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The Heart Clinic

Conquering  Diseases of the Heart

| Research Report Card | | Antioxidants and Statin Drugs | | High Blood Pressure |
| Cholesterol | | Antioxidant Vitamins & Simvastatin-Niacin Therapy | | Antioxidants | | Heart-Friendly Products | | High homocysteine Levels |

Cardiovascular disease affects millions of people each year. According to the latest statistics in the 2001 Heart and Stroke Statistical Update, published by the American Heart Association (AHA), cardiovascular disease (CVD) claimed 958,775 lives in the United States in 1999. It has also been reported that more than 60 million Americans have one or more types of CVD, including high blood pressure, coronary heart disease (CHD), heart failure, stroke or congenital cardiovascular defects (National Health and Nutrition Examination Survey III (NHANES III), CDC/NCHS and the AHA, 1988-94).

While genetics play a large role in heart disease, modern lifestyles can also increase the risk. Secondhand smoke, inactive lifestyles and poor diet can take a toll on heart health. In one published paper, co-author Lyn Patrick, N.D., estimated that by the year 2020, cardiovascular disease would be responsible for 36 percent of all deaths and the leading cause of death in the world (Altern Med Rev, 6,3:248-71, 2001). The authors hypothesized that the rise in cardiovascular death might be due to a worldwide increase in smoking. "An estimated 21 million smokers in developed countries (with one-third of the world's population) have died as a result of tobacco use in the last decade," they wrote, adding that obesity (30 percent of U.S. adults are obese) and diabetes (80 percent of diabetics die of CVD) are also prominent factors. However, preventive measures such as controlling high blood pressure, balancing cholesterol levels and taking heart-friendly supplements may potentially keep the heart healthy and ward off more serious conditions for those at risk.

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High Blood Pressure

High blood pressure is a common heart condition found in the adult population. It is so prevalent that one in five Americans is diagnosed with it (NHANES III, CDC/NCHS, 1988-94). Two other conditions--atherosclerosis, a build-up of fatty deposits or plaque on blood vessel walls, and arteriosclerosis, a loss of elasticity in the artery walls--contribute to hypertension (high blood pressure) and degeneration of the heart muscle. Researchers have hypothesized that high blood pressure is a result of fatty deposits and loss of elasticity, which causes blood vessels to narrow and raise pressure. As the pressure increases, it adds stress on the arteries and creates a rapid build-up of plaque, which may "break loose," leading to strokes, heart attacks and other ischemic conditions such as angina, poor kidney function and reduced eyesight.

The most serious heart conditions, such as a heart attack, can occur when a clot, a spasm or an accumulation of plaque blocks blood flow to the heart. A stroke can also result, which is caused when a clot interrupts blood flow to the brain or when blood vessels burst. In a study funded by the National Heart, Lung and Blood Institute (NHLBI), published in the November 2001 New England Journal of Medicine (345:1291-7, 2001), researchers further confirmed that high blood pressure significantly increased the risk of heart attack, stroke and heart failure. They also found that those with high blood pressure have a 1.5 to 2.5 times greater risk of suffering from a cardiovascular condition in 10 years vs. those with optimal blood pressure levels. "This study underscores that, when it comes to blood pressure, any elevation over normal puts people at a significant cardiovascular risk," said NHLBI Director Claude Lenfant. "While more research is needed on this topic, it's advisable that high to normal blood pressure be treated." He added that for most individuals, treatment can consist of such lifestyle changes as following a healthy diet, lowering dietary intake of saturated fat and cholesterol, choosing foods low in salt and other forms of sodium, losing extra weight, becoming physically active and limiting alcoholic beverages.

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Cholesterol

Most individuals diagnosed with cardiovascular disease also have elevated cholesterol levels. Low HDL cholesterol levels (known as the "good" cholesterol) and high LDL cholesterol (known as the "bad" cholesterol) are more specifically linked to cardiovascular disease than total cholesterol. HDL, for example, protects arteries by scavenging and sending excess cholesterol back to the liver where it is metabolized into hormones and bile acids. HDL also acts as a scavenger preventing plaques from adhering to vessel walls. Without these scavengers, or when the ratio of HDL to LDL is off, plaques can harden the arteries and cause atherosclerosis. Currently, there is no definitive method to raise HDL; (Editors Note--Simvastatin or Zocor coupled with Niacin will raise  Good Cholesterol - HDls) however, exercise, a healthy diet and weight loss have been said to improve HDL levels.

Recent scientific research has suggested a Mediterranean diet, rich in olive oil, may also have a beneficial impact on heart disease and cholesterol (Curr Atheroscler Rep, 3,6:437-45, 2001). In another study, researchers compared a Mediterranean diet with a standard Western diet in patients who had suffered a first myocardial infarction. After five years, there was a 76-percent reduction in cardiac events in the Mediterranean group (J Am Cardiol 28:1103-8, 1996). In a follow-up report, those who stayed on the diet continued to experience its health effects (Circulation, 99: 779-85, 1999).

While dietary intervention continues to remain the initial choice for the prevention and treatment of CVD, the nature of dietary modification remains controversial, suggested researchers at the University of Massachusetts, Lowell (J Am Coll Nutr, (5 Supple):421S-427S; discussion 440S-442S, 2001). They noted that, "reducing calories from total fat, without decreasing saturated fat intake results in insignificant changes in LDL. Similarly, diet intervention that focuses solely on lowering dietary cholesterol and saturated fat intake not only decreases LDL, but also HDL and therefore may not improve the lipoprotein profile."

The review suggests that soy protein, soluble fiber, soy lecithin and plant sterols, as well as polyphenols, isoflavones, folic acid and vitamins B6 and B12, may reduce the risk of CVD without changing levels of lipoprotein cholesterol.

In an attempt to promote a healthy LDL profile, NHLBI's National Cholesterol Education Program (NCEP) established new cholesterol guidelines. The guidelines define "normal" LDL levels as 100 mg/dl (milligrams per deciliter of blood serum), "borderline high" as 103 to 159 mg/dl, and "high" as 160 to 189 mg/dl. As a result of these guidelines, more people with borderline profiles may find physicians recommending cholesterol-lowering medication, in addition to lifestyle changes.

Several supplements have been touted to lower cholesterol. Niacin (vitamin B3) has been used since the 1950s to lower triglycerides, a type of fat in the blood associated with low levels of HDL. Folic acid (vitamin B9) is known to lower homocysteine (an amino acid) levels, which have been linked to risk of stroke (J Lab Clin Med, 133:572-82, 1999), as do vitamins B12, B6 and betaine. Since elevated homocysteine levels are associated with heart disease and increased atherosclerosis, these supplements are ideal for any heart-healthy plan.

One long-term favorite cholesterol-lowering supplement is garlic. A plethora of research was published this year showing that garlic can lower LDL and increase HDL. Evidence from these studies points to the fact that garlic may stabilize plasma lipids, enhance fibrinolytic activity, inhibit platelet aggregation and reduce blood pressure and glucose levels (J Nutr, 131(3s):977S-9S, 2001).

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Antioxidant Vitamins & (Zocor) Simvastatin-Niacin Therapy!

Antioxidant vitamins and lipid therapy: end of a long romance?

Brown BG, Cheung MC, Lee AC, Zhao XQ, Chait A.


Department of Medicine, Division of Cardiology, University of Washington School of Medicine, Seattle, USA. bgbrown@u.washington.edu

During the past decade, the perception flourished that lipid and antioxidant therapy were 2 independent avenues for cardiovascular protection. However, studies have shown that commonly used antioxidant vitamin regimens do not prevent cardiovascular events. We found that the addition of antioxidant vitamins to simvastatin-niacin therapy substantially blunts the expected rise in the protective high density lipoprotein (HDL)2 cholesterol and lipoprotein(A-I) subfractions of HDL, with apparent adverse effects on the progression of coronary artery disease. To better understand this effect, 12 apolipoproteins, receptors, or enzymes that contribute to reverse cholesterol transport have been examined in terms of their relationship to HDL2 and lipoprotein(A-I) levels and the potential for antioxidant modulation of their gene expression. Three plausible candidate mechanisms are identified: (1) antioxidant stimulation of cholesteryl ester transfer protein expression/activity, (2) antioxidant suppression of macrophage ATP binding cassette transmembrane transporter A1 expression, and/or (3) antioxidant suppression of hepatic or intestinal apolipoprotein A-I synthesis or increase in apolipoprotein A-I catabolism. 

In summary, antioxidant vitamins E and C and beta-carotene, alone or in combination, do not protect against cardiovascular disease. Their use for this purpose may create a diversion away from proven therapies. Because these vitamins blunt the protective HDL2 cholesterol response to HDL cholesterol-targeted therapy, they are potentially harmful in this setting. We conclude that they should rarely, if ever, be recommended for cardiovascular protection.

PMID: 12377728 [PubMed - in process]

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Antioxidants

Antioxidant vitamins E and C, selenium and bioflavonoids also have potential benefits. (This is an item of dispute, The Editor) These nutrients are said to protect the inner layer of veins and arteries from disease-producing agents. Antioxidants are important to the body in that they serve as natural guards against free radicals, which can contribute to many degenerative diseases, including CVD. Free radicals are atoms with an unpaired electron that can cause an adverse chemical event and set off a chain reaction. Antioxidants, in turn, can donate an electron to the free radical to combat oxidation.

Vitamin E is one of the most researched and controversial nutrients for reducing cholesterol. This fat-soluble vitamin can reduce the risk of coronary heart disease in a number of ways, including slowing and reducing the oxidation of cholesterol. But, some research published in 2001 showed no relationship between vitamin E supplementation and the prevention of cardiovascular mortality (Atherosclerosis, 159,1:193-200, 2001; Nutrition, 17,10:793-6, 2001).

Researchers have suggested more studies need to be conducted on the bioavailablity of vitamin E and that appropriate dosages may yield different results. W.H. Leong, vice president of Carotech Inc., further supported this stance, adding that there are eight forms of vitamin E--four forms of tocopherols and four forms of tocotrienols. "The idea that one single form of vitamin E--alpha tocopherol--out of eight fractions is a 'magic bullet' and assuming that the others are worthless denies the very fact that nature put seven other tocopherols and tocotrienols out there for a reason," Leong said. "We have unfortunately used technology to prematurely pinpoint a single compound. This has caused many of us to miss the boat as far as protection from vitamin E is concerned." Leong added that the best vitamin E formula to take for reducing the risk of coronary heart disease or in reducing lipid peroxidation is one that contains all the eight forms of vitamin E.

Another study published by researchers from the National Institute of Public Health and Environment, The Netherlands, noted that there was a lack of convincing evidence proving that vitamin E, carotenoids or vitamin C could protect against coronary heart disease (J Nutr Health Aging, 5,3:144-9, 2001). Observational research from the group indicated that flavonols and polyphenols with strong antioxidant properties present in plant foods might protect against coronary heart disease.

Over the past two decades, considerable evidence has been gathered to support the hypothesis that soy, plant sterols and omega-3 fatty acids have beneficial effects on cholesterol and high blood pressure.  Soy protein with naturally occurring bioactives, for example, can lower cholesterol and decrease plaque formation in the arteries. Plant sterols and stanols absorb cholesterol from the diet, also lowering irregular heartbeats associated with sudden cardiac death and lower triglcyerides. In one study, researchers found that functional foods enriched with 2 to 3 g of plant stanols and sterols could cause a 10- to 15-percent reduction in LDL cholesterol when taken daily (Nutr Metab Cardiovasc Dis, 11, 1: 31-40, 2001).

The Heart of the Matter

As more heart-friendly products enter the market, alternatives to traditional treatments for CVD are giving consumers more options to address and defeat this often fatal disease. Alternative treatments such as chelation therapy and coenzyme Q10 (CoQ10) ingestion continue to be touted as effective approaches, and other heart-friendly minerals and supplements are progressively gaining a share of the marketplace. As research continues to be published on these supplements, concerns about the potential dangers of mixing antioxidants with statins are forcing many heart-friendly products to the limelight . As these concerns continue to be raised and investigated, retailers should be prepared to answer consumer questions on the topic. AHA's Web site (www.americanheart.org) offers the latest news on heart health and the National Institute of Health's Web site (www.nih.gov) has fact sheets and helpful information on this deadly disease.

Susan Colebank contributed to this story.

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Research Report Card

The following is the short list of the hottest heart nutrients on the market today. 
bulletCoenzyme Q10 (CoQ10) | Order | This is an essential nutrient in the body that has been studied extensively since it was first isolated from a cow's heart in 1957. In the early 70's, researchers documented that a deficiency in CoQ10 may be a predecessor for heart disease, and that cholesterol-lowering drugs such as simavastatin may reduce the amount of naturally occurring CoQ10 in a person's body. One recent study reported that CoQ10 may be able to help with chronic heart failure (CHF) management. The researchers, from Virginia Commonwealth University, recommended it as adjuvant therapy for CHF patients, not as a monotherapy (Pharmacotherapy, 21,7:797-806, 2001). Between 10 and 30 mg/d is the dose recommended for healthy individuals; those with heart problems may want to consume between 30 and 150 mg/d.
bulletAcetyl-L-carnitine  | Order|This naturally occurring, vitamin-like substance is one that many people are lacking; carnitine deficiency is marked by such problems as obesity, fatigue, elevated triglycerides and heart problems. Long researched for its triglyceride-lowering benefits, the latest trial found that it may be helpful in open heart surgery recovery. In a trial on newborn rabbits, researchers from the Heart Institute of Japan found that carnitine supplementation may help with fatty acid metabolism after open heart surgery, a method that could be applied to infants (Ann Thorac Surg, 71,2:648-53, 2001). This alkaloid can be taken in amounts of 500 to 3,000 mg/d for optimal results.
bulletPlant sterols, stanols & sterolins Since the 1920s, plant sterols and stanols have been studied for their health benefits; in more recent times, the sterol glucose sterolin has been under investigation. These plant-based nutrients have been found to be highly beneficial in lowering LDL cholesterol levels. However, researchers from Maastricht University in The Netherlands reported that sterols and stanols might lower concentrations of plasma carotenoids (Curr Opin Lipidol 11,6:571-6, 2000). The Food and Drug Administration (FDA) issued a stanol/sterol health claim pertaining to cholesterol health in 2001. FDA reported that studies found taking 1.3 g/d of plant sterols or 3.4 g/d of plant stanols may significantly lower cholesterol levels.
bulletSoy This legume is chockfull of beneficial properties, including preventing LDL cholesterol from oxidizing. It is still unknown which compound--a mixture of isoflavones, a particular isoflavone, the soy protein or the entire soy food--best protects against heart disease. Recently, researchers from Emory University found that soy isoflavones may reduce the risk of heart disease by working in an anti-estrogen manner on estrogen receptors that, when awry, may promulgate the potential for heart disease (Endocrinology, 142,7:2946-52, 2001). Postmenopausal women who suffer from haywire estrogen have a higher-than-average risk for heart disease. However, researchers from UCLA found that taking soy phytoestrogens along with flavonoids and ascorbic acid reduced LDL oxidation in a significant manner (J Agric Food Chem, 49,1:308-14, 2001). FDA approved a heart-health claim for soy foods in late 1999, stating that 25 g/d may reduce the risk for heart disease.
bulletDHEA  | Order |This adrenal hormone may protect against ischemic heart disease, especially in men. Researchers at the New England Research Institutes found that low DHEA and DHEA sulfate levels may predict the risk for this heart condition (Am J Epidemiol, 153,1:79-89, 2001).
bulletHawthorn Hawthorn fruit extract is hypothesized to be cardiovascular protective, hypotensive and hypocholesterolemic. Researchers from the Chinese University of Hong Kong reported that either the hawthorn itself provides enough antioxidant activity to keep LDL from oxidizing, or else it aids in maintaining vitamin E levels (another antioxidant) which in turn combats LDL oxidation (J Nutr Biochem, 12,3:144-52, 2001).
bulletPlant-Based Antioxidants: Pycnogenol®, grapeseed extract, lycopene Researchers from the University of Arizona found that 200 mg/d of Pycogenol, or French maritime pine bark, may reduce platelet aggregation in smokers (Integr Med, 2,2:73-7, 2000). According to researchers from Georgetown University, 100 mg of grapeseed extract combined with 200 mcg of chromium decreased total cholesterol and LDL levels significantly (J Med, 31,5-6:227-46, 2000). Low lycopene plasma levels, according to researchers from the University of Kuopio in Finland, may be associated with early atherosclerosis (Arterioscler Thromb Vasc Biol, 20,12:2677-81, 2000).

*Consumers should discuss supplementation of any  products with their doctor to find what is right for them.

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Antioxidants and Statin Drugs

Researchers have reported that antioxidant vitamins and minerals may help statin drugs reduce overall cholesterol levels, but when combined with those drugs, they may impede the drugs' ability to increase "good" cholesterol levels. In a 12-month study of 153 patients with coronary artery disease and low levels of HDL cholesterol, subjects were randomly assigned to a cholesterol-regulating drug (simvastatin with niacin), antioxidants (vitamin C and E, beta carotene and selenium), a combination of statins and antioxidants, or a placebo (Art, Thromb, Vasc Bio, 21: 1320-6, 2001). Both the statin and statin/antioxidant groups had significant reductions in plasma cholesterol, triglyceride and LDL cholesterol. However, HDL improved in the statin participants while remaining the same in the antioxidant group. It is still unknown which one or ones are the culprit or whether it is the antioxidants that have an adverse effect.

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