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Cardiovascular Disease


Heart disease and stroke are the most common cardiovascular diseases. They are the first and third leading causes of death for both men and women in the United States, accounting for nearly 40% of all annual deaths. More than 910,000 Americans die of cardiovascular diseases each year, which is 1 death every 35 seconds. Although these largely preventable conditions are more common among people aged 65 or older, the number of sudden deaths from heart disease among people aged 15–34 has increased.

In addition, more than 70 million Americans currently live with a cardiovascular disease. Coronary heart disease is a leading cause of premature, permanent disability in the U.S. workforce. Stroke alone accounts for disability among about 1 million Americans. More than 6 million hospitalizations each year are because of cardiovascular diseases.

The economic impact of cardiovascular diseases on our nation’s health care system continues to grow as the population ages. The cost of heart disease and stroke in the United States is projected to be $403 billion in 2006, including health care expenditures and lost productivity from death and disability. ( aag_cvh2006.pdf )

Definitions of Cardiovascular Disease Risk Factors

Total cholesterol

Cholesterol is a waxy fat like substance. Total cholesterol refers to the sum of the different sub-fractions of cholesterol that are measured in the blood. Total cholesterol is an independent risk factor for cardiovascular disease. The National Cholesterol Education Program says 240 is considered high. A person with this level has twice the risk of heart disease compared with someone whose cholesterol is 200 mg/dL. Total cholesterol 200-239 is borderline high cholesterol. Any cholesterol level of 200 mg/dL or more increases your risk. (More than half the adults in the United States have levels above 200 mg/dL)

LDL cholesterol

Low density lipoprotein (LDL): A subfraction of total cholesterol. (Like oil and vinegar, cholesterol and blood do not mix well. So, for cholesterol to travel through, it is coated with a layer of protein to make it a lipoprotein. Hence the name LDL-cholesterol) LDL is the 'bad' or athrogenic cholesterol fraction. More directly correlated with risk for CVD then total really. Excess LDL builds up in your arteries (simplistically). The higher the level of LDL, the greater your risk for heart disease. Generally above 130 is considered high, but some high risk individuals should have that even lower.

HDL cholesterol

High density lipoprotein: a subfraction of total cholesterol. The 'good' or non arthrogenic cholesterol fraction. General thought that the higher the better as it appears to 'pick up' or remove athrogenic LDL from the bloodstream.


Another type of fat carried in the blood. Most of the body's fat tissue is in the form of triglycerides, stored for use as energy. High triglyceride levels also are associated with increased CVD risk.

Cholesterol/HDL Ratio (tChol/HDL-C)

A ratio of the two and an independent predictor of CVD. Generally tracks with LDL, but not always. You can see that you can have a very high HDL and a modestly elevated Cholesterol, and still have a good ratio. What is a good ratio? Most literature suggests 4 is an excellent number to shoot for.

Triglyceride/HDL Ratio (TG/HDL-C)

This one is not as well known, but it is also an independent predictor of CVD. Probably even more important, it seems to be a good predictor of insulin resistance or Metabolic Syndrome, and has been used by some (importantly Gerald Reaven) as a surrogate marker for insulin resistance. What's good? Less then 3.5 would be considered good

Fat Mass

% body fat is pretty self explanatory. Once a woman goes over about 30% fat, there is a dramatic correlation with illness and disease. Weight scales can't determine the lean-to-fat ratio of that weight. An individual can be "over-weight" and not "over-fat." A bodybuilder, for example, may be 8% body fat, yet at two hundred and fifty pounds may be considered "over-weight" by a typical height-weight chart. Therefore, these charts are not a good indication of a person's ideal body weight for optimal health.

Fat loss/Lean mass Ratio

From the preceding you can see that losing more fat then lean is highly desirable, and so a greater change in this ratio is a good thing.

High sensitivity C-reactive protein (hs-CRP)

A very sensitive marker of systemic inflammation in the body. It's actually an inflammatory mediator produced in the liver. This sensitive test measures 'sub acute' inflammation. That is, someone with rheumatoid arthritis would have a very high level. That's not sub acute. However, if this marker is used to measure inflammation in individuals who don't have overt inflammatory conditions it can pick up sub acute 'smoldering' if you will. It could be anything smoldering, but there has been a lot of work done in the past 10 years that suggests that many people with no overt inflammatory condition and who have elevated levels (not as high as RA mind you) are at increased risk for CVD. Hence this is an independent risk factor for CVD and the general acceptance that CVD is in part an inflammatory mediated condition.


Another metabolite measured in the blood. Homocysteine is actually a by product of certain normal metabolic amino acid breakdown and processing. However, if it is elevated it suggests a 'sluggish' conversion or reconversion from one amino acid to another. (This conversion is controlled by enzymes and these enzymes are driven in part, by certain vitamins that act as cofactors. Hence you can often drive or quicken this process with folic acid, B6, B12 etc.) The problem here is that homocysteine, akin to LDL cholesterol, appears to be athrogenic, i.e. it damages the vessel wall. Thus high levels are independently associated with CVD. Additionally high levels appear to be independently associated with strokes and dementia as well as other things.

Hemoglobin A1C (HbA1C)

This is a measure of long term blood sugar control. It is actually measuring changes in the hemoglobin molecule brought about by bouncing against glucose in the blood stream. Essentially glucose in the blood is bumping up against red blood cells (which contain hemoglobin). The more glucose 'bumps' against RBC's the more 'pock marks' it makes on that molecule. You can measure these marks as HbA1C. So you can see the higher the number, the higher glucose is overall in the blood. Since RBC's stay around for 120 days, you can get a good assessment of long term blood sugar control. It is generally used in diabetics; however, it is now very clear that even modestly elevated HbA1C-within the normal range-is actually an increased risk for CVD.

Fasting insulin

Insulin is a hormone secreted by the pancreas in response to glucose levels in the blood. Insulin's main action is to open up, or unlock the cellular 'door' to allow glucose to get into cells. Glucose needs insulin to get into a cell. In Insulin resistance (Metabolic Syndrome) insulin is not working efficiency and so the pancreas pours out more insulin. This is good, because then in many people their blood sugar remains in the normal range. However it is also bad as insulin has various other metabolic effects-it causes, increased triglycerides, decreased HDL, increased blood pressure etc. So higher levels of insulin are associated with Metabolic Syndrome and CVD

Blood Pressure

Pressure exerted by the blood upon the walls of the blood vessels, measured by means of a sphygmomanometer (BP cuff), and expressed in millimeters of mercury. The numerator is the maximum pressure that follows systole (pumping) of the left ventricle of the heart and the denominator the minimum pressure (that accompanies cardiac diastole). (Adult) blood pressure is considered normal at 120/80 where the first number is the systolic pressure and the second is the diastolic pressure. Hypertension (there are different stages) starts at greater then 140/90.

Fasting glucose

The level of glucose or 'blood sugar.' Fasting, anything below 100 mg/dl is considered normal, 100-125 is considered 'impaired glucose tolerance' (IGT) and 126 or greater is considered diabetic. IGT just means, as with many things, there is a continuum, and this is in the danger zone. Some people consider this 'prediabetic.'

Therapeutic Lifestyle Changes (TLC)

Therapeutic Lifestyle Changes (TLC) are recommended as a first line treatment for a variety of common health problems by many national health organizations, including:

Lifestyle-related, chronic health problems:

FirstLine Therapy® (FLT) is a therapeutic lifestyle changes (TLC) program that is clinically effective, yet easy to implement. FLT provides time-saving tools that make it easy for you to integrate recommendations for diet and exercise with medical foods and other lifestyle changes, in a format that patients can understand and follow.

Most importantly, patients get results with the FLT program. Many are able to achieve their risk-reduction goals without medication in as little as 12 weeks on FLT.

Moderate Risk Reduction

Therapeutic Lifestyle Change

Severe Risk Reduction

Clinical Note

If your patients are on cholesterol lowering drugs (e.g. statins), consider adding:

CoQ-10 ST-100TM — 1-2 softgels daily

CoQ-10 ST features 30 mg of a stabilized, all natural encapsulation of coenzyme Q10 (CoQ10) manufactured to achieve exquisite quality, purity, and bioavailability
The depletion of the essential nutrient CoQ10 by the increasingly popular cholesterol lowering drugs, HMG CoA reductase inhibitors (statins), has grown from a level of concern to one of alarm. With ever higher statin potencies and dosages, and with a steadily shrinking target LDL cholesterol, the prevalence and severity of CoQ10 deficiency is increasing noticeably. An estimated 36 million Americans are now candidates for statin drug therapy. Statin-induced CoQ10 depletion is well documented in animal and human studies with detrimental cardiac consequences in both animal models and human trials. This drug-induced nutrient deficiency is dose related and more notable in settings of pre-existing CoQ10 deficiency such as in the elderly and in heart failure.1

Published data already indicated that statins can cause myopathies and rhabdomyolysis with renal failure. Moreover, on May 1, 2000, the FDA issued a warning about liver failure as an adverse reaction of statin use, based on reports that more than half of 62 patients with liver failure died. An estimate claims that the drugs can cause liver and muscle injury in up to 1% of users. For the US this will equal up to 130,000 patients with liver and muscle toxicity symptoms. Moreover, statins use is also implicated the increased incidence of cataracts, neoplasia, peripheral neuropathies, and some psychiatric disturbances.2

Statin-induced CoQ10 deficiency is completely preventable with supplemental CoQ10 with no adverse impact on the cholesterol lowering or anti-inflammatory properties of the statin drugs.1


  1. Langsjoen PH, Langsjoen AM The clinical use of HMG CoA reductase inhibitors and the associated depletion of coenzyme Q10. A review of animal and human publications. Biofactors 2003;18:101- 111
  2. Bliznakov E. Lipid lowering drugs (statins), cholesterol, and coenzyme Q10: the Baycol case – a modern pandora’s box. Biomed Pharmacother, 2002;56:56-9.

Angina Pectoris

Acute pain in the chest resulting from decreased blood supply to the heart muscle (myocardial ischemia). A syndrome due to myocardial oxygen deficit, characterized by prolonged substernal, thoracic pain which is precipitated chiefly by emotion, exercise, or the ingestion of a heavy meal. It is caused by a temporary inability of the coronary arteries to supply sufficient blood to the heart muscle.

Nutrients Involved

DMG, coenzyme Q10, vitamin E, l-carnitine, taurine, magnesium, potassium, selenium, chromium and calcium

Suggested Nutritional Supplementation

According to Alan R. Gaby, M.D., vitamin E should be included in the nutritional treatment of angina relative to its capacity to improve blood flow and to prevent the production of tissue-damaging free radicals.
Research has shown DMG to be a physiologically active nutrient that: (1) Is an anti-stress agent that can significantly improve physical and mental performance; (2) Can improve and stimulate oxygen utilization and thereby reduce hypoxic (low oxygen) states in the body tissues; (3) Can cause marked improvement in patients with circulatory insufficiency and angina pectoris; (4) Can reduce elevated cholesterol, triglycerides, and improve circulation; (5) and can lower high blood pressure.

Dietary Suggestions


Atherosclerosis is a slow, complex disease in which fatty substances, cholesterol, cellular waste products, calcium, and other substances build up in the inner lining of an artery. This buildup is called plaque. Atherosclerosis is derived from the Greek words athero (meaning gruel or paste) and sclerosis (meaning hardness). The effects of atherosclerosis differ depending upon which arteries in the body narrow and become clogged with plaque. For example, plaque buildup in the vessels that supply the heart with oxygen-rich blood may cause chest pain and lead to a heart attack while plaque buildup in the arteries that supply blood to the brain may result in a stroke.
According to the Centers for Disease Control, heart disease is the leading cause of illness and death in the United States and most other Western countries. Close to one million deaths per year in the United States alone are attributable to heart disease, double the number of deaths from cancer. Because atherosclerosis is highly preventable and the risk factors are well-documented, preventive measures such as lowering blood pressure and LDL (“bad”) cholesterol levels, smoking cessation, losing weight, and increasing physical activity should be followed.

Signs and Symptoms

Atherosclerosis shows no symptoms until a significant percentage (40%) of a vessel becomes obstructed with plaque and a complication occurs. Symptoms vary depending upon which arteries in the body narrow and become clogged with plaque.

Coronary Artery Disease (CAD)

CAD is caused by plaque buildup in the vessels that supply the heart with oxygen-rich blood. When the tissues of the heart begin to become deprived of oxygen (ischemia), chest pain (angina) occurs. If the artery becomes completely blocked, cells in the heart begin to die and a heart attack may occur. Symptoms of CAD are usually triggered by physical exercise, sexual activity, exposure to cold weather, anger, or stress. The most common symptoms of CAD include:

Cerebrovascular Disease (Stroke)

Cerebrovascular disease is caused by plaque buildup in the arteries that supply the brain with oxygen-rich blood. Cerebrovascular disease causes transient ischemic attack (a sudden loss of brain function with complete recovery within 24 hours) and stroke. Symptoms may include:

Peripheral Artery Disease

Peripheral artery disease is caused by plaque buildup in the arteries that supply the extremities of the body (such as the hands and feet) with oxygen-rich blood. Symptoms may include:
Many researchers believe that atherosclerosis is caused by damage to the innermost layer of the artery known as the endothelium. High blood pressure, elevated LDL ("bad") cholesterol, an abnormal accumulation of homocysteine (an amino acid produced by the human body), tobacco smoke, diabetes, hormonal changes following menopause, and infection are all thought to contribute to endothelial damage. Once the endothelium is damaged, it becomes easier for fats, cholesterol, cellular waste products, calcium, and other substances to become deposited in the artery wall. This buildup thickens the endothelium significantly. As a result, the diameter of the artery shrinks, blood flow decreases, and oxygen supply is dramatically reduced. Blood clots may also form on top of the plaque or damaged endothelium, thereby blocking the artery, and completely cutting off blood supply.

Because many people do not have the classic risk factors of atherosclerosis (such as cigarette smoking and high blood pressure), it is possible that there may be other contributing factors or causes of atherosclerosis, such as inflammation from an infection or autoimmune disease.

Risk Factors


A healthcare practitioner can determine your risk for heart disease by conducting a variety of tests. Blood tests detect elevated levels of cholesterol, homocysteine, and blood clotting factors. A stress test (otherwise known as an exercise tolerance test) monitors heart rate and blood pressure while an individual walks on a treadmill or rides a stationary bicycle. An electrocardiogram (ECG) is used during a stress test to measure and record the electrical activity of the heart. ECGs can detect abnormal heart rhythms, scar formation in the heart muscle from a prior heart attack, and areas of decreased blood flow when the heart is strained (as with physical activity). Advanced imaging techniques used during a stress test (such as an ultrasound) can determine precise areas of decreased blood flow to the heart. Angiograms (or angiography) can reveal arterial damage and plaque buildup.

Preventive Care

Making careful lifestyle choices is an important first step in preventing atherosclerosis. Some healthy habits include:

Treatment Approach

Atherosclerosis shows no symptoms until a complication (such as chest pain or a heart attack) occurs. For this reason, lifestyle choices such as achieving and maintaining a normal weight, lowering blood pressure and cholesterol, exercising regularly, quitting smoking*, and reducing stress, are all important steps in preventing atherosclerosis. Once a complication occurs, however, surgery and other Procedures may be required to remove plaque from clogged arteries or to create a detour around a blocked artery. Healthy diets designed to lower cholesterol, blood pressure, and excess body weight are essential in the treatment of atherosclerosis. Nutrition and dietary supplements, such as vitamin E, omega-3 fatty acids, and folate (vitamin B9) may be effective when used in addition to certain medications. Herbs, such as hawthorn, have also shown promise in lowering cholesterol levels and reducing the risk of heart disease.

Stop Smoking—Cigarette smoking acutely increases the heart rate and arterial blood pressure and may therefore affect the pattern of arterial blood flow. Using a non-invasive ultrasound technique, cigarette smoking was shown to increase arterial wall stiffness and to alter the pattern of arterial blood flow. These effects may help to explain why smoking and some other factors favor the development of atherosclerosis.

Nutrition and Dietary Supplements

Healthy eating habits can help reduce high blood cholesterol, high blood pressure, and excess body weight -- three of the major risk factors for heart disease. The American Heart Association (AHA) has developed dietary guidelines that help lower fat and cholesterol intake and reduce the risk of heart disease. The main goal of these guidelines is to promote an overall healthy eating pattern, maintain an appropriate body weight, and reach desirable cholesterol and blood pressure levels. The AHA does not recommend very low-fat diets as these diets may lead to deprivation of essential fatty acids as well as an undesired reduction in HDL (“good”) cholesterol levels. The AHA also advises against high-protein diets due to the lack of scientific evidence supporting their weight-loss effectiveness or any other claims of health benefits. In general, Western diets are considered to be too high in protein, particularly animal protein (which is high in fat and cholesterol). In adults, high levels of protein can cause kidney damage and bone loss.

The AHA recommends the following to prevent the development or progression of atherosclerosis:

In addition to the recommendations listed above, the AHA suggests that individuals who have heart disease or are at a high risk of developing heart disease consider the more specialized diets below:

Diets for People with High Cholesterol

The National Cholesterol Education Program (NCEP) recommends saturated fat intake of no more than 7% of total calories, cholesterol limited to less than 200 mg/day, little to no trans fatty acids (such as fried foods), intake of both plant stanols/ sterols (2 grams/day) and soluble fiber (10 to 25 grams/day), weight loss, and exercise. Studies have also shown that replacing dietary animal protein with soy protein may reduce total cholesterol, LDL (“bad”) cholesterol, and triglycerides (a major form of fat in the blood) without affecting HDL (“good”) cholesterol levels. The AHA also recommends a diet high in unsaturated fat diet rather than a very low-fat diet for individuals with atherogenic dyslipidemia (a condition marked by high triglycerides, low HDL cholesterol, obesity, high blood pressure, and/or diabetes).

Diets for People with High Blood Pressure

The Dietary Approaches to Stop Hypertension (DASH) diet emphasizes a diet rich in fruits, vegetables, and low-fat or non-fat dairy products to provide high intake of potassium, magnesium, and calcium sources. Sodium intake should be less than 6 g/day. Weight loss, regular physical activity, and limiting of alcohol intake are also very important factors for lowering blood pressure.

Mediterranean Diet

The Mediterranean Style Diet is comprised of whole grains, fresh fruits and vegetables, fish, olive oil, and moderate, daily wine consumption. Unlike the AHA diets, the Mediterranean Style Diet is not low in all fats; it is low in saturated fat but high in monounsaturated fatty acids. In a long-term study of 423 patients who suffered a heart attack, those who followed a Mediterranean Style Diet had a 50% to 70% lower risk of recurrent heart disease compared with controls who received no special dietary counseling. The intervention diet emphasized bread, root and green vegetables, daily intake of fruit, fish and poultry, olive and canola oils, margarine high in alpha-linolenic acid (an omega-3 polyunsaturated fatty acid found in flaxseed, walnuts, and canola oil), along with discouragement of ingestion of red meat and total avoidance of butter and cream.

Supplements and Vitamins

Folic Acid, Vitamin B6, Vitamin B12, Betaine

Many studies indicate that patients with elevated levels of the amino acid homocysteine are roughly 1.7 times more likely to develop coronary artery disease and 2.5 times more likely to suffer from a stroke than those with normal levels. Homocysteine levels are strongly influenced by dietary factors, particularly vitamin B9 (folic acid), vitamin B6, vitamin B12, and betaine. These substances help break down homocysteine in the body. Some studies have even shown that healthy individuals who consume higher amounts of folic acid and vitamin B6 are less likely to develop atherosclerosis than those who consume lower amounts of these substances.

Omega-3 Fatty Acids

There is strong evidence that omega-3 fatty acids (namely EPA and DHA) found in fish oil can help prevent and treat atherosclerosis by inhibiting the development of plaques and blood clots. In one study of 223 patients with coronary artery disease, those who received fish oil supplements daily for 2 years demonstrated a significant improvement in symptoms compared to those who did not receive the supplements. A second study of heart attack survivors found that daily supplementation with omega-3 fatty acids dramatically reduced the rate of death, subsequent heart attacks, and stroke.


Studies suggest that patients who take L-carnitine supplementation soon after suffering a heart attack may be less likely to suffer a subsequent heart attack, die of heart disease, and experience chest pain and abnormal heart rhythms. In addition, people with coronary artery disease who use L-carnitine along with standard medication may be able to sustain physical activity for longer periods of time.


Evidence suggests that antioxidants may play a role in the prevention of atherosclerosis. Antioxidants are believed to prevent fatty buildup in the arteries by suppressing the oxidation of LDL (“bad”) cholesterol. They may also reduce the likelihood of blood clot formation and may help relax blood vessels thereby improving blood flow.

Vitamin E

Population-based studies suggest that vitamin E supplements may help prevent the development and progression of heart disease.


Low blood levels of this antioxidant may worsen atherosclerosis. Cigarette smoking and alcohol ingestion are believed to contribute to selenium deficiency. It is not known, however, whether selenium supplementation has any influence on the development or progression of atherosclerosis.

Coenzyme Q10 (CoQ10)

Researchers believe that CoQ10 inhibits blood clot formation and boosts levels of antioxidants. One study found that people who received daily CoQ10 supplements within 3 days of a heart attack were significantly less likely to experience subsequent heart attacks and chest pain and were also less likely to die of the condition than those who did not receive the supplements.


Test tube, animal, and some population-based studies suggest that the flavonoids quercetin, resveratrol, and catechins (all found in high concentration in red wine) may help reduce the risk of atherosclerosis. By acting as antioxidants, there nutrients appear to protect against the damage caused by LDL cholesterol.

Vitamin D

Low levels of vitamin D may increase the risk of calcium build-up in the arteries, a significant component of atherosclerotic plaque. Atherosclerotic plaque build up in blood vessels can lead to a heart attack or stroke.


Low levels of melatonin in the blood have been associated with heart disease, but it is not clear, whether melatonin levels are low in response to having heart disease or if low levels of melatonin predispose people to developing this condition. In addition, several studies in rats suggest that melatonin may protect the hearts of these animals from the damaging effects of ischemia.


Suggested Nutritional Supplementation



Hans Nieper, MD noted that treatment with magnesium for 18 months improved blood vessel elasticity (measured by capillarioscopy) in about 90% of patients to an extent close to normal.

Dietary Suggestions

NOTE: Avoid alcoholic beverages.


Acupuncture may be particularly useful for reducing risk factors for heart disease. It is considered an excellent treatment for people who wish to quit smoking and some studies indicate that it may aid in weight loss as well as cholesterol and blood pressure reduction.

Massage and Physical Therapy

Although few studies have examined the effectiveness of massage therapy on atherosclerosis, massage has a relaxing effect and it has been shown to reduce stress-related hormone levels. Lowering stress hormone levels positively influences cholesterol and blood pressure and may therefore reduce the risk of heart disease. In addition, relaxation techniques may help individuals comply with habits necessary to reduce risk of atherosclerosis, such as dieting, quitting smoking, and exercising. Also, at least one study has found that massage can lower blood pressure.

Cardiac Arrhythmia

Arrhythmia (ah-rith'me-ah): Variation from the normal rhythm, especially of the heartbeat.

Sinus arrhythmia: The physiologic cyclic variation in heart rate related to vagal impulses to the sinoatrial node; it occurs commonly in children and in the aged.

Nutrients Involved

EPA/DHA oils, taurine, magnesium, potassium, calcium, chromium, coenzyme Q10

Suggested Nutritional Supplementation

Omega-3 fatty acids (EPA-DHA) have been shown to have beneficial effects in experimental studies of cardiac arrhythmia.
Experimental study suggests that CoQ10 exhibits an effective anti-arrhythmic action, not merely on organic heart disease, but also on ventricular premature beats (VPBs) supervening in diabetes mellitus.

Maintenance Supplementation

Dietary Suggestions

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