% compared to those not eating the fruit. Compared to placebo, kiwi fruit consumption also lowered blood triglycerides levels by 15%. Reduced platelet aggregation and blood triglyceride levels in subjects have been linked with reduced incidence and severity of cardiovascular disease. (47)

 

Resveratrol has potential applications in cardiovascular disease:

Resveratrol was found to possess several potential benefits for heart health in in-vitro and in animal studies requiring more research for confirmation in humans. Fukuda, S et al found that resveratrol promoted angiogenesis (growth of new blood vessels) from pre-existing vessels of an ischemic heart (restriction in blood supply to tissues) in a rat model of myocardial infarction (MI) (61). Resveratrol at a dose of 2.5 or 5 mg/kg improved post-ischemic ventricular recovery, reduced myocardial infarct size, and reduced cardiomyocyte cell compared to the control group, but doses at 25 or 50 mg/kg had multiple harmful heart effects (65). Sato et al. demonstrated that an ethanol-free red wine extract and trans-resveratrol are cardio-protective against ischemia (restriction in blood supply to tissues) by functioning as a strong antioxidant (62). These findings support the benefits of red wine on heart health which may be a much safer way of obtaining the benefit of resveratrol rather than resveratrol supplements due to safety concerns of lack of regulation, unknown effective dose, and lack of standardization. Resveratrol (and red wine) also provides cardio-protection by mechanism of the inhibition of platelet aggregation (63). This may result in lower risk of thrombosis in atherosclerotic coronary arteries.

Although resveratrol inhibits platelet activation and has anti-inflammatory properties, paradoxically, it promotes atherosclerosis in hypercholesterolemic rabbits. The effects of resveratrol, a chemopreventive compound found in the skin of red grapes and in other food products, were examined on the development of atherosclerotic in rabbits fed 0.5% cholesterol. At the end of the 60-day study period, all rabbits (fed or not fed cholesterol) had similar liver function and had hypercholesterolemia or high levels of cholesterol in the blood. However, compared to the control group, resveratrol-treated rabbits had an increase in atherosclerotic lesions (p<0.002). This suggests that resveratrol results in atherosclerotic development, rather than protecting against it. (64)

For further information, interactions, and adverse reactions of resveratrol: See resveratrol in Preventive Health Advisor.

 

Niacin and simvastatin for the prevention of coronary disease:

In a 3-year double-blinded, placebo-controlled trial by Brown et al, treatment with niacin added to simvastatin dramatically reduced cardiac events, improved stenosis of coronary arteries, and reduced LDL cholesterol (LDL-C) levels in coronary heart disease. Patients (n=160) with previous heart attacks, previous coronary intervention, and established angina were randomly assigned to 1 of 4 regimens: simvastatin plus niacin, antioxidant vitamins, simvastatin–niacin plus antioxidants, or placebo. All patients also had at least one stenosis over 50% or 3 stenoses of at least 30%. If LDL-C was 110 mg/dL or lower at the start of the study, patients received 10 mg simvastatin and 20 mg if LDL-C was greater than 110 mg/dL. Patients receiving simvastatin (Zocor) had their dose titrated to a goal LDL-C level of 40 to 90 mg/dL. In the first year, if any patient had a LDL-C below 90 mg/dL, the simvastatin dose was increased by 10 mg/d and was decreased by 10 mg/d if LDL-C was below 40 mg/dL at any time. Placebo patients were given 10 mg simvastatin if LDL-C was greater than 140 mg/dL, with a target of 130 mg/dL or less. In patients receiving niacin, the dose was titrated over 1 month to at least 1000 mg twice per day (mean final dose 2.4 grams/day). Niacin 50 mg twice per day was used as the placebo to produce a flushing effect and thus keep patients blinded. Antioxidants were given twice daily, with total dosage of 800 IU vitamin E, 1000 mg vitamin C, 25 mg natural beta-carotene, and 100 μg selenium. Results of this study revealed that major heart events were cut by 60-90% in patients taking simvastatin plus niacin. They also had significantly fewer cardiovascular events than those given placebo (21% vs 2.6%). However, addition of antioxidants actually reduced this effect: when antioxidant therapy was added to lipid lowering, the rate of clinical events increased to that observed with placebo. There was also no difference between patients receiving antioxidants alone and those receiving placebo. Patients receiving simvastatin plus niacin had small increases in aspartate aminotransferase (higher levels of this enzyme may signal heart or liver disease), creatine kinase (marker of heart, muscle damage), uric acid, homocysteine (high levels increase risk of heart attacks, strokes, blood clots), and insulin. (66)

 

Vitamin C and cardiovascular disease:

An analysis was conducted on 19,496 men and women, ages 45 to 79, in the U.K. The participants’ blood was tested for ascorbic acid (a form of vitamin C) and they were placed in five groups (quintiles) according to their serum ascorbic acid levels. Men and women were tracked separately. The researchers observed how many people died of cardiovascular disease, ischemic heart disease, cancer, and all causes in each of the blood ascorbic acid quintiles. In every case (except for women at risk of cancer), death rates were significantly lower among those with higher blood ascorbic acid levels. Those with the highest ascorbic acid levels compared to the lowest levels had half the risk of dying from ischemic heart disease, cardiovascular disease, and all causes combined.

Additionally, a 20 micromol/L increase in blood ascorbic acid concentration, the same as a 50 g per day increase in fruit and vegetable intake, was associated with about a 20% reduction in risk of all-cause mortality. (73)

Vitamin C has been shown to be beneficial for people with certain diseases or conditions. High intakes of vitamin C have been associated with decreased risk of heart disease, cancer, eye diseases, and neurological conditions. High dose vitamin C, with an upper tolerable level set at 2g, has been shown to be safe. Among healthy individuals, the recommended daily intake of vitamin C is 75 mg for women and 90g for men. (74)

 

Vitamin B12 and coronary artery disease:

In a study involving 816 subjects (368 with coronary artery disease [CAD] and 448 controls) in India, levels of vitamin B12 were found to be significantly lower in patients with CAD, as compared to controls. Vegetarians were found to have lower levels of vitamin B12 and a higher incidence of coronary artery disease compared to nonvegetarians. (76)

 

Policosanol and coronary heart disease:

Forty-five patients with coronary heart disease (CHD) were treated with either policosanol (5 mg) twice daily (n=15), policosanol (5 mg) plus 125 mg aspirin (n=15), or placebo plus 125 mg aspirin (n=15) and followed for 20 months. At the end of the study, functional capacity increased, rest decreased, exercise chest pain or discomfort (angina) improved, and a significant reduction in heart events were reported in all groups, especially in the policosanol plus aspirin group. (77)

 

 

Summary: Cardiovascular Disease- How to Reverse Heart Disease

• According to the Centers of Disease Control as of 2010, the leading cause of death in the United States is heart disease and coronary artery disease makes up the largest proportion of these deaths.

 

• Atherosclerosis is the primary disease process of the coronary arteries leading to coronary heart disease. Atherosclerosis was described by a world renowned Cardiologist, William C. Roberts, MD as the leading cause of heart attacks, stroke, and peripheral vascular disease. This author enforced that cholesterol intake causes atherosclerosis. (80)

 

• Risk factor modifications to prevent or improve coronary heart disease:
  • For further information on weight loss, hyperlipidemia, hypertension, diabetes mellitus, aerobic exercise, resistance training, or smoking cessation, please see these individual sections in Preventive Health Advisor.
  • According to the American Heart Association (AHA) Scientific Statement, Diet and Lifestyle Recommendations: Revision 2006 by Lichtenstein, AH et al, the key to the prevention of coronary heart disease (CHD) or improvement of the CHD course is the emphasis of the following goals for cardiovascular disease risk reduction (82):
    • Diet recommendations by the AHA:
      • Eat a healthful diet the majority of the time including vegetables, fruits, whole grains, fat-free or low fat dairy, beans, lean meat, poultry, and oily fish at least twice weekly. Limit total cholesterol to 300 mg per day for healthy adults and for patients with LDL cholesterol under 100 mg/dl. Limit cholesterol to 200 mg per day for patients with coronary artery disease.
      • Total fat intake limited to under 25–35 percent of total calories per day.
      • Saturated fat intake limited to under 7 percent of total calories per day.
      • Trans fat intake should be under 1 percent of total calories per day.
      • Other fat in the diet should come from monounsaturated or polyunsaturated oils from unsalted nuts, seeds, oily fish, and vegetable oil such as canola or olive oil.
    • Maintain a healthy bodyweight: Maintain a healthy bodyweight with a body mass index (BMI) between 18.5-24.9 kg/m².
      • The AHA defines overweight as 25-29.9 kg/m², and obesity as greater than or equal to 30 kg/m². BMI can be calculated from the basic formula: [Weight (lb) / (Inches of height)²] x 703. BMI may also be calculated using a commonly available BMI calculator such as that available here: http://www.nhlbi.nih.gov/guidelines/obesity/BMI/bmicalc.htm from the NIH National Heart, Lung and Blood Institute.
    • The lipid profile should be monitored by the primary care physician who should work with the patient to achieve lipid profile goals:
      • Achieve LDL, HDL, triglyceride and total cholesterol goals. The Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol has established that the following lipid profile is optimal (as cited in Lichtenstein, 2006):
        • LDL optimal under 100 mg/dl, near optimal 100-129 mg/dL, borderline high 130-159 mg/dL, high 160-189 mg/dL, and very high over 190 mg/dL.
        • Total cholesterol is recommended to be under 200 mg/dL.
        • No specific goals for HDL and triglycerides exist but HDL under 40 mg/dL for men and under 50 mg/dL for women as wells as a triglyceride level of over 150 mg/dL are all associated with metabolic syndrome.
      • Roberts view of lipid profile goals are more strict than the AHA and recommends the following (80):
        • LDL cholesterol needs to be <100 mg/dL and ideally <70 mg/dL.
        • Total cholesterol should be <150 mg/dL, and the high-density lipoprotein (HDL) cholesterol >20 mg/dL.
        • The low HDL goal is rationalized by the author that levels below 20 are not dangerous if LDL and total cholesterol is also low.
    • Blood pressure:
      • Focus on achieving normal blood pressure.
      • According to the AHA, the lifetime risk of hypertension is about 90% and any elevation above a normal blood pressure of 120 systolic over 80 diastolic increases risk of coronary heart disease even if elevated into pre-hypertensive levels.
    • Blood glucose levels:
      • Keep blood glucose in normal range:
      • According to the AHA, normal fasting blood glucose is less than or equal to 100 mg/dL and a fasting blood glucose of of greater than or equal to 126 is diagnostic of diabetes.
      • Weight loss, exercise, and avoidance of concentrated sweets can greatly improve control of glucose and insulin resistance.
    • Exercise goals: Maintain a physically active lifestyle as regular activity promotes cardiovascular fitness.
    • Smoking: Stay away from tobacco.

 

• The American Heart Association metrics were applied by Artero, EG et al in The Aerobics Center Longitudinal Study. The authors described that in order to reduce the risk of cardiovascular mortality over the course of 11 years by 50-60% goals must meet at least 3 out of 4 of the following (79):
  • 1) Total cholesterol lower than 200 mg/dL
  • 2) Blood pressure lower than 120/80 mm Hg
  • 3) Not having diabetes
  • 4) Free of heart disease
  • AND meet at least 2 out of 4 of the following:
  • 1) No smoking
  • 2) Normal body mass index (BMI)
  • 3) Engaging in physical activity
  • 4) Eating healthfully

 

• Importance of homocysteine levels and risk of heart attack: Homocysteine levels should be monitored by the primary care physician. Patients with total homocysteine levels above 18.6 micromoles per liter are at a significantly increased risk for heart attack (odds ratio [OR]=2.43) and stroke (OR=2.53) (67).

 

• Evidence-based diet and exercise combination programs for coronary artery disease:
  • The Pritikin Program evidence-based benefits after 12-15 days (34, 35, 36):
    • Body mass index, 3% reduction
    • Blood pressure, glucose and LDL, all with 10%-15% reduction
    • Triglycerides, 36% reduction
    • Slowed or reversed progression of coronary heart disease and reduce the need for coronary artery bypass grafts (CABG), rates of angioplasty procedures and percutaneous interventions.
    • Usually program is done for 3-4 weeks allowing additional benefit.

 

• Pritikin Program includes (33,34,35):
  • Very low fat, less than 10% of calories.
  • Low sodium and avoid salty foods.
  • High fiber with at least five ½-cup servings of whole grains daily (wheat, oats, and brown rice or starch vegetables such as potatoes, and dried beans and peas.
  • Refined grain products (white flour, regular pasta, white rice) are limited to two servings daily.
  • At least four 1-cup servings of raw vegetables daily or ½-cup servings of cooked vegetables. Dark green, leafy, and orange or yellow vegetables are preferred
  • At least three servings of fruit, one of which can be fruit juice.
  • Two servings daily of calcium-rich foods such as nonfat milk, nonfat yogurt or fortified and enriched soymilk.
  • No more than one caffeinated drinks daily. Instead drink water, low-sodium vegetable juices, grain-based coffee substitutes or caffeine-free teas.
  • No more than four alcoholic drinks per week for women and no more than seven for men, with red wine preferred over beer or distilled spirits.
  • No more than seven egg whites per week.
  • No more than 2 ounces (about 1/4 cup of nuts) daily.
  • Moderate amounts of fish, nonfat dairy, and lean meat with no more than one 3.5 cooked serving of animal protein per day with fish and shellfish are preferred. Lean poultry should optimally be limited to once a week and lean beef to once a month.
  • Adapted to vegetarians by replacing animal protein with protein from soy products, beans, or lentils.
  • Avoid fried foods, dressing with fat, and fatty sauces, animal fats, processed meat, dairy products not made with non-rat milk, egg yolks, salty snacks, cakes, cookies, and similar high-calorie choices.
  • Eat frequently with three meals a day plus two snacks.
  • Artificial sweeteners such as Splenda are okay.
  • 45 minutes of moderate exercise daily such as walking.
  • Medicare may approve coverage for qualifying individuals with a history or risk of cardiovascular events. The program has been approved for coverage under Part B of Medicare. Medicare will reimburse eligible beneficiaries for up to 72 one-hour ICR sessions, up to 6 sessions per day, at the Pritikin Longevity Center & Spa.

 

• The Dean Ornish Program for Reversing Heart Disease (36):
  • The Ornish program evidence-based benefits:
  • Weight loss of 13.3 pounds in the first 12 weeks and 15.9 pounds after 1 year.
  • Significant reductions in systolic blood pressure (BP), diastolic BP, total cholesterol, triglycerides, and LDL-cholesterol after 12 weeks were still significant after 1 year.
  • Exercise capacity increased by 18% after 12 weeks and 24% after one year.
  • Reductions in depression were still significant after 1 year.
  • Hemoglobin A1C in diabetics continued to decrease after one year.
  • Improvement in severity of angina after 1 year.

 

• Ornish Program includes (36):
  • Plant-based, meatless diet, meditation, and regular exercise with adherence to the program between 85 to 90% after one year in hospitals and clinics that have offered it.
  • Medicare Part B covers The Dean Ornish Program for Reversing Heart Disease, under Intensive Cardiac Rehabilitation (ICR). Eligibility includes acute myocardial infarction within the preceding 12 months, a coronary artery bypass surgery, current stable angina pectoris, heart valve repair or replacement, percutaneous transluminal coronary angioplasty or coronary stenting, a heart or heart-lung transplant, or other cardiac conditions as specified through a national coverage determination. (36)

 

• Vegetarian diet and cardiovascular disease was researched by Huang. T et al (50):
  • All-cause mortality, mortality from circulatory diseases, and mortality from cerebrovascular diseases in vegetarians was lower when compared to non-vegetarians by 9%, 16%, and 12%, respectively.
  • Vegetarians had a statistically reduced rate of ischemic heart disease mortality by 29% and reduced cancer incidence by 18%.

 

• The Therapeutic Lifestyle Changes Diet for coronary heart disease (37,38):
  • Saturated fat below 7% of the total calories.
  • Total fat intake 25-35% of daily total calories.
  • Cholesterol intake below 200 milligrams each day.
  • Sodium intake under 2400 mg per day.
  • Calorie intake should be kept to a level needed for maintaining healthy weight but reduce blood cholesterol level.

 

• Effect of adding 30 minutes of daily exercise at 50-75% of age-predicted maximum heart rate, to a Therapeutic Lifestyle Changes Diet (TLC) in 6 months (37):
  • Assisted 89% of participants to reach an LDL cholesterol goal of under 130 mg/dL without lowering HDL levels or needing to add or increase lipid lowering therapy.
  • Mean total cholesterol, LDL cholesterol and triglycerides decreased by 9.2% (p=0.08), 9.3% (p<0.018), and 18.8% (p<0.05), on average respectively.
  • HDL cholesterol increased 2.6% on average (p=0.41).
  • Women: 12.3% reduction in LDL cholesterol and an 11.4% increase in HDL cholesterol
  • Men: 7.9% reduction in LDL cholesterol and no change in HDL
  • Systolic and diastolic blood pressure (BP) decreased 9% (p<0.001) and 13%, respectively (p <0.0001).
  • BP reductions were two-fold greater than in the Diet and Systolic Hypertension study (DASH).
  • 50% reduction in angina.

 

• Nut consumption and risk of coronary events according to Fraser (43):
  • Consumption of almonds and walnuts may result in an 8% to 12% reduction in LDL
  • Frequent consumption of nuts has been linked with a 30% to 50% decreased risk of coronary heart disease.

 

• Tree nuts and peanut consumption according to Kris-Etherton PM et al (44):
  • Four most recent U.S. studies reviewed by this author estimates that Americans who eat five or more servings of nuts per week have a 35% reduced risk of developing coronary heart disease.
  • Improve CHD related oxidation, inflammation, vascular reactivity.
  • Lower total and LDL cholesterol based on their fatty acid profile plus contain other bioactive compounds with cholesterol-lowering properties.

 

• Fruit, vegetable intake and cardiovascular disease: Ovesen reviewed the amount of fruit and vegetable intake by weight to lower risk of ischemic heart disease and found (48):
  • Eight published cohort studies resulted in an overall reduction in the risk of developing IHD of approximately 20%.
  • Maximum amount of fruits and vegetables which impacted risk of ischemic heart disease was determined to be 800 grams per day.

 

• Whole grains and cardiovascular disease: Whole grain intake (average 2.5 servings per day vs. 0.2 servings per day) was associated with a 21% lower risk of CVD events (45).

 

• Soy protein and coronary artery disease: The Food and Drug Administration (FDA) has approved a statement on food labels that soy protein may reduce the risk of coronary artery disease by lowering cholesterol levels when included in a diet low in saturated fat and cholesterol (42).

 

• Purple potatoes and hypertension: 6-8 small microwaved purple potatoes eaten twice a day dropped diastolic blood pressure by 4.3% and systolic blood pressure 3.5% (49).

 

• Beta carotene and cardiovascular disease:
  • Beta carotene intake in the form of vegetables was associated with a lower risk of cardiovascular and cancer mortality and with a lower risk for death from all causes (68).
  • Do not consume beta-carotene supplements as no benefit was seen and these may be harmful (100).
  • Eating 5 fruits and vegetables per day provides the individual with about 5.2 to 6 mg/day of food based beta-carotene. This amount allows plasma carotenoid levels to rise to a plasma level of 0.37 umol/L associated with a lower risk of cancer, cardiovascular and all-cause mortality.
  • A beta-carotene level of 0.34-0.52 umol/L is ideal. When food based beta carotene was consumed in amounts over 42 mg per day, levels increased to 0.83 umol/L which is higher than necessary (69).
  • To see concentrations of beta-carotene in foods, please see: Nutritive Value of Foods, United States Department of Agriculture, Agricultural Research Service, Home and Garden Bulletin Number 72. This may be accessed at (102): https://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR25/nutrlist/sr25w321.pdf
  • For more information, please see beta-carotene section of Preventive Health Advisor.

 

• Vitamin D levels, cardiovascular-related mortality, and all-cause mortality:
  • In a study on adult men, Michaëlsson K et al found that a vitamin D concentration of 24 to 34 ng/ml (60 to 85 nmol/L) approximately translates to a vitamin D dose of 2000 IU/d and corresponded to the lowest cardiovascular-related and all-cause mortality (103).
  • Overall mortality was increased by 50–60% among subjects in the lowest 10% and highest 5% of the vitamin D level curve distribution, whereas cardiovascular mortality was increased only in the bottom 10%. Vieth reported that the ideal level of vitamin D intake for adults should be 50 mg (2000 IU) per day (104).
  • Bosomworth NJ conducted a review of multiple studies, and determined that 500-1500 IU/d of vitamin D reduced all-cause mortality (105).
  • After Sun Q, et al followed 74,272 women and 44,592 men over 20 years, 9,886 cases of coronary heart disease and stroke occurred, and a 16% reduction in heart disease was seen among men with an intake of 600 IU or more per day of vitamin D, compared with those with an intake of 100 IU (106).
  • For more information, please see vitamin D section of Preventive Health Advisor.

 

• Vitamin D and hypertension:
  • Goel RK found that subjects taking 33,000 IU of vitamin D every 2 weeks for 3 months plus standard therapy were noted to have a reduction in systolic blood pressure (BP) of 7.5 mm Hg compared to a 3.6 mmHg reduction in the standard therapy group, but diastolic BP in both groups increased by 2.1 mmHg and 1.3 mmHg, respectively. (107).
  • A double-blind randomized controlled trial of 148 women with a mean age of 74 years tested 1200 mg calcium plus 800 IU vitamin D(3) and found that systolic blood pressure (SBP) decreased by 9.3% and heart rate by 5.4% compared with 1200 mg/day of calcium alone. 81% in the vitamin D3 and calcium group compared with 47% in the calcium group showed a decrease in SBP of 5 mm Hg or more. (108)
  • Vitamin D and cardiovascular disease: Maintain favorable levels of vitamin D in all patients with any risk factors for cardiovascular disease. Vitamin D is not established as a direct cause of cardiovascular disease, but vitamin D deficiency is associated with a higher incidence of hypertension, hyperlipidemia, coronary artery disease, stroke, chronic kidney disease, and diabetes mellitus type 2 (113). A retrospective analysis showed that patients with diabetes mellitus have a very low 25-hydroxy vitamin D level, and also found that high levels of triglycerides, LDL cholesterol, and HbA1C had a consistent association with vitamin D deficiency in type 2 diabetes patients (112).
  • For more information, please see vitamin D section of Preventive Health Advisor.

 

• Red wine and cardiovascular disease:
  • Moderate red wine consumption has been associated with (55):
    • Decreased cardiovascular risk
    • Reduced mortality
    • Improved cholesterol profile,
    • Bone density increase in older adults
    • Reduced risk of esophageal and gastric cancer
    • Better reduction of both mortality risk and risk of cardiovascular disease than spirits, beer and white wine.
    • Increase in HDL cholesterol.
  • Relative risk of cardiovascular and cerebrovascular mortality was significantly less for those who had a low to moderate intake of wine, but beer intake did not change mortality risk much and drinking spirits increased mortality (56).
  • At the end of a 4-week study period, results showed that drinking red wine in moderation increased HDL cholesterol by 11–16%, decreased fibrinogen by 8–15% and according to the authors was associated with beneficial changes in blood lipids and fibrinogen that may help to reduce the risk of CVD (57).
  • De Gaetano and Cerletti reported that after red wine consumption (30 g alcohol daily for 4 weeks) as compared to the same amount of alcohol given as spirit such as vodka, whiskey, gin, tequila, or rum resulted in a significant increase in HDL cholesterol levels and a decreased oxidation of LDL cholesterol. The authors reviewed a meta-analysis which indicated a significant negative relationship between moderate wine drinking of 150-300 ml daily and the risk of cardiovascular events. In conclusion, moderate wine consumption is linked with prevention of cardiovascular disease. (58)
  • 400 mL/day of red wine for 6 weeks significantly decreased LDL cholesterol concentrations by 8% and increased HDL cholesterol concentrations by 17% and reduced cardiovascular disease risk compared to no effect for placebo (59).

 

• Drinking alcohol and cardiovascular disease:
  • Drinking red wine has significantly better cardiovascular disease risk reduction compared to beer, vodka, whiskey, gin, tequila, or rum (58).
  • However, in one study, drinking alcohol in light to moderate amounts 3–4 or 5–7 days per week has been associated with a decreased risk of cardiovascular disease by about 25% and lower risk of myocardial infarction compared with men who consumed alcohol less than once per week (60).
  • In another study, beer intake did not change mortality risk much and drinking spirits increased mortality (56).

 

• Chocolate consumption and risk of coronary artery disease:
  • Consumption of chocolate 1-4 times per week and more than 5 times per week was associated with a 26% and 57% lower risk of coronary heart disease (CHD) respectively compared to those subjects who did not consume chocolate (39).
  • Non-chocolate candy consumption was associated with a 49% higher risk of CHD after comparing 5 or more times per week vs. none per week (39).
  • Using non-eaters of chocolate as a baseline, the researchers concluded that those who ate 1-3 servings per month had a 6% reduced amount of calcified atherosclerotic plaque in the coronary arteries, eating chocolate once per week had a 22% reduction, and consuming chocolate at least 2 times per week had a 32% reduction (40).
  • After observing a variable age group of adults who consumed flavonol-rich cocoa every day for four to six days, the older adults showed significant blood vessel function improvement compared to the younger adults (41).

 

• According to James J. E., caffeine, through its daily consumption from a variety of sources (coffee, teas, soft drinks, chocolate and medicines), may have an impact on cardiovascular risk. By typically increasing resting blood pressure (BP) in adults by about 4/2 mmHg which according to the author, could be responsible for premature deaths of about 14% for coronary heart disease and 20% for stroke. (54)

 

• Green tea and cardiovascular disease:
  • Green tea and cardiovascular disease (CVD) population study according to Kuriyama, S et al of “the Ohsaki Study” (51):
    • Researchers followed 40,530 Japanese adults up to 11 years.
    • Women who drank ≥ 5 cups/day of green tea had a 31% lower risk of dying from CVD and a 23% lower risk of mortality from all causes than women who drank <1 cup/day.
    • Women who drank 1 to 2 cups/day or 3 to 4 cups/day green tea had a 16% and 31% reduced risk of CVD, respectively.
    • Those who drank 1 to 2 cups/day or 3 to 4 cups/day green tea had a 2% and 18% reduced risk of all-cause mortality, respectively.
    • The protective effect of green tea was stronger in women than in men.
    • In men who drank ≥ 5 cups/day green tea their all-cause mortality risk fell by 12%.
    • Men who drank 1 to 2 cups/day or 3 to 4 cups/day green tea had a 7% and 5% reduced risk of all cause-mortality, respectively.

 

• Coffee, green tea, black tea, oolong tea consumption and cardiovascular disease risk (53):
  • Compared with non-tea drinkers, women consuming green tea at 1-6 cups/week, 1-2 cups/day, 3-5 cups/day and ≥ 6 cups/day had a 66%, 72%, 61%, and 58% reduced risk of coronary heart disease compared to non-tea drinkers.
  • Men drinking ≥ 1 cups/day of oolong tea benefited from a 61% reduced risk of CVD.
  • Individuals in the second highest quintile of total caffeine intake had a total CVD risk reduction of 38% in men and 22% in women.

 

• Aerobic Exercise:
  • Benefits:
    • Individuals of all ages capable of aerobic exercise should do so most days of the week for the following benefits: heart and lung conditioning, improved pumping efficiency of the heart, improved circulatory system (83), weight control and less obesity (84), cholesterol reduction (84,27), triglyceride lowering (84), lowering of blood pressure (30), lower rate of smoking (29), control of diabetes (89,90), lower cardiac mortality (29), and reduced all-cause mortality (29).
    • Benefits of aerobic exercise, 1 hour per day, 5 days per week, over 10 years (84):
      • With exercise alone: Decrease body mass index about 11.5 kg/m^2, reduce total cholesterol by about 11 points, and reduce their triglycerides by about 105 mg/dl.
      • With exercise plus low fat, high fiber, complex carbohydrate diet: Decrease in body mass index about 16.5 kg/m^2, lower total cholesterol about 33 points, reduction of LDL about 20 points, and reduction of triglycerides about 109 mg/dl.
      • Aerobic exercise safely increases endurance in heart failure patients (88).
      • Aerobic exercise done along with or without a cardiac rehab program reduces cardiac and all-cause mortality in coronary artery disease.
    • Aerobic exercise may reduce the risk of disability and mortality of older adults into their 80s (91).
  • Starting exercise in apparently healthy adults:
    • According to the American College of Sports Medicine (ACSM) and the American Heart Association (AHA), older adults need moderate-intensity (between 5-6 on a 10-point scale) aerobic endurance activity for a minimum of 30 min which can be achieved in short 10 minute sessions on five days each week or vigorous-intensity aerobic, (rated a 7-8 on a 10-point scale) activity for a minimum of 20 min on 3 days each week.
  • Amount of activity according to the World Health Organization (92):
    • The most benefit from physical activity is achieved with at least 2.5 hours of aerobic exercise of moderate intensity per week, which can be accumulated in 10-minute periods.
    • At least 2 days/week vigorous intensity aerobic exercise and resistance exercises for muscle strengthening are recommended.
    • Increased intensity, frequency and duration of exercise is associated with increased added health benefits.
  • American College of Sports Medicine (ACSM) Cardiorespiratory Training Guidelines:
    • Main components of an exercise session per ACSM include warm-up, conditioning stimulus, and cool down. Warm-up before the session and cool down after the session of exercise consists of 5-15 minutes of activity at 50% training intensity of the conditioning stimulus.
    • Guide aerobic exercise training for patients according to ACSM guidance by calculating training intensity, then proceed through training progression according to the initial, improvement, and maintenance stages.
  • Power walking: This exercise is generally an effective initial aerobic activity for beginners. Start walking at a normal pace and continue to increase the walking speed over 10 minutes to reach a heart rate of 110 – 120 beats per minute resulting in mild perspiration. Then continue to follow the ACSM guidelines.
  • Fat burning potential (using fat for energy as opposed to carbohydrates or protein) will is maximized at moderate intensity aerobic exercise at a rate of 65% of the maximum oxygen consumption (85). This level may be estimated by determining training intensity calculated according to the ACSM guidance as noted above.

 

• Starting exercise in chronically ill patients:
  • The most respected credible source available for exercise prescription is Thompson et al, American College of Sports Medicine’s (ACSM’s) Guidelines for Exercise Testing and Prescription (26).
  • Risk of exercise exceeds the benefits in the following medical conditions (26):
    • Recent myocardial infarction, unstable angina, ventricular arrhythmias, aortic dissection, aortic aneurysm, congestive heart failure, severe aortic stenosis, inflammation of the heart muscle or pericardium, pericarditis, pulmonary embolism, intracardiac thrombi, blockage of the main artery of the lung or one of its branches, and acute infection.
  • The following medical conditions may increase the risk of complications during exercise: In the following medical conditions, exercise may increase the risk of complications may still be beneficial (26):
    • Untreated or uncontrolled high blood pressure, moderate aortic stenosis, severe narrowing of the left ventricle of the heart just below the aortic valve, mitral stenosis, atrial arrythmias, swelling of a blood vessel in the heart that occurs after a heart attack, ventricular bigeminy or trigeminy, frequent premature ventricular contractions, deterioration of the heart muscle, metabolic disease (diabetes, thyroid disease, etc) or electrolyte abnormality, chronic or recurrent infectious disease such as malaria and hepatitis, neuromuscular, musculoskeletal or rheumatoid diseases made worse by exercise, or complicated pregnancy. For these conditions, the physician should refer to the ACSM’s guidelines for exercise testing and prescription.
  • Risk of sudden cardiac death and approach to patients with ventricular arrhythmias prior to exercise:
    • Arrhythmias (abnormal heart rhythm) may cause symptoms of transient palpitations, chest pressure, chest pain, lightheadedness and shortness of breath and all require Cardiology for evaluation and treatment.
    • The American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee (ACC/AHA/ESC) published guidelines for prevention of sudden cardiac death (SCD) in patients with ventricular arrythmias (32):
      • About 50% of all deaths related to coronary heart disease (CHD) occur suddenly within 1 hour after a cardiac event.
      • Cigarette smoking is an independent risk factor for SCD whether or not coronary heart disease is present.
      • The SCD of young athletes is rare, but an electrocardiogram (EKG) is indicated prior to competitive sports in young patients which may reveal abnormalities and help define a risk of ventricular arrythmias.
      • An echocardiogram may be considered prior to participation in competitive sports if concern exists or if an EKG is abnorml.
  • Exercise cardiac stress testing referral is required in patients with (31):
    • Patients with suspected or known coronary artery disease, typical and atypical angina or prior heart attack.
    • Healthy people without symptoms with multiple heart risk factors (high cholesterol, high blood pressure, family history, obese, diabetes mellitus) or concurrent chronic diseases or those in a high-risk stressful occupations
    • Men over age 40 and women over age 50 who have been inactive but plan to start vigorous exercise.
    • Evaluation of exercise capacity in patients with heart disease involving one or more of the valves of the heart, those with heart rhythm disorders, and those with pacemakers.
  • Clinical cardiopulmonary exercise testing:
    • May be done by referral for treadmill or cycle ergometer testing.
    • For patients interested in improving their health status despite chronic disease conditions
    • Can be used to evaluate a patient’s response to exercise while taking medications
    • 6 minute walk test (86,87,26):
      • May be used to determine baseline exercise capacity before and after medications, surgery, and pulmonary or cardiac rehab programs.
      • The patient is instructed to walk as far as possible at their desired intensity without jogging.
      • Requires timer, cones to mark turnarounds, lap counter, and safety equipment such as defibrillator, crash cart, emergency personnel, oxygen, and chair in the walking area.
      • Thousands of subjects in several studies have previously performed the test without adverse events.
      • Contraindicated in those with myocardial infarction or unstable angina within the past month, heart rate over 120 and blood pressure of 180/100 (86,87). It is also contraindicated in recent myocardial infarction, unstable angina, ventricular arrhythmias, aortic dissection, aortic aneurysm, congestive heart failure, severe aortic stenosis, inflammation of the heart muscle or pericardium, pericarditis, pulmonary embolism, intracardiac thrombi, blockage of the main artery of the lung or one of its branches, and acute infection (26).
  • Cardiac Rehab Programs:
    • Silberman and colleagues reported that 2974 patients participating in an intensive cardiac rehabilitation program reported significant improvements in body mass index (BMI), triglycerides, low density lipoprotein cholesterol, total cholesterol, hemoglobin A1c, systolic blood pressure, diastolic blood pressure, depression, hostility, exercise, and functional capacity at 12 weeks and 1 year. (28)
    • A systematic review and meta-analysis of randomized controlled trials by Taylor et al found that exercise based cardiac rehabilitation for a duration of 0.25–30 months reduces risk of all cause and cardiac mortality by 20% amd 26% respectively, and improves a number of cardiac risk factors in patients with coronary heart disease (29).
  • Medication effect upon exercise (31):
    • Beta Blockers reduce heart rate and blood pressure during both rest and exercise and will increase baseline exercise capacity in patients with pre-existing angina and will either decrease or have no effect on those patients without angina.
    • Calcium channel blockers will increase baseline exercise capacity in patients with pre-existing angina and have no effect on patients without angina. During rest and exercise, nifedipine increases heart rate and decreases blood pressure. Dilitiazem and verapamil decrease both heart rate and blood pressure during rest and exercise.
    • Nitrate medications or nitroglycerin increase heart rate and blood pressure during rest and exercise. They will increase baseline exercise capacity in patients with pre-existing angina and have no effect on those patients without angina. In patients with CHF, nitrates will increase or have no effect upon baseline exercise capacity.
    • Diuretics and exercise: These medications increase the production of urine but do not effect exercise capacity except potentially in patients with congestive heart failure by relieving edema in the lungs. Heart rate during rest and exercise is not affected. Blood pressure may decrease or remain unaffected with the use of diuretics. They may lower hydration status.
    • Bronchodilators and exercise: Methylxanthines such as theophylline, sympathomimetic agents (such as ephedra, pseudoephedrine, amphetamines and methamphetamines), cromolyn sodium, and corticosteroids such as prednisone or methylprednisolone increase exercise capacity in patients with limited bronchospasm. During rest and exercise, methylxanthines and sympathomimetic agents (albuterol) increase or have no effect on heart rate and blood pressure. Sympathomimetic agents may also increase blood pressure during rest and exercise. Cromolyn sodium and corticosteroids have no effect on either heart rate or blood pressure during rest and exercise.
    • Hyperlipidemic agents and exercise: These medications with the exception of clofibrate and nicotinic acid, a.k.a. niacin, have no effect on heart rate or blood pressure. In patients with prior heart attack, clofibrate may increase arrhythmias and angina.
    • Niacin may reduce blood pressure.
    • Nicotine may increase blood pressure and heart rate.
    • Antihistamines have no effect on heart rate and blood pressure during rest and exercise. They also have no effect on exercise capacity. Cold medicine with sympathomimetic agents may increase heart rate or blood pressure during rest and exercise.
    • Levothyroxine thyroid hormone replacement may increase heart rate and blood pressure during rest and exercise. It has no effect on exercise capacity except if a patient has angina, it may become worse.
    • Alcohol and exercise: Alcohol has no effect on heart rate but chronic use of alcohol increases blood pressure during rest and exercise. Alcohol has no effect on exercise capacity.
    • Hypoglycemic agents include insulin and oral agents which have no effect on heart rate and blood pressure during rest and exercise. They also have no effect on exercise capacity.

 

• Aspirin and coronary artery disease:
  • 22,507 cancer-free postmenopausal women provided information on aspirin and NSAID use and aspirin use was found to decrease the risk of mortality from coronary artery disease by 25% and reduced the risk of all-cause mortality by 18% (78).
  • Aspirin for prevention of cardiovascular disease and stroke according to the U.S. Preventive Services Task Force (USPSTF) (99):
    • Ideal dose of aspirin: According to the USPSTF, the ideal dose of aspirin is not known, but a dose of 75 mg per day appears as effective as higher doses and may have less risk of gastrointestinal bleeding.
    • The USPSTF recommendation for prevention of cardiovascular disease in men:
      • Men younger than 45 years: For myocardial infarction prevention in men younger than 45 years the USPSTF recommends against the use of aspirin since the benefit for prevention of cardiovascular events are small.
      • Men age 45 to 79 years: The USPSTF strongly recommends the use of aspirin when the potential benefit due to a reduction in myocardial infarctions is more beneficial than the potential harm due to gastrointestinal hemorrhage.
      • Men and Women 80 years of age and older: According to the USPSTF, there is insufficient evidence to determine the risk verses benefit of taking aspirin by men and women over 79 years of age for the prevention of cardiovascular disease.
    • Aspirin and prevention of ischemic stroke in women:
      • Cardiovascular events were not reduced in women by aspirin;
      • Women are not believed to benefit from aspirin for heart disease but women do benefit from aspirin in the prevention of ischemic stroke.
      • Women age 55 to 79 years: The USPSTF strongly recommends aspirin when the potential benefit due to a reduction in ischemic strokes (which occur when an artery to the brain is blocked) is more beneficial than the potential harm due greater gastrointestinal hemorrhage.
      • Women 55 years old or younger: The USPSTF recommends against the use of aspirin for stroke prevention since the benefit for prevention of ischemic stroke is small.

 

• Calcium intake and coronary artery disease: As a result of the release of new data from cohort studies, it is advisable for men and women to avoid a total daily calcium intake of over 1400 mg per day from diet and supplements due to an increased risk of cardiovascular mortality. Calcium supplements are not advised and risk may outweigh the benefit if the amount of calcium taken in the diet is unknown.

 

• Omega-3 fatty acids and coronary heart disease:
  • American Heart Association (AHA) fish, fish oil, and oil intake recommendation (1):
    • All adults are recommended to eat fish (particularly fatty fish) at least two times per week.
    • AHA also recommends eating plant-derived omega-3 fatty acids, tofu and other forms of soybeans, walnuts and flaxseeds and their oils.
    • For patients with coronary heart disease it is recommended they consume about 1 gram of two kinds of omega-3 fatty acids shown to be cardio-protective, EPA and DHA
    • Omega-3 fish oil is beneficial for treatment of elevated triglycerides. Patients needing triglyceride lowering, should have fish oil prescribed by a physician. The AHA recommends a daily intake of 2-4 grams of EPA+DHA for elevated triglycerides, but a patient should only be prescribed over 3 grams of omega-3 fish oil from a physician due an increased risk of bleeding.
  • Omega-3 fish oil benefits in coronary artery disease, myocardial infarction and mortality:
    • A review of 14 randomized clinical trials reported that fish oil is associated with a reduction in total mortality and sudden death, but not nonfatal heart attacks (2).
    • A 3.5-year study including 11,324 myocardial infarction (MI) survivors with an MI occurring within 3 months) showed that fish oil supplementation at a dose of 1 gram daily, but not vitamin E at a dose of 300 mg daily, significantly reduced the total rate of all-cause death, nonfatal MI, and nonfatal stroke (3).
    • Significant 20% reduction in deaths from cardiac causes, but it was not beneficial in terms of arrhythmic events, or all-cause mortality (4).
    • In a randomized controlled trial called the GISSI-Prevenzione trial done in Italy, 11,324 patients with pre-existing coronary heart disease (CHD) were randomly allocated to either 300 mg vitamin E, 850 mg omega-3 fatty acid ethyl esters (eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]), both, or no treatment and followed for 3.5 years noted the following results (7):
      • 15% reduction in mortality, nonfatal myocardial infarction, and nonfatal stroke was seen in participants taking 850 mg omega-3 fatty acid alone.
      • Participants taking omega-3 fatty acid after 6-months experienced a 2.5% increase in HDL cholesterol and a 4% reduction in triglycerides.
      • 20% reduction in all-cause mortality and a 45% reduction in sudden death.
    • A randomized controlled trial by Burr et al. found that patients who had a myocardial infarction showed a 29% reduction in mortality over 2 years by eating three fish meals a week (8).
    • Kromhout and colleagues followed Greenland Eskimos over 20 years and found an inverse association between fish intake and coronary heart disease (CHD) mortality which was more than 50% lower among the men who consumed at least 30 grams of fish per day than among those who did not eat fish (10).
    • Fish oil vs. mustard oil for coronary artery disease: A 12-month, randomized, placebo-controlled trial in 360 patients given fish oil 1.08 g/day, mustard oil 2.9 g/day, or placebo within 18 hours of myocardial infarction symptoms noted a  reduction in total cardiac events in patients treated with fish oil or mustard oil compared with placebo, but total cardiac deaths were not reduced (9).
    • Omega-3 fish oil adverse reactions and interactions:
      • A total of 10 studies were reviewed by Villani AM et al to determine potential serious adverse effects of fish oil at a dose of under 1.86 grams per day (98). It was found that there were no serious adverse effects reported in 994 adults over 59 years of age and other non-serious adverse effects were not significantly different from placebo (98).
      • Fish oil has been reported to affect platelet aggregation, reduce vitamin K dependent factors which may be associated with an increased anticoagulation (reduce blood clotting) effect. Consumption should be avoided when taking anticoagulants like aspirin, warfarin, or ticlopidine because of the potential increased risk of bleeding (97).
      • A case of a 67-year old woman taking warfarin (1.5 mg/day), an increase in her fish oil intake from 1 g/day to 2 g/day was associated with an increase in time for blood to clot as measured by the international normalized ratio (INR) which went from 2.8 to 4.3 within 1month, and decreased to 1.6 after the fish oil dose was reduced (94).
      • An intake of 6 grams per day of docosahexaenoic acid (DHA) found no significant difference found in blood coagulation, platelet function, or thrombotic parameters including prothrombin time, activated partial thromboplastin time, antithrombin-III levels, and platelet aggregation (96).
      • Fish oil may contain harmful contaminants such as heavy metals including mercury, dioxins, and polychlorinated biphenyls (PCBs). This risk can be reduced by purchasing fish oil that has undergone a purification process specified on the label (approved by the FDA, EPA, or US Pharmacopeia) (95)

 

• Coenzyme Q10 and coronary artery disease (CAD):
  • Yalcin et al. found that concentrations in patients with CAD and healthy individuals were found to be 0.41 and 0.77 micromol/l, respectively (p < 0.01) and that CAD patients had a lower coenzyme Q10 to low density lipoprotein ratio (15).
  • Coenzyme Q10 at a dose of 120 mg per day for 28 days in 73 patients with acute myocardial infarction resulted in a lower number of cardiac events including cardiac related death and nonfatal heart attack (15% vs 30.9%), ischemia related chest pain (9.5 vs 28.1), arrhythmia (9.5% vs. 25.3%), and poor left ventricular function (8.2% vs. 22.5%) (14).
  • Coenzyme Q10 and vascular endothelial function: Supplemental coenzyme Q10 resulted in a clinically significant, 1.7% increase in flow-dependent endothelial-mediated dilation (17) which may be the mechanism responsible for some of the benefit seen with the use of coenzyme Q10 used in coronary artery disease.

 

• Resveratrol, hyperlipidemia, and heart health: Resveratrol has several potential benefits for heart health in in-vitro and in animal studies requiring more research for confirmation in humans. Other than consuming resveratrol in the form of red wine, resveratrol supplements are not recommended at this time. Findings in research support the benefits of red wine on heart health rather than resveratrol supplements due to the safety concerns of lack of regulation, unknown effective dose, and lack of standardization.
  • Fukuda, S et al found that resveratrol promoted angiogenesis (growth of new blood vessels) from pre-existing vessels of an ischemic heart (restriction in blood supply to tissues) in a rat model of myocardial infarction (MI) (61).
  • Resveratrol at a dose of 2.5 or 5 mg/kg improved post-ischemic ventricular recovery, reduced myocardial infarct size, and reduced cardiomyocyte cell compared to the control group, but doses at 25 or 50 mg/kg had multiple harmful heart effects (65).
  • Sato et al. demonstrated that an ethanol-free red wine extract and trans-resveratrol are cardio-protective against ischemia (restriction in blood supply to tissues) by functioning as a strong antioxidant (62).
  • Resveratrol (and red wine) also provides cardio-protection by mechanism of the inhibition of platelet aggregation (63). This may result in lower risk of thrombosis in atherosclerotic coronary arteries.
  • Resveratrol-treated rabbits had an increase in atherosclerotic lesions compared to a control group (64). This suggests that resveratrol results in atherosclerotic development, rather than protecting against it.
  • For further information, interactions, and adverse reactions of resveratrol: See resveratrol and red wine in Preventive Health Advisor.

 

• Treatment of endothelial function: Endothelial function is the ability of blood vessels to respond to the body’s blood flow requirements characterized by inflammation, reduced dilation of the blood vessels and an increased tendency to form clots. Thus, endothelial function is important for cardiovascular health.
  • Coenzyme Q10 for patients with endothelial dysfunction: A meta-analysis examining the results of five randomized controlled trials found that CoQ10 supplementation is associated with significant endothelia function improvement (17).
  • Lycopene supplementation of 15 mg daily taken by 126 healthy men reduced markers of oxidative stress and endothelial dysfunction (18).

 

• Creatine phosphate for myocardial protection:
  • Three days before surgery, creatine phosphate supplementation showed improved heart function after bypass surgery with less ventricular arrhythmias and reduced use of inotropic drugs (19).
  • Creatine phosphate given during cardiac surgery and the early postoperative period reduced CK and CKMB levels plus resulted in a lower percentage of arrhythmias compared to controls (20).

 

• Allicor and risk of ischemic heart disease (IHD) (21):
  • After 1-year of allicor treatment, the 10-year absolute risk of IHD was reduced by10.7%.
  • 10 year risk of both acute myocardial infarction, and sudden death were reduced 22.7%.
  • Reduction in total cholesterol and LDL cholesterol for men ( by 27.9 and 22.5 mg/dl, respectively) and women (by 11.4 and 10.8 mg/dl, respectively) was also reported.
  • Allicor used by women was also reported to prevent age-related cardiovascular risk.

 

• L-propionylcarnitine and L-carnitine: According to researchers supplementation with L-propionylcarnitine (LPC, important for energy production in cells) may be beneficial to individuals suffering from ischemia. In men with left coronary artery disease administered either 15 mg/kg of LPC or placebo (22):
  • Ischemia was reduced and left ventricular ejection fraction increased by 18%.
  • Recovery of heart function after pacing increased among those taking LPC.

 

• L-carnitine and angina:
  • Daily use of L-carnitine, 1 gram twice daily after 4 weeks, compared to placebo required an increase in exercise workloads to exacerbate their angina and 22.7% of L-carnitine and 9.1% of placebo participants became free of angina (23).
  • Individuals with angina Patients with 2 or more angina attacks per week took 500 mg L-propionylcarnitine, and compared to placebo, L-propionylcarnitine increased the time to 0.1 mV ST-segment depression and exercise duration improved by 5% (24).
  • L-carnitine reactions and interactions: L-carnitine had no effect on blood pressure or heart-rate. (23,24)

 

• Broccoli sprouts and ischemia: Broccoli sprouts may protect against ischemia, but more research is needed (46).

 

• Kiwi fruit and cardiovascular disease: Consuming 2-3 kiwi fruit per day for 28 days lowered blood triglycerides levels by 15%, and reduced platelet aggregation which has been linked with reduced incidence and severity of cardiovascular disease (47).

 

• Niacin and simvastatin: In a 3-year double-blinded, placebo-controlled trial by Brown et al, treatment with niacin added to simvastatin had the following results (66):
  • Promoted regression of stenosis.
  • Reduced major cardiac events by 60-90%.
  • Reduced LDL cholesterol (LDL-C) levels in coronary heart disease.
  • When antioxidant therapy was added to lipid lowering, the rate of clinical events increased to that observed with placebo.
  • No difference was seen between patients receiving antioxidants alone and those receiving placebo.
  • Patients receiving simvastatin plus niacin had small increases in aspartate aminotransferase, creatine kinase, uric acid, homocysteine, and insulin.

 

• Vitamin C and cardiovascular disease :
  • According to Khaw, KT et al (73)
    • 19,496 men and women, ages 45 to 79 were tested for ascorbic acid and in every case (except for women at risk of cancer), death rates were significantly lower among those with higher blood ascorbic acid levels.
    • Those with the highest ascorbic acid levels compared to the lowest levels had half the risk of dying from ischemic heart disease, cardiovascular disease, and all causes combined.
    • A 20 micromol/L increase in blood ascorbic acid concentration, the same as a 50 gram per day increase in fruit and vegetable intake, was associated with about a 20% reduction in risk of all-cause mortality.
  • According to Jacob and Sotoudeh (74),
    • High intakes of vitamin C have been associated with decreased risk of heart disease.
    • Vitamin C upper tolerable level is set at 2g and has been shown to safe

 

 

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