Cardiovascular Disease- How to Reverse Heart Disease

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