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Cardiovascular Disease

Introduction

What should I know about Cardiovascular Disease?

Diseases of the heart and circulation are so common and the public is so well acquainted with the major symptoms that result from cardiovascular disorders that patients, and occasionally physicians, wrongly attribute many unrelated complaints to cardiovascular disease (CVD). (1) It should not be a surprise that this occurs since most patients are aware that cardiovascular disease remains the leading cause of death in the United States. There are four principle properties of the cardiovascular system that can be evaluated to provide information to help manage cardiovascular disease. (2) These include:

    movement of electrical signals through the heartheart pump function blood flow through the heart anatomy

Ischemia is a decrease in the amount of oxygen flowing to the heart due to a decrease in blood flow to the heart. Ischemia is noticed most frequently as chest discomfort. Heart function that is adequate at rest may not be adequate during physical stress or strain. Thus, a history of chest pain or discomfort only during activity is characteristic of heart disease. Decreases in the pumping ability of the heart frequently appear as weakness and fatigue. As the disease becomes more severe, the skin may become pale, the blood pressure can be low and the patient may even occasionally pass out. A failing heart can cause fluid (edema) to build up throughout various parts of the body and could cause shortness of breath. When the blood vessels cause obstructions to blood flow the symptoms resemble congestive heart failure. Arrhythmias or irregular heart rhythms can suddenly develop. All of these signs and symptoms may disappear as quickly as they developed.

Patients with cardiovascular disease may also be completely without symptoms. They may also have high blood pressure, a heart murmur, an abnormal chest x-ray or an abnormal electro cardiogram (ECG or EKG). In cardiovascular disease, taking a medical history, interview, and physical examination remain the most important parts of patient assessment. (3) While there are many technologically advanced tests available, they are only effective when used with a complete medical history and physical examination. A medical history enables the examiner to establish a relationship with the patient, develop an awareness of how the patient feels about the problems and their quality of life, as well as an evaluation of the problem’s severity. (4) Particular attention should be paid to the family history.

There are many risk factors for cardiovascular disease. Three that cannot be changed are older age, male gender, and a family history of CVD. Additionally, three other major risk factors include cigarette smoking, high cholesterol and high blood pressure. Other identified factors associated with increased risk for cardiovascular disease include lack of exercise, diabetes, obesity, too much alcohol, increased homocysteine levels, certain infections and inflammation, estrogens, androgens, and certain psychosocial factors. The combination of multiple risk factors must also be considered.

The American Heart Association/American College of Cardiology (AHA/ACC) have set up guidelines for preventing heart attack and death in patients with cardiovascular disease. (5) Their recommendations are:

    Stop smoking; including cigarettes, cigars, pipes or other types of smoking. Lower your cholesterol; talk to your healthcare professional to find out what your goal cholesterol levels are (total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides). Your blood pressure should be 140/90 mmHg or less; if you have heart failure or kidney disease, less than 130/85 mmHg; if you have diabetes, less than 130/80 mmHg. Exercise; 30 minutes of activity 3 to 4 times per week, this is best if done every day. If you have diabetes your HbA1c should be less than 7%. The HbA1c is also known as the glycosylated hemoglobin test. In this lab test, a small blood sample determines the average blood glucose over a given period of time, usually several months. Your Body Mass Index (BMI) should be between 18.5 to 24.9 kg/m2. The BMI is a measure of a healthy weight for your height. Talk to your healthcare professional or see the "Obesity, Weight Loss" health condition to learn how to calculate your BMI.

Statistic

World Health Organization, 2007.

  • CVDs are the number one cause of death globally: more people die annually from CVDs than from any other cause;
  • An estimated 17.5 million people died from CVDs in 2005, representing 30% of all global deaths. Of these deaths, an estimated 7.6 million were due to coronary heart disease and 5.7 million were due to stroke.
  • Over 80% of CVD deaths take place in low- and middle-income countries and occur almost equally in men and women;
  • By 2015, almost 20 million people will die from CVDs, mainly from heart disease and stroke. These are projected to remain the single leading causes of death.

World Health Organization, 2002.

  • Cardiovascular Disease caused a total of  35,719 deaths in Malaysia.

American Heart Association, Biostatistical Fact Sheets, 1998.

    Cardiovascular Disease accounted for 39.2% of total deaths of white males in the United States in 1998. Cardiovascular Disease accounted for 43% of total deaths white females in the United States in 1998. Cardiovascular Disease accounted for 34.2% of total deaths for African American males in the United States in 1998. Cardiovascular Disease accounted for 41.4% of total deaths for African American females in the United States in 1998. 7.2% of Hispanic American males 20 years or older have coronary heart disease. 6.8% of Hispanic American females 20 years or older have coronary heart disease. In the United States in 1997, an estimated 607,000 of Coronary Bypasses were performed on 366,000 patients. From 1979 to 1997, the number of coronary bypass procedures increased 432% and the number of patients increased 227%. In 1997, 69% of coronary bypass procedures were performed on men.

American Heart Association, 2006.

    According to 2003 estimates, 71,300,000 Americans have one or more forms of cardiovascular disease (CVD). Claimed 910,614 lives in 2003 (37.3 percent of all deaths or 1 of every 2.7 deaths). Over 152,000 Americans killed by CVD are under age 65. 2003 death rates from CVD were 359.1 for white males and 479.6 for black males; for white females 256.2 and for black females 354.8 (Death rates are per 100,000 population. The rates listed use the year 2000 standard U.S. population as the base for age adjustment). From 1993 to 2003 death rates from CVD declined 22.1 percent. Despite this decline in the death rate, in the same 10-year period the actual number of deaths declined only 4.6 percent.

Signs and Symptoms

The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.

For many patients there are no real symptoms, but there are some important signs that may be found during a doctor’s appointment. These signs may include high blood pressure, a heart murmur, an abnormal chest x-ray, or an irregular heart pattern found when having an electrocardiogram (ECG or EKG). Many patients do exhibit signs and symptoms. Chest pain or a feeling of pressure, like a heavy weight being placed on the chest, is one of the most common. This pain may seem to travel to the neck and jaw, or to the left shoulder and down the left arm. Shortness of breath, difficulty breathing, or being unable to breathe properly unless in an upright position is also very common. Some people may also experience chest pain while exercising, but not when resting. A feeling of weakness or becoming easily fatigued, palpitations (rapid, bounding heart beat that you can feel), swelling in the ankles or legs, chronic cough, and fainting can also occur.

General

  • No Symptoms may be present
  • Chest pain
  • Pain in the neck and jaw
  • Pain in the left shoulder and down the left arm
  • Shortness of breath or difficulty breathing
  • Being unable to breathe properly unless in an upright position
  • Chest pain that occurs while exercising, but not when resting
  • Feeling of weakness or becoming easily fatigued
  • Palpitations (rapid, bounding heart beat that you can feel)
  • Swelling in the ankles or legs
  • Chronic cough
  • Fainting

Treatment Options

Conventional

Treatment consists of a wide variety of interventions from life style changes to surgery. Generally, if an individual has no evidence of cardiovascular disease, but has one or more known risk factors for the development of heart disease, a plan for risk reduction should be developed and implemented. This may include dietary restrictions, smoking cessation, weight loss, or other life-style modifications. The individual should be reevaluated at intervals to assess compliance, and see whether risk factors are actually being reduced.

Asymptomatic, or mildly symptomatic patients with valvular heart disease should be evaluated at 6 to 12 month intervals. Early signs of deterioration can be detected in this manner, and invasive treatment such as cardiac catheterization or surgery may be performed, if necessary, prior to development of disabling symptoms or irreversible damage.

It is important to establish criteria for deciding the form of treatment to be used in patients with ischemic heart disease. Surgery and angioplasty should be reserved for patients with ischemic heart disease in whom it has been demonstrated that these treatments are superior to medical treatments. Specific treatments employed for patients with symptoms of congestive heart failure, cardiac arrhythmias, etc. are widely varied, and should be reserved for a discussion of individual complaints.

Nutritional Suplementation


Vitamin E

Experimental and epidemiological evidence supports the hypothesis that oxidation of LDL cholesterol is a risk factor in the development of atherosclerosis. Vitamin E is a well researched substance with evidence suggesting it prevents the oxidative damage that leads to atherosclerosis. In one study, patients taking 1,600 mg/day of vitamin E recorded a 50% decrease in oxidative damage to LDL cholesterol. (6)

A World Health Organization-sponsored study reported the fact that a low blood level of vitamin E is the most important risk factor in deaths from ischemic heart disease—more important than elevated cholesterol, high blood pressure, or smoking. (7) Ischemic heart disease is a localized anemia due to a mechanical obstruction of the blood supply, which is usually due to arterial narrowing from atherosclerosis. In another study, it was reported that individuals taking 100 IU of vitamin E or more daily had a substantial reduction in the progression of atherosclerosis. (8)


Vitamin C

Vitamin C, also, plays an important role in the prevention of cardiovascular disease. In a study that was conducted at UCLA, it was reported that men who took 800 mg of vitamin C daily had a 42% reduction in mortality from cardiovascular disease, compared to men who only consumed the FDA's Recommended Dietary Allowance (RDA) of 60 mg of vitamin C daily. This study also reported that men consuming the larger amounts of vitamin C lived an average of 6 years longer than the men who only consumed the RDA of 60 mg of vitamin C daily. (9)


L-Carnitine

Carnitine is an important nutrient for cardiovascular health. Carnitine’s primary function is to facilitate the transport of fatty acids across cellular membranes into the mitochondria where they are utilized in the production of energy. This is extremely important for the heart, which is the most energy-demanding muscle in the body. Studies report that carnitine can be therapeutically useful in the treatment of various forms of cardiovascular disease such as angina, (10) , (11) acute myocardial infarction, (12) peripheral vascular disease, (13) arrhythmias, (14) and abnormal blood lipids. (15)


Coenzyme Q10 (CO-Q10)

Coenzyme Q10 is a nutrient recently being recognized as playing a role in cardiovascular health. It functions as an antioxidant and is also a cofactor in several enzymatic steps in the generation of energy in the mitochondria of all cells. The heart is the most active muscle in the human body, a decline in energy due to a deficiency of CoQ10 can first affect heart function.

In one double-blind study, patients with severe congestive heart failure who were given 150 mg/day of CoQ10 had a 38% decrease in hospitalizations due to worsening of heart failure compared to the control group. At the same time, episodes of pulmonary edema decreased by 60% and angina episodes decreased by 53%. (16) In another study it was shown that the symptoms of cardiovascular disease got progressively worse as CoQ10 levels declined. Treatment with 100 mg of coenzyme Q10 daily resulted in both subjective and objective improvement in 69% of patients with cardiomyopathy and 43% of patients with ischemic heart disease. (17)


Vitamin B6, Vitamin B12

Over the past several years, elevated homocysteine has become recognized as one of the primary risk factors to cardiovascular disease. In one metabolic pathway, vitamin B6 is necessary to convert homocysteine to cystathionine. In another metabolic pathway, folic acid and vitamin B12 are required to remethylate homocysteine back to methionine. A deficiency of any one of these three B-vitamins can lead to elevated homocysteine. (18)

Several studies have documented the fact that supplementation with folic acid, vitamin B6, and vitamin B12 can effectively lower homocysteine levels. (19) , (20) , (21) , (22) There are wide variations in the dosages of these B-vitamins used in different studies. It is now recognized that even moderate elevations of homocysteine represent a strong independent risk to cardiovascular disease.

Other studies involving hundreds of patients who had undergone successful coronary angioplasty have evaluated these individuals following six months of therapy on vitamin B6, vitamin B12 and folic acid, comparing the results to patients on placebo. After one year, the patients on the vitamin therapy had lower rates of related cardiovascular events including heart attacks and repeated angioplasty. (23) , (24)


Magnesium

Magnesium is a key mineral for cardiovascular health. It performs functions similar to numerous cardiovascular drugs. It inhibits platelet aggregation (like aspirin), thins the blood (like warfarin), blocks calcium uptake (like nifedipine), and relaxes blood vessels (like ACE inhibitors such as enaparil). Magnesium also increases oxygenation of the heart muscle by improving cardiac contractibility. (25)

Adequate magnesium is associated with reduced incidence of angina, cardiac spasms, and arrhythmias, as well as having relaxing and antispasmodic effects of the blood vessels. On the other hand, magnesium deficiency is associated with increased incidence of atherosclerosis, hypertension, strokes, and heart attacks. (26) It is now recognized that many heart attacks happen to individuals with relatively healthy hearts. It is a magnesium deficiency that causes a cardiac spasm, which results in death. (27)


Omega-3 Fatty Acids

The authors of a paper in the June 2000 issue of the Mayo Clinic Proceedings provide a nice summary of the history of omega-3 fatty acids as they have gradually been recognized to play a key role in the prevention and treatment of cardiovascular-related diseases. Their review states the following. "During the past 25 years, the cardiovascular effects of marine omega-3 (omega-3) fatty acids have been the subject of increasing investigation. In the late 1970's, epidemiological studies revealed that Greenland Inuits had substantially reduced rates of acute myocardial infarction compared with Western control subjects. These observations generated more than 4,500 studies to explore this and other effects of omega-3 fatty acids on human metabolism and health. From epidemiology to cell culture and animal studies to randomized controlled trials, the cardioprotective effects of omega-3 fatty acids are becoming recognized. These fatty acids, when incorporated into the diet at levels of about 1 g/d, seem to be able to stabilize myocardial membranes electrically, resulting in reduced susceptibility to ventricular dysrhythmias, thereby reducing the risk of sudden death. The recent GISSI (Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto miocardico)-Prevention study of 11,324 patients showed a 45% decrease in risk of sudden cardiac death and a 20% reduction in all-cause mortality in the group taking 850 mg/d of omega-3 fatty acids. These fatty acids have potent anti-inflammatory effects and may also be antiatherogenic. Higher doses of omega-3 fatty acids can lower elevated serum triglyceride levels; 3 to 5 g/ d can reduce triglyceride levels by 30% to 50%, minimizing the risk of both coronary heart disease and acute pancreatitis." (28)


Potassium

People consuming diets containing foods that are high in potassium have a lower incidence of hypertension. (29) Epidemiological evidence reveals that increasing potassium intake can lower blood pressure in individuals who have essential hypertension and increasing dietary potassium can also result in a reduction of antihypertensive medications. (30)

Diets high in potassium have also been reported to protect against death from strokes. In a 12-year study, individuals who died from strokes were found to have significantly lower potassium intake than survivors of strokes and individuals who died from other causes. (31)


Selenium

Low plasma selenium has been considered a significant risk factor for cardiovascular disease. (32) Selenium has a cardioprotective effect against drugs and other xenobiotics that are cardiotoxic (e.g. Adriamycin). Selenium has a known antiviral capability, which may protect the heart from agents such as the coxsackie B4 viruses. (33)


Soy Isoflavones

It has been proposed that isoflavones play a beneficial role in the prevention of atherosclerosis via several mechanisms. A study involving monkeys suggested that improvements in cholesterol levels were partially responsible for lower rates of atherosclerosis in the groups fed soy protein diets. (34) Genistein, one of the chemicals in soy isoflavones, reportedly inhibits platelet aggregation or the clumping together of platelets to form a clot or thrombus. Also, genistein reportedly decreases the replication and division of smooth muscle cells which is one of the primary cell types that can adversely affect plaques. (35) , (36) Antioxidant properties and effects on the flexibility of arterial walls may also have a positive impact on the prevention of atherosclerosis. (37)

A study concluded that 20 grams (with 80 mg of isoflavones) of soy protein for five weeks could help reduce total cholesterol levels and blood pressure among men which might be effective in reducing cardiovascular disease. (38) Studies have found that supplementation with soy isoflavones exerted favorable effects on vasomotor symptoms and a reduction in LDL and an increase in HDL levels. (39) , (40)


Beta-1,3 Glucan

Beta-glucans appear to be the major cholesterol lowering agents in oat bran fiber. Studies have shown that the beta-1, 3 glucans in oat bran can lower total cholesterol and LDL, or "bad," cholesterol levels in patients with high cholesterol. (41) , (42) The US Food and Drug Administration (FDA) has approved beta-glucan to reduce cardiovascular disease risk. Studies have confirmed that risk reduction by reducing cholesterol levels. (43)


Lycopene

One study matched a control group of 483 healthy middle-aged to elderly women to an equivalent group that had CVD. Blood levels of lycopene, other carotenoids, and retinol were measured in both groups. The results found that those who had the highest blood levels of lycopene had a 50% reduced risk of CVD when compared to those who had the lowest levels. The authors concluded that the results of this study warrant further investigations into the mechanisms of lycopene. (44)

Herbal Suplementation


Hawthorn

Hawthorn is used as a vasodilator and circulatory stimulant. (45) It has been used extensively by doctors in Europe in its standardized form in various cardiovascular and peripheral circulatory conditions. Its combination of effects on the heart leads to its use as a tonic, especially for the elderly where mitral stenosis and minor heart failure may be present. Studies have reported a reduction in blood pressure due to arteriosclerosis and chronic nephritis with the use of hawthorn. (46) It is also used for peripheral vascular diseases, such as Raynaud’s disease. Hawthorn is used in Europe by physicians to help maintain digoxin levels while decreasing the need for the pharmaceutical medication. Hawthorn is reported to have the ability to regulate both low and high blood pressure. Its bioflavonoids reportedly dilate both peripheral and coronary blood vessels. (47) This leads to its use in decreasing angina attacks.


Garlic

Garlic has been reported to lower total cholesterol, LDL cholesterol and triglycerides, and increase HDL cholesterol. (48) , (49) , (50) Garlic may be of benefit in the prevention of heart disease and atherosclerosis. (51) , (52) Garlic may inhibit platelet aggregation and influence blood viscosity through its fibrinolytic activity. (53) , (54) , (55) This leads to the use of garlic in the prevention of strokes, heart attacks, and various thrombus events. (56) , (57) , (58) Also, the antioxidant effect in aged garlic has been reported to be beneficial in preventing stroke and arteriosclerosis. (59)

A recent study reported no effect of garlic oil on serum lipids. (60) However, the product used was garlic oil, which is processed and heated garlic. The impact of processing is an important fact to keep in mind when using garlic supplements. Changes can occur in the active constituents when exposed to cooking or other processing which can render the garlic product virtually ineffective. Cooking is known to denature proteins and therefore may inactivate the enzyme (allinase) that is necessary in converting alliin into allicin, the major bio-active constituent in garlic.


Psyllium Seed

Studies suggest that psyllium may also help control cholesterol levels. (61) Its high levels of soluble fiber may reduce the absorption of cholesterol from the bloodstream while stimulating the liver to produce cholesterol-lowering bile acids. The US Food and Drug Administration (FDA) has approved psyllium to reduce cardiovascular disease risk. Studies have confirmed that risk reduction by decreasing cholesterol levels. (62)

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