Heart Disease

Understanding Heart Disease

Heart disease is the leading cause of death for both men and women—it kills more women than all types of cancer combined, including breast cancer (Centers for Disease Control and Prevention [CDC], 2018). The good news is that lifestyle changes can significantly lower your risk of heart disease, even if you are genetically predisposed (Khera et al., 2016). Just as heart disease and cancer can develop over long periods of time, lifestyle changes can be implemented over your lifetime—you don’t have to wait for a heart attack. But if you’ve had a heart attack or other warning signs, there is still a lot you can do. Simply saying “Don’t eat fat” is passé, and now we have much more effective diet and lifestyle recommendations.

Primary Symptoms

When heart disease reduces the supply of blood to the heart muscle, symptoms can include angina—chest pain that may feel like burning, squeezing, pressure, or numbness—as well as shortness of breath and fatigue. When the blood supply is completely cut off, the heart stops beating, which is a heart attack, or myocardial infarction (Physicians Committee for Responsible Medicine, 2015).

It’s been said that symptoms of a heart attack are different for women than they are for men, but recent research has found that this is not necessarily true. The most common symptoms in both men and women are chest pain, sweating, shortness of breath, and nausea. Additional symptoms include lightheadedness and pain or discomfort in the arms, back, neck, jaw, or upper stomach. If you experience these symptoms, keep in mind that women are less likely to be correctly diagnosed and treated than men. Also of note for women: Although technology has kept people with heart disease alive longer, women have a higher risk of dying after a heart attack, bypass surgery, or angioplasty than men, making prevention even more important for women (Alraies & Pina, 2019; Ferry et al., 2019; Mosca et al., 1997).

Potential Causes of Heart Disease and Related Health Concerns

A complex set of genetic and environmental factors have been implicated in heart disease. The focus of this article is ischemic heart disease caused by atherosclerosis, which has multiple causes, including high blood pressure, high blood sugar, high cholesterol, inflammation, and use of tobacco.

Tobacco

Smoking, secondhand smoke exposure, low-tar cigarettes, and smokeless tobacco are huge risk factors for heart attacks. They promote cardiovascular disease by damaging artery walls and inducing blood clots. E-cigarettes also expose users to toxic compounds. In controlled experiments just ten puffs caused measurable damage to the endothelial cells lining blood vessels and prevented the blood vessels from being able to dilate in order to lower blood pressure. We won’t really know how safe or unsafe e-cigarettes are until more research is completed (Ambrose & Barua, 2004; Eltorai, Choi, & Eltorai, 2019).

Inflammation and Oxidized LDL

The buildup of atherosclerotic plaque is a years-long process. When arteries are examined very early on in the process, the first change seen is inflammation. Inflammation refers to white blood cells exiting the blood and entering a tissue. In this case, the white blood cells squeeze in between the endothelial cells lining the artery and migrate below the endothelial cells into the wall. Inside the arterial wall, white blood cells, primarily the “garbage collectors” called macrophages, accumulate cholesterol and fat, resulting in plaque formation.

Why and how macrophages begin entering arteries and forming plaque is not entirely understood, but one stimulus is high levels of the cholesterol and fat-carrying particle called low-density lipoprotein (LDL). Macrophages are attracted to LDL when the particles have been oxidized, forming oxidized LDL. Macrophages enter arterial walls, scavenge the oxidized LDL that they find, and begin a cycle of producing inflammatory mediators that attract more white blood cells and cause more LDL to become oxidized. One factor contributing to this cycle is a high level of LDL in the blood—measuring the blood level of LDL is part of most routine checkups because it is a strong predictor of heart disease. Another factor promoting this cycle is ongoing inflammation, and this can be assessed by measuring the level of C-reactive protein (CRP), an inflammatory marker, in the blood (Chistiakov, Bobryshev, & Orekhov, 2016; Endemann et al., 1993; Gao et al., 2018; Parthasarathy, Steinberg, & Witztum, 1992; Poston, 2019; Steinberg & Witztum, 2010).

Blood Cholesterol

High blood cholesterol is only one of many risk factors for heart disease—even without high cholesterol, other factors can cause heart disease—but it is an extremely important one. High cholesterol is a good predictor of cardiovascular disease, and lowering blood cholesterol lowers the risk of heart attacks. Cholesterol is not all bad, though, or your body wouldn’t make it. Cholesterol is needed by every cell and every membrane in the body. (Being born with a defect in cholesterol production causes birth defects such as not developing two eyes [Nanni, Schelper, & Muenke, 2000].) The problem is when your liver makes too much cholesterol—or less commonly, when your diet is very high in cholesterol. Dietary factors that cause the liver to produce cholesterol are discussed in the dietary changes section of this article.

Cholesterol and fat (triglyceride) are not water soluble, so they are carried in the blood in particles called lipoproteins, in which a core of fat and cholesterol is covered with proteins and phospholipids. High levels of low-density lipoprotein (LDL)—in particular, small, dense LDL—are associated with a high risk of developing heart disease. Lipoprotein (a) is another particle predictive of heart disease. In contrast, high-density lipoprotein (HDL) also contains cholesterol and fat, but this lipoprotein has a protective effect. (Cholesterol Treatment Trialists’ [CTT] Collaboration, 2010; Nair, 2013; O’Donoghue Michelle L. et al., 2019; Steinberg & Gotto, 1999; Steinberg & Witztum, 2010; The Nobel Foundation, 2019).

Blood Pressure

Blood pressure is determined by the amount of blood in circulation and by how narrow blood vessels are. High blood pressure is silent, meaning you often aren’t aware of it while it is damaging blood vessels and leading to heart disease, stroke, and kidney disease. Healthy arteries can expand (dilate) in order to lower blood pressure and contract in order to increase blood pressure. When blood pressure is poorly regulated and high pressure persists, the force of the blood damages endothelial cells lining arteries, contributing to atherosclerosis and other pathologies (Mayo Clinic, 2018a; NHLBI, n.d.-b).

Blood Sugar

High blood sugar is a major risk factor for cardiovascular diseases, and heart disease is the major cause of death in diabetes. High blood sugar causes inflammation and oxidative stress, damaging the endothelial cells lining arteries and impairing their ability to regulate blood pressure. Work with your medical professionals to control your blood sugar, both the sugar you eat and the sugar your liver produces. See the article in this series on diabetes for more information on prevention and treatment of high blood sugar (American Heart Association [AHA], 2019a; Durrer et al., 2019; Engel et al., 2019).

Blood Clots

The formation of arterial plaque is a slow process. The suddenness of a heart attack or stroke can be due to plaque rupturing and a blood clot forming on the damaged vessel, blocking the last remaining open portion of the artery. Whereas a healthy artery is muscular and elastic, an atherosclerotic artery is weak and unstable, consisting of thickened lesions filled with a gruel made up of dead cells, fats, calcium, and cholesterol and covered with a thin, fragile cap (AHA, 2019b; Mayo Clinic, 2018b).

Genes

Although environmental factors are important contributors to ischemic heart disease, between 35 and 60 percent of causes are thought to be inherited. Over ninety genes associated with heart disease have been identified, but so far adding up the increased risks from all of these explains only 25 percent of how the disease is inherited. A genetic risk score—a polygenic risk score—can be calculated for an individual by adding up the risk scores associated with each of their gene variants. Polygenic scoring that will predict CVD is close to being ready for clinical use in Caucasians and Asians but is not yet generally available.

The hope is that genetic risk scores can be used to identify people most at risk of heart attacks so that they can implement lifestyle changes and be given preventative treatments. These scores may be especially valuable in identifying people younger than age forty who are at risk of developing early-onset disease. Genetic screening can now be done on a computerized microarray chip that assesses multiple genetic risk variants.

For certain kinds of hereditary heart diseases not discussed in this article—such as familial amyloidosis or familial dilated cardiomyopathy—your doctor may recommend specific genetic tests.

The first well-characterized example of a gene variant responsible for heart disease was familial hypercholesterolemia. This is when mutations in genes for the LDL receptor (LDLR gene) cause LDL to build up in the blood, which then leads to premature heart disease (the Nobel Foundation, 2019). Familial hypercholesterolemia is a rare example of heart attacks directly resulting from a mutation in one of a few genes (LDLR, APOB, PCSK9, and LDLRAP1).

The APOE ε4 allele is another common gene polymorphism identified early on that predicts an increased risk of heart disease, as well as dementia. Apo E is a protein component of several lipoproteins. Gene sequencing has identified rarer variants in multiple genes—APOA5, APOC3, NPC1L1, SCARB1, ANGPTL4, LPL, and SVEP1—that are associated with increased risk of heart attack. The APOA5 and APOC3 genes encodes proteins, apo A and apo C, found in several lipoproteins. However, many of the genes implicated in heart disease are not obviously related to lipoproteins, fat metabolism, or inflammation (Elosua & Sayols-Baixeras, 2017; Roberts, 2018; Roberts, Campillo, & Schmitt, 2019).

Depression

Depression is consistently linked with increased risk of heart disease, but whether it promotes disease or is a consequence has not been clear. Recent research has shown that being depressed is a risk factor for developing heart disease and is predictive of additional heart attacks in those already diagnosed with heart disease (NHLBI, 2017; Vaccarino et al., 2019).

Stress

Fatal heart attacks tripled in the days after the 1981 earthquake in Athens. A more subtle stressor was also linked with increased numbers of fatal heart attacks: On the fourth of the month, historically considered an unlucky number in Chinese and Japanese cultures, the rate of fatal heart attacks among Chinese and Japanese people in California was 27 percent higher than in white people. Data came from hundreds of thousands of death certificates in the US from 1973 to 1998 (Phillips et al., 2001; Trichopoulos, Zavitsanos, Katsouyanni, Tzonou, & Dalla-Vorgia, 1983).

Stress can impact risk of heart disease in multiple ways, including contributing to anxiety, depression, inactivity, and high blood pressure. And it is proposed that chronic stress activates the immune system, leading to inflammation. Stress is not as significant a risk factor as cigarette smoking and high cholesterol, but in people who already have cardiovascular disease, stress can trigger heart attacks and affect recovery (Kivimäki & Steptoe, 2018; G. E. Miller & Blackwell, 2006).

Cannabis

Smoking marijuana has been linked with a variety of cardiovascular problems, including abnormal heartbeat and heart attack, and research is urgently needed to define safe conditions of use (Jouanjus Emilie, Lapeyre‐Mestre Maryse, Micallef Joelle, & French Association of the Regional Abuse and Dependence Monitoring Centres (CEIP-A) Working Group on Cannabis Complications, 2014; Rezkalla & Kloner, 2019).

Air Pollution

Population studies have strongly correlated levels of air pollution with rates of heart disease and death from heart disease. Long-term exposure to fine particulate air pollution has been correlated with increased death from heart disease and stroke. And increased risk has been documented at levels of fine particulate matter that are within currently accepted standards.

Further, controlled studies have documented adverse effects of air pollution on the cardiovascular system. Breathing in urban levels of diesel exhaust was shown to induce risk factors for heart disease in healthy people for up to twenty-four hours after exposure. Breathing diesel exhaust damaged arteries, as measured by a reduced ability of arteries to dilate (expand), and induced inflammation, as measured by the marker CRP (Hayes et al., 2020, Tousoulis et al., 2020).

Related Health Concerns

Atherosclerosis causes blood vessels throughout the body to become blocked. In addition to heart attacks, blocked blood vessels can lead to peripheral artery disease, dementia, stroke, and impotence. Do you know an older person who doesn’t want to walk more than a few steps because of painful legs? This might be because peripheral artery disease keeps their feet and legs from receiving an adequate blood supply. A common cause of dementia is when blood supply to the brain is affected, starving it of nutrients. This can be a gradual, slow development or can happen with no warning—i.e., a stroke. An anti-smoking billboard showed a cowboy smoking a limp cigarette because smoking causes CVD and can result in impotence. Since all of these atherosclerosis-related diseases share a common etiology, a family history of one indicates an increased risk of the others (Diaconu et al., 2019; Morley, Sharma, Horsch, & Hinchliffe, 2018).

This article will not cover other heart-related medical conditions, such as abnormal heartbeats or heart valves, heart infections, or the broken heart syndrome—heart failure induced by extreme emotional stress—which is more common in women (Genetic and Rare Diseases Information Center, 2017).

How Heart Disease Is Diagnosed

1. All too often, a heart attack is the first indication of heart disease. But heart disease can be diagnosed by looking at a combination of symptoms, family history, and test results:

2. • Blood tests are used to determine levels of risk factors, including cholesterol, triglyceride, specific lipoproteins, blood sugar, and markers of inflammation. The AHA recommends measuring blood pressure yearly starting at age twenty, measuring blood sugar every three years and blood cholesterol every five years. It recommends discussing your weight, diet, activity level, and smoking habits with your doctor regularly. Depending on your family history, lifestyle, and test results, your doctor may recommend one or more of the additional tests below (AHA, 2019d).

3. • Echocardiography is used to measure the heart’s pumping capacity.

4. • Electrocardiograms (EKG, ECG) show whether the heart rhythm is steady.

5. • Stress tests look at how well the heart functions during physical stress from exercise.

6. • CT scans (computed tomography, aka CAT scan) use X-rays to create 3D images of the heart and blood vessels and can detect calcium buildup and blocked arteries. (The amount of radiation from one CT scan is equivalent to the amount of radiation the average person is exposed to in daily life over a period of one to five years. Your doctor will take into account your age and the amount of radiation exposure you’ve had when deciding whether to recommend a CT scan. Information about radiation exposure from CT scans can be found here.)

7. • Cardiac MRI (magnetic resonance imaging) can help detect damage to the heart or problems with blood flow.

8. • PET scans (positron emission tomography) use radioactive tracers to look at blood flow.

9. • A coronary calcium scan detects calcium buildup and uses an electron beam CT or a multidetector CT (MDCT) machine. (This exposes you to the amount of radioactivity you would typically be exposed to in one year.)

10. • Angiography is used to visualize the coronary arteries following injection of a dye. (NHLBI, 2019, n.d.-a; U.S. Food & Drug Administration, 2017)

Dietary Changes for Heart Disease

We are way beyond the egg-white and fat-free diet prescription for heart disease that many people suffered with fruitlessly from the 1970s until recently. Eating the low-fat diet recommended by the American Medical Association and the American Dietetic Association typically didn’t achieve desirable results. So doctors concluded that changing lifestyle was not helpful—that genetic predisposition was overriding lifestyle and could only be conquered with drugs and surgery. We now know much more about the significant benefits that diet can provide.

It’s very difficult to carry out well-controlled diet experiments for long enough periods of time to see whether a particular diet reduces heart attacks. It is possible to carry out controlled experiments for shorter periods of time—weeks or months—to assess the effects of diet on known risk factors for heart attacks, such as blood cholesterol, blood sugar, blood pressure, and inflammation. Another common research approach is correlating what people say they eat with their long-term health. The latter approach may reveal an association between a dietary pattern and heart health but cannot demonstrate whether the association is meaningful or random. Further, the accuracy of the questionnaires used in these studies has been challenged (Schaefer et al., 2000).

Plant-Based Diets

Plant-based, vegetarian, and vegan diets have been linked to reduced risk of cardiovascular diseases, and controlled studies have shown that part of this benefit may be due to blood-pressure-lowering effects (Kahleova, Levin, & Barnard, 2017). Significant benefits are also due to the cholesterol-lowering effects of plant-based diets.

Plant oils contain primarily unsaturated fats that lower blood cholesterol, in contrast to animal fats, which contain high proportions of saturated fats that increase blood cholesterol. The AHA has concluded that switching from saturated to unsaturated fats can reduce risk of cardiovascular disease by 30 percent, similar to the effects of the commonly prescribed statin drugs.

Have you ever known vegetarians whose diets are high in refined carbohydrates, such as bagels and cookies? They won’t reap the benefits of a vegetarian diet—the effects are seen when vegetables, nuts, avocados, and oils are included because of their fibers, cholesterol-lowering unsaturated fats, phytosterols, and antioxidants (Sacks et al., 2017).

Ornish versus Atkins versus South Beach

Quite a few diets have reported that they lower blood cholesterol—is there a way to distinguish them? First, it’s important to know that any time you are losing weight, your blood cholesterol is probably going down simultaneously. What’s more difficult to find is a diet that can keep cholesterol low when you’re maintaining weight. In one well-controlled study, people ate either the very low-fat Ornish diet, the low-carbohydrate Atkins diet, or the Mediterranean South Beach diet. As far as blood cholesterol, the Ornish and South Beach diets were best at keeping it low, and they were the best at supporting arterial function. The function that was assessed was the ability of arteries to dilate—dilation and contraction are how arteries help regulate blood pressure (M. Miller et al., 2009).

The Atkins diet, which allows foods high in protein and fat, such as meat and cheese, can be excellent for weight loss, but this is because people eat fewer calories when they can’t have fries or muffins or soda. The idea of eating steak and cheese and cream sounds appealing, but people eat less overall and lose weight. If the strict diet isn’t maintained, and a few fries and a shake are added in with that steak, it’s not the most favorable for arterial health.

Eggs and Dietary Cholesterol

There has been a popular, but incorrect, perception that scientists keep changing their minds about eggs. It was not nutritional scientists who said that eggs should be avoided. Public health officials and medical doctors made the incorrect assumption that the cholesterol content of eggs made them undesirable. The rationale was that the cholesterol from eggs would contribute to high blood cholesterol, which is an important risk factor for heart disease. The problem with this reasoning is that most of the cholesterol in the body is synthesized in the liver, and it’s more important to keep the liver from making cholesterol than it is to avoid eating it.

If you eat cholesterol, say in eggs or shrimp, most people’s livers will respond by making less cholesterol. In some cases eating cholesterol will cause blood cholesterol to go up, but it’s both kinds of blood cholesterol, the “good” HDL and the “bad” LDL, and the ratio is not worrisome. Hopefully the message has gotten out that eggs—which are inexpensive and nutritious with protein, vitamin B12, vitamin A, lecithin, and choline—do not need to be avoided (Kim & Campbell, 2018; Lemos, Medina-Vera, Blesso, & Fernandez, 2018; Soliman, 2018).

Dietary Fats and Blood Cholesterol

The kinds of fats we eat have a much more significant effect on our blood cholesterol than the cholesterol we eat. Consuming saturated and trans fats causes the liver to produce more cholesterol and results in higher blood cholesterol. It may seem counterintuitive, but eating cholesterol-rich shrimp will not raise blood cholesterol as much as eating too much coconut oil. The saturated fats that increase blood cholesterol the most are the kinds in dairy products and coconut oil. This doesn’t mean that these foods have no place in a healthy diet, as foods should be judged as a whole, not evaluated merely on the basis of the types of fats they contain.

Dairy products can be good sources of protein, vitamin B12, and calcium. Fermented dairy products, such as yogurt and kefir, are valuable sources of beneficial probiotic bacteria, and aged cheeses are excellent sources of vitamin K2. However, dairy products are not a necessary part of a healthy diet, and many people don’t tolerate the milk sugar lactose or other components of dairy. Coconut oil can be a useful source of energy, as some of its fatty acids, called medium chain triglycerides, are digested and metabolized differently from the long chain triglycerides in most fats. Choose dairy products and products containing coconut oil that are low in sugar and minimally processed, and be mindful as to whether they adversely affect your LDL cholesterol (F. B. Hu, Manson, & Willett, 2001; Kris-Etherton & Yu, 1997).

Meat

Different meats contain varying amounts of the saturated fats that increase blood cholesterol. Compared to grain-fed beef, grass-fed beef is higher in omega-3 fats and lower in cholesterol-raising saturated fats. Moderate daily consumption of lean beef as part of a healthy diet does not necessarily increase blood cholesterol. This doesn’t mean it’s healthy to eat an entire pound of well-marbled steak in one sitting—the amount and type of meat and the side dishes are important. Vegetables contain plant sterols and fibers that decrease blood cholesterol.

Compared to beef, the fats in pork are a little less saturated, so not as blood-cholesterol-raising, and chicken fat is even less saturated. Not all foods can be simply classified as healthy or unhealthy—foods contain complex mixtures of fats and nutrients and phytochemicals, and all that can be influenced by the way the food is prepared. A small serving of ham with a yam and some Swiss chard is not equivalent to eating deep-fried pork with a salty sauce and white rice (Daley, Abbott, Doyle, Nader, & Larson, 2010; Gilmore et al., 2011; O’Dea, Traianedes, Chisholm, Leyden, & Sinclair, 1990).

Unsaturated Fats and Cholesterol

Eating saturated fat may cause blood cholesterol to increase, but unsaturated fatty acids have the opposite effect. Unsaturated fats include the monounsaturated fat oleic acid, found in olive oil, and a number of polyunsaturated fats. (“Mono” refers to one double bond and “poly” refers to multiple double bonds.) Polyunsaturated fats are classified as omega-3 or omega-6.

All dietary monounsaturated and polyunsaturated—both omega-3 and omega-6—fats lower blood cholesterol. Oils that contain mostly unsaturated fats include those from fish, olives, canola, soy, sunflower, corn, safflower, avocado, walnut, flax, and most other plant oils (Hannon, Thompson, An, & Teran-Garcia, 2017; Kris-Etherton & Yu, 1997; Shatwan, Weech, Jackson, Lovegrove, & Vimaleswaran, 2017).

An additional benefit of polyunsaturated fats is that two of them are essential nutrients, meaning that they are not made by the human body and they are as essential in our diet as vitamin C and protein. One of the essential fatty acids is alpha-linolenic acid (ALA), an omega-3 fatty acid, found in flax, walnuts, soy, canola, and seafood. The other essential fatty acid is linoleic acid, an omega-6 fatty acid, found in most vegetable oils and meats. Linoleic acid has significant health benefits, including being linked to lower CVD mortality despite the overblown bad press about omega-6 fats (Allport, 2008; Virtanen, Wu, Voutilainen, Mursu, & Tuomainen, 2018).

Oxidized Fats

There is a downside to polyunsaturated fats, both omega-3 and omega-6, and that is their susceptibility to oxidation. A prominent theory why fats and cholesterol are deposited on the walls of arteries is that the arteries are being used as garbage dumps for LDL that has been oxidized. As discussed in the potential causes section of this article, LDL that has been oxidized is readily deposited into arterial walls, and the level of oxidized LDL is thought to be an important risk factor for heart disease. Eating antioxidants might seem to be the solution to preventing oxidation of LDL, but in practice this has not proven effective (Chistiakov et al., 2016; Gao et al., 2018; Steinberg, 1997).

What may be more effective is eating fats that are resistant to oxidation; when they are incorporated into LDL, they will render it less susceptible to oxidation. Here is where the saturated fats in meat, dairy, and coconut oil shine—they are resistant to oxidation. However, the preferable fat is the monounsaturated fatty acid oleic acid, which both resists oxidation and is cholesterol-lowering (Parthasarathy et al., 1990).

Red Wine

Is that glass of red wine truly good for you? Studies that asked why Americans have more heart attacks than the French concluded that higher red wine consumption coincided with better heart health. Other studies have found that equal heart benefits are also associated with beer and spirits (Haseeb, Alexander, & Baranchuk, 2017).

There is also controlled research that points to benefits of wine and alcohol consumption. Wine and grapes contain polyphenol antioxidants, and there is a good deal of evidence that they can support the health of arteries. Resveratrol has multiple benefits that are discussed in the nutrients and supplements section of this article. Flavonoid polyphenols, such as quercetin, have anti-clotting, anti-oxidation, and anti-inflammatory activities (Perez-Vizcaino, Duarte, & Andriantsitohaina, 2006). Alcohol itself—ethanol—is a powerful drug that increases HDL, the “good” blood cholesterol. And in preliminary research, ethanol has been shown to prevent cells from dying when they are deprived of oxygen, as happens to brain cells in a stroke and to heart cells during a heart attack (Chen, Gray, & Mochly-Rosen, 1999; Ginsberg, 2000; Su et al., 2017).

It’s important to remember that research points to benefits of light to moderate consumption of alcoholic beverages, and that more than one or two small drinks daily can be detrimental to more than your ability to drive safely. Alcohol can trigger atrial fibrillation, a rapid, irregular heartbeat that may be felt as heart palpitations and that can cause blood clots and stroke. Heavy drinking is associated with elevated blood pressure in men and with lower life expectancy. Given the harmful effects of alcohol in excess, and the lack of direct evidence that the long-term benefits outweigh possible harm, recommending alcohol consumption for health benefits is not justified (Bell, 2018; Haseeb et al., 2017; Piano, Burke, Kang, & Phillips, 2018; Wood et al., 2018).

The Portfolio Diet

If you combined multiple diet and supplement approaches into one plan, how powerful would it be? The Portfolio diet does just this—it is plant-based, low in saturated fat, and high in mono- and polyunsaturated fats. Almonds, soy, oats, okra, and eggplant are eaten daily. The Portfolio diet also includes two supplements discussed in the nutrients and supplements section of this article: plant sterols (from enriched margarine) and soluble fiber (from psyllium). In a small clinical study, the Portfolio diet was compared to a low-fat control diet and to a drug commonly used to lower blood cholesterol. (The cholesterol-lowering statin drugs are discussed in the conventional treatments section of this article.) After one month, the Portfolio diet was as effective as a low dose of a statin drug at lowering blood cholesterol (Jenkins et al., 2003).

The low-fat control diet included the kinds of foods that were promoted for cardiovascular health for many years—skim milk, egg whites, and bran. Not surprisingly, the low-fat diet did not result in lower blood cholesterol. This sort of low-fat diet resulted in boring meals, few benefits, and the conclusion by patients and doctors that the only alternative was to turn to drugs.

Multiple studies since 2003 have validated the Portfolio approach for lowering cholesterol (Chiavaroli et al., 2018). It could be difficult to follow the Portfolio diet closely, though. To see a daily menu plan for the Portfolio diet, open Table 4 in the Jenkins paper. The column on the left gives menu items for the control low-fat diet, and the column on the right shows the Portfolio choices.

Nutrients and Supplements for Heart Disease

Supplements containing plant sterols and fibers have been clinically demonstrated to lower blood cholesterol and are worth trying before concluding that a cholesterol-lowering drug is necessary. Resveratrol and probiotics also appear to positively impact risk factors for heart disease. Whether or not omega-3 fats from fish oil significantly reduce heart disease is still being debated.

Plant Sterols

Plants don’t contain cholesterol, but they do contain closely related molecules called plant sterols and stanols. A number of clinical trials have established the cholesterol-lowering abilities of plant sterols and stanols. The FDA allows foods and supplements to make claims about reduced risk of coronary heart disease based on their content of these ingredients. You can get plant sterols from fatty plant foods, such as oils (like extra-virgin olive oil, corn oil, and rice bran oil), nuts (like walnuts and cashews), peanuts, whole grains, beans, and avocados. Or you can buy supplements called plant sterols, beta-sitosterol, or phytosterols. There are also foods enriched with these compounds—e.g., Benecol margarines. Take the supplements with every fat-containing meal and the phytosterols or stanols will bind to cholesterol and cause it to be excreted from your body. The meal does not have to contain cholesterol for these compounds to be effective—they will bind to and deplete the body of cholesterol that the liver has produced (Food and Drug Administration, 2018; Law, 2000; Yang et al., 2019).

Soluble Fiber

Some soluble fibers are very effective at lowering blood cholesterol. Soluble fibers are found in most plant foods, with superstars being eggplant, okra, flax seed, and beans. Oats, barley, and mushrooms are good sources of the soluble fiber beta-glucan. Apple, orange, pear, guava, and citrus are good sources of pectin. The most common fiber supplement used to lower blood cholesterol is psyllium seed husk, commonly sold as Metamucil but also available without artificial sweeteners as a bulk item (Brouns et al., 2011; McRorie & McKeown, 2017; Wei et al., 2009).

Probiotic Supplements

1. Probiotic supplements have been shown to improve risk factors for heart disease, including blood sugar, blood cholesterol, and blood pressure (Choi, Lew, Yeo, Nair Parvathy, & Liong, 2015):

2. • Significant reductions in LDL cholesterol resulted from twice-daily use of 50 billion microencapsulated Lactobacillus reuteri NCIMB 30242 (Jones, Martoni, Parent, & Prakash, 2012).

3. • Lower levels of LDL and of oxidized LDL were reported following daily use of 1.2 billion probiotics—a mixture of three strains of Lactobacillus plantarum, CECT 7527, CECT 7528, and CECT 7529 (Fuentes, Lajo, Carrión, & Cuñé, 2013).

4. • Reductions in blood sugar and increased insulin sensitivity were reported after twelve weeks of synbiotic supplements containing three probiotic bacteria species—2 billion each Lactobacillus acidophilus, Lactobacillus casei, and Bifidobacterium bifidum—plus 800 milligrams of the prebiotic inulin (Tajabadi-Ebrahimi et al., 2017).

Omega-3 Fats

Fish oil contains the long omega-3 fats—DHA (docosahexaenoic acid) and EPA (eicosapentaenoic acid)—that have many roles in our bodies, including helping to regulate blood pressure, blood cholesterol, blood-clotting tendencies, and blood triglyceride. Interest in fish oil was sparked many years ago with the observation that Eskimos had little heart disease, but there is still debate as to whether supplements have significant effects on cardiovascular health.

Our bodies can make DHA and EPA from the shorter omega-3 fat alpha-linolenic acid (ALA), which we consume in walnuts, flax, soy, and canola. What hasn’t been clear is whether or not we make optimal amounts of DHA and EPA. Vegans don’t eat significant amounts of DHA or EPA, although they might get a tiny bit from some seaweeds, so their EPA and DHA are all made in their bodies from ALA that they consume. Although blood levels of DHA and EPA are lower in vegans than in omnivores, vegans can have excellent cardiovascular health (Welch, Shakya-Shrestha, Lentjes, Wareham, & Khaw, 2010). This would argue against the need to eat fish or take omega-3 supplements, as long as people consume enough ALA.

Two recent meta-analyses of multiple clinical trials reached differing conclusions as to whether omega-3 supplements reduce heart attacks. An analysis of seventy-nine randomized clinical trials from the Cochrane Database of Systematic Reviews concluded that there was little, if any, benefit of omega-3 supplements for heart attack, stroke, mortality, etc. (Abdelhamid et al., 2018). The authors attributed previous reported benefits to biased studies. On the other hand, an analysis of thirteen trials from Harvard Medical School concluded that fatal heart attacks could be reduced by around 8 percent by marine omega-3 supplements (Y. Hu, Hu, & Manson, 2019).

The latter analysis included positive data from the recent Vitamin D and Omega-3 Trial (VITAL), which compared more than 12,000 people taking one gram of omega-3 fat daily to a similarly large placebo group. The omega-3 supplement was Omacor, a prescription product containing fatty acid ethyl esters. The group taking Omacor had fewer heart attacks compared to the placebo group, and this effect was largest in African Americans. However, total cardiovascular events (stroke, heart attack, and death) were not reduced overall by Omacor. There was one group of people who had fewer total cardiovascular events when taking Omacor—those who reported eating fish infrequently Manson et al., 2019).

The question of omega-3s and heart health has not been fully answered—as we learn more about individual variability in genomes and in microbiomes, we will likely move from asking “Do fish oil supplements benefit everyone?” to asking “Who will benefit most from fish oil supplements?”

Homocysteine and B Vitamins

A high level of the amino acid homocysteine in the blood is a risk factor for CVD, and adequate levels of folic acid and vitamins B6 and B12 are required for normal homocysteine regulation. A recent review concluded that there may be some benefit of folic acid and B vitamin supplements for CVD and stroke (Jenkins et al., 2018), although they are not always helpful (Abraham & Cho, 2010; Lonn et al., 2006). Another good reason to take a multivitamin or a B-complex is because of the prevalence of B vitamin deficiencies in older adults (National Institutes of Health [NIH], Office of Dietary Supplements, 2019a, 2019b).

Reservatrol

Some of the benefits of wine are attributed to resveratrol, a polyphenol found in grape skins and seeds as well as in Polygonum cuspidatum, a plant used in traditional Chinese medicine. Many, but not all human clinical studies involving resveratrol have demonstrated benefits for blood pressure, blood sugar, blood lipids, and inflammation. It appears that people with diabetes may benefit more from resveratrol than others. Significant benefits are seen in people with diabetes for blood pressure, blood sugar, and insulin sensitivity. For many people, 100 to 500 milligrams resveratrol daily may be worthwhile (Fogacci et al., 2018; Haghighatdoost & Hariri, 2018, 2019; Koushki, Dashatan, & Meshkani, 2018; Zhu, Wu, Qiu, Yuan, & Li, 2017).

Lifestyle Support for Heart Disease

Research has demonstrated benefits of stress management and physical activity for people with heart disease. The most significant benefits come with a comprehensive lifestyle program that combines these practices with a careful diet.

Dean Ornish’s Lifestyle Program

Thirty years ago, a comprehensive lifestyle program was shown to halt the progression of coronary artery disease. Unfortunately, it has not proven simple to implement the program on a large scale because not many people can commit to getting adequate rest, eating a healthy diet, and devoting generous time for stress management and exercise.

Beginning in 1990,Dean Ornish, MD, at the Preventive Medicine Research Institute, together with researchers from UCSF, recruited people recovering from recent heart attacks who were willing and able to commit to this lifestyle shift. The program included exercise and at least one hour daily of stress reduction with stretching, meditation, and breathing exercises. Participants met with support groups for four hours twice a week. And they ate a vegetarian diet with no animal products except for egg whites and one cup of nonfat milk or yogurt a day. At the beginning and the end of the study, coronary arteries were imaged in order to measure the thickness of arterial plaque and to assess the extent to which blood flow was restricted.

Only one year of strict adherence to the Ornish lifestyle program significantly reduced plaque in coronary arteries. At five years, benefits were even more significant, with a huge difference in arterial-wall thickness and half as many heart-related medical events. This was the first time lifestyle interventions were shown to be capable of stopping disease, and the program has since been implemented at several hospitals, with similar findings (Frattaroli, Weidner, Merritt-Worden, Frenda, & Ornish, 2008; Koertge et al., 2003; Ornish et al., 1990, 1998).

Not all lifestyle interventions have reported such impressive outcomes, but looking at twelve similar studies that combined nutrition and exercise recommendations with relaxation and psychological motivational coaching, one meta-analysis confirmed significant benefits for reducing heart attacks, angioplasty, and related occurrences by 62 percent, and for reducing thickened artery walls that occlude blood flow (Aldana et al., 2007; Cramer et al., 2015).

The evidence is fairly convincing: If a person with heart disease can implement a strict multipronged lifestyle program, it will be worthwhile. However, we can’t say for sure which parts of the Ornish lifestyle protocol are essential to reap the benefits or if they all are. In one large study, attendance at the social support programs seemed to be very important—those who attended most regularly had better blood pressure and other measures of health. This makes sense when you think of the benefits reported in other research on people with strong social networks. It also seems like the element of the program people might be most tempted to skimp on due to a busy schedule (Schulz et al., 2008).

Stress Reduction

The Mindfulness Based Stress Reduction (MBSR) program has been shown to reduce anxiety, depression, blood pressure, and body mass index (BMI) in patients with coronary heart disease. This is a specific program that includes training in several types of meditation, mindful walking, mindful eating, and breath work (Parswani, Sharma, & Iyengar, 2013).

Physical Activity

Being sedentary is associated with risk factors for CVD, such as high blood sugar, and being active and exercising reduces CVD risk factors. Light-intensity activity is worthwhile when it comes to risk of CVD—try for at least 150 minutes per week, and more is better. Even better is to both reduce the time spent being sedentary and also increase the amount of moderately vigorous physical activity (Chastin et al., 2019; Knaeps et al., 2018).

Being depressed is linked with poor survival in people with CVD, and research has consistently demonstrated that depression and anxiety are helped by exercise, even in people with CVD (Verschueren et al., 2018).

Conventional Treatment Options for Heart Disease

Modern medicine has made significant advances in surgical techniques and implanted devices, and there are some powerful drugs available to lower cholesterol and blood pressure. For those with stable arterial disease, management with drugs may be as effective as surgery. However, while the side effects of the newest drugs aren’t as bad as the previous generation of drugs, they can be significant.

Cholesterol-Lowering Statins

Statins are drugs that keep your liver from producing cholesterol. They are effective at lowering blood cholesterol and preventing heart attacks. Some common statins are atorvastatin, lovastatin, pravastatin, rosuvastatin, and simvastatin. Lowering LDL cholesterol by only around 40 mg/dl with a statin has been shown to lower the chances of a heart attack by at least 20 percent and the chances of dying by over 20 percent. Lowering LDL cholesterol even more improves the odds even more. The more intensive the treatment is, the more cholesterol is reduced, and the fewer heart attacks and deaths. Statins also have anti-inflammatory effects that appear to be an important part of the equation. Statins lower a marker of inflammation called CRP, and this probably contributes to their benefits (Cholesterol Treatment Trialists’ (CTT) Collaboration, 2010).

The 2013 guidelines from the American College of Cardiology (ACA) and the American Heart Association (AHA) include a controversial recommendation that people with LDL cholesterol as low as 70 to 100 mg/dl take a statin if they have other risk factors for cardiovascular disease, such as diabetes, or even if they have an estimated 7.5 percent chance of some CVD outcome in the next ten years (Stone et al., 2013). This recommendation is controversial because it would greatly increase the number of people taking statins, and we don’t know whether taking a statin when you have this amount of risk will end up saving lives. Like most drugs, statins have side effects, including damaging muscles and increasing the risk of developing diabetes.

Supplementation with coenzyme Q10 can reduce statin-induced muscle pain, weakness, cramps, and tiredness, according to a meta-analysis of twelve randomized, controlled clinical trials. Coenzyme Q10 works in the mitochondria to convert fuel into energy, which is especially crucial in muscle cells. In addition to blocking the production of cholesterol, statins block the overlapping pathway by which coenzyme Q10 is produced. Damage to mitochondria probably contributes to the side effects of statins (Qu et al., 2018).

The benefits versus risks of statins are something to discuss with your medical doctor. If you have had a heart attack, angioplasty, or bypass, you are at high risk for another event, and the benefits of statins outweigh the downsides. If you have very high LDL (over 190 mg/dl) or diabetes, the same goes—these are strong predictors of heart attacks. Otherwise making a treatment decision is complicated. Consider discussing with your doctor if you have a close relative with a family history of premature heart disease, CRP higher than 2 milligrams per liter, or calcium buildup in arteries.

Bound to add to the controversy and to the complexity of the decision is evidence that statins may have anticancer activity, in particular against breast cancers, with multiple statin and breast cancer studies underway now. And using statins has been reported to result in healthier types of bacteria in the gut. On the other hand, evidence is also accumulating that statins may cause diabetes, albeit at a low rate (Agarwala, Kulkarni, & Maddox, 2018; Borgquist, Bjarnadottir, Kimbung, & Ahern, 2018, Vieira-Silva et al., 2020).

Other Cholesterol Medications

The 2013 ACA/AHA guidelines recommend medications like fibrates, niacin, and ezetimibe only if patients are statin intolerant or statins don’t result in the desired LDL lowering. Ezetimibe works differently from statins—it blocks cholesterol absorption—and has been shown to work well with statins to further lower cholesterol and to lower occurrence of CVD. Another class of cholesterol-lowering drugs has been shown to be effective, but they are expensive and injected (not oral): Praluent (alirocumab) and Repatha (evolocumab). Evolocumab inhibits an enzyme called PSCK9, resulting in better removal of LDL from the blood (Reklou et al., 2018; Vavlukis & Vavlukis, 2018).

Controlling Blood Pressure

There are a variety of medications for blood pressure control, including calcium channel blockers (amlodipine), ACE inhibitors (lisinopril), beta-blockers (propranolol), and diuretics (chlorthalidone). As shown by the enormous ALLHAT clinical trial, the diuretic worked as well and possibly better than other drugs. It’s very common to need more than one of these drugs to effectively control blood pressure to below 140/90 millimeters of mercury (mm Hg), but the conclusion from this study was that a diuretic should be tried first (ALLHAT Officers and Coordinators for the ALLHAT Collaborative Research Group. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, 2002; Cushman et al., 2002).

The current recommendation is to keep blood pressure below 120/80. Two large studies have shown that intensive blood pressure control has benefits for fewer heart attacks. Intensive treatment generally means taking multiple drugs to achieve a goal. However, intensive blood pressure control doesn’t seem to be helpful for people with diabetes if they are also being treated intensively for blood sugar (ACCORD Study Group et al., 2010; Beddhu et al., 2018; SPRINT Research Group et al., 2015).

Side effects of blood pressure medications may include very low blood pressure, low potassium, low magnesium, and kidney damage. Keep records of the medications you take, the dates you’ve taken them, and side effects and benefits.

Aspirin

Do not take aspirin, even low-dose aspirin, on your own without consulting with your doctor. Aspirin can prevent the blood clots that precipitate heart attacks and are the cause of some types of stroke, so it’s tempting to think that regular use of a low dose would be a safe preventative measure. However, aspirin can cause bleeding, and for many people this risk outweighs the possible benefits. If you’ve had a heart attack or stroke, your doctor may prescribe aspirin. If you are over seventy, drink alcohol regularly, or are undergoing any medical procedures, aspirin is not recommended (AHA, 2019c; Zheng & Roddick, 2019).

Surgical Interventions

Preliminary reports from a long-awaited clinical trial indicate that for some people with stable coronary artery disease, drugs and lifestyle treatment are as effective as surgical intervention, as discussed in the clinical trials section of this article.

If medical treatment with drugs and lifestyle are not sufficient and chest pain is worsening, or in the event of a heart attack, surgery may be used to restore blood flow to the heart. Options include angioplasty and stents to open blocked vessels, as well as bypass surgery. In angioplasty, a small balloon is inflated in a blocked coronary artery to widen it and to allow increased blood flow to the heart. After angioplasty, the artery may be propped open with a metal stent, a wire mesh tube. In coronary bypass surgery, a blood vessel from another part of your body is used to replace a blocked coronary artery (Mayo Clinic, 2019).

Alternate Treatment Options for Cardiovascular Health

Several herbs used traditionally for cardiovascular health have been validated in recent clinical research. Turmeric has multiple benefits for arterial wall health, and hawthorn can provide valuable support for a weak heart. Chelation therapy is an intriguing new possibility.

Chelation Therapy

The American College for the Advancement of Medicine has been somewhat of a renegade organization, promoting chelation therapy for CVD in the absence of controlled studies demonstrating its benefits and in the absence of buy-in from conventional medical organizations. Chelation means binding, and here it refers to using the chelator EDTA to bind lead, cadmium, and/or calcium. Using EDTA to remove these minerals from the body is hypothesized to reduce risk of heart attacks. Typically, chelation therapy involves more than the chelator EDTA; infusions also contain high doses of vitamin C, magnesium, and other ingredients.

The National Institutes of Health (NIH), which funds and oversees much of the medical research in the US, decided to determine whether or not chelation therapy was beneficial. They brought together conventional medical researchers—who reportedly were sure the therapy would fail—with practitioners who use the therapy. And they did a large, controlled clinical study. Combining weekly EDTA chelation therapy with high-dose oral supplements significantly reduced the number of heart attacks and related events. The EDTA chelation therapy consisted of an infusion of EDTA plus vitamins and minerals (see table 3 in Lamas et al., 2012). The oral supplement was a multivitamin plus minerals with a high dose of many vitamins (see table 4). The combination of chelation therapy and oral supplements appeared to be better than either alone. With this one trial, two alternative treatments were shown to have significant value for heart health. This evidence was good enough to make the National Center for Complementary and Integrative Health fund a second, confirmatory study—see the clinical trials section of this article to learn more about it (Lamas et al., 2014, 2012, 2013; Lamas & Ergui, 2016).

Working with Traditional Medicine, Herbalists, and Holisitic Healers to Support Heart Health

Holistic approaches often require dedication, guidance, and close consultation with an experienced practitioner. Functional, holistic-minded practitioners (MDs, DOs, and NDs) may use herbs, nutrition, meditation, mindfulness practices, and exercise to support the entire body and its ability to heal itself. Traditional Chinese medicine (TCM) degrees include LAc (licensed acupuncturist), OMD (doctor of Oriental medicine), or DipCH (NCCA) (diplomate of Chinese herbology from the National Commission for the Certification of Acupuncturists). Traditional Ayurvedic medicine from India is accredited in the United States by the American Association of Ayurvedic Professionals of North America and the National Ayurvedic Medical Association. There are several certifications that designate an herbalist. The American Herbalists Guild provides a listing of registered herbalists, whose certification is designated RH (AHG).

Hawthorn Leaf and Flower Extracts

Diseased arteries and high blood pressure can cause acute conditions, like heart attack and stroke, and they can also result in a chronic condition called congestive heart failure, where the heart muscle is worn out and weak and can’t pump blood effectively (Mayo Clinic, 2017). A stringent review of multiple clinical trials found that hawthorn (Crataegus spp) provided significant relief of symptoms of heart failure, including shortness of breath and fatigue, and improved the ability to exercise. It appears to be safe used alone or with other therapies. This shouldn’t be surprising as it has been used in traditional medicines of China, North America, and Europe for many years. Preclinical research has revealed multiple ways in which hawthorn works: If the heart muscle is not getting enough blood, hawthorn can not only help dilate arteries to increase blood flow, but it can protect the heart muscle from dying of oxygen deprivation, and it also helps the heart contract strongly (Holubarsch, Colucci, & Eha, 2018; Pittler, Guo, & Ernst, 2008; J. Wang, Xiong, & Feng, 2013; Zorniak, Szydlo, & Krzeminski, 2017). Consult your health care practitioner about the commercially available supplements containing dried hawthorn leaf and flower.

Turmeric and Curcumin

1. Turmeric is a deep golden spice used in Indian cooking and in Ayurvedic healing for centuries—add it generously to soups and other dishes for flavor, color, and health benefits. Curcumin and related compounds, together referred to as curcuminoids, appear to be responsible for many of turmeric’s anti-inflammatory and antioxidant effects (Kunnumakkara et al., 2017). Benefits of curcumin for arterial health and disease prevention include:

2. • Lowering of cholesterol and triglyceride levels as confirmed by a recent meta-analysis (Qin et al., 2017)

3. • Improved function of endothelial cells that line arteries, produce nitric oxide, and dilate to increase blood flow (Oliver et al., 2016; Santos-Parker et al., 2017)

4. • Anti-inflammatory and antioxidant effects (Jiang et al., 2017)

Clinical trials of curcumin have reported mixed results. Significant benefits were demonstrated in a well-controlled clinical study of patients who recently had coronary artery bypass grafting (CABG) surgery. Patients who took four grams of curcuminoids for eight days had drastically fewer heart attacks than those taking a placebo (Wongcharoen et al., 2012). On the other hand, no benefits were reported from curcumin in a larger study of people undergoing surgery for aortic aneurysm—inflammation was not reduced in older patients given four grams of curcumin for four days (Garg et al., 2018).

Herbal Blood Pressure Support

Plants used to support healthy blood pressure include lavender, fennel, and chamomile, and there is now a better understanding of why they are effective. Lowering blood pressure requires that arteries can expand (dilate), and in order to do that the muscle layer in the artery wall needs to relax. One way to induce arterial muscle relaxation is to open channels in cells that let potassium through. It’s been demonstrated that extracts of plants used commonly for blood pressure support are able to open these channels. In addition to lavender, fennel seed, and chamomile, extracts from basil, oregano, marjoram, thyme, and ginger opened these potassium channels. Extracts from plants used for other medicinal purposes did not have the same effect (Manville et al., 2019).

A Statin in Red Yeast Rice

Red yeast rice is rice fermented with a particular kind of yeast, Monascus purpureus, that produces a cholesterol-lowering statin. (You can go to the conventional treatments section to read about the potent cholesterol-lowering properties of statin drugs.) Red yeast rice is used in TCM and as an ingredient in some dishes, such as Peking duck. However, because the FDA is concerned that the amount of statin in commercially available supplements would not be uniform, it has banned the sale of red yeast rice containing any statin. Any supplement sold in the US either has no statin, and therefore little benefit, or is being sold illegally with an unknown amount of statin (National Center for Complementary and Integrative Health, 2013).

Berberine for Blood Sugar and Cholesterol

Berberine is an alkaloid found in plants (e.g., Indian barberry) that have been used in TCM for many years. Small clinical trials have provided evidence that high doses of berberine—purified and concentrated from plant sources—can lower cholesterol and blood sugar. Effective doses were 300 to 500 milligrams three times daily, and these doses were shown to be safe for up to three months, albeit with some stomach discomfort. If you use berberine, take it with meals and reevaluate your blood cholesterol after a month or two to make sure you are getting the desired cholesterol-lowering effects. Be aware that we do not know much about the long-term safety of high doses of purified, concentrated berberine (Kong et al., 2004; Ni et al., 1995; Yin, Xing, & Ye, 2008).

New and Promising Research on Heart Disease

With morethan 2,500 active clinical trials and numerous preclinical investigations ongoing, we can’t begin to cover here the many aspects of heart disease research. Many investigations seek ways to lower known risk factors for heart disease, such as high blood cholesterol, blood pressure, and blood sugar. It’s a longer-term proposition to assess the effect of a treatment on the number of heart attacks.

Drugs versus Surgery

If your heart isn’t getting enough blood through the coronary arteries, is it better to be treated surgically or with medications? A worldwide clinical trial sponsored by NYU Langone Health and led by Judith Hochman, MD, NYU, and David Maron, MD, Stanford University, aimed to answer that question. The trial is called ISCHEMIA, which is the technical term for lack of oxygen. People with ischemic heart disease were given medication and lifestyle advice, and some also had surgical procedures to open up partially clogged vessels. Results were announced at the AHA meeting on November 16, 2019; reportedly, as far as preventing heart attacks, surgical procedures were not more effective than medication alone (Diagnostic and Interventional Cardiology, 2019; ISCHEMIA Trial Research Group et al., 2018).

Hormone Replacement Therapy

Hormone replacement therapy (HRT) with estrogen does not lower rates of heart disease in menopausal women. Because premenopausal women have fewer heart attacks than men, it was believed that HRT would reduce heart attacks in postmenopausal women. The Women’s Health Initiative (WHI) was a controlled clinical study of more than 68,000 postmenopausal women designed to demonstrate the benefits of estrogen and progesterone HRT. Contrary to the hypothesis, HRT did not prevent heart disease, and the value of HRT for heart health began to be seriously questioned (NHLBI, n.d.-c; Women’s Health Initiative, n.d.).

Gum Disease and Teeth Brushing

Periodontal disease has been associated with other diseases, including heart disease. The theory is that inflammation in the mouth may be linked to inflammation throughout the body. This theory predicts that reducing inflammation in the mouth, by better controlling plaque buildup on the teeth and gums, could have benefits in addition to oral health. There is some evidence for this theory from a randomized trial using a toothpaste that calls attention to plaque by turning it green. Use of this toothpaste presumably improved plaque removal and would be expected to reduce inflammation in the mouth. In a recent study, it was demonstrated that use of this toothpaste also reduced a blood marker of inflammation, CRP. Check with your dentist about the best oral hygiene routine for you. Further research is needed to see if this finding can be repeated and to learn how to optimize oral hygiene in order to reduce inflammation (Acharya et al., 2020).

Gut Microbiota

Research in animals and indirect evidence in humans points to a role for our gut microbes in our cardiovascular health (Ma & Li, 2018). Bacteria make highly inflammatory products such as endotoxin, which is normally kept out of the body by a well-functioning gut barrier. However, when the cells lining the intestine do not form a healthy barrier, endotoxin can enter the body and initiate inflammation. Endotoxin activates white blood cells, causing them to stick to the walls of arteries and migrate inside the vessel walls. (It also causes white blood cells to accumulate in the intestine.) This is the beginning of the inflammatory process that is seen early in arterial wall disease as discussed in the potential causes section.

The gut microbiota also impacts arterial health by influencing blood pressure. Transplanting a complete gut microbial community—a fecal transplant—from animals with high blood pressure can induce high blood pressure in the recipient animals (Durgan, 2017; Durgan et al., 2016).

Fasting

In the truest sense of the word, fasting means not consuming anything except water. In more common fasting protocols, people consume juice or small amounts of food, or skip meals, for twelve or twenty-four hours. Various iterations have been studied for their effects on a variety of conditions, including high blood pressure. In 2001, Goldhamer et al. reported significant improvements in hypertensive patients after ten to eleven days of water-only fasting. Patients ate only fruits and vegetables for two to three days before the fast and followed a strict vegan diet for six to seven days afterward. Fasting can be dangerous, but this study was carried out in a clinic under medical supervision (Goldhamer, Lisle, Parpia, Anderson, & Campbell, 2001; Longo & Mattson, 2014).

“Alternate-day fasting” is a term used to describe a regimen in which people eat as much as they want every second day, and on alternate days they eat some fraction of their normal intake (Kroeger et al., 2018). It has been studied as an approach to weight loss and for treatment of risk factors for cardiovascular disease. Is this sort of fasting better than other diets for weight loss and for reducing risk of CVD? One study said no, that it was as beneficial to go on a standard low-calorie diet as it was to do alternate-day fasting. Both the fasting group and the group on a low-calorie diet ended up eating about 25 percent fewer calories than they normally ate, and both groups lost weight and had lower blood pressure and lower blood triglyceride (fat) (Sundfør, Svendsen, & Tonstad, 2018). Alternate-day fasting may be more appealing and just as effective as a low-calorie diet.

For people who are overweight and who also have high blood sugar, blood pressure, triglyceride, or cholesterol, losing weight is usually helpful, and it might be worth trying various sorts of eating plans (low-calorie, alternate-day fasting, low-carb, low-fat, etc.) to see which feels easiest and healthiest. Fasting is still an active area of research, so we can expect further developments and new kinds of recommendations.

Hardening of the Arteries

When calcium is inappropriately deposited on the walls of arteries along with cholesterol, your arteries begin to harden—which is called calcification. Reasons for this are poorly understood. A coronary calcium CT scan can detect this, but as previously mentioned will expose you to radiation. Some but not all studies have suggested that calcium supplements could contribute to heart attacks, possibly because they are promoting arterial calcium deposition. Supplementation with calcium plus vitamin D has not been associated with increased heart attacks.

Vitamin K can help direct the calcium you eat to bones and away from arteries. In one clinical trial, healthy postmenopausal women who took a particular kind of vitamin K that is found in fermented foods, K2-MK-7, had healthier arteries that were less stiff than women who took a placebo. A similar vitamin K is found in aged cheeses, and green vegetables contain yet another form of vitamin K (Knapen et al., 2015).

The Obesity Paradox

Cardiovascular health shouldn’t be assumed to be strong in thin people and poor in overweight people. Fitness, not fatness, is key. Heart disease is more likely when obesity is associated with poor cardiovascular fitness, diabetes, high blood cholesterol, or high blood pressure. Obesity is not as much of a problem in people who have good metabolic and cardiovascular health.

It has been recently recognized that the relationship between body weight and risk of heart disease is more complex than previously assumed. This is called the “obesity paradox”: Being overweight or mildly obese can be protective in people who have CVD—they tend to live longer than thinner people with CVD. How this works isn’t really understood, but the take-home message is that a particular body weight may not be the most important factor. Fitness and good health are not synonymous with being thin, and we have more to learn about the relationship between weight and longevity (Kachur, Lavie, De, Milani, & Ventura, 2017; Lavie, McAuley, Church, Milani, & Blair, 2014).

Depression and Heart Disease

Depression is unusually common in people with heart disease, and being depressed is associated with very poor survival rates (NHLBI, 2017). In a clinical trial designed to see if treating depression with drugs and/or psychotherapy could prevent heart attacks, treatment for depression did significantly help reduce heart attacks. However, treatment with drugs and/or psychotherapy for depression did not improve long-term survival rates (Stewart, Perkins, & Callahan, 2014). See the article in this series on depression for a discussion of the best treatment approaches.

Clinical Trials for Heart Disease

Clinical trials are research studies intended to evaluate a medical, surgical, or behavioral intervention. They are done so that researchers can study a particular treatment that may not have a lot of data on its safety or effectiveness yet. If you’re considering signing up for a clinical trial, it’s important to note that if you’re placed in the placebo group, you won’t have access to the treatment being studied. It’s also good to understand the phase of the clinical trial: Phase 1 is the first time most drugs will be used in humans, so it’s about finding a safe dose. If the drug makes it through the initial trial, it can be used in a larger phase 2 trial to see whether it works well. Then it may be compared to a known effective treatment in a phase 3 trial. If the drug is approved by the FDA, it will go on to a phase 4 trial. Phase 3 and phase 4 trials are the most likely to involve the most effective and safest up-and-coming treatments.

In general, clinical trials may yield valuable information; they may provide benefits for some people but have undesirable outcomes for others. Speak with your doctor about any clinical trial you are considering. Clinicaltrials.gov contains a comprehensive database of clinical trials including listings under “cardiovascular disease” and “heart disease.” We’ve also outlined some below.

Mental Health

At Cedars-Sinai Medical Center in Los Angeles, Waguih William IsHak, MD, FAPA, of the Department of Psychiatry and Behavioral Neurosciences, began recruiting in November 2018 for a study of treatment options for people with depression and heart failure. A different clinical trial at NYU School of Medicine under the direction of Tanya Spruill, MD, is asking whether mindfulness-based cognitive therapy can help women with high blood pressure. The therapy will target risk factors that disproportionately affect women, such as negative thinking, and will be delivered via the telephone.

More on Chelation Therapy

Positive results from a clinical trial of chelation therapy combined with a high-dose multivitamin supplement were discussed in the research section of this article. The results were significant enough that an additional trial, TACT2, is being carried out for confirmation. TACT2 is still enrolling people who have had a heart attack and who have diabetes. People will receive either a placebo, infused EDTA, an oral multivitamin, or both EDTA and multivitamin. They’ll be followed for several years to see if treatments reduce additional heart attacks. Gervasio Lamas, MD, from the Mt. Sinai Medical Center, Miami, is heading up this clinical trial.

Sleep Apnea

Sleep apnea is associated with increased risk of CVD. A clinical study led by Raj Dedhia, MD, MS, will be recruiting people who are willing to have their tongue shocked to help with sleep apnea. Since so many people are not able or willing to use the continuous positive airway pressure (CPAP) hose-and-mask device to treat sleep apnea, this trial will evaluate a different way of keeping people’s throats from closing up and blocking breathing. A device is surgically implanted in the tongue and used to electrically stimulate the tongue during sleep. Tests will be carried out to determine if this has benefits for blood pressure and a number of other risk factors that could affect CVD.

Another clinical trial, called the WHISPER trial (Women’s Health Initiative Sleep Hypoxia Effects on Resilience), is asking whether low levels of oxygen from sleep apnea are associated with heart attacks and cardiovascular events.

Resources and Related Reading

Medical organizations and government institutes provide extensive information about symptoms, diagnosis, and treatment of heart disease.

1. • American Heart Association (AHA)

2. • Centers for Disease Control and Prevention (CDC)

3. • Mayo Clinic

4. • National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. The NIH has a program specifically to increase women’s awareness of heart disease.

goop has published in-depth discussions on prevention of heart disease, with information of particular relevance for women.

1. • “A Cardiologist’s Guide for Women: How to Prevent Heart Disease”: an interview with Rony Shimony, a cardiologist at Mount Sinai in New York City

2. • “A Lifestyle Program for Preventing and Undoing Chronic Disease”: an interview with Dean Ornish, MD, a clinical professor of medicine at UCSF, and Anne Ornish, from the Preventive Medicine Research Institute

3. • “Don’t Blame the Salt Shaker: Hidden Sodium and Our Hypertension Problem”: an interview with Bonnie Liebman, MS, former director of nutrition at the Center for Science in the Public Interest

Disclaimer

This article is for informational purposes only, even if and to the extent that it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The information and advice in this article is based on research published in peer-reviewed journals, on practices of traditional medicine, and on recommendations made by health practitioners, the National Institutes of Health, the Centers for Disease Control and Prevention, and other established medical science organizations; this does not necessarily represent the views of goop.