Alternative Therapies in Coronary Artery Disease: Vitamins, Supplements, Diets and Associated Topics

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Alternative Therapies in Coronary Artery
DiseaseVitamins, Supplements, Diets and
Associated Topics

• Carl R. Szot, MD
• December 2, 2002

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Vitamin E

• Fat soluble compounds with alpha-tocopherol being
  the most common
• Natural sources include vegetables, nuts and nut
  oils
• Deficiency is rare and associated with posterior
  column degeneration and loss of large caliber
  peripheral nerves
• Excess is only an issue in people on coumadin or
  in premature infants

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Vitamin EProposed Mechanisms of Action

• Decreases oxidation of LDL
• Inhibits smooth muscle cell growth
• Inhibits platelet adhesion

• Improves endothelial function
• In fat fed rabbits reduces atherosclerosis

Clinical Cardiology 1993 16 116-118
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Vitamin EHuman Studies

• Iowa Womens Health
• Prospective study of 34,000 postmenopausal women
• High dietary Vitamin E intake was associated with
  lower CAD risk

NEJM 1996 334 (18) 1156-62
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Vitamin EHuman Observational Studies

• Health Professionals follow up to the Physicians
  Health Study
• 39,910 men ages 40-70
• Subjects with the highest Vitamin E intake had a
  36 lower risk of CAD events after 4 years

NEJM 1993 328 (20) 1450-1466
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Vitamin E Human Studies

• Nurses Health Study
• 87,245 women ages 34-59 with no prior CAD
• Those taking 100 iu of Vitamin E for 2 years
  Had 40 lower risk of developing CAD after 8
  years.

NEJM 1993 328 (20) 1444-49
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Vitamin E Randomized Trials

• Cambridge Heart Antioxidant Study (CHAOS)
• 2002 patients with prior CAD prospectively
  randomized to Vitamin E (400-800 iu/day)
• 77 reduction in nonfatal MI
• No change in overall mortality

Lancet 1996 347 (9004) 781-86
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Vitamin ERandomized Trials

• Alpha-tocopheral Beta Carotene Prevention Trial
  (ABC)
• 50mg/day of Vitamin E had no effect on the risk
  of MI or death
• 50mg/day of Vitamin E plus 20mg/day of
  beta-carotene resulted in greater rate of
  coronary death
• Trial was mainly for lung cancer prevention

NEJM 1994 330 (15) 1029-35
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Vitamin C

• Less potent antioxidant than E
• Inhibits platelet aggregation
• Deficiency Scurvy
• Excess may lead to B12 deficiency or oxalate
  stones
• Less evidence than exists for Vitamin E

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Vitamin C Human Studies

• NHANES I
• 11,349 subjects taking Vitamin C supplements
• Subjects taking Vitamin C had a lower relative
  risk of CV death (.58)

Epidemiology 1992 3(3) 194-202
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Vitamin CHuman Studies

• The Nurses Health and the Health Professionals
  Follow up Study
• Slightly lower relative risk (.8) in subjects in
  highest quintile of Vitamin C consumption

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Vitamin C and EHeart Protection Study

• 2x2 Trial
• simvistatin 40 mg vs. placebo
• vitamin E 600 mg, vitamin C 250 mg, beta
  carotene 20 mg vs. placebo
• Over 10,000 patients randomized to vitamin arm

Lancet 2002 360 23-33
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Vitamin C and EHeart Protection Study

• No difference in vascular and nonvascular
  mortality
• No difference in cancer rate
• No difference in major vascular events

Lancet 2002 360 23-33
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Fish OilOmega -3 Fatty Acids

• Epidemiologic data suggests improved outcomes in
  patients eating fish
• DART ( Diet and Reinfarction Trial) showed 29
  reduction in all cause mortality after 2 years of
  increased fish/fish oil intake
• GISSI Prevenzione showed a 45 decrease in SCD
  and 20 decrease in all cause mortality after 3
  1/2 years of supplementation

Lancet 1989 2 (8666) 757-61 Lancet 1999 354
(9177) 447-55
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Olive Oil

• Oleic acid ( monounsaturated )
• In a trial comparing an AHA Step I diet, an
  average American control diet and an olive oil
  enriched diet showed similar reductions of LDL
  compared to control, but unchanged HDL with olive
  oil ( decreased 4 with Step II.) Triglycerides
  fell 13 with olive oil but increased 11 with
  the Step II diet.

AMJ Clinical Nutrition 1999 70(6) 1009-15
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Nuts

• 80 of calories from fat Monounsaturates and
  alpha-linolenic acid ( an omega -3)
• Also rich in Vitamin E, folic acid, K, Mg,
  flavanoids
• 1/4 to 1/3 cup daily can reduce LDL levels by up
  to 10

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Nuts- Data

• Health Professionals Follow Up Study showed
  increased intake of alpha-linolenic acid lowered
  MI risk by 60
• Nurses Health Study showed 35 CAD reduction
  associated with nut intake
• Physicians Health Study showed reduction in
  sudden and total CAD death, but not in nonfatal
  MI associated with nut intake

BMJ 1996 313 (7049) 84-90. BMJ 1998 317
(7169) 1341-5 Archives Internal Medicine 2002
162 1382-87
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Fats

• Good- monounsaturated-- olive oil, canola oil,
  nuts omega-3 --
  fish, nuts
• Bad- saturated-- red meat, cheese, butter
  
  trans- fatty acids-- processed foods
• Omega-6 oils- (corn, soybean, sunflower) are
  probably neutral in effect

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Diets
Postgraduate Medicine 2002 112 (2) 34-44
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AHA Diet

• Step I-
• Total Fat

• Step II-
• Total Fat cholesterol

A paucity of evidence for improved outcomes
exists for the AHA diets and some evidence
exists for continued disease progression
BMJ 2001 322(7289) 757-63
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Mediterranean Diet

• Greece, Crete, parts of France and Italy display
  low rates of CAD
• Monounsaturates and Omega-3 fatty acids are not
  limited
• Fresh fruits and vegetables, fish, nuts, moderate
  alcohol
• Low in trans fatty acids

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Mediterranean DietDATA

• Lyon Diet Heart Study of 605 MI survivors
• 55 reduction in risk of death and 50 reduction
  in recurrent cardiac events over a 4
  year period
• Reduction not explained by changes in lipid
  factors

Circulation 1999 99 (6) 779-85
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Mediterranean DietDATA

• GISSI - Prevenzione
• Multivariate analysis showed fish, fruit,
  vegetables and olive oil all conferred benefit
  over a 4 year period

Circulation 2002 105 1887-903
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Mediterranean DietSuggestions- Carbs and Proteins

• EAT
• Whole fruits and vegetables
• Whole grain cereal
• Bran, brown rice
• Peas, beans
• Lean meat, fish, poultry, vegetable protein

• DONT EAT
• Refined carbohydrates
• White bread, biscuits
• Bacon, sausage
• Processed fatty meat
• High fat dairy

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Mediterranean DietSuggestions- Fats

• EAT
• Olive oil
• Fish
• Flaxseed, spinach, tree nuts

• DONT EAT
• Trans-fatty acids
• Fast food
• Doughnuts
• Chips, crackers
• Margarine made with partially hydrogenated oil

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Alcohol

• Evidence of cardioprotective effect of alcohol
  first appeared in Framingham data
• At levels of consumption of greater than two
  drinks/day for men and one drink /day for women
  all cause mortality overwhelms cardioprotective
  effect
• Mechanisms include HDL raising, changes in
  inflammatory markers and improvement in insulin
  resistances.

Lancet 2001 357 (9258) 763-7