Lifestyle Modifications for Cardiovascular Prevention: The Mediterranean Diet, Fish, Oils and other Supplements: should we recommend them?

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Lifestyle Modifications for Lifestyle Modifications for Cardiovascular Prevention:Cardiovascular Prevention:

The Mediterranean Diet, Fish, Oils and other Supplements: should we recommend them?

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OutlineOutline

• What are the benefits of the What are the benefits of the Mediterranean diet?Mediterranean diet?

• Should we advise our patients to take Should we advise our patients to take fish oil supplements?fish oil supplements?

• What are the risks and benefits of What are the risks and benefits of complementary/alternative complementary/alternative medications?medications?

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““Father of the low carb diet”Father of the low carb diet”

Herbivorous animals do not grow fat easily, at least Herbivorous animals do not grow fat easily, at least until age has reduced them to a state of inactivity; until age has reduced them to a state of inactivity; but they fatten very quickly as soon as they begin but they fatten very quickly as soon as they begin to be fed on potatoes, grain, or any kind of to be fed on potatoes, grain, or any kind of flour. ... The second of the chief causes of obesity flour. ... The second of the chief causes of obesity is the floury and starchy substances which man is the floury and starchy substances which man makes the prime ingredients of his daily makes the prime ingredients of his daily nourishment. As we have said already, all animals nourishment. As we have said already, all animals that live on farinaceous food grow fat willy-nilly; that live on farinaceous food grow fat willy-nilly; and man is no exception to the universal law. and man is no exception to the universal law. Brillat-Savarin, Jean-Anthelme (1825). The (1825). The Physiology of Taste. Physiology of Taste. Penguin Books. .

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Mediterranean Diet ParadoxMediterranean Diet Paradox

• People living in Mediterranean countries People living in Mediterranean countries tend to consume relatively high tend to consume relatively high amounts of fat, they have far lower rates amounts of fat, they have far lower rates of cardiovascular disease than in of cardiovascular disease than in countries like the United States, where countries like the United States, where similar levels of fat consumption are similar levels of fat consumption are found. found.

• A parallel phenomenon is known as the A parallel phenomenon is known as the “French Paradox”“French Paradox”

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Mediterranean DietMediterranean Diet

• Modern nutritional recommendation Modern nutritional recommendation inspired by the traditional dietary inspired by the traditional dietary patterns of coastal regions of Spain, patterns of coastal regions of Spain, southern Italy, Crete, and coastal Greece southern Italy, Crete, and coastal Greece in the 1960sin the 1960s

• The most commonly version of the The most commonly version of the Mediterranean diet was presented by Dr Mediterranean diet was presented by Dr Walter Willett of Harvard University's Walter Willett of Harvard University's School of Public Health in the mid-1990sSchool of Public Health in the mid-1990s

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USDA Center for Nutrition Policy and Promotion 2005

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Mediterranean DietMediterranean Diet

• Abundant plant foods (legumes), fresh fruit as the Abundant plant foods (legumes), fresh fruit as the typical daily desserttypical daily dessert

• Olive oilOlive oil is the principal source of fat is the principal source of fat • Dairy products (principally cheese and yogurt)Dairy products (principally cheese and yogurt)• Fish and poultry consumed in low to moderate Fish and poultry consumed in low to moderate

amountsamounts• Zero to four eggs consumed weeklyZero to four eggs consumed weekly• Red meat consumed in low amountsRed meat consumed in low amounts• Wine consumed in low to moderate amountsWine consumed in low to moderate amounts• Total fat: 25 - 30%, < 8% Saturated fatsTotal fat: 25 - 30%, < 8% Saturated fats

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Mediterranean Diet: Possible Mediterranean Diet: Possible Mechanisms for Beneficial EffectsMechanisms for Beneficial Effects

• Low in saturated fat, high in monounsaturated fat Low in saturated fat, high in monounsaturated fat and dietary fiberand dietary fiber

• Olive oil : very high levels of monounsaturated Olive oil : very high levels of monounsaturated fats (oleic acid)fats (oleic acid)

• Epidemiological studies suggests that a higher Epidemiological studies suggests that a higher proportion of monounsaturated fats in the diet is proportion of monounsaturated fats in the diet is linked to a reduction in coronary heart disease linked to a reduction in coronary heart disease riskrisk

• Clinical data shows that antioxidants in olive oil Clinical data shows that antioxidants in olive oil provide additional heart health benefits:provide additional heart health benefits:• LDL cholesterol reductionLDL cholesterol reduction• anti-inflammatory anti-inflammatory • anti-hypertensive effectsanti-hypertensive effects

Covas, M.I., 2007;Pharmacol. Res. 55 (3): 175–86

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359:229-241 359:229-241 July 17, 2008Weight Loss with a Low-Carbohydrate, Weight Loss with a Low-Carbohydrate,

Mediterranean, Mediterranean, or Low-Fat Dietor Low-Fat Diet

• Iris Shai, R.D., Ph.D., Dan Schwarzfuchs, M.D., Yaakov Henkin, M.D., Iris Shai, R.D., Ph.D., Dan Schwarzfuchs, M.D., Yaakov Henkin, M.D., Danit R. Shahar, R.D., Ph.D., Shula Witkow, R.D., M.P.H., Ilana Danit R. Shahar, R.D., Ph.D., Shula Witkow, R.D., M.P.H., Ilana Greenberg, R.D., M.P.H., Rachel Golan, R.D., M.P.H., Drora Fraser, Greenberg, R.D., M.P.H., Rachel Golan, R.D., M.P.H., Drora Fraser, Ph.D., Arkady Bolotin, Ph.D., Hilel Vardi, M.Sc., Osnat Tangi-Ph.D., Arkady Bolotin, Ph.D., Hilel Vardi, M.Sc., Osnat Tangi-Rozental, B.A., Rachel Zuk-Ramot, R.N., Benjamin Sarusi, M.Sc., Dov Rozental, B.A., Rachel Zuk-Ramot, R.N., Benjamin Sarusi, M.Sc., Dov Brickner, M.D., Ziva Schwartz, M.D., Einat Sheiner, M.D., Rachel Brickner, M.D., Ziva Schwartz, M.D., Einat Sheiner, M.D., Rachel Marko, M.Sc., Esther Katorza, M.Sc., Joachim Thiery, M.D., Georg Marko, M.Sc., Esther Katorza, M.Sc., Joachim Thiery, M.D., Georg Martin Fiedler, M.D., Matthias Blüher, M.D., Michael Stumvoll, M.D., Martin Fiedler, M.D., Matthias Blüher, M.D., Michael Stumvoll, M.D., Meir J. Stampfer, M.D., Dr.P.H., for the Dietary Intervention Meir J. Stampfer, M.D., Dr.P.H., for the Dietary Intervention Randomized Controlled Trial (DIRECT) Group Randomized Controlled Trial (DIRECT) Group

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NEJM StudyNEJM Study

• Examined the effects of three diets: Examined the effects of three diets:

• low-carblow-carb

• low-fatlow-fat

• MediterraneanMediterranean

• Involved 322 participants x 2 yearsInvolved 322 participants x 2 years

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Effect of Diet Type on Weight Effect of Diet Type on Weight Change: 2 YearsChange: 2 Years

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ResultsResults

• Low-carb and Mediterranean promoted Low-carb and Mediterranean promoted greatest weight loss, 12 lbs and 10 lbs, greatest weight loss, 12 lbs and 10 lbs, respectively.respectively.

• Low-fat diet resulted in a loss of 7 lbsLow-fat diet resulted in a loss of 7 lbs• Caveats: Caveats:

• 86% of the study participants were men - low-86% of the study participants were men - low-carb and Mediterranean diets produced similar carb and Mediterranean diets produced similar amounts of weight loss in the overall study amounts of weight loss in the overall study results and in the menresults and in the men

• In women, the Mediterranean diet produced In women, the Mediterranean diet produced 3.8 kg (8.4 lbs) more weight loss on average 3.8 kg (8.4 lbs) more weight loss on average than the low-carb dietthan the low-carb diet

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Effect of Diet Type on LipidsEffect of Diet Type on Lipids

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Evidence Statement:Evidence Statement:

• ““LDL-C should continue to be the LDL-C should continue to be the primary target of cholesterol lowering primary target of cholesterol lowering therapy”therapy”

• Multiple lines of evidence:Multiple lines of evidence:- GeneticGenetic

- EpidemiologicEpidemiologic

- Experimental animals and Lab investigationsExperimental animals and Lab investigations

- Controlled clinical trials – strong causal Controlled clinical trials – strong causal relationship between LDL and CHDrelationship between LDL and CHD

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Lowering LDL-C: Dietary Lowering LDL-C: Dietary PortfolioPortfolio

• Objective: Objective:  To determine whether a diet To determine whether a diet containing all recommended food containing all recommended food components (AHA/NCEP Panel III) components (AHA/NCEP Panel III) leads to cholesterol reductionleads to cholesterol reduction

comparable with that of a statin comparable with that of a statin

• Dietary Portfolio:Dietary Portfolio:• 1.0 g plant sterols/1000 kcal1.0 g plant sterols/1000 kcal

• 9.8 g viscous fibers/1000 kcal9.8 g viscous fibers/1000 kcal

• 21.4 g soy protein/1000 kcal21.4 g soy protein/1000 kcal

• 14 g whole almonds/1000 kcal14 g whole almonds/1000 kcal

Jenkins et al. JAMA . 2003;290:502-510

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Lowering LDL-C: The Portfolio Diet Lowering LDL-C: The Portfolio Diet as Good as Lovastatin 20 mg dailyas Good as Lovastatin 20 mg daily

o Control

Portfolio

Statin

LDL-C LDL-C/ HDL Ratio C-Reactive Protein

Jenkins et al. JAMA . 2003;290:502-510

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Effects of Diet on CV Complications Effects of Diet on CV Complications After 1After 1stst MI: The Lyon Diet-Heart Study MI: The Lyon Diet-Heart Study

• Aim: To assess whether a Mediterranean Aim: To assess whether a Mediterranean Diet diet would reduce recurrence rate Diet diet would reduce recurrence rate after a first MIafter a first MI

• Design: Design:

• Prospective – s/p first MIProspective – s/p first MI

• Randomized 605 men and women to control Randomized 605 men and women to control or dietor diet

• Follow up: 46 monthsFollow up: 46 months

De Lorgeril et al. Lancet 1994, Circulation 1999

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Mediterranean Style Diet in the Mediterranean Style Diet in the Lyon Heart StudyLyon Heart Study

• Increase whole grains – breadIncrease whole grains – bread

• Increase root and green vegetables Increase root and green vegetables

• Increase fishIncrease fish

• Fruit dailyFruit daily

• Less red meat – more poultryLess red meat – more poultry

• Pragmatic approach: most pts would not Pragmatic approach: most pts would not replace butter for olive oil - replace with replace butter for olive oil - replace with margarine - high in linoleic and margarine - high in linoleic and αα-linolenic -linolenic fatty acidsfatty acids

• Use canola or olive oil for food preparationUse canola or olive oil for food preparationDe Lorgeril et al. Lancet 1994, Circulation 1999

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Effect of Mediterranean Lyon Effect of Mediterranean Lyon Diet Diet Cumulative survival without non-fatal MI or major secondary

end points

% W

ithou

t Eve

nt

De Lorgeril et al. Lancet 1994, Circulation 1999

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Lyon Diet StudyLyon Diet Study

• Al cause mortality was reduced by 70%Al cause mortality was reduced by 70%

• Study was so successful that the Study was so successful that the ethics committee decided to stop the ethics committee decided to stop the study prematurely so that the results study prematurely so that the results could be made available to the public could be made available to the public immediatelyimmediately

De Lorgeril et al. Lancet 1994, Circulation 1999

UCSFCopyright ©2008 BMJ Publishing Group Ltd.

Sofi, F. et al. BMJ 2008;337:a1344

All Cause Mortality Based on 2 point increase in Adherence to Med Diet

Sofi F, et al. Adherence to Mediterranean diet and health status BMJ 2008; 337: a1344.

UCSFCopyright ©2008 BMJ Publishing Group Ltd.

Sofi, F. et al. BMJ 2008;337:a1344

CV mortality associated with 2 point increase in adherence for Mediterranean diet

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Meta-analysisMeta-analysis

• Strict adherence to a Mediterranean diet Strict adherence to a Mediterranean diet reduced reduced

• Risk of dying from cancer – 9%Risk of dying from cancer – 9%

• Risk of dying from CV disease – 6%Risk of dying from CV disease – 6%

• Risk of developing Parkinson’s and Risk of developing Parkinson’s and Alzheimer’s – 13 %Alzheimer’s – 13 %

Sofi F, et al. Adherence to Mediterranean diet and health status BMJ 2008; 337: a1344.

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Mediterranean Diet: Mediterranean Diet: Beneficial Health EffectsBeneficial Health Effects

• A study published in Archives of A study published in Archives of General Psychiatry shows that people General Psychiatry shows that people who followed the Mediterranean diet, an who followed the Mediterranean diet, an eating regimen that is rich in fruits, eating regimen that is rich in fruits, vegetables, whole grains, fish, and nuts, vegetables, whole grains, fish, and nuts, were less likely to develop depressionwere less likely to develop depression

Sanchez et al. Arch Gen Psychiatry 2009

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Summary:Summary:Mediterranean DietMediterranean Diet

• CV Benefits:CV Benefits:• Overall lower CV riskOverall lower CV risk

• Decreased mortality post-MIDecreased mortality post-MI

• Actions:Actions:• Promotes weight lossPromotes weight loss

• Lowers LDL cholesterol and triglyceridesLowers LDL cholesterol and triglycerides

• Raises HDLRaises HDL

• Anti-inflammatory effectsAnti-inflammatory effects

• Lowers Blood pressureLowers Blood pressure

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AHA 2006 Diet and Lifestyle AHA 2006 Diet and Lifestyle Recommendations Recommendations

• Balance calorie intake and physical activityBalance calorie intake and physical activity• Consume diet rich in vegetables and fruits. Consume diet rich in vegetables and fruits. • Choose whole-grain, high-fiber foods. Choose whole-grain, high-fiber foods. • Consume fish, especially oily fish, at least twice Consume fish, especially oily fish, at least twice

a week. a week. • Limit your intake of saturated fat to <7% of Limit your intake of saturated fat to <7% of

energy, energy, transtrans fat to <1% of energy, and fat to <1% of energy, and cholesterol to <300 mg per day by     cholesterol to <300 mg per day by     • choosing lean meats and vegetable alternativeschoosing lean meats and vegetable alternatives• selecting fat-free (skim), 1%-fat, and low-fat dairy selecting fat-free (skim), 1%-fat, and low-fat dairy

products; and     products; and     • minimizing intake of partially hydrogenated fats. minimizing intake of partially hydrogenated fats.

Circulation. 2006;114:82-96s

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AHA 2006 Diet and Lifestyle AHA 2006 Diet and Lifestyle Recommendations Recommendations

• Minimize your intake of beverages and Minimize your intake of beverages and foods with added sugars. foods with added sugars.

• Choose and prepare foods with little or no Choose and prepare foods with little or no salt. salt.

• If you consume alcohol, do so in If you consume alcohol, do so in moderation. moderation.

• When you eat food that is prepared When you eat food that is prepared outside of the home, follow the AHA Diet outside of the home, follow the AHA Diet and Lifestyle Recommendationsand Lifestyle Recommendations

Circulation. 2006;114:82-96

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Rationale for Lifestyle ChangesRationale for Lifestyle Changes

• Atherosclerosis linked to obesity early in Atherosclerosis linked to obesity early in lifelife• PDAY studyPDAY study

• Lifestyle changes prevent progression of Lifestyle changes prevent progression of borderline risk factors borderline risk factors • Diabetes Prevention Program Diabetes Prevention Program

• Finnish Diabetes Prevention TrialFinnish Diabetes Prevention Trial

• In patients with CHD, lifestyle changes In patients with CHD, lifestyle changes can improve outcomescan improve outcomes• STARS Trial, Lyon TrialSTARS Trial, Lyon Trial

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Fish Oil and Heart Disease:Fish Oil and Heart Disease:Long-chain n-3 polyunsaturated fatty acids Long-chain n-3 polyunsaturated fatty acids

(n-3 PUFA)(n-3 PUFA)

• Absorbed from GI tractAbsorbed from GI tract

• Transported to liver as TG Transported to liver as TG w/in chylomicronsw/in chylomicrons

• Released into circulation Released into circulation as lipoprotein particles as lipoprotein particles (LDL, HDL, phospholipids(LDL, HDL, phospholipids

• Incorporated into cell Incorporated into cell membranes in heart and membranes in heart and brainbrain

• EPA may be converted to EPA may be converted to PGE3 which affects PGE3 which affects inflammation and inflammation and thrombosisthrombosis

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Intake of Fish or Fish Oil and Intake of Fish or Fish Oil and Relative Risk of CHD DeathRelative Risk of CHD Death

• Study of Prospective Cohort Studies and Study of Prospective Cohort Studies and Randomized Clinical TrialsRandomized Clinical Trials

• Modest consumption of fish ( 250-500 Modest consumption of fish ( 250-500 mg/dmg/d of EPA and DHA) lowers relative risk of EPA and DHA) lowers relative risk for CVD by 25% or morefor CVD by 25% or more

• HigherHigher intakes do not substantially further intakes do not substantially further lower CHD mortality.lower CHD mortality.

Mozaffarian D, Rimm EB. JAMA. 2006

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Intake of Fish and Fish Oil and RR Intake of Fish and Fish Oil and RR of CHD Deathof CHD Death

Mozaffarian D, Rimm EB.JAMA. 2006 296:1885

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Potential Dose Responses and Time Course of Potential Dose Responses and Time Course of Clinical Events in Response to Fish Oil IntakeClinical Events in Response to Fish Oil Intake

Mozaffarian D, Rimm EB. JAMA. 2006 296:1885

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Fish Oil: Where do we stand?Fish Oil: Where do we stand?

• PRO:PRO:• Modest reduction in Modest reduction in

progression of progression of atherosclerosisatherosclerosis

• May reduce risk of Non-May reduce risk of Non-fatal MI/ACS at high fatal MI/ACS at high dosesdoses

• Reduces incidence of Reduces incidence of sudden deathsudden death

• Mild reduction in total Mild reduction in total mortalitymortality

• Reduced incidence of Reduced incidence of Atrial fibrillationAtrial fibrillation

• CON:CON:• No effect on No effect on

restenosis post-PCIrestenosis post-PCI

• No effect on No effect on recurrent VT in recurrent VT in patients with ICD’spatients with ICD’s

• No effect on strokeNo effect on stroke

• No effect on HFNo effect on HF

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Fish Oil:Fish Oil:Beneficial EffectsBeneficial Effects

• Lowers triglycerides by 25 - 30%:Lowers triglycerides by 25 - 30%:• Dose: 3 - 4 g/dDose: 3 - 4 g/d

• Reduced HR and BP (Reduced HR and BP ( SVR) SVR) • Age > 45Age > 45

• Dose: 3 - 4 g/d for 8 wksDose: 3 - 4 g/d for 8 wks

• Increased HR variabilityIncreased HR variability

• Improved diastolic LV function without Improved diastolic LV function without effect on systolic functioneffect on systolic function

• Antiarrythmic effects not well understoodAntiarrythmic effects not well understood

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Fish Oil:Fish Oil:No EffectsNo Effects

• Glucose metabolismGlucose metabolism• No change in HgA1C levelsNo change in HgA1C levels

• InflammationInflammation• No appreciable effect on CRP levels in controlled studiesNo appreciable effect on CRP levels in controlled studies

• No consistent effect on platelet aggregation, No consistent effect on platelet aggregation, fibrinogen levels or Factors VII and VIIfibrinogen levels or Factors VII and VII

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Fish Oil:Fish Oil:Side effectsSide effects

• GI disturbances, especially nausea, dose GI disturbances, especially nausea, dose dependent (20% at 4 g/d)dependent (20% at 4 g/d)

• Fishy taste with eructationFishy taste with eructation

• Bleeding - no increased risk at up to 4 g/dBleeding - no increased risk at up to 4 g/d

• ContaminantsContaminants• Mercury - most preparations have no to Mercury - most preparations have no to

minimal mercuryminimal mercury

• PCB’sPCB’s

• DioxanDioxan

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Practical Fish Oil Facts:Practical Fish Oil Facts:• Active Forms: Active Forms:

• Eicosapentaenoic acid (EPA)Eicosapentaenoic acid (EPA)

• Docosahexaenoic acid (DHA)Docosahexaenoic acid (DHA)

• Preparations:Preparations:• Prescription: Lovaza and OmacorPrescription: Lovaza and Omacor

• Should contain both EPA and DHAShould contain both EPA and DHA

• Use the ones made from small fish (less mercury) or Use the ones made from small fish (less mercury) or algaealgae

• Dosing:Dosing:• Target dose = 250 - 500 mg/d of EPA and DHATarget dose = 250 - 500 mg/d of EPA and DHA

• Approximately 1g fish oil supplement/dayApproximately 1g fish oil supplement/day

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Who should take Fish Oils?Who should take Fish Oils?

• Patients with known CHDPatients with known CHD• 1 - 2 servings of oily fish/week recommended 1 - 2 servings of oily fish/week recommended

(Class I)(Class I)

• If unable or unwilling, daily fish oil supplement If unable or unwilling, daily fish oil supplement is reasonable (Class II)is reasonable (Class II)

• Patients without known CHDPatients without known CHD• 1 - 2 servings of oily fish/week recommended 1 - 2 servings of oily fish/week recommended

(Class II)(Class II)

• If unable or unwilling, daily fish oil supplement If unable or unwilling, daily fish oil supplement is reasonable (Class II)is reasonable (Class II)

From UptoDate

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How much fish is necessary?How much fish is necessary?

From UptoDate

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Complementary and Alternative Complementary and Alternative MedicinesMedicines

• > 15 million people consume CAM> 15 million people consume CAM

• $34 billion dollars in US alone out of $34 billion dollars in US alone out of pocketpocket

• Majority are Herbal products, Majority are Herbal products, considered “food” and not regulated considered “food” and not regulated as drugsas drugs

• Use not consistently disclosed to MDUse not consistently disclosed to MD

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Data from Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in Data from Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of complementary and alternative medicine by US adults: 1997–use of complementary and alternative medicine by US adults: 1997–

2002. Altern Ther Health Med 2005;11:42–9.2002. Altern Ther Health Med 2005;11:42–9.

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75 yo man presents with new 75 yo man presents with new onset of atrial fibrillationonset of atrial fibrillation

• Anticoagulation and amiodarone are Anticoagulation and amiodarone are recommendedrecommended

• Medications: noneMedications: none

• PE:PE:• BP 155/96, HR 100 irreg, irregBP 155/96, HR 100 irreg, irreg

• Lungs clearLungs clear

• No JVD, cor - holosystolic murmur at apexNo JVD, cor - holosystolic murmur at apex

• No edemaNo edema

• EKG: atrial fibrillation rate 90-120, LVHEKG: atrial fibrillation rate 90-120, LVH

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75 yo man presents with new 75 yo man presents with new onset of atrial fibrillationonset of atrial fibrillation

On closer questioning he is taking the following On closer questioning he is taking the following supplements:supplements:

GinsengGinsengGinkgo bilobaGinkgo bilobaSt. John’s WortSt. John’s WortSaw PalmettoSaw PalmettoVitamin DVitamin DFolateFolateVitamin EVitamin EFish oilFish oil

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He is reluctant to start anticoagulation He is reluctant to start anticoagulation and metoprolol 25 mg bid is prescribedand metoprolol 25 mg bid is prescribed

• What are potential interactions What are potential interactions between his CAM and warfarin?between his CAM and warfarin?

• Could they be contributing to his Could they be contributing to his hypertension and atrial fibrillation?hypertension and atrial fibrillation?

• Are there other potentially harmful Are there other potentially harmful effects?effects?

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Increased bleeding risk with Increased bleeding risk with WarfarinWarfarin

HerbHerb UseUseAlfalfaAlfalfa Arthritis, hyperlipidemia, DMArthritis, hyperlipidemia, DM

Angelica (dong quai)Angelica (dong quai) Appetite loss, dyspepsiaAppetite loss, dyspepsia

BilberryBilberry Circulatory disorder, DMCirculatory disorder, DM

FenugreekFenugreek HyplipidemiaHyplipidemia

GarlicGarlic High cholesterol, HTNHigh cholesterol, HTN

GingkoGingko Poor circulation, cognitive disorderPoor circulation, cognitive disorder

GingerGinger High cholesterol, indigestionHigh cholesterol, indigestion

KelpKelp Cancer, obesityCancer, obesity

KheliaKhelia Muscle spasmsMuscle spasms

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Decreased effectiveness of Decreased effectiveness of WarfarinWarfarin

HerbHerb UseUseGinsengGinseng Aging, stressAging, stress

Green teaGreen tea Cognition, weight loss, diureticCognition, weight loss, diuretic

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Other important Other important considerations: considerations:

HerbHerb UseUse Potential adverse Potential adverse effecteffect

HawthornHawthorn CHF, hypertensionCHF, hypertension Digoxin toxicityDigoxin toxicity

LicoriceLicorice Ulcer, cirrhosis, coughUlcer, cirrhosis, cough Digoxin toxicityDigoxin toxicity

StorphanthusStorphanthus CHFCHF Digoxin toxicityDigoxin toxicity

Lily of the valleyLily of the valley CHFCHF Digoxin toxicity, inc beta-Digoxin toxicity, inc beta-blocker effectblocker effect

St. John’s wortSt. John’s wort DepressionDepression Decreased digoxin Decreased digoxin concentrationconcentration

Night-blooming cereusNight-blooming cereus CHFCHF Increases effects of ACE, Increases effects of ACE, beta-blocker, digoxinbeta-blocker, digoxin

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Effects on Blood PressureEffects on Blood Pressure

• IncreaseIncrease• CapsicumCapsicum

• GinsengGinseng

• LicoriceLicorice

• Ma-huang (ephedra)Ma-huang (ephedra)

• YohimbineYohimbine

• DecreaseDecrease• Irish mossIrish moss

• KelpKelp

• YohimbineYohimbine

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Arrhythmic considerations:Arrhythmic considerations:

• HypkalemiaHypkalemia• Aloe veraAloe vera

• GossypolGossypol

• LicoriceLicorice

• HyperkalemiaHyperkalemia• OleanderOleander

• QT prolongationQT prolongation• Aloe veraAloe vera

• Bitter orangeBitter orange

• EchinaceaEchinacea

• Ginkgo bilobaGinkgo biloba

• GinsengGinseng

• GuaranaGuarana

• HawthornHawthorn

• Horny goat weedHorny goat weed

• LicoriceLicorice

• Lily of the valleyLily of the valley

• Night-blooming cereusNight-blooming cereus

• OleanderOleander

• RhodiolaRhodiola

• St. John’s wortSt. John’s wort

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Contamination relatively Contamination relatively commoncommon

• Heavy metalsHeavy metals

• PharmaceuticalsPharmaceuticals

• Colchicine in ginkgoColchicine in ginkgo

• Dietary supplements containing drugs Dietary supplements containing drugs for erectile dysfunction, lovastatin and for erectile dysfunction, lovastatin and sibutraminesibutramine

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Vitamins in Prevention of CV Vitamins in Prevention of CV DiseaseDisease

• FolateFolate• Lowers homocysteine levels, which are associated with CV Lowers homocysteine levels, which are associated with CV

diseasedisease

• Randomized trials show no benefitRandomized trials show no benefit

• May lower risk of HTN (Retrospective study from NHS in May lower risk of HTN (Retrospective study from NHS in women)women)

• Supplementation not recommendedSupplementation not recommended

• Vitamin DVitamin D• Increasing recognition of vitamin D deficiencyIncreasing recognition of vitamin D deficiency

• Low levels associated with increased total and CV mortalityLow levels associated with increased total and CV mortality

• Recommendation:Recommendation:• 600 IU daily for Fx prevention600 IU daily for Fx prevention

• 800 IU daily if previous Fx800 IU daily if previous Fx

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Vitamins in Prevention of CV Vitamins in Prevention of CV DiseaseDisease

• Anti-oxidant vitaminsAnti-oxidant vitamins• Vitamin A, E and CVitamin A, E and C

• No benefit on cardiovascular diseaseNo benefit on cardiovascular disease

• Vitamin E may increase risk of HFVitamin E may increase risk of HF

• Vitamin B12Vitamin B12• Deficiency common in elderlyDeficiency common in elderly

• Supplement of 2.4 mcg/day reasonableSupplement of 2.4 mcg/day reasonable

• No known toxity at these dosesNo known toxity at these doses

UCSFRapola, JM, Virtamo, J, Ripatti, S, et al Lancet 1997; 349:1715

Finnish Alpha Tocopherol Beta Carotene Cancer Prevention Study

• 1862 male smokers with prior Hx MI1862 male smokers with prior Hx MI

• Randomly assigned to alpha tocopherol (50 mg Randomly assigned to alpha tocopherol (50 mg per day), beta carotene (20 mg per day), both, or per day), beta carotene (20 mg per day), both, or placeboplacebo

• Endpoint: first major cardiac eventEndpoint: first major cardiac event

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Most of evidence does not Most of evidence does not favor use of antioxidantsfavor use of antioxidants

• HOPE (HOPE-TOO showed slight increase HOPE (HOPE-TOO showed slight increase in HF in Vit E treated groupin HF in Vit E treated group

• Heart Prevention studyHeart Prevention study

• Women’s Antioxidant Cardiovascular Women’s Antioxidant Cardiovascular StudyStudy

• WAVEWAVE

• GISSIGISSI

• CHAOS - reduced rate of MI not CV CHAOS - reduced rate of MI not CV mortalitymortality

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Patient reluctant to follow my advice and has Patient reluctant to follow my advice and has started selenium and magnesium; he refers started selenium and magnesium; he refers

me to this web siteme to this web site

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Two years later . . .Two years later . . .

• Remains in atrial fibrillationRemains in atrial fibrillation

• BP 140’s - 160’sBP 140’s - 160’s

• Suffered minor stroke but still Suffered minor stroke but still refuses warfarinrefuses warfarin

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Complementary and Alternative Complementary and Alternative Medications:Medications:

• Routinely inquire about their use and Routinely inquire about their use and doses as well as preparationsdoses as well as preparations

• Discuss potential adverse effectsDiscuss potential adverse effects

• Inform patients about drug-herb Inform patients about drug-herb interactionsinteractions

• Additional clinical trials needed and better Additional clinical trials needed and better regulation of the industry is warranted.regulation of the industry is warranted.