Dietary changes that may be helpful
Dietary fat independently affects heart attack risk. The Nurses’ Health Study found
that eating foods high in saturated fats (meat and dairy fat) and trans fatty acids
(margarine, hydrogenated vegetable oils, and many processed foods containing hydrogenated
vegetable oils) was directly associated with many nonfatal heart attacks and deaths from coronary heart disease.1 Consuming
foods high in monounsaturated fat, such as olive oil, and polyunsaturated fat, as found in
nuts and most vegetable oils, is linked to a decreased risk. This same study revealed that
margarine increased the incidence of heart attack, particularly among women who had eaten
margarine consistently for more than a decade.2 Other studies report a direct
association between frequent consumption of meat and butter and heart attack
occurrence.3
Research consistently shows that people who frequently eat nuts have a dramatically reduced
risk of heart disease;4 5 this could be because nut consumption lowers
cholesterol levels.6 7
Of nuts commonly consumed, almonds and walnuts may be most effective at lowering cholesterol,
and macadamia nuts may be least beneficial.8 Hazelnuts9 and pistachio
nuts10 may also help lower cholesterol.
Nuts contain many nutrients that could be responsible for protection against heart disease,
including fiber, vitamin E, alpha-linolenic acid (found primarily in
walnuts), oleic acid, magnesium, and arginine. Therefore, exactly how nuts lower
cholesterol or lower the risk of heart disease remains somewhat unclear. Some doctors even
believe that nuts may not be directly protective. Rather, people who eat nuts may not
eat as much dairy, eggs, or trans fatty acids from margarine and processed food, the avoidance
of which would reduce both cholesterol levels and the risk of heart disease.11 12 Nonetheless,
the remarkable consistency of research outcomes strongly suggests that nuts directly protect
against heart disease. Although nuts are loaded with calories, a recent preliminary study
reported that adding hundreds of calories per day from nuts for six months did not increase
body weight in humans13 —an outcome supported by several other
reports.14 Even when increasing nut consumption has led to weight gain, the amount
of added weight has been remarkably less than would be expected given the number of calories
added to the diet.15
Several trials report that eating fish decreases heart attack deaths16
17 and reduces the size of the infarct,18 though some researchers have not
confirmed these findings.19 The link between fish eating and heart attack
prevention is supported by research showing that
fish oil supplements help reverse
atherosclerosis.20
Eating eggs may increase heart attack risk. People who consume eggs have been reported to
be more likely to die from all types of heart
disease, including heart attack, in some,21 although not all,
research.22 Increased oxidation, a state associated with heart attack risk, may be
the key. Cooking or exposure to air oxidizes the cholesterol in eggs.23 Eating eggs
enhances LDL (“bad”) cholesterol oxidation,24 which may in turn
contribute to heart attack risk.
Eating a diet high in refined carbohydrates (e.g., white flour, white rice, simple sugars)
appears to increase the risk of coronary heart disease, and thus of heart attacks, especially
in overweight women.25
A high-fiber diet, particularly
water-soluble fiber (high in oats, psyllium seeds, fruit, vegetables, and legumes), is
associated with decreased risk of both fatal and nonfatal heart attacks,26 probably
because these fibers are known to lower cholesterol.27 However, large trials
separately studying men and women who were followed for years, have linked the greatest
protection to water-insoluble fiber (from cereals),28 29 though
scientists have yet to understand why. Until the details are better understood, doctors often
recommend increasing intake of fruit, vegetables, beans, oats, and whole grains. In a
preliminary study,30 the total number of deaths from cardiovascular disease was
found to be significantly lower among men with high fruit consumption.
Making positive dietary changes immediately following a heart attack is likely to decrease
the chance of a second heart attack. In one study, individuals began eating more vegetables
and fruits, and substituted fish, nuts, and legumes for meat and eggs 24–48 hours after
a heart attack. Six weeks later, the diet group had significantly fewer fatal and nonfatal
heart attacks than a similar group who did not make these dietary changes.31 This
trend continued for an additional six weeks.32
Many doctors tell people trying to reduce their risk of heart disease to avoid all meat, margarine, and other
processed foods containing hydrogenated oils and dairy fat. Fish are often suggested instead
of meat; nuts instead of snack foods containing hydrogenated oils; olive oil instead of
butter; nonfat yogurt, milk, and even cheese instead of full or reduced fat versions of the
same foods; and oatmeal instead of eggs for breakfast.
People who eat diets high in alpha-linolenic acid (ALA), which is found in canola and flaxseed oils, have higher blood levels of
omega-3 fatty acids than those consuming lower amounts,33 34 which may
confer some protection against
atherosclerosis. In 1994, researchers conducted a study in people with a history of heart
disease, using what they called the “Mediterranean” diet.35 The diet
was significantly different from what people from Mediterranean countries actually eat, in
that it contained little olive oil. Instead, the diet included a special margarine high in
ALA. Those people assigned to the Mediterranean diet had a remarkable 70% reduced risk of
dying from heart disease compared with the control group during the first 27 months. Similar
results were also confirmed after almost four years.36 The diet was high in beans
and peas, fish, fruit, vegetables, bread, and cereals; and low in meat, dairy fat, and eggs.
Although the authors believe that the high ALA content of the diet was partly responsible for
the surprising outcome, other aspects of the diet may have been partially or even totally
responsible for decreased death rates. Therefore, the success of the Mediterranean diet does
not prove that ALA protects against heart disease.37
Most studies confirm that light to moderate alcohol consumption (one to three drinks per
day) significantly reduces both fatal and nonfatal heart attack risk38
39 40 41 compared to heavy or no drinking,42
43 though a few reports find the link to protection both weak and statistically
insignificant.44 In France, abundant red wine drinking was assumed to be
responsible for the country’s remarkably low incidence of heart disease. However, a
lower intake of animal fats in the French diet now appears to be the primary reason for what
has been called the French paradox.45 However, as animal fat intake continues to
increase in France, a trend that began in the 1970s, researchers now speculate that heart
disease and heart attacks will also increase.
Although red wine has been branded best for heart disease in a few reports, all types of
alcoholic beverages appear to be beneficial.46 Whether red wine has a clear
advantage over other forms of alcohol remains unclear. Alcohol reduces the risk for heart
attacks because it increases HDL (“good”) cholesterol47 and acts as a
blood thinner.48 High levels of another risk factor for heart attacks,
lipoprotein(a), have also been reported to be lowered by drinking alcohol.49
Despite this healthful effect, alcohol consumption can cause liver disease (e.g., cirrhosis), cancer,
high blood pressure, alcoholism, and, at
high intake, even an increased risk of heart attack. As a result, some doctors never recommend
alcohol, even for people at risk for heart attack. Nevertheless, because limited intake of
alcohol lowers heart attack risk, some people at high risk for heart attack who are not
alcoholics, have healthy livers and normal blood pressure, and are not at an especially high
risk for cancer, may benefit from light drinking. In fact, since heart disease is the leading cause of death in the
United States, and alcohol reduces that risk, most studies report that light drinkers live
slightly longer on average than teetotalers. In an analysis of 16 trials, men who drank less
than two drinks per day and women who averaged less than one drink per day were likely to
slightly outlive those who did not drink at all.50 In the same report, however,
people who drank beyond these moderate levels in men and low levels in women were
more likely to die sooner than were nondrinkers. In deciding whether light drinking might
do more good than harm, people at high risk for heart attack should consult a doctor.
Drinking five cups of coffee or more per day has been shown to increase the risk of
nonfatal heart attack in both men51 and women.52 Though many studies
find such links,53 many others do not.54 Nevertheless, heavy coffee
drinking should be avoided. This disparity may result in part from the fact that
paper-filtered coffee does not raise
cholesterol but percolated, boiled, or French press coffees do. Several recent studies
have linked coffee drinking to increased blood levels of homocysteine, another risk factor for heart disease.55 56 In this
regard, research has yet to absolve paper-filtered coffee, because these studies have not
examined separate effects for coffee prepared by different methods.
Recent preliminary evidence has implicated salt consumption as a risk factor for heart
disease and death from heart disease in overweight people.57 Among overweight
persons, an increase in salt consumption of 2.3 grams per day was associated with a 44%
increase in coronary heart disease mortality, a 61% increase in cardiovascular disease
mortality, and a 39% increase in mortality from all causes. Blinded, intervention trials are
still needed to confirm these preliminary observations.
Preliminary research conducted several decades ago suggested that high sugar consumption
increased heart attack risk.58 Some researchers at that time disagreed59
and others have subsequently been unable to find a link. Nevertheless, sugar has been
associated with reduced HDL (“good”) cholesterol,60 increased triglycerides,61 as well as an increase in
other risk factors linked to heart attacks.62 As a result, many doctors recommend
that people reduce their intake of sugar despite the fact that high sugar intake leads to only
slightly higher risks of heart disease in most reports.63
Vitamins that may be helpful
L-carnitine is an amino acid important for transporting fats that can be
turned into energy in the heart. Clinical trials have reported that taking L-carnitine
(4–6 grams per day) increases the chance of surviving a heart attack.87
88 89 In one double-blind trial, individuals with suspected heart attack were
given 2 grams of L-carnitine per day for 28 days.90 At the completion of this
study, infarct size, as well as the number of nonfatal heart attacks, was lower in the group
receiving L-carnitine versus the placebo group. Double-blind research using L-carnitine
intravenously also shows promise.91
Vitamin C has been reported to protect
blood vessels from problems associated with heart attack risk in a variety of
ways.92 93 94 However, research attempting to link vitamin C
directly to protection from heart attacks has been inconsistent.95 96
The reason for this discrepancy appears related to the amount of vitamin C intake investigated
in these studies. True or marginal vitamin C deficiencies do appear to increase the
risk of suffering heart attacks.97 98 However, in trials comparing
acceptable (i.e., non-deficient) vitamin C levels to even higher levels, additional vitamin C
has not been protective.99 Therefore, though many doctors recommend that people at
high risk for heart attack take vitamin C—often 1 gram per day—most evidence
currently suggests that consuming as little as 100–200 mg of vitamin C per day from food
or supplements may well be sufficient.
Coenzyme Q10 (CoQ10) also contributes to
the energy-making mechanisms of the heart and has been reported to lower lipoprotein(a), a
risk factor for heart disease.100
Animal studies confirm CoQ10’s ability to protect heart muscle against reduced blood
flow.101 102 In one double-blind trial, either 120 mg of CoQ10 or
placebo was given to people who had recently survived a heart attack. After 28 days, the CoQ10
group had experienced significantly fewer repeat heart attacks, fewer deaths from heart
disease, and less chest pain than the placebo group.103 In another double-blind
study of people suffering a heart attack, supplementation with 60 mg of coenzyme Q10 twice a
day for one year significantly reduced the incidence of recurrent cardiac events (fatal or
non-fatal heart attack). 104 Treatment was begun within 72 hours of the onset of
the heart attack. CoQ10 used with selenium
(see below) has also been reported to increase the rate of heart attack
survival.105
The relation between selenium and
protection from heart attacks remains uncertain. Low blood levels of selenium have been
reported in people immediately following a heart attack,106 suggesting that heart
attacks may increase the need for selenium. However, other researchers claim that low selenium
levels are present in people before they have a heart attack, suggesting that the lack of
selenium might increase heart attack risk.107 One report found that low blood
levels of selenium increased the risk of heart attack only in smokers,108 and
another found the link only in former smokers.109 Yet others have found no
link between low blood levels of selenium and heart attack risk whatsoever.110 In a
double-blind trial, individuals who already had one heart attack were given 100 mcg of
selenium per day or placebo for six months.111 At the end of the trial, there were
four deaths from heart disease in the placebo
group but none in the selenium group (although the numbers were too small for this difference
to be statistically significant). In other controlled research, a similar group was given
placebo or 500 mcg of selenium six hours or less after a heart attack followed by an ongoing
regimen of 100 mcg of selenium plus 100 mg of
coenzyme Q10 per day.112 One year later, six people had died from a repeat
heart attack in the placebo group, compared with no heart attack deaths in the supplement
group. Despite the lack of consistency in published research, some doctors recommend that
people at risk for a heart attack supplement with selenium—most commonly 200 mcg per
day.
Several studies113 114 including two double-blind
trials115 116 have reported that 400 to 800 IU of natural vitamin E reduces the risk of heart attacks. However,
other recent double-blind trials have found either limited benefit,117 or no
benefit at all from supplementation with synthetic vitamin E.118 One of the
negative trials used 400 IU of natural vitamin E119 —a similar amount and
form to previous successful trials. In attempting to make sense of these inconsistent findings
the following is clear: less than 400 IU of synthetic vitamin E, even when taken for years,
does not protect against heart disease. Whether 400 to 800 IU of natural vitamin E is or is
not protective remains unclear.
In one study, intravenous injections of NAC
(N-acetyl cysteine) decreased the amount of tissue damage in people who had suffered a heart
attack.120 Whether oral NAC would have the same effect is unknown.
Fish oil contains the beneficial omega-3
fatty acids EPA and DHA, which have led to
partial reversal of atherosclerosis in a
double-blind trial.121 In another double-blind trial, individuals were given either
fish oil (containing about 1 gram of EPA and 2/3 gram of DHA) or mustard oil (containing about
3 grams alpha linolenic acid, another omega-3 fatty acid) 18 hours after a heart attack. Both
groups experienced fewer nonfatal heart attacks compared to a placebo group, while the fish
oil group also experienced fewer fatal heart attacks.122 The largest published
study on omega-3 fatty acids for heart attack prevention was the preliminary GISSI Prevenzione
Trial,123 which reported that 850 mg of omega-3 fatty acids from fish oil per day
for 3.5 years resulted in a 20% reduction in total mortality and a 45% decrease in sudden
death. Other investigators suggest that fish oil reduces the amount of heart muscle damage
from a heart attack and enhances the effect of blood-thinning medication.124 People
wishing to supplement with fish oil should take fish oil supplements that include at least
small amounts of vitamin E, which may protect
this fragile oil against free radical damage.125
Blood levels of the antioxidant nutrients
vitamins A, C, and E, and beta-carotene are reported to be lower in people with a history of
heart attack, compared with healthy individuals.126 The number of free radical
molecules is also higher, suggesting a need for antioxidants. Streptokinase, a drug therapy
commonly used immediately following a heart attack, enhances the need for
antioxidants.127
Taking antioxidant supplements may improve the outcome for people who have already had a
heart attack. In one double-blind trial, people were given 50,000 IU of vitamin A per day, 1,000 mg of vitamin C per day, 600 IU of vitamin E per day, and approximately 41,500 IU of beta-carotene per day or placebo.128
After 28 days, the infarct size of those receiving antioxidants was significantly smaller than
the infarct size of the placebo group.
Blood levels of magnesium are lower in
people who have a history of heart attack.129 Most trials have successfully used
intravenous magnesium right after a heart attack occurs to decrease death and complications
from heart attacks.130 By far the largest trial did not find magnesium to be
effective.131 However, other researchers have argued that delaying the initial
infusion of magnesium and administering the magnesium for too short a period may have caused
this negative result.132 People with a history of heart attack or who are at risk
should consult with their cardiologist about the possible use of immediate intravenous
magnesium should they ever suffer another heart attack.
Except for a link between high levels of magnesium in drinking water and a low risk of
heart attacks,133 134 little evidence suggests that oral magnesium
reduces heart attack risk. One trial found that magnesium pills taken for one year actually
increased complications for people who had suffered a heart attack.135
While another study reported that 400–800 mg of magnesium per day for two years
decreased both deaths and complications due to heart attacks, results are difficult to
interpret because those taking oral magnesium had previously received intravenous magnesium as
well.136 While increasing dietary magnesium has reduced the risk of heart
attacks,137 foods high in magnesium may contain other protective factors that might
be responsible for this positive effect. Therefore, evidence supporting supplemental oral
magnesium to reduce the risk of heart attacks remains weak.
High blood levels of the amino acid
homocysteine have been linked to an increased risk of heart attack in most,138
139 140 141 though not all,142 143
studies. A blood test screening for levels of homocysteine, followed by supplementation with
400 mcg of folic acid and 500 mcg of vitamin B12 per day could prevent a significant number of
heart attacks, according to one analysis.144 Folic acid145 146 and vitamins
B6 and B12 are known to lower homocysteine.147
There is a clear association between low blood levels of folate and increased risk of heart
attacks in men.148 Based on the available research, some doctors recommend 50 mg of
vitamin B6, 100–300 mcg of vitamin B12, and 500–800 mcg of folic acid per day for
people at high risk of heart attack.
Low levels of beta-carotene in fatty tissue
have been linked to an increased incidence of heart attacks, particularly among
smokers.149 One population study found that eating a diet high in beta-carotene is
associated with a lower rate of nonfatal heart attacks.150 However, beta-carotene
supplementation may not offer the same protection provided by foods that contain
beta-carotene. Most,151 152 but not all, trials153 have found
that supplemental beta-carotene is not associated with a reduced risk of heart attacks.
Years ago, researchers reported that taking
chondroitin sulfate for six years substantially reduced the risk of fatal and nonfatal
heart attacks in people with heart
disease.154 155 156 Chondroitin may work by inhibiting atherosclerosis and by acting as an
anticoagulant. The few doctors aware of these older studies sometimes recommend that people
with a history of heart disease or who are at risk for heart attack take approximately 500 mg
of chondroitin sulfate three times per day.
The possibility that vitamin D
supplementation may increase the risk of heart disease remains an unproven and controversial
issue. A preliminary trial suggested that a high intake of vitamin D from both dietary and
supplemental sources increased heart attack risk.157 However, other researchers
have found that blood levels of vitamin D are no higher in people who had suffered a heart
attack when compared to control groups.158 Similarly, atherosclerosis does not
appear to correlate with blood levels of vitamin D.159 In fact, one trial found
that higher levels of activated vitamin D correlated with less artery-clogging
calcium deposits in humans.160
Relatively high blood levels of
calcium—sometimes a marker for high vitamin D intake—have been associated with
high risk of heart attacks in Sweden.161 However, high dietary vitamin D intake in
Sweden often comes from high-fat dairy products, so the high calcium levels might simply
reflect diets higher in dairy fat and have nothing to do with vitamin D.
Despite the lack of consistent evidence, some researchers continue to have concerns. Vitamin D supplementation has reversed some of
the beneficial effects of estrogen use in
women with risk factors for heart
disease,162 an outcome confirmed by others using only 300 IU of vitamin D per
day.163 Further research is required to determine whether supplemental vitamin D
increases heart attack risk.
Although several reports have linked iron
(both through diet and supplements) to an increased risk of heart disease, a recent analysis
of 12 trials has found no link whatsoever between iron status and the risk of heart
disease.164 While it remains prudent for a variety of other reasons for people not
to supplement iron unless a deficiency has been diagnosed, supplemental iron now appears
unlikely to substantially increase the risk of suffering a heart attack.
Are there any side effects or interactions?
Refer to the individual supplement for information about any side effects or interactions.
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