Coronary artery disease (CAD)

12 March 2013

Coronary artery disease (CAD)

Coronary artery disease (CAD), also known as coronary heart disease (CHD), occurs when the coronary arteries (the blood vessels that supply oxygen-rich blood to the heart muscle) gradually become narrowed or blocked by plaque (a combination of fatty material, calcium, scar tissue, and proteins) deposits.

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BACKGROUND

Coronary artery disease (CAD), also known as coronary heart disease (CHD), occurs when the coronary arteries (the blood vessels that supply oxygen-rich blood to the heart muscle) gradually become narrowed or blocked by plaque (a combination of fatty material, calcium, scar tissue, and proteins) deposits. The plaque deposits decrease the space through which blood can flow, leading to poor blood flow. As platelets (disc-shaped particles in the blood that aid clotting) come to the area, blood clots form around the plaque, causing the artery to narrow even further. Sometimes, the blood clot breaks apart, and blood supply is restored. In other cases, the blood clot (coronary thrombus) may totally block the blood supply to the heart muscle (coronary occlusion). This lack of blood flow (called ischemia) can "starve" some of the heart muscle and lead to chest pain (angina). A heart attack (myocardial infarction) results when blood flow is completely blocked, usually by a blood clot forming over a plaque that has ruptured. Unhealthy habits, such as a diet high in cholesterol and other fats, smoking, and lack of exercise accelerate the deposit of fat and calcium within the inner lining of coronary arteries.

CAD is the most common form of heart disease and the leading cause of death in men and women in the United States. CAD affects about 14 million men and women in the United States, and claims more lives than the other seven leading causes of death combined.

Atherosclerosis: Coronary artery disease is a type of atherosclerosis in which plaque builds up inside the arteries that carry blood to the heart. As the artery walls thicken, the passageway for blood narrows. Sometimes platelets gather at the narrow area and form a clot that decreases or prevents blood flow to the region of the heart supplied by the artery. Atherosclerosis can also lead to stroke (lack of oxygen) in the brain.

RISK FACTORS AND CAUSES

Causes of and risk factors associated with developing coronary artery disease (CAD) include high cholesterol and low-density lipoprotein (LDL) levels in the blood, low levels of high-density lipoprotein (HDL), high blood pressure, smoking, diabetes mellitus, obesity, age, family history of heart disease, sedentary or inactive lifestyle, stress, and male gender.

SIGNS AND SYMPTOMS

Chest pain: The most common symptom of coronary artery disease (CAD) is chest pain, or angina (angina pectoris). Angina is described as a discomfort, heaviness, pressure, aching, burning, numbness, fullness, squeezing or painful feeling. Angina that begins suddenly or lasts only a few seconds is less likely to be angina. Angina usually begins in the chest, but it can also start or spread to different areas of the body, such as down the left arm (most common site), to the left shoulder, to the neck or lower jaw, to the mid-back, or down the right arm. It can be mistaken for indigestion or heartburn, and the pain can be difficult to pinpoint. The chest pain associated with angina usually begins at a low level, and then gradually increases over several minutes to a peak. Angina that occurs during activities will usually decrease when the activity is stopped. Angina may also be caused by the use of drugs such as cocaine or amphetamines, exposure to cold temperatures, anger, smoking, or eating a heavy meal.

Other symptoms that can occur with coronary artery disease include shortness of breath, palpitations (irregular heart beats or arrhythmias), a fast heartbeat (tachycardia), weakness or dizziness, nausea, and increased sweating.

Heart attack: A heart attack (myocardial infarction) may also occur, and the symptoms in men and women may differ. A study found that many women reported warning symptoms one month prior to having a heart attack. These symptoms included unusual fatigue, sleep disturbances, and shortness of breath. Only 30% reported chest pain, which the majority of men report.

Unfortunately, sometimes a heart attack is the first sign of coronary artery disease (CAD). According to the Framingham Heart Study, over 50% of men and 63% of women who died suddenly of CAD (mostly from heart attack) had no previous symptoms of this disease.

Some individuals who have CAD and insufficient blood flow to the heart muscle (ischemia) do not have any symptoms. This is called "silent ischemia." In rare instances a patient may even have a "silent heart attack," which is a heart attack without symptoms.

DIAGNOSIS

Physical examination and tests: Risk factors of stroke are evaluated, including high blood pressure, high cholesterol levels, calcium levels, diabetes, medications, elevated levels of homocysteine and/or C-reactive protein (CRP, a marker of inflammation), and obesity.

Cardiac stress test: A stress test determines how well the blood is flowing to the heart during exercise compared to resting. The patient either walks on a treadmill or is given an intravenous (in the veins) medication that simulates exercise (usually dipyridamole or Persantine©) while connected to an electrocardiograph (ECG) machine. A nuclear stress test involves the injection of radioactive isotopes (most commonly, technetium or Tc99m sestamibi), and then blood flow to and from the heart is visualized using a type of camera.

Carotid ultrasonography: This procedure evaluates blood flow using a wand-like device (transducer) that sends high-frequency sound waves into the neck to determine if there is any narrowing or clotting in the carotid arteries.

Arteriogram: Arteriogram (or angiogram) views arteries in the heart, brain, kidney, and many other parts of the body not normally seen in X-rays. A thin, flexible tube (catheter) is inserted through a small incision, usually in the groin area. The catheter is manipulated through the major arteries and into the carotid or vertebral artery. A dye is then injected through the catheter to provide X-ray images of the arteries.

Computerized tomography angiography (CTA): In computerized tomographic angiography (CTA), a dye is injected into the blood and X-ray beams create a three-dimensional image of the blood vessels in the neck and brain. CTA is used to look for aneurysms or blood vessel malformations and to evaluate arteries for narrowing. CT scanning, which is done without dye, can provide images of the brain and show hemorrhages, but without as much detailed information regarding the blood vessels.

Magnetic resonance imaging (MRI): An MRI uses a strong magnetic field to generate a three-dimensional view of the brain. This test is sensitive for detecting an area of brain tissue damaged by an ischemic stroke (lack of blood flow and oxygen to the brain). Magnetic resonance angiography (MRA) uses this magnetic field and a dye injected into the veins to evaluate arteries in the neck and brain.

COMPLICATIONS

The lack of blood flow to the heart can lead to irreversible damage to the heart muscle.

Invasive surgery may be required, such as coronary artery bypass graft surgery (CABG).

Chest pain (angina) may lead to a heart attack (myocardial infarction), which may cause sudden death.

TREATMENT

Treatment aims to balance blood supply to the heart with maintaining oxygen demand, and preventing worsening coronary heart disease.

Medications: Various medications can be used to prevent CAD and to treat the symptoms. These include platelet inhibitors ("thin" the blood) such as aspirin (81-325mg daily, may cause bleeding) or Plavix© (clogidogrel), beta blockers (decrease the heart rate and blood pressure; reducing the heart's demand for oxygen, which may cause fatigue) such as metoprolol (Lopressor©, Toprol©), nitroglycerin (increases the oxygen available to the heart by dilating coronary arteries; may cause headache), calcium channel blockers (slow heart rate and dilate coronary blood vessels; may slow heart rate) such as amlodipine (Norvasc©) or diltiazem (Cardizem©), angiotensin inhibiting drugs or ACE inhibitors (dilate blood vessels and increase oxygen to the heart; may cause cough) such as lisinopril (Prinivil©, Zestril©) or ramipril (Altace©), and statins or HMG-CoA reductase inhibitors (help lower cholesterol levels; may cause liver problems or muscle pain) such as atorvastatin (Lipitor©) or lovastatin (Mevacor©).

Interventional procedures: Common interventional procedures to treat coronary artery disease (CAD) include balloon angioplasty (PTCA or percutaneous transluminal coronary angioplasty) and stent placement (using a wire mesh that expands in the blood vessel, allowing more blood to flow normally). These procedures are considered non-surgical because they are done by a cardiologist through a tube or catheter that is inserted into a blood vessel. Several types of balloons, stents (some contain anti-clotting medications), and/or catheters are available to treat the plaque within the vessel wall. The physician chooses the type of procedure based on individual patient needs.

Coronary artery bypass graft surgery (CABG): Coronary artery bypass graft (CABG) surgery is when one or more blocked blood vessels is bypassed by a graft and normal blood flow is restored to the heart. These grafts usually come from the patient's own arteries and veins located in the chest, leg, or arm. The graft goes around the clogged artery to create new pathways for oxygen-rich blood to flow to the heart. Some problems associated with CABG include a heart attack (occurs in 5% of patients), stroke (occurs in 5%, with the risk greatest in those over 70 years old), blood clots, death (occurs in 1 - 2% of individuals), and sternal wound infection (occurs in 1 - 4%). Infection is most often associated with obesity, diabetes, or having had a previous CABG. In about 30% of patients, "post-pericardiotomy syndrome" can occur anywhere from a few days to six months after surgery. The symptoms of this syndrome are fever and chest pain, and it can be treated with medications (antibiotics, nitroglycerin, and anti-inflammatory drugs). The incision in the chest or the graft site (if the graft was from the leg or arm) can be itchy, sore, numb, or bruised. Some individuals report memory loss, loss of mental clarity or "fuzzy thinking" following a CABG.

Alternate coronary artery bypass graft surgery (CABG) methods: Alternate methods of CABG have been developed in recent times. Off-pump coronary artery bypass surgery (OPCAB) is a technique of performing bypass surgery without the use of cardiopulmonary bypass (the heart-lung machine). Further refinements to OPCAB have resulted in minimally invasive direct coronary artery bypass surgery (MIDCAB) which is a technique of performing bypass surgery through a very small incision (cut). This procedure also eliminates many of the problems associated with conventional coronary artery bypass surgery, including major wound healing and infection.

TMR: TMR or transmyocardial laser revascularization is a treatment that helps improve blood flow to areas of the heart not treated by angioplasty or surgery. A special carbon dioxide (CO2) laser is used to create small channels in the heart muscle, improving blood flow in the heart. Frequently, it is performed along with coronary artery bypass, but on occasion has been done alone.

EECP: Individuals with persistent angina (chest pain) symptoms who have exhausted the standard treatments without successful results may be candidates for enhanced external counter pulsation (EECP). EECP may stimulate the openings or formation of small branches of blood vessels in the heart, which creates a natural bypass around narrowed or blocked arteries.

Angiogenesis: Angiogenesis means growing new blood vessels. Investigators are studying several substances that if administered through the vein or directly into the heart will trigger the production of new blood vessels increasing blood flow to the heart muscle.

INTEGRATIVE THERAPIES

Strong scientific evidence:

Beta-glucan: The sum of existing positive evidence for use of beta-glucan for hyperlipidemia is promising. More research is needed to make definitive conclusions.

Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.

Beta-sitosterol: Beta-sitosterol is one of the most common dietary phytosterols (plant sterols) found and synthesized exclusively by plants such as in fruits, vegetables, soybeans, breads, peanuts and peanut products. Many studies in humans and animals have demonstrated that supplementation of beta-sitosterol into the diet decreases total serum cholesterol as well as low-density lipoprotein (LDL) cholesterol and may be of benefit for patients with hypercholesterolemia (high levels of blood cholesterol).

Caution is advised when taking beta-sitosterol supplements, as numerous adverse effects including drug interactions are possible. Beta-sitosterol supplements are not generally used during pregnancy or breastfeeding unless otherwise advised by a doctor.

Calcium: Calcium chloride may be given intravenously (IV) by a qualified healthcare professional in cardiac resuscitation, particularly after open-heart surgery, when epinephrine fails to improve weak or ineffective myocardial contractions. Calcium chloride is contraindicated for cardiopulmonary resuscitation in the presence of ventricular fibrillation. CPR with calcium chloride should only be done under the supervision of a qualified healthcare professional.

Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with hypercalcaemia (high levels of calcium in the blood), hypercalciuria (high levels of calcium in urine), hyperparathyroidism (high levels of parathyroid hormone), bone tumors, digitalis toxicity, ventricular fibrillation (ventricles of the heart contract in unsynchronized rhythm), kidney stones, kidney disease, or sarcoidosis (inflammation of lymph nodes and various other tissues). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria (absence of hydrochloric acid in gastric juices) or arrhythmia (irregular heartbeat). Calcium appears to be safe in pregnant or breastfeeding women; talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

Niacin: Niacin is a well-accepted treatment for high cholesterol. Multiple studies show that for high cholesterol, niacin has significant benefits on levels of high-density cholesterol (HDL or "good cholesterol"), with better results than prescription drugs such as "statins" like atorvastatin (Lipitor©).

Avoid niacin/vitamin B3 if allergic to niacin or niacinamide. Avoid with history of liver disease or dysfunction, irregular heartbeats (arrhythmia), heart disease, blood clotting, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout or diabetes. Avoid if pregnant or breastfeeding.

Omega-3 fatty acids: There is strong scientific evidence from human trials that omega-3 fatty acids from fish or fish oil supplements (EPA + DHA) significantly reduce blood triglyceride levels. Benefits appear to be dose-dependent. Fish oil supplements also appear to cause small improvements in high-density lipoprotein ("good cholesterol"); however, increases (worsening) in low-density lipoprotein levels (LDL/"bad cholesterol") are also observed. It is not clear if alpha-linolenic acid significantly affects triglyceride levels; there is conflicting evidence regarding hypertriglyceridemia.

Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single 6-ounce meal per week, and in young children to less than 2 ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat 7 ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. Psyllium contains a high level of soluble dietary fiber, and is the chief ingredient in many commonly used bulk laxatives, such as Metamucil© and Serutan©. Psyllium is well studied as a cholesterol lowering agent with generally modest reductions seen in blood levels of total cholesterol and low-density lipoprotein ("bad cholesterol"). Effects have been observed following eight weeks of regular use. Psyllium does not appear to have significant effects on high-density lipoprotein ("good cholesterol") or triglyceride levels. Because only small reductions have been observed (total cholesterol and LDL), people with high cholesterol should discuss the use of more potent agents with their health care provider.

Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or prolonged psyllium exposure who have not manifested allergic or hypersensitive symptoms. Prescription drugs should be taken one hour before or two hours after psyllium. Adequate fluid intake is required when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.

Red yeast rice: Since the 1970s, human studies have reported that red yeast lowers blood levels of total cholesterol, low-density lipoprotein/LDL ("bad cholesterol"), and triglyceride levels. Other products containing red yeast rice extract can still be purchased, mostly over the Internet. However, these products may not be standardized and effects are not predictable. For lowering high cholesterol, there is better evidence for using prescription drugs such as lovastatin.

Avoid if allergic or hypersensitive to red yeast. Avoid with liver disease. Use cautiously with bleeding disorders. Avoid if pregnant or breastfeeding.

Soy: Numerous human studies report that adding soy protein to the diet can moderately decrease blood levels of total cholesterol and low-density lipoprotein ("bad" cholesterol). Small reductions in triglycerides may also occur, while high-density lipoprotein ("good" cholesterol) does not seem to be significantly altered. Some scientists have proposed that specific components of soybean, such as the isoflavones genistein and daidzein, may be responsible for the cholesterol-lowering properties of soy. However, this has not been clearly demonstrated in research and remains controversial. It is not known if products containing isolated soy isoflavones have the same effects as regular dietary intake of soy protein. Dietary soy protein has not been proven to affect long-term cardiovascular outcomes from high cholesterol, such as heart attack or stroke.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk (not specifically designed for infants). People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy supplementation.

Good scientific evidence:

Arginine: Early evidence from several studies suggests that arginine taken by mouth or by injection may improve exercise tolerance and blood flow in arteries of the heart. Benefits have been shown in some patients with coronary artery disease and chest pain (called angina). However, more research is needed to confirm these findings and to develop safe and effective doses.

Avoid if allergic to arginine, or with a history of stroke, or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin©) and blood pressure drugs or herbs or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

Avocado: Avocados added to the diet may lower total cholesterol, LDL ("bad" cholesterol), HDL ("good" cholesterol) and triglycerides. Additional study is needed before a strong recommendation can be made concerning high cholesterol.

Avoid if allergic or hypersensitive to avocado, banana, chestnut or natural rubber latex. Use cautiously with anticoagulants (like warfarin). Avoid with monoamine oxidase inhibitors (MAOIs). Doses greater than found in a normal diet is not recommended if pregnant or breastfeeding. Some types of avocado may be unsafe when breastfeeding.

Barley: The Food and Drug Administration (FDA) has announced that whole grain barley and barley-containing products are allowed to claim that they reduce the risk of coronary heart disease (CHD). To qualify for the health claim, the barley-containing foods must provide at least 0.75 gram of soluble fiber per serving of the food.

Several small, randomized studies suggest that high fiber barley, barley bran flour, and barley oil elicit small reductions in serum cholesterol levels by increasing cholesterol excretion. Barley ß-glucan extracts vary in their functionality with respect to cholesterol reduction. At least one barley ß-glucan concentrate, Barliv™ barley Betafiber, has demonstrated the ability to lower cholesterol in a human clinical trial. There is good evidence from existing research to support the use of barley along with a cholesterol-lowering diet in mild cases of hypercholesterolemia. Larger and longer studies are warranted to more rigorously confirm the effects of barley on hyperlipidemia.

Use cautiously in all patients due to possible risk of contamination with fungi. Use cautiously in children. Use cautiously in patients taking hypoglycemic agents, due to possible additive properties. Use cautiously in patients taking cardiac agents, as hordenine in the root of germinating barley is a sympathomimetic. Fiber may reduce gastrointestinal transit and can, therefore, reduce the absorption of various orally administered agents. Avoid use in patients with celiac disease. Gluten found in barley may exacerbate this condition.

Betaine anhydrous: Overall, betaine supplementation has shown significant reductions in both fasting and postmethionine load homocysteine. However, additional studies are needed to better understand the effects of betaine on hyperhomocysteinemia.

Avoid if allergic/hypersensitive to betaine anhydrous or cocamidopropylbetaine, a form of betaine. Use cautiously with renal disease, obesity, and psychiatric conditions. Avoid if pregnant or breastfeeding.

Carob: Fiber, such as oat fiber, has been shown to reduce serum cholesterol levels. Carob pod fiber or carob bean gum may also have this ability, although additional research is needed to better understand the effects of carob on hypercholesterolemia (high cholesterol).

Avoid if allergic/hypersensitive to carob (Ceratonia siliqua), its constituents, or any plants in the Fabaceae family, including tamarind. Avoid with metabolic disorders, with a chromium, cobalt, copper, iron, or zinc disorder or deficiency, renal disorders, or acute diarrhea. Avoid in underweight infants. Use cautiously in patients with anemia, known allergy to peanuts and other nuts, complications with powdered, bulk forming laxative drinks, diabetes, or hyperlipidemia. Use cautiously if taking oral herbs or drugs. Use cautiously in hypouricemic patients. Avoid if pregnant or breastfeeding.

Chia: Early studies in animals and humans suggest that diets containing chia seed may decrease risk factors for cardiovascular disease. Evidence suggests that the benefits of Salba© in humans are similar to those of other whole grains. Further study is needed.

There is limited safety data on chia. Avoid if allergic or sensitive to chia, sesame, or mustard seed. Use cautiously with low blood pressure or bleeding disorders. Use cautiously if taking anti-cancer, antioxidant, blood pressure-lowering, or blood thinning agents, or agents that are broken down in the liver. Avoid if pregnant or breastfeeding.

Chitosan: Evidence from several trials suggests that chitosan may have a beneficial effect on hyperlipidemia, including serum lipid profiles, lowering total and LDL cholesterol while raising HDL (high density lipoprotein) cholesterol levels. This appears especially true when combined with a hypocaloric diet. However, the studies reporting the largest benefits used chitosan in combination with other active ingredients, which makes a causal statement for chitosan impossible. Future efficacy trials of chitosan should evaluate relative efficacy and safety of this substance alone compared to other interventions and determine whether chitosan my act in synergy with other substances. In addition, if efficacy is firmly established, optimum dosage needs to be determined.

Avoid if allergic or sensitive to chitosan or shellfish. Use cautiously with diabetes or bleeding disorders. Use cautiously if taking drugs, herbs, or supplements that lower blood sugar or increase the risk of bleeding. Chitosan may decrease absorption of fat and fat-soluble vitamins from foods. Chitosan is not recommended during pregnancy or breastfeeding.

Gamma oryzanol: Gamma oryzanol seems to reduce total cholesterol, LDL, HDL and triglycerides. Additional study is needed to establish gamma oryzanol's effect on hyperlipidemia.

Avoid if allergic/hypersensitive to gamma oryzanol, its components, or rice bran oil. Use cautiously if taking anticoagulants (blood thinners), central nervous system (CNS) suppressants, growth hormone, drugs or herbs that alter blood sugar levels, immunomodulators, luteinizing hormone or luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering or thyroid drugs, herbs or supplements. Use cautiously with diabetes, hypothyroidism, hypoglycemia, hyperglycemia and high cholesterol. Avoid if pregnant or breastfeeding.

Garlic: Multiple studies in humans have reported small reductions in total blood cholesterol and low-density lipoproteins ("bad cholesterol") over short periods of time (4 to 12 weeks) with use of garlic. It is not clear if there are benefits for hyperlipidemia after this amount of time. Effects on high-density lipoproteins ("good cholesterol") are not clear. This remains an area of controversy. Well-designed and longer studies are needed in this area.

Avoid if allergic or hypersensitive to garlic or other members of the Lilaceae (lily) family (like hyacinth, tulip, onion, leek, chive). Avoid with history of bleeding problems, asthma, diabetes, low blood pressure or thyroid disorders. Stop using supplemental garlic two weeks before dental/surgical/diagnostic procedures and avoid using immediately after such procedures to avoid bleeding problems. Avoid supplemental doses if pregnant or breastfeeding.

Ginseng: Ginseng appears to have antioxidant effects that may benefit patients with heart disorders. Some studies suggest that ginseng also reduces oxidation of low-density lipoprotein (LDL or "bad") cholesterol and brain tissue. Better studies are needed.

Avoid ginseng if known allergy to plants in the Araliaceae family. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in ginseng formulations.

Globe artichoke: Preliminary human study suggests that cynarin and artichoke extracts may have lipid lowering effects. More research is needed in this area.

Use cautiously if allergic/hypersensitive to members of the Asteraceae or Compositae family (e.g., chrysanthemums, daisies, marigolds, ragweed, arnica), due to possible cross-reactivity. Use cautiously with cholelithiasis or biliary/bile duct obstruction or kidney disease. Avoid if pregnant or breastfeeding.

L-carnitine: Evidence from clinical trials suggests that L-carnitine and L-propionyl-carnitine (propionyl-L-carnitine) are effective in reducing symptoms of angina. Carnitine may not offer further benefit when patients continue conventional therapies. Additional study is needed to confirm these findings.

Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Niacin: Niacin decreases blood levels of cholesterol and lipoprotein (a), which may reduce the risk of atherosclerosis ("hardening" of the arteries). However, niacin also can increase homocysteine levels, which may have the opposite effect. Overall, the scientific evidence supports the use of niacin in combination with other drugs (but not alone) to decrease cholesterol and slow the process of atherosclerosis. More research is needed in this area before a firm conclusion can be drawn.

Omega-3 fatty acids, fish oil, alpha-linolenic acid: Several large studies of populations ("epidemiologic" studies) report a significantly lower rate of death from heart disease in men and women who regularly eat fish. Other epidemiologic research reports no such benefits. It is not clear if reported benefits only occur in certain groups of people, such as those at risk of developing heart disease. Overall, the evidence suggests benefits of regular consumption of fish oil. However, well-designed randomized controlled trials which classify people by their risk of developing heart disease are necessary before a firm conclusion can be drawn concerning the effects of fish oil on primary cardiovascular disease prevention.

Pantethine: Numerous trials have examined the effects of pantethine taken by mouth on hyperlipidemia. Reductions in total cholesterol, low-density lipoprotein (LDL), and triglycerides have occurred. However, additional study is needed in this area to confirm these findings.

Avoid if allergic or hypersensitive to pantethine or any component of the formulation. Use with caution with bleeding disorders. Avoid if pregnant or breastfeeding.

Policosanol: Policosanol is a cholesterol-lowering natural mixture of higher aliphatic primary alcohols, isolated and purified from sugar cane wax. The effects of policosanol supplementation on exercise-ECG testing responses have been studied in individuals with coronary heart disease. Beneficial changes were noted in functional capacity, rest and exercise angina (chest pain), cardiac events and maximum oxygen uptake. Although this represents early compelling evidence, further research is necessary before a clear conclusion can be reached.

Caution is advised when taking policosanol, as adverse effects including drug interactions are possible. Policosanol supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor.

Sweet almond: Early studies in humans and animals report that for high cholesterol, whole almonds may lower total cholesterol and low-density lipoprotein (LDL/"bad" cholesterol) and raise high-density lipoprotein (HDL/"good" cholesterol"). It is not clear what dose may be safe or effective.

Avoid if allergic or hypersensitive to almonds or other nuts. Use cautiously with heart disease, diabetes, or low blood sugar. Use cautiously if taking cardiovascular agents (including antilipemics), antidiabetics, estrogens, phytoestrogens, and fertility agents. Use cautiously if pregnant or breastfeeding.

Yoga: There is intermediate evidence to support the use of yoga as an adjunct therapy in the prevention of coronary artery disease. Yoga was one part of a comprehensive program of lifestyle changes demonstrated to lessen blockages in coronary arteries, angina episodes, and cardiac events. Yoga appears to improve a number of cardiovascular disease risk factors, including blood pressure, plasma cholesterol, and blood sugar among healthy volunteers. Lower fibrinogen levels and increased fibrinolytic activity may lower the risk of myocardial infarction.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Zinc: There is some evidence that zinc may improve cholesterol ratio of HDL "good cholesterol" versus LDL "bad cholesterol," which would be considered a positive effect. Well-designed clinical trials are needed before a conclusion can be made about the use of zinc for high cholesterol.

Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid with kidney disease. Use cautiously if pregnant or breastfeeding.

Unclear or conflicting scientific evidence:

Acupuncture: Some research has suggested that acupuncture might help reduce distress and symptoms of angina pectoris, but this has not been consistently shown in other studies.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders or with drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (like asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers.

Alfalfa: Reductions in blood levels of total cholesterol and low-density lipoprotein ("bad cholesterol") have been reported in animal studies and in a small number of human cases. High-density lipoprotein ("good cholesterol") has not been altered in these cases. Although this evidence is promising, better research is needed before a firm conclusion can be reached about the use of alfalfa for hyperlipidemia or atherosclerosis.

Avoid if allergic to alfalfa, clover, or grass. Avoid with a history of lupus. Avoid before any surgery/dental/diagnostic procedures that may have a risk of bleeding, and avoid use immediately after these procedures. Use cautiously with stroke, hormone conditions (breast tenderness, breast cancer, ovarian cancer, menstrual problems), diabetes, hypoglycemia, thyroid disease, gout, blood clots, seizures, liver disease, or kidney disease. Use cautiously with blood sugar-altering medications, aspirin or any aspirin products, ibuprofen, and blood-thinners (like warfarin). Use cautiously if operating heavy machinery or driving. Alfalfa may be contaminated with dangerous bacteria (like E. coli, Salmonella, Listeria). Avoid if pregnant or breastfeeding.

Amaranth oil: Amaranth plus a low-sodium, heart-healthy diet decreased cholesterol and blood pressure in patients with coronary heart disease. However, additional evidence is needed before a recommendation can be made in this area.

Amaranth is generally considered safe. Avoid if allergic or sensitive to amaranth. Use cautiously with diabetes, low blood sugar, low blood pressure, immune system disorders, or kidney disorders. Use cautiously if pregnant or breastfeeding.

American hellebore: Isolated jervine alkaloids found in American hellebore have been studied for cardiovascular dysfunction. Additional study is needed before a firm recommendation can be made.

Avoid if allergic/hypersensitive to plants in the lily family (Liliaceae) or to American hellebore or any related species of Veratrum. Use cautiously with cardiovascular disease, cardiac dysfunction, arrhythmias, hemodynamic instability and compromised kidney function. Use cautiously in if taking drugs-excreted by the kidney, diuretics, asthma medications or blood pressure medications. Avoid if pregnant or breastfeeding.

Aortic acid: Mesoglycan is a structural aspect of cardiovascular vessels and organs. Preliminary study indicates that mesoglycan may reduce blood vessel thickening, however, additional research is needed regarding the use of this agent for atherosclerosis.

Due to the heparan sulfate content of mesoglycan, patients with an allergy to heparin or heparinoid derivatives should use caution. Use cautiously with coagulation (blood) disorders or if taking anticoagulation therapy. Use cautiously with hypertension (high blood pressure) or if taking antihypertension drugs. Avoid if pregnant or breastfeeding.

Arabinogalactan: It is unclear what effect arabinogalatan has on blood cholesterol levels, including triglycerides, in patients with high cholesterol. Limited early study did not show an effect of arabinogalactan in patients with normal cholesterol levels. More studies are needed.

Avoid if allergic or sensitive to arabinogalactan or larch. People who are exposed to arabinogalactan or larch dust may have irritation of the eyes, lungs, or skin. Use cautiously in people with diabetes, digestive problems, or immune system disorders, and in people who consume a diet that is high in fiber or low in galactose. Arabinogalactan should not be used during pregnancy or breastfeeding.

Arginine: Studies suggest that arginine supplementation after myocardial infarction (heart attack) may decrease heart damage, but further research is needed to confirm these findings. Arginine-supplemented "blood cardioplegic solution" may provide heart protection during coronary artery bypass grafting (CABG). Some research also suggests that arginine may help treat or prevent high cholesterol.

Ashwagandha: In a case series, 12 patients were administered powdered roots of ashwagandha for 30 days by mouth. The authors reported significant decreases in serum total cholesterol levels, triglycerides, low density lipoprotein (LDL), and very low density lipoproteins (VLDL). Additional evidence is required to better determine the effectiveness of ashwagandha for hypercholesterolemia.

Avoid if allergic or hypersensitive to ashwagandha products or any of their ingredients. Dermatitis (allergic skin rash) was reported in three of 42 patients in an ashwagandha trial. There are few reports of adverse effects associated with ashwagandha, but there are few human trials using ashwagandha, and most do not report the doses or standardization/preparation used. Avoid with peptic ulcer disease. Ashwagandha may cause abortions based on anecdotal reports. Avoid if pregnant or breastfeeding.

Astaxanthin: There is insufficient evidence to recommend for or against the use of astaxanthin for hyperlipidemia prevention. More research is needed to make a conclusion.

Avoid if allergic/hypersensitive to astaxanthin or related carotenoids, including canthaxanthin, or with hypersensitivity to an astaxanthin algal source, such as Haematococcus pluvialis. Use cautiously if taking 5-alpha-reductase inihibitors, hypertensive agents, asthma medications, such as etirizine dihydrochloride and azelastine, cytochrome P450 metabolized agents, menopause agents or oral contraception, or Helicobacter pylori agents. Use cautiously with hypertension, parathyroid disorders, and osteoporosis. Avoid with hormone-sensitive conditions, immune disorders or if taking immunosuppressive therapies. Avoid with previous experience of visual changes while taking astaxanthin and with low eosinophil levels. Avoid if pregnant or breastfeeding.

Astragalus: Astragalus products are derived from the roots of Astragalus membranaceus or related species, which are native to China. In Chinese medicine, herbal mixtures containing astragalus have been used to treat heart diseases. There are several human case reports of reduced symptoms and improved heart function, although these are not well described. High quality human research is necessary before a conclusion can be drawn about the use of astragalus for coronary heart disease.

Caution is advised when taking astragalus supplements, as adverse effects including drug interactions are possible. Astragalus supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor.

Ayurveda: Abana is a combination herbal and mineral formulation traditionally used in Ayurveda for heart health and cardiac disease. Early studies report that abana may reduce the frequency and severity of angina.

There is preliminary evidence that the herb guggul (Commiphora) may reduce serum cholesterol and serum triglyceride levels, increase HDL and decrease LDL levels. More studies are needed to validate the use of guggul for high cholesterol.

Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Ayurvedic herbs can interact with other herbs, foods and drugs. A qualified healthcare professional should be consulted before taking.

Beet: Increased dietary fiber intake is recommended based on findings that support its antilipemic effects and potential benefits for reducing the risk of cardiovascular disease. Beet pulp and pectin have been studied and used as sources of dietary fiber in humans. Research suggests that cholesterol-lowering effects of sugar beet fiber may be partially due to the activity of byproducts produced in the large intestine as a result of fermentation by colonic bacteria. Clinical trials have evaluated the effects of beet fiber for hyperlipidemia. More research is needed in this area.

Avoid with an allergy or hypersensitivity to any part of the beet plant, including the beet root, beet leaves, beet fiber, or other members of the Chenopodiaceae family.

Berberine: Berberine may reduce triglycerides, serum cholesterol, and LDL cholesterol. Higher quality trials are needed before berberine's effects for hyperlipidemia can be established.

Avoid if allergic or hypersensitive to berberine, to plants that contain berberine [Hydrastis canadensis (goldenseal), Coptis chinensis (coptis or goldenthread), Berberis aquifolium (Oregon grape), Berberis vulgaris (barberry), and Berberis aristata (tree turmeric)], or to members of the Berberidaceae family. Avoid in newborns due to potential for increase in free bilirubin, jaundice, and development of kernicterus. Use cautiously with cardiovascular disease, gastrointestinal disorders, hematologic disorders, leucopenia, kidney disease, liver disease, respiratory disorders, cancer, hypertyraminemia, diabetes, or hypotension. Use cautiously in children due to lack of safety information. Use cautiously in individuals with high exposure to sunlight or artificial light. Use cautiously for longer than eight weeks due to theoretical changes in bacterial gut flora. Use cautiously if taking anticoagulants, antihypertensives, sedatives, anti-inflammatories, medications metabolized by CYP P450 3A4 including cyclosporin, or any prescription medications. Avoid if pregnant or breastfeeding.

Beta glucan: Evidence suggests that reductions in endothelial function induced by a high fat meal may be prevented when a high fat meal is taken along with a beta-glucan-containing cereal or vitamin E. Diabetes, hyperlipidemia (high cholesterol), and hypertension (high blood pressure) data are also promising. Further study is needed regarding cardiovascular disease. Early research suggests that treatment with beta glucan may be effective for heart protection during coronary artery bypass grafting (CABG).

Bilberry: Bilberry (Vaccinium myrtillus) also known as the European blueberry, is widely used as an antioxidant for general health. Bilberry has been used traditionally to treat heart disease and atherosclerosis (hardening of the arteries). There is some laboratory research in this area, but there is no clear information in humans.

Caution is advised when taking bilberry supplements, as adverse effects including an increase in bleeding and drug interactions are possible. Bilberry supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

Biotin: A combination of biotin and chromium may help lower cholesterol and decrease the risk of developing clogged arteries (called atherosclerosis) in diabetics. However, other research of biotin alone found that biotin did not affect cholesterol, glucose, or insulin levels, but did decrease triglyceride levels. More research with biotin alone is needed to better determine its effects on cardiovascular disease risk in diabetics.

Avoid if hypersensitive to constituents of biotin supplements.

Black tea: There is conflicting evidence from a small number of studies examining the relationship of tea intake with the risk of heart attack. Tea may reduce the risk of platelet aggregation or endothelial dysfunction, proposed to be beneficial against blocked arteries in the heart. The long-term effects of tea consumption on heart attack prevention and cardiovascular risk factors, such as cholesterol levels and atherosclerosis, are not fully understood. Other research suggests that drinking black tea regularly does not affect plasma homocysteine levels or blood pressure. Black tea may increase heart rate.

Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances or insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism and irritability.

Borage seed oil: Gamma linolenic acid may decrease plasma triglyceride levels and increase HDL-cholesterol concentration. However, more research is needed to better define borage's effects on hyperlipidemia.

Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or taking warfarin or other anticoagulant or antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid if pregnant or breastfeeding.

Carrageenan: The hypolipidemic effect of carrageenan has been investigated in clinical study. Total cholesterol and triglyceride levels were both significantly reduced following the consumption of an experimental diet containing carrageenan-enriched foods. Further clinical trials are required before carrageenan can be recommended for hyperlipidemia.

Use cautiously in patients with, or at risk for, cancer, gastrointestinal disorders, immune disorders, inflammatory disorders, bleeding disorders, low blood pressure, or diabetes. Use cautiously in combination with any oral medication, as the fiber in carrageenan may impair the absorption of oral medications.

Chamomile: Chamomile is not well-known for its cardiac effects, and there is little research in this area. Large, well-designed randomized controlled trials are needed before a firm conclusion can be made concerning its use for cardiovascular conditions.

Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions and shortness of breath have been reported. Chamomile eyewash can cause allergic conjunctivitis (pinkeye). Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.

Chondroitin sulfate: Several studies in the early 1970s assessed the use of oral chondroitin for the prevention of subsequent coronary events in patients with a history of heart disease or heart attack. Although favorable results were reported, due to methodological weaknesses in this research and the widespread current availability of more proven drug therapies for patients in this setting, a recommendation cannot be made for use of this agent for coronary artery disease.

Use cautiously if allergic or hypersensitive to chondroitin sulfate products and with shellfish allergy. Use cautiously with bleeding disorders and with blood-thinners like warfarin (like Coumadin©). Avoid with prostate cancer or increased risk of prostate cancer. Avoid if pregnant or breastfeeding.

Chromium: Studies show conflicting results in using chromium to treat cardiovascular disease or high cholesterol. A few studies show that chromium may lower cholesterol, but other studies show no effects. Many natural medicine experts and textbooks do not recommend chromium for treating high cholesterol over more proven therapies.

Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, and stroke and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

Coenzyme Q10 (CoQ10): Preliminary small human studies suggest that CoQ10 may reduce angina and improve exercise tolerance in people with clogged heart arteries. There is conflicting evidence from research on the use of CoQ10 in patients with dilated or hypertrophic cardiomyopathy. There is also not enough scientific evidence to recommend for or against the use of CoQ10 in patients with coronary heart disease, heart attack or hypertriglyceridemia.

Allergy associated with Coenzyme Q10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix©), blood pressure, blood sugar, cholesterol or thyroid drugs. Avoid if pregnant or breastfeeding.

Copper: The effects of copper intake or blood copper levels on cholesterol, atherosclerosis (cholesterol plaques in arteries), or cardiovascular disease remain unclear. Studies in humans are mixed, and further research is needed.

Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia, occasionally observed in disease states including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and controlled fibrocalculous pancreatic diabetes (a unique form of secondary diabetes mellitus). Avoid with genetic disorders affecting copper metabolism such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6mg/L. Use cautiously with anemia, arthralgias and myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The United States Recommended Dietary Allowance (RDA) is 1,000µg for pregnant women. The United States Recommended Dietary Allowance (RDA) is 1,300µg for nursing women.

Corydalis: Corydalis may be of benefit for angina pectoris. More studies are needed.

Corydalis is generally considered safe. Avoid if allergic or sensitive to corydalis. Avoid if taking sedative or hypnotic drugs, drugs that treat abnormal heart rhythms (including bepridil), pain relievers, and anti-cancer drugs. Avoid if pregnant or breastfeeding.

Creatine: Early studies have evaluated the effect of creatine on hyperlipidemia, ischemic heart disease, and myocardial infarction. More clinical trials are needed before a conclusion can be made.

Avoid if allergic to creatine or with diuretics (like hydrochlorothiazide, furosemide (Lasix©)). Use caution in asthma, diabetes, gout, kidney, liver or muscle problems, stroke or a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.

Danshen: A small number of poor-quality studies report that danshen may provide benefits for treating disorders of the heart and blood vessels, including heart attacks, cardiac chest pain (angina), myocarditis, and hyperlipidemia. Early studies suggest that danshen may improve blood levels of cholesterol (lowers LDL or "bad" cholesterol and triglycerides and raises HDL or "good" cholesterol). Large high-quality studies are needed.

Avoid if allergic or hypersensitive to danshen. Use cautiously with altered immune states, arrhythmia, compromised liver function or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin or hypotensives including ACE inhibitors such as captopril, or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders, low blood pressure and following cerebal ischemia. Avoid if pregnant or breastfeeding.

DHEA (dehydroepiandrosterone): Initial studies report possible benefits of DHEA supplementation in patients with cholesterol plaques ("hardening") in their arteries. There is conflicting scientific evidence regarding the use of DHEA supplements in patients with heart failure or diminished ejection fraction. Other therapies are more proven in this area, and patients with heart failure or other types of cardiovascular disease should discuss treatment options with a cardiologist.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use with caution in adrenal or thyroid disorders or with anticoagulants, or drugs, herbs or supplements for diabetes, heart disease, seizure or stroke. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

PREVENTION

High blood pressure (hypertension) control: One of the most important things that can be done for prevention of coronary artery disease (CAD) is to reduce high blood pressure. Blood pressure should be a systolic reading of 120 and a diastolic reading of 80 (120/80mmg Hg). Exercising, managing stress, maintaining a healthy weight, and limiting sodium and alcohol intake are all ways to keep blood pressure in check. Medications to treat hypertension, such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers may be used.

Cholesterol and saturated fat intake reduction: Eating less cholesterol and fat, especially saturated fat, may reduce the amount of plaque arteries. Most people should aim for a low density lipoprotein (LDL) level below 130mg/dL. If there are other risk factors for heart disease, the target LDL may be below 100mg/dL. If the individual is at a very high risk for heart disease, such as having a previous heart attack, an LDL level below 70mg/dL may be optimal. Statin drugs (HMG-CoA reductase inhibitors) can be prescribed to help maintain healthy cholesterol levels.

Platetet inhibitors: In otherwise healthy men older than 50 years, an aspirin 325mg every other day prevents myocardial infarction (at a rate of 2 men per 1,000) but not stroke. In otherwise healthy women older than 45 years, an aspirin 100mg every other day prevents ischemic stroke (at a rate of 3 women per 1,000) but not myocardial infarction. Platelet inhibitors, or antiaggregants (prevent platelet clumping), such as aspirin may increase in the risk of gastrointestinal bleeding. Other platelet inhibitors include dipyridamole (Persantine©), ticlopidine (Ticlid©), and clopidogrel (Plavix©). A 15% relative risk reduction in vascular events (stroke, death, and MI) has been documented for aspirin compared with placebo.

Smoking cessation: Smoking is a major risk factor for coronary artery disease. Nicotine constricts blood vessels and forces the heart to pump harder. A buildup of carbon monoxide (CO) reduces oxygen in the blood and damages the lining of the blood vessels.

Diabetes control: Managing diabetes with diet, exercise, weight control and medication is essential. Strict control of blood sugar may reduce damage to the heart.

Flu shots: Flu shots for patients with chronic cardiovascular disease are now used routinely.

Weight control: Being overweight contributes to other risk factors for stroke, such as high blood pressure, cardiovascular disease, and diabetes. Weight loss of as little as 10 pounds may lower blood pressure and improve cholesterol levels.

Exercise: Exercise can lower blood pressure, increase the level of HDL cholesterol (good cholesterol), and improve the overall health of blood vessels and heart. It also helps control weight, control diabetes and reduce stress. Thirty minutes daily of exercise is normally recommended.

Stress management: Stress can cause an increase in blood pressure along with increasing the blood's tendency to clot. Managing stress can be vital to keeping a heart healthy.

Diet: Eat healthy foods. A brain-healthy diet should include five or more daily servings of fruits and vegetables, foods rich in soluble fiber (such as oatmeal and beans), foods rich in calcium (dairy products, spinach), soy products (such as tempeh, miso, tofu and soy milk), and foods rich in omega-3 fatty acids, including cold-water fish, such as salmon, mackerel and tuna. Pregnant women and women who plan to become pregnant in the next several years should limit their weekly intake of cold-water fish because of the potential for mercury contamination. The U.S. Food and Drug Administration (FDA) has announced that whole grain barley and barley-containing products are allowed to claim that they reduce the risk of coronary artery disease.