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Ischemic heart disease

Related Terms

Alexithymia, angina, angina pectoris, angiogenesis, angiogram, arteriogram, atherosclerosis, blood clot, C-reactive protein, cholesterol, computerized tomography angiography (CTA), coronary artery bypass graft surgery (CABG), coronary heart disease (CHD), coronary occlusion, coronary thrombus, diabetes, enhanced external counter pulsation (EECP), heart attack, high-density lipoprotein (HDL), homocysteine, intravenous, low-density lipoprotein (LDL), magnetic resonance imaging (MRI), minimally invasive direct coronary artery bypass surgery (MIDCAB), myocardial infarction, obesity, percutaneous transluminal coronary angioplasty platelet (PTCA), silent ischemia, smoking, stress test, transmyocardial laser revascularization (TMR), ultrasonography.

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 ?-glucan extracts vary in their functionality with respect to cholesterol reduction. At least one barley ?-glucan concentrate, BarlivT 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 1,000?g for pregnant women. The United States Recommended Dietary Allowance (RDA) is 1,300?g 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.

Dong quai: There is insufficient evidence to support the use of Dong quai for the treatment of coronary artery disease. More studies are needed.

Although Dong quai is accepted as being safe as a food additive in the United States and Europe, its safety in medicinal doses is not known. Long-term studies of side effects are lacking. Avoid if allergic/hypersensitive to Dong quai or members of the Apiaceae / Umbelliferae family (like anise, caraway, carrot, celery, dill, parsley). Avoid prolonged exposure to sunlight or ultraviolet light. Use caution with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with diabetes, glucose intolerance or hormone sensitive conditions (like breast cancer, uterine cancer or ovarian cancer). Do not use before dental or surgical procedures. Avoid if pregnant or breastfeeding.

Elderberry and elder flower: Reliable human evidence is currently unavailable evaluating elder alone as a treatment for hyperlipidemia. Early study reports that elderberry juice may decrease serum cholesterol concentrations and increase low-density lipoprotein (LDL or "bad" cholesterol) stability. Additional research is needed in this area before a firm conclusion can be reached. Elder should not be used in the place of other more proven therapies, and patients are advised to discuss with their primary healthcare provider before using elderberry for treatment of high cholesterol.

Avoid if allergic to elder or to plants related to honeysuckle. Reports exist of allergies from contact with fresh elder stems. Use caution with diabetes, high blood pressure or urinary problems, or with drugs used for any of these conditions. Use caution with anti-inflammatories, diuretics, and laxatives. Avoid if pregnant or breastfeeding.

Fenugreek: There is insufficient evidence to support the use of fenugreek as an agent for hyperlipidemia. Additional research is needed in this area.

Avoid if allergic to fenugreek or chickpeas. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use cautiously with asthma, diabetes or a history of ulcers or stroke. Avoid if pregnant. Children should not take doses larger than what is commonly found in foods.

Flaxseed and flaxseed oil: It has been proposed that flaxseed, and its lignan complex, may exert a beneficial effect on plaque formation or cardiovascular outcomes from atherosclerosis, based on purported antioxidant and lipid-lowering properties. There is a paucity of high-quality direct human data in this area. However, there is promising evidence regarding the role of n-3 polyunsaturated fatty acids (PUFA) and alpha-linolenic acid (ALA) (present in flaxseed) for improving outcomes in individuals with coronary artery disease (CAD). Despite this evidence, it remains unclear if flaxseed supplementation improves human cardiovascular endpoints, and dosing regimens are not established.

Multiple poor-quality human studies have administered flaxseed products and measured effects on hyperlipidemia, with mixed results. There is a lack of well-designed human trials in this area, thus, strong evidence-based recommendations cannot be made at this time.

Flaxseed has been well-tolerated in studies for up to four months. Avoid if allergic to flaxseed, flaxseed oil or other plants of the Linaceae family. Avoid large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed with a history of esophageal stricture, ileus, gastrointestinal stricture or bowel obstruction. Avoid with history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis or inflammatory bowel disease. Use cautiously with a history of a bleeding disorder or with drugs that increase bleeding risk (like anticoagulants and non-steroidal anti-inflammatories (like aspirin, warfarin, Advil?), high triglyceride levels, diabetes, mania, seizures or asthma. Avoid if pregnant or breastfeeding. Avoid with prostate cancer, breast cancer, uterine cancer or endometriosis. Avoid ingestion of immature flaxseed pods.

Folate: Preliminary data suggests that folic acid lowers homocysteine levels and might reduce the risk of cardiovascular disease and hyperhomocysteinemia. Large randomized controlled trials are needed before a firm conclusion can be drawn.

Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

Gamma oryzanol: Gamma oryzanol has been used to reduce restenosis (return of blood vessel blockages after treatment) after coronary dilation, in combination with ticlopidine and probucol. Although restenosis was not impacted by any of the treatments, study with gamma oryzanol alone is needed to establish its effect for prevention of restenosis after coronary angioplasty.

Garlic: Preliminary research in humans suggests that deposits of cholesterol in blood vessels may not grow as quickly in people who take garlic. It is not clear if this is due to the ability of garlic to lower cholesterol levels, or to other effects of garlic on atherosclerosis.

Ginkgo: Animal and limited human data suggest a role of ginkgo in heart blood flow. More research is needed to better understand the effects of ginkgo on cardiovascular disease.

Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy or oak or cashews, then allergy to ginkgo is possible. Avoid with blood-thinners (like aspirin or warfarin (Coumadin?)) due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.

Ginseng: Several studies from China report that ginseng in combination with various other herbs may reduce symptoms of coronary artery disease. Low quality studies have evaluated various doses of Panax ginseng to reduce cholesterol levels in patients with hyperlipidemia. One study found no significant benefit in postmenopausal women, but used a dose of 500mg. Benefit was found in another study in an unknown population using a dose of 2g Panax ginseng extract three times a day. More studies with quality methodologies and doses would be helpful to ascertain the effects of Panax ginseng.

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

Goldenseal: In limited available clinical study, berberine reduced triglycerides, serum cholesterol, and LDL cholesterol. However, HDL cholesterol was not affected. Higher quality trials are needed to better determine the role of goldenseal in hypercholesterolemia.

Use cautiously in patients with cardiovascular disease, bleeding disorders, diabetes, gastrointestinal disorders, increased bilirubin levels, or glucose-6-phosphate deficiency. Use cautiously during pregnancy.

Grape seed: Historical statistics suggest that wine may reduce the risk of heart disease and may be of benefit for hypercholesterolemia. Animal studies suggest that grape seed may decrease cholesterol deposits in blood vessels and may reduce the amount of injury to heart muscle during a "heart attack."

Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with drugs processed using the liver's "cytochrome P450" enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid with disorders that increase the risk of bleeding or with active bleeding disorders (stomach ulcers, bleeding into the brain, etc.). Avoid if pregnant or breastfeeding.

Grapefruit: There is promising but inconclusive human evidence to support the use of grapefruit pectin in the prevention of heart disease. Additional study is needed in this area.

Avoid if allergic/hypersensitive to grapefruit or its constituents. Use cautiously if taking cytochrome P450 3A4 substrates, such as blood thinners, heart medications, anticonvulsants, antidepressants, antihistamines, blood pressure medications, benzodiazepines, calcium channel blockers, caffeine, corticosteroids, diabetes medications, erectile dysfunction medications, estrogens, immune modulators, HMG-CoA reductase inhibitors, macrolide antibiotics, or protease inhibitors. Use cautiously if drinking red wine, tonic water, or if smoking. Use cautiously with liver cirrhosis, if at risk for kidney stones, if have undergone gastric bypass surgery, and with diabetes. Use cautiously if pregnant or breastfeeding.

Green tea: There is evidence that regular intake of green tea may lower cholesterol levels and reduce the risk of cardiovascular conditions, like heart attack or atherosclerosis (clogged arteries). Laboratory studies, animal studies, and limited human research suggest possible benefits of green tea for hypercholesterolemia and hypertriglyceridemia. Better human evidence is necessary in this area.

Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously with diabetes or liver disease. Caution is advised when taking green tea supplements, as adverse effects including drug interactions are possible. Green tea supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

Guggul: Prior to 2003, the majority of scientific evidence suggested that guggulipid elicits significant reductions in serum total cholesterol, low-density lipoprotein (LDL), and triglycerides, as well as elevations in high-density lipoprotein (HDL). However, most published studies were small and methodologically flawed. In August 2003, a well-designed trial reported small significant increases in serum LDL levels associated with the use of guggul compared to placebo. No significant changes in total cholesterol, high-density lipoprotein (HDL), or triglycerides were measured. These results are consistent with two prior published case reports. Although this evidence provides preliminary evidence against the efficacy of guggul for hypercholesterolemia, due to the precedent of prior research and historical use, further study is necessary before a definitive conclusion can be reached for the use of this therapy for hyperlipidemia.

Avoid if allergic to guggul. Avoid with history of thyroid disorders, anorexia, bulimia or bleeding disorders. Signs of allergy to guggul may include itching and shortness of breath. Avoid if pregnant or breastfeeding.

Gymnema: Reductions in levels of serum triglycerides, total cholesterol, very low-density lipoprotein (VLDL), and low-density lipoprotein (LDL) have been observed in animals following the administration of gymnema. The mechanism may by via a decrease in the synthesis or increase in the metabolism of cholesterol, or through decreased intestinal fat absorption. One study of gymnema in type 2 diabetes patients reported decreased cholesterol and triglyceride levels as a secondary outcome. Further study is needed to better determine the effectiveness of gymnema for hyperlipidemia.

Avoid if allergic or sensitive to plants in the Asclepiadaceae (milkweed) family. Use cautiously with prescription drugs that may lower blood sugar levels. Dosing adjustments may be necessary.

Hawthorn: Hawthorn (Crataegus spp.), a flowering shrub of the rose family has an extensive history of use in cardiovascular disease dating back to the 1st Century. Increased blood flow to the heart and heart performance has been observed in animals when given hawthorn supplements. Clinical research indicates that hawthorn may be effective in decreasing frequency or severity of anginal symptoms. Hawthorn has not been tested in the setting of concomitant drugs such as beta-blockers or ACE-inhibitors, which are often the standard-of-care. At this time, there is insufficient evidence to recommend for or against hawthorn's use in angina.

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

Honey: In general, the evidence supporting the use of honey to treat hypercholesterolemia is weak. Additional study is needed to make a firm recommendation.

Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe in recommended doses. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.

Horny goat weed: Horny goat weed is traditionally used to treat cardiovascular diseases, like atherosclerosis. Early study suggests that horny goat weed may improve symptoms associated with ischemic cardio-cerebral vascular diseases. However, additional study is needed before a conclusion can be made.

Avoid if allergic/hypersensitive to horny goat weed (Epimedium grandiflorum), its constituents, or related plants in the Berberidaceae family. Use cautiously with tachyarrhythmia, decreased blood pressure, frequent nosebleeds, musculoskeletal disorders, bipolar disorder, immune function disorders, homocysteine disorders, hypothyroid conditions, and cardiovascular disease. Use cautiously if taking anticoagulant or antiplatelet (blood thinning) medications, antihypertensive (blood pressure) medications, antidepressants (MAOIs), interleukins, or cholesterol-lowering medications. Avoid with hormone-sensitive conditions or if taking estrogen or oral contraception. Avoid if pregnant or breastfeeding.

Kudzu: Kudzu (Pueria lobota) is well known to people in the Southeastern U.S. as an invasive weed, but it has been used in Chinese medicine for centuries. Kudzu has a long history of use in the treatment of cardiovascular disease, including acute myocardial infarction, and heart failure. A small number of poorly designed trials found kudzu to reduce the frequency of angina events in human subjects. Overall, available studies have been methodologically weak.

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

Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Case studies report that breathing techniques used in Kundalini Yoga may help people with angina pectoris reduce symptoms and the need for medication. A specific breathing technique of Kundalini yoga reputed to help prevent heart attacks was examined in one study to determine its effects on heart function. The technique is as follows: one breath per minute of respiratory exercise with slow inspiration for 20 seconds, breath retention for 20 seconds, and slow expiration for 20 seconds. This occurs for 31 consecutive minutes. The technique was found to stabilize the heart's electrical wave patterns, which may have value for maintaining cardiovascular health.

Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, poor memory or concentration. Avoid certain 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. Use cautiously with mental disorders as some techniques may cause an altered state of consciousness. Kundalini Yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.

Lactobacillus acidophilus: There is conflicting information from several human studies regarding the effects of Lactobacillus acidophilus-enriched dairy products in patients with high cholesterol. It may lower blood levels of total cholesterol or low-density lipoprotein ("bad cholesterol").

Avoid if allergic to dairy products containing L. acidophilus. Avoid with history of an injury or illness of the intestinal wall, immune-disease or heart valve surgery. Avoid with prescription drugs, like corticosteroids, because of the risk of infection. Use cautiously with heart murmurs. Antibiotics or alcohol may destroy Lactobacillus acidophilus. Therefore, it is recommended that Lactobacillus acidophilus be taken three hours after taking antibiotics or drinking alcohol. Some individuals can use antacids (like famotidine (Pepcid?), esomeprazole (Nexium?)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

L-carnitine: Although preliminary research is promising, there is insufficient available evidence to recommend for or against the use of carnitine for hyperlipoproteinemia (high levels of lipoprotein and cholesterol in blood) or myocardial infarction. Additional study is needed in this area.

Lemongrass: Early research has not shown any effect of lemongrass in patients with hypercholesterolemia. More research is needed in this area.

Avoid if allergic/hypersensitive to lemongrass, its constituents, or any members of the Poaceae family. Use cautiously if taking diabetic or cardiac medications or medications metabolized by cytochrome P450. Use cautiously with liver conditions. Avoid if pregnant or breastfeeding.

Lutein: Currently, there is insufficient available evidence to recommend for or against the use of lutein for atherosclerosis. Additional study is needed in this area.

Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously if at risk for cardiovascular disease or cancer. Avoid if pregnant or breastfeeding.

Lycopene: It has been suggested that lycopene may be helpful in people with atherosclerosis or high cholesterol, possibly due to antioxidant properties. Several studies have been published in this area, most using tomato juice as a treatment. Results have not agreed with each other, and this issue remains unclear.

Avoid if allergic to tomatoes or to lycopene. Due to a lack of conclusive data, avoid if pregnant or breastfeeding.

Macrobiotic diet: There is evidence that a macrobiotic diet might contribute to an improved ratio of HDL (good cholesterol) to LDL (bad cholesterol). However, more research is needed to explore whether such effects on cholesterol levels are reliable and meaningful.

There is a risk of nutritional deficiencies with use of a macrobiotic diet. However, this can be avoided with appropriate menu planning. Use cautiously with cancer or other medical conditions without expert planning or supplementation. Avoid in children or adolescents without professional guidance or appropriate supplementation. Avoid in pregnant or lactating women due to potential deficiencies, unless properly supplemented.

Magnesium: Magnesium has been studied for acute myocardial infarction, cardiac arrest, and coronary artery disease. Study results are mixed and additional research is needed.

Use cautiously in patients with bleeding disorders, or in those taking anticoagulants or antiplatelet agents, antidiabetic agents, or antihypertensive agents. Use intravenous magnesium sulfate with extreme caution in patients with eclampsia. Avoid in patients with atrioventricular heart block, renal failure, or severe renal disease. Avoid intravenous magnesium in women with toxemia during the first few hours of labor.

Meditation: There is currently not enough evidence that meditation has any clinical effects in cardiovascular disease. More studies are needed to determine whether meditation may have benefits and whether specific techniques might be more effective than others. Meditation may offer general benefits for mood and stress, which are likely to aid in cardiac care. However, more studies are needed to recommend meditation as a specific treatment during cardiac rehabilitation. Transcendental Meditation?, along with other therapies, has been reported to be of benefit for older patients with atherosclerosis, particularly in those with apparent cardiovascular heart disease.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and should not be used as the sole approach to illnesses.

Music therapy: Music therapy may improve cardiac conditions and may have effects on heart rate and breathing rate. Additional research is needed. Music therapy is generally known to be safe.

Nopal: Nopal may aid in reducing hyperlipidemia, although there is currently insufficient evidence to make a strong recommendation for this condition.

Avoid if allergic/hypersensitive to nopal (Opuntia spp.), any of its constituents, or members of the Cactaceae family. Use cautiously if taking medications that alter blood sugar, cholesterol or blood pressure. Use cautiously with thyroid dysfunction and rhinitis (runny or congested nose) or asthma. Avoid with immunosuppression or impaired liver function. Avoid if pregnant or breastfeeding. It is recommended that oral doses of dried nopal be taken with at least eight ounces (250mL) of water.

Omega-3 fatty acids: Preliminary studies report reductions in angina pectoris (chest pain) associated with fish oil intake. Some research also reports that regular intake of fish or fish oil supplements reduces the risk of developing plaques from atherosclerosis in the arteries of the heart, while other research reports no effects. Additional evidence is necessary before a firm conclusion can be drawn in this area. Although some studies suggest benefits for secondary cardiovascular disease prevention, others do not.

Ozone therapy: Autohemotherapy (AHT) is a technique that withdraws blood from the body, mixes it with ozone gas, and then injects it back into the body through a vein or muscle. There is limited preliminary study of AHT in a small number of patients with history of a heart attack. A decrease in total cholesterol and low-density lipoproteins ("bad" cholesterol) was reported. However, this research was not well designed. Better research is necessary before a firm conclusion can be reached for the use of ozone therapy in patients with cardiovascular disease.

Autohemotherapy has been associated with transmission of viral hepatitis, and with a possible case of dangerously lowered blood cell counts. Consult a qualified health professional before undergoing any ozone-related treatment.

Pantethine: Data has shown that pantethine exhibits lipid-modulating effects. Additional human study is needed regarding the use of pantethine for ischemic heart disease.

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

Pantothenic acid: Pantothenic acid itself has not been shown to have any cholesterol-lowering effects. However, a chemical derivative of pantothenic acid called pantethine has been studied for high cholesterol, with compelling preliminary evidence in humans.

Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.

Peony: Dandi Tablet is a traditional Chinese medicine (TCM) formula containing peony; in the TCM paradigm, Dandi Tablet is used for purportedly tonifying Shen and activating blood circulation. Additional high-quality research is required to evaluate the use of this formulation for lipid lowering effects and for coronary heart disease prevention or treatment.

Avoid if allergic or sensitive to peony. Avoid with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.

Physical therapy: Physical therapy has been used to treat coronary syndrome X (syndrome X), which is a chronic pain disorder with exercise-induced chest pain. Early evidence is promising, but additional study is needed to make a firm recommendation for the use of physical therapy for cardiovacular conditions.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. Persistent pain and fractures of unknown origin have been reported. Physical therapy may increase the duration of pain or cause limitation of motion. Pain and anxiety may occur during the rehabilitation of patients with burns. Both morning stiffness and bone erosion have been reported in the physical therapy literature although causality is unclear. Erectile dysfunction has also been reported. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Policosanol: Policosanol has been used to treat high cholesterol. However, some newer research suggests that policosanol may not be as beneficial as previously thought.

Avoid if allergic or hypersensitive to policosanol. Use cautiously if taking aspirin or blood pressure medications. Use cautiously with high blood pressure. Use cautiously if pregnant or breastfeeding.

Pomegranate: Preliminary study results of pomegranate for atherosclerosis are mixed. Consumption of a juice containing a combination of fruits, including pomegranate, was found to have a beneficial effect on high cholesterol. Additional studies are needed to confirm these early findings.

Avoid if allergic or hypersensitive to pomegranate. Avoid with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root/stem bark should only be used under supervision of a qualified healthcare professional. Use cautiously with liver damage or disease. Pomegranate supplementation can be unsafe during pregnancy when taken by mouth. The bark, root and fruit rind can cause menstruation or uterine contractions. Avoid if breastfeeding due to a lack of scientific data.

Prayer: Prayer may have far reaching healing effects that are hard to study. Initial studies in patients with heart disease report variable effects on severity of illness, complications during hospitalization, procedure outcome, or death rates when intercessory prayer is used.

Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time it takes to consult with a healthcare professional or receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches, and require an open dialog between patients and caregivers. Based on clinical study, patients certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know they were being prayed for.

Probiotics: There is limited evidence suggesting probiotics may help reduce low density lipoprotein (LDL or "bad") cholesterol, a risk factor for cardiovascular disease, in overweight people. These findings are tentative and more evidence is needed to arrive at firm conclusions.

Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional, such as a psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner. Its purpose is the exploration of thoughts, feelings and behavior for the purpose of problem solving or achieving higher levels of functioning. Alexithymia, or the inability to express one's feelings may influence the course of coronary heart disease (CHD). Educational sessions and group psychotherapy may decrease the incidence of alexithymia and coronary heart disease.

Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to worsening of symptoms or increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

Pycnogenol: Pycnogenol? may reduce low-density lipoprotein (LDL/"bad cholesterol") levels and increase high-density lipoprotein (HDL/"good cholesterol") levels. Due to conflicting data, further studies are necessary before a clear conclusion can be drawn on the use of pycnogenol for high cholesterol.

Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia, or bleeding disorders. Use cautiously if taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.

Qi gong: There is some evidence suggesting that Qi gong may be used in the treatment of angina and atherosclerosis. More studies would lead to a better understanding of this technique.

Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders. In cases of potentially serious conditions, Qi gong should not be used as the only treatment instead of more proven therapies, and should not delay the time it takes to see an appropriate healthcare provider.

Quercetin: Quercetin is one of the almost 4,000 bioflavonoids (antioxidants) that occur in foods of plant origin, such as red wine, onions, green tea, apples, berries, and brassica vegetables (cabbage, broccoli, cauliflower, turnips). Several of the effects of flavonoids that have been observed in laboratory and animal studies suggest that they might be effective in reducing cardiovascular disease risk. Studies in humans using polyphenolic compounds from red grapes showed improvement in endothelial function in patients with coronary heart disease. Antioxidant and cholesterol-lowering effects are proposed.

Quercetin is generally considered safe when taken at doses normally found in foods. Avoid if allergic or hypersensitive to quercetin. Possible eye, skin, gastrointestinal and/or respiratory tract infection may occur. Avoid if pregnant or breastfeeding.

Red clover: Red clover has been shown to improve the flow of blood through arteries and veins. However, it has not been clearly shown to have beneficial effects on high cholesterol. Due to conflicting study results, further research is needed in this area before a recommendation can be made.

Avoid if allergic to red clover or other isoflavones. Use cautiously with hormone replacement therapy (HRT) or birth control pills, history of a bleeding disorder, breast cancer, or endometrial caner. Avoid if pregnant or breastfeeding.

Red yeast rice: Red yeast rice is the product of yeast (Monascuspurpureus) grown on rice, and is served as a dietary staple in some Asian countries. It contains several compounds collectively known as Monacolins, substances known to inhibit cholesterol synthesis. One of these, "Monacolin K" is a potent inhibitor of HMG-CoA reductase, and is also known as lovastatin (Mevacor?). Preliminary evidence reports that taking red yeast riceby mouth may improve blood flow and may be effective for treatment of coronary heart disease.

Caution is advised when taking red yeast rice supplements, as adverse effects including drug interactions are possible. Red yeast rice supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor. Red yeast rice should not be used in people with liver problems or in heavy alcohol users.

Reishi: Reishi (Ganoderma lucidum) is a fungus (mushroom) that grows wild on decaying logs and tree stumps.Reishi has been used in traditional Chinese medicine for more than 4,000 years to treat liver disorders, high blood pressure, arthritis and other ailments. A reishi supplement was reported to improve major symptoms of coronary heart disease such as angina (chest pain), palpitations (irregular heart beats), shortness of breath, high blood pressure, and high cholesterol in patients. Long-term studies are needed to evaluate the efficacy and safety of reishi in coronary heart disease.

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

Relaxation therapy: Early research in patients with angina reports that relaxation may reduce anxiety, depression, frequency of angina episodes, need for medication, and physical limitations. Large well-designed studies are needed to confirm these results.

Early research of relaxation techniques in people who have had a heart attack suggests that fewer future heart attacks may occur when relaxation is regularly practiced. However, only a small number of patients have been studied. Better research is necessary before a firm conclusion can be reached on this use of this therapy for heart attack risk reduction.

Avoid with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, then relaxing the muscles) should be used cautiously with illnesses like heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time to diagnosis or treatment with more proven techniques.

Resveratrol: Resveratrol is used as an antioxidant in various health conditions, including cardiovascular disease. Laboratory animal studies suggest resveratrol helps restore blood flow to the heart. Well-designed clinical trials in humans using resveratrol are needed.

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

Rhubarb: Rhubarb has been examined for its effects on hypercholesterolemia. In one study, a combination product containing rhubarb (Rheum palmatum) seemed to lower cholesterol. In another study, rhubarb (Rheum rhabarbarum) stalk fiber also seemed to lower cholesterol. However, large, high quality studies using rhubarb as a monotherapy are needed.

Avoid if allergic/hypersensitive to rhubarb, its constituents, or related plants from the Polygonaceae family. Avoid using rhubarb for more than two weeks because it may induce tolerance in the colon, melanosis coli, laxative dependence, pathological alterations to the colonic smooth muscles, and substantial loss of electrolytes. Avoid with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12 due to water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, history of kidney stones, or thin or brittle bones. Use cautiously if taking anti-psychotic drugs or oral drugs, herbs or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

Safflower: Safflower yellow injection may improve both western and traditional Chinese medicine symptoms for angina pectoris and coronary artery disease. More high-quality studies are needed to establish the effect of safflower yellow injection. Limited available evidence suggests that safflower oil may be of benefit for atherosclerosis, familial hyperlipidemia, and hypercholesterolemia. More study is needed before a firm conclusion can be drawn.

Avoid if allergic/hypersensitive to safflower, Carthamus tinctorius, safflower oil, daisies, ragweed, chrysanthemums, marigolds or any related constituents. Use parenteral safflower oil emulsions cautiously in newborns. Use cautiously if taking anticoagulants (blood thinners) or anti-platelet drugs, immunodepressants or pentobarbital. Use cautiously with diabetes, hypotension, inadequate liver function, hypercoagulability, and skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.

Scotch broom: Scotch broom herb has been taken by mouth traditionally for a variety of conditions related to the heart or blood circulation. These include abnormal heart rhythms (arrhythmias), fast heart rate (tachycardia), swelling in the legs (peripheral edema), water in the lungs (pulmonary edema, congestive heart failure), and low blood pressure (hypotension). Sparteine may affect the electrical conductivity of heart muscle (similar to type 1A antiarrhythmic drugs such as quinidine). However, there is limited evidence in humans and it is not clear if sparteine found in the plant form has clinically meaningful effects. These potential properties of scotch broom may be dangerous in individuals with heart disease or taking cardiac medications. People with cardiovascular conditions should be evaluated and supervised by a licensed healthcare professional.

Avoid if allergic or hypersensitive to scotch broom or any of its constituents, including sparteine. Smoking or taking the flower or above-ground parts of scotch broom by mouth may not be safe, due to the presence of toxic alkaloids. Poisoning of livestock grazing on scotch broom has been reported. Nausea/vomiting has developed in children from sucking on the flowers of the related species, French broom. Small amounts of scotch broom may be safe in otherwise healthy individuals. Use in foods as a flavoring or coloring agent is generally considered safe. Medical supervision is recommended when using this herb. Scotch broom seeds have been used as a coffee substitute, which may carry a significant risk of toxicity. Avoid if pregnant or breastfeeding.

Sea buckthorn: Sea buckthorn (Hippophae) may help to improve cardiovascular disease. More, higher quality research is needed in this area.

Avoid if allergic or hypersensitive to sea buckthorn, its constituents, or members of the Elaeagnaceae family. Use cautiously if taking angiotensin converting enzyme (ACE) inhibitors, anticoagulants and antiplatelet agents (blood thinners), antineoplastics (anticancer agents), or cyclophosphamide or farmorubicin. Avoid higher doses than food amounts if pregnant or breastfeeding.

Selenium: Low selenium levels have been associated with the development of cardiomyopathy, and selenium supplementation is likely of benefit in such cases (for example in Keshan disease and Chagas' disease). However, most cases of cardiomyopathy are not due to low selenium levels and therefore selenium may not be helpful. It has been suggested that low selenium levels may be a risk for coronary heart disease, although this remains unclear. Despite the documented antioxidant and chemopreventive properties of selenium, studies of the effects of selenium intake and supplementation on cardiovascular disease yield inconsistent findings. Better-designed trials are needed to reach a firm recommendation.

Avoid if allergic or sensitive to products containing selenium. Avoid with history of nonmelanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.

Shea butter: In clinical trials, shea butter/oil was shown to lower increases in postprandial lipids and postprandial factor VII coagulant concentrations. Additional trials with larger sample sizes are needed to confirm shea butter's proposed lipid-lowering effects.

Avoid in patients taking anticoagulants. Avoid in individuals with a latex allergy as anecdotal information suggests that some shea butter formulations may contain latex.

Soy: Further investigation is needed before a conclusion can be made about the use of soy for cardiovascular disease.

Spirulina: In animal studies, spirulina has been found to lower blood cholesterol and triglyceride levels. Preliminary poor-quality studies in humans suggest a similar effect. Better research is needed before a firm conclusion can be drawn about the use of spirulina for high cholesterol.

Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; and if consuming a high-protein diet. Avoid in children and if pregnant or breastfeeding.

Squill: Currently, there is insufficient available evidence to recommend for or against the use of squill for coronary artery disease. Additional study is needed.

Avoid if allergic or hypersensitive to Urginea maritima or members of the Liliaceae family. Avoid with heart, stomach, or intestine problems. Avoid with history of high potassium or high calcium levels. Use cautiously with cardioglycosides. Avoid if pregnant or breastfeeding.

Tai chi: There is evidence that suggests tai chi decreases blood pressure and cholesterol as well as enhances quality of life in patients with chronic heart failure. Most studies have used elderly Chinese patients as their population; therefore, additional research is needed before a firm conclusion can be drawn about the use of this technique for cardiovascular disease or cardiovascular rehabilitation.

Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

Taurine: Taurine may offer benefit to individuals with hypercholesterolemia. More study is needed to make a conclusion. Taurine is an amino acid and it is unlikely that there are allergies related to this constituent.

However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, coagulation disorders, potential for mania, or epilepsy. Avoid consumption of energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients, then consuming alcohol or exercising. Use cautiously if pregnant or breastfeeding because taurine is a natural component of breast milk.

Transcutaneous electrical nerve stimulation (TENS): Several small, brief studies report benefits of TENS on angina. However, most studies were conducted during the late 1980s and early 1990s, and were not well designed or reported. New drugs for heart disease have been developed since these studies were conducted, and people with heart disease or chest pain are advised to seek immediate medical attention from a licensed physician.

Avoid with implantable devices, like defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

Thiamin (Vitamin B1): Thiamin has been studied as a way to help widen arteries that are too narrow. Regular intake of thiamin might help slow the progression of atherosclerosis. However, additional research is needed.

Avoid if allergic or hypersensitive to thiamin. Rare hypersensitivity/allergic reactions have occurred with thiamin supplementation. Skin irritation, burning, or itching may rarely occur at injection sites. Large doses may cause drowsiness or muscle relaxation. Thiamin appears safe if pregnant or breastfeeding. Use cautiously if pregnant or breastfeeding.

Thymus extract: Preliminary evidence suggests that thymus extract may increase left ventricular function, exercise tolerance, and survival. Additional study is needed regarding the use of thymus extract for cardiomyopathy.

Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy, with thymic tumors, myasthenia gravis (neuromuscular disorder), untreated hypothyroidism, or if taking hormonal therapy. Avoid if pregnant or breastfeeding; thymic extract increases human sperm motility and progression.

Traditional Chinese medicine (TCM): TCM herb combinations have been found to improve some markers of coronary heart disease. The traditional Chinese method of Liqi Kuanxiong Huoxue combined with conventional treatment has been reported to reduce symptoms of stable and unstable angina. More studies of better design are needed before recommendations can be made.

Chinese herbs can be potent and may interact with other herbs, foods or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.

Tribulus: Preliminary research suggests that tribulus (Tribulus terrestris) may be beneficial to patients with coronary heart disease. Additional study is needed to further evaluate its clinical effectiveness.

Avoid if allergic/hypersensitive to Tribulus terrestris or the members of the Zygophyllaceae family. Use cautiously with enlarged prostate or prostate cancer, and diabetes. Use cautiously if taking steroids, or blood pressure medication like beta-blockers, calcium channel blockers, or digoxin. Avoid if pregnant or breastfeeding.

Turmeric: Early studies suggest that turmeric may lower levels of low-density lipoprotein ("bad cholesterol") and total cholesterol in the blood. Better human studies are needed before a conclusion can be made for the use of turmeric for high cholesterol.

Avoid if allergic or hypersensitive to turmeric, curcumin, yellow food colorings, or plants belonging to the Zingiberaceae (ginger) family. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, hypoglycemia, or gallstones. Use cautiously with blood-thinners, such as warfarin (like Coumadin?), and blood sugar-altering medications. Avoid in medicinal amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.

Vitamin B12: Some evidence suggests that folic acid plus vitamin B12 and pyridoxine daily can decrease the rate of restenosis in patients treated with balloon angioplasty. But this combination does not seem to be as effective for reducing restenosis in patients after coronary stenting. Due to the lack of evidence of benefit and potential for harm, this combination of vitamins should not be recommended for patients receiving coronary stents.

Hyperhomocysteinemia (high homocysteine levels in the blood) is a risk factor for coronary, cerebral, and peripheral atherosclerosis, recurrent thromboembolism, deep vein thrombosis, myocardial infarction (heart attack), and ischemic stroke. Folic acid, pyridoxine (vitamin B6), and vitamin B12 supplementation can reduce total homocysteine levels; however, this reduction does not seem to help with secondary prevention of death or cardiovascular events such as stroke or myocardial infarction in people with prior stroke. More evidence is needed to fully explain the association of total homocysteine levels with vascular risk and the potential use of vitamin supplementation.

Some evidence suggests that vitamin B12 in combination with fish oil might be superior to fish oil alone when used daily to reduce total serum cholesterol and triglycerides. Well-designed clinical trials of vitamin B12 supplementation alone are needed before a conclusion can be made on the use of vitamin B12 for high cholesterol.

Avoid vitamin B12 supplements if allergic or hypersensitive to cobalamin, cobalt, or any other vitamin B12 product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the Recommended Dietary Allowance (RDA). There is not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.

Vitamin B6: There are conflicting findings about the potential benefit or harm of taking folic acid plus vitamin B6 and vitamin B12 following angioplasty. Further research is needed before a conclusion can be made.

High homocysteine levels in the blood (hyperhomocysteinemia) are a risk factor for cardiovascular disease, blood clotting abnormalities, myocardial infarction (heart attack), and ischemic stroke. Taking pyridoxine supplements alone or in combination with folic acid has been shown to be effective for lowering homocysteine levels. However, it is not clear if lowering homocysteine levels results in reduced cardiovascular morbidity and mortality. Until definitive data is available, the current recommendation is screening of 40 year-old men and 50 year-old women for hyperhomocysteinemia. Decreased pyridoxine concentrations are also associated with increased plasma levels of C-reactive protein (CRP). CRP is an indicator of inflammation that is associated with increased cardiovascular morbidity in epidemiologic studies.

Avoid vitamin B6 products if sensitive or allergic to any of their ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Avoid excessive dosing. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). Use cautiously if pregnant or breastfeeding.

Vitamin C (ascorbic acid): Due to its antioxidant properties, vitamin C has been used in patients with ischemic heart disease. Early data suggest that vitamin C may have a benefit on blood flow in the heart but more research is needed to confirm these findings.

Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding. It is not clear if vitamin C supplements in doses higher than Dietary Reference Intake recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.

Vitamin D: There is insufficient evidence regarding the use of vitamin D for hypertriglyceridemia.

Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

Vitamin E: Vitamin E has been evaluated in patients with angina, atherosclerosis and high cholesterol in numerous laboratory, population, and clinical trials. It remains unclear if there are clinically meaningful benefits, and it is not known what the effects of vitamin E are compared to (or in combination with) other agents that have been clearly demonstrated as beneficial for these conditions. Further research is warranted before a clear conclusion can be drawn.

Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid above the recommended daily level in pregnant women and breastfeeding women.

White horehound: Early study shows that white horehound may lower cholesterol and triglyceride blood levels and may be of benefit for patients with atherosclerosis. Further research is needed to confirm these results.

Avoid if allergic or hypersensitive to white horehound or any member of the Lamiaceae family (mint family). White horehound is generally considered safe when used to flavor foods. Use cautiously with diabetes, high/low/unstable blood pressure, high levels of sodium in the blood, irregular heartbeats or gastrointestinal disease (like ileus, atony or obstruction). Use cautiously with diuretics (drugs that increase urine production). Avoid if pregnant or breastfeeding.

Wild yam: Animal studies have shown that wild yam can reduce the absorption of cholesterol from the gut and may be of benefit for patients with hyperlipidemia. Early studies in humans have shown changes in the levels of certain sub-types of cholesterol, including decreases in low-density lipoprotein (LDL, or "bad cholesterol") and triglycerides and increases in high-density lipoprotein (HDL, or "good cholesterol"). More studies are needed in this area.

Avoid if allergic or hypersensitive to wild yam or any member of the Dioscorea plant family. Use cautiously with a history of hormone-sensitive conditions (such as fibroids, endometriosis, or cancer of the breast, uterus, or ovary), asthma, blood clots, stroke, low blood sugar, or diabetes. Use cautiously if taking hormone replacement therapy, birth control pills, or blood sugar-altering agents. Avoid if pregnant or breastfeeding.

Yucca: A blend of partially purified Yucca schidigera and Quillaja saponaria extracts may reduce cholesterol levels in patients with hypercholesterolemia. However, additional study is needed in this area, with yucca studied alone.

Avoid if allergic or hypersensitive to yucca (Yucca schidigera), its constituents, or members of the Agavaceae family. Use cautiously if taking antihyperlipidemia (cholesterol lowering) agents. Avoid if pregnant or breastfeeding.

Fair negative scientific evidence:

Acacia: There is preliminary evidence that acacia may not be helpful for hypercholesterolemia.

Acacia is generally considered safe when taken in the amounts typically found in foods. Avoid if allergic to acacia, pollen or any members of the Fabaceae or Leguminosae family. Use cautiously if taking amoxicillin or iron. Use cautiously with gastrointestinal disorders, respiratory disorders or pink eye. Acacia may prevent the body from absorbing drugs, and tannins from acacia may increase the risk of certain cancers. Avoid if pregnant or breastfeeding.

Beta-carotene: Although several studies suggest that diets high in fruits and vegetables containing beta-carotene appear to reduce the risk of cardiovascular disease, most randomized controlled trials with oral supplements of beta-carotene have not supported these claims. A Science Advisory from the American Heart Association states that the evidence does not justify the use of antioxidants such as beta-carotene for reducing the risk of cardiovascular disease.

Avoid if sensitive to beta-carotene, vitamin A or any other ingredients in beta-carotene products.

Chelation therapy: Evidence does not support the use of EDTA chelation therapy in heart disease even though there is strong popular interest in this use.

Use cautiously in individuals taking warfarin; individuals with osteoporosis or other bone deficiency conditions; individuals with serious deficiencies of essential minerals that may be further depleted by chelation (would require replacement).

Evening primrose oil: Early study of evening primrose oil shows a lack of beneficial effects on cardiovascular health and function.

Avoid if allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid with seizure disorders. Use cautiously with mental illness drugs. Stop use two weeks before surgery with anesthesia. Avoid if pregnant or breastfeeding.

Glucosamine: Glucosamine does not appear to alter LDL or HDL levels in patients with chronic joint pain or hypercholesterolemia.

Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use caution with diabetes or history of bleeding disorders. Avoid if pregnant or breastfeeding.

Omega-3 fatty acids, fish oil, alpha-linolenic acid: Although fish oil may reduce triglycerides, beneficial effects in patients with hypercholesterolemia have not been demonstrated.

Relaxation therapy: Initial research in which patients were given an advice and relaxation audiotape within 24 hours of hospital admission for a heart attack found a reduction in the number of misconceptions about heart disease, but no benefits on measured health-related outcomes.

Vitamin C (ascorbic acid): Vitamin C does not appear to be of benefit for heart disease prevention.

Vitamin E: Vitamin E does not appear to be of benefit for heart disease prevention.

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.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

American Heart Association. .

Boekholdt SM, Sandhu MS, Day NE, Luben R, Bingham SA, Peters RJ, Wareham NJ, Khaw KT. Physical activity, C-reactive protein levels and the risk of future coronary artery disease in apparently healthy men and women: the EPIC-Norfolk prospective population study. Eur J Cardiovasc Prev Rehabil. 2006;13(6):970-6.

Duffey KJ, Gordon-Larsen P, Jacobs DR Jr, Williams OD, Popkin BM. Differential associations of fast food and restaurant food consumption with 3-y change in body mass index: the Coronary Artery Risk Development in Young Adults Study. Am J Clin Nutr. 2007;85(1):201-8.

Harris WS, Assaad B, Poston WC. Tissue omega-6/omega-3 fatty acid ratio and risk for coronary artery disease. Am J Cardiol. 2006 Aug 21;98(4A):19i-26i. Epub 2006 May 30.

National Institutes of Health. .

Natural Standard: The Authority on Integrative Medicine. .

U.S. Food and Drug Administration. .

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