Cardiovascular disease, also referred to as circulatory disease and heart disease, is the number one cause of death in the United States. According to the American Heart Association, since 1963, Congress has required the president to proclaim February "American Heart Month" in order to raise awareness of cardiovascular disease and its risks. People with cardiovascular disease may not have any symptoms, or they may experience difficulty breathing during exertion or when lying down, fatigue, lightheadedness, dizziness, fainting, depression, memory problems, confusion, frequent waking during sleep, chest pain, awareness of the heartbeat, sensations of fluttering or pounding in the chest, swelling around the ankles, or a large abdomen. Recognize the Risk Factors Many risk factors are associated with cardiovascular disease; most can be managed, but some cannot. The aging process and hereditary predisposition are risk factors that cannot be altered. Until age 50, men are at greater risk than women of developing heart disease, though once a woman enters menopause, her risk triples.1 Major risk factors you can treat or control include tobacco smoke,2 high blood cholesterol, high blood pressure, physical inactivity, obesity and overweight, and diabetes mellitus. Several diseases play a role in the development of cardiovascular disease. Many people with cardiovascular disease have elevated or high cholesterol levels.3 Low HDL cholesterol (known as the "good" cholesterol) and high LDL cholesterol (known as the "bad" cholesterol) are more specifically linked to cardiovascular disease than is total cholesterol.4 Atherosclerosis (hardening of the arteries) of the vessels that supply the heart with blood is the most common cause of heart attacks. Atherosclerosis and high cholesterol usually occur together, though cholesterol levels can change quickly and atherosclerosis generally takes decades to develop. Hypertension (high blood pressure) is a major risk factor for cardiovascular disease, and the risk increases as blood pressure rises.5 Glucose intolerance and diabetes constitute separate risk factors for heart disease. Smoking increases the risk of heart disease caused by hypertension. According to some studies, a high triglyceride level is an independent risk factor for heart disease in some people.6 High homocysteine levels have also been identified as an independent risk factor.7 Abdominal fat, or a "beer belly," versus fat that accumulates on the hips, is associated with increased risk of cardiovascular disease and heart attack.8 Overweight individuals are more likely to have additional risk factors related to heart disease, specifically hypertension, high blood sugar levels, high cholesterol, high triglycerides, and diabetes. Dietary Diagnosis A diet high in fruits and vegetables,9 fiber,10 and fish11 appears protective against heart disease, while a high intake of saturated fat (found in meat and dairy fat) and trans fatty acids (in margarine and processed foods containing hydrogenated vegetable oils)12 may contribute to heart disease. A large study of male healthcare professionals found that those men eating mostly a "prudent" diet (high in fruits, vegetables, legumes, whole grains, fish, and poultry) had a 30% lower risk of heart attacks compared with men who ate the fewest foods in the "prudent" category.13 By contrast, men who ate the highest percentage of their foods from the "typical American diet" category (high in red meat, processed meat, refined grains, sweets, and desserts) had a 64% increased risk of heart attack, compared with men who ate the fewest foods in that category. A parallel study of female healthcare professionals showed a 15% reduction in cardiovascular risk for those women eating a diet high in fruits and vegetables-compared with those eating a diet low in fruits and vegetables.14 Preliminary evidence has linked high salt consumption with increased cardio-vascular disease incidence and death among overweight, but not normal weight, people.15 Moderate alcohol consumption appears protective against heart disease.16 However, light alcohol consumption in men with established coronary heart disease is not associated with either benefit or deleterious effect.17 Supplements for Heart Health Fish oil contains EPA (eicosapentaenoic acid) and DHA (docosa-hexaenoic acid), both omega-3 fatty acids. These omega-3 fatty acids keep blood triglycerides in check and may inhibit the progression of atherosclerosis.18 EPA and DHA have also been reported to help prevent cardiac arrhythmias.19 Studies indicate that tocotrienols--members of the vitamin E family--maintain a healthy cardiovascular system.20 Like vitamin E, tocotrienols may offer protection against atherosclerosis by preventing oxidative damage to LDL cholesterol (oxidation of LDL cholesterol is believed to be one of the triggering factors for atherosclerosis).21 In patients with severe atherosclerosis of the carotid artery--the main artery supplying blood to the head--200 mg of tocotrienols per day reduced lipid peroxides in the blood. Vitamin C protects LDL cholesterol from oxidative damage; only when LDL is damaged does cholesterol appear to lead to heart disease.22 Vitamin C may also protect against heart disease by reducing the stiffness of arteries and the tendency of platelets to clump together.23 Researchers have shown that vitamin C improves nitric oxide activity.24 Nitric oxide is needed for the dilation of blood vessels, potentially important in lowering blood pressure and preventing spasms of arteries in the heart that might otherwise lead to heart attacks. Numerous medicinal plants and plant compounds have demonstrated an ability to protect LDL cholesterol from free radical damage. In a four-year clinical trial studying people 50 to 80 years old with atherosclerosis,25 900 mg of a standardized garlic supplement reduced arterial plaque formation by 5 to 18%. The benefits were most notable in women. Evidence suggests that guggul can significantly improve cholesterol and triglyceride levels in people.26 Psyllium has also been studied as a way to reduce cholesterol and triglyceride levels. An analysis of all double-blind trials in 1997 concluded that a daily amount of 10 grams psyllium lowered cholesterol levels by 5% and LDL cholesterol by 9%.27 References: 1. Kannel WB. Hazards, risks, and threats of heart disease from the early stages to symptomatic coronary heart disease and cardiac failure. Cardiovasc Drugs Ther 1997;11 Suppl:199-212 [review]. 2. Law MR, Morris JK, Wald NJ. Environmental tobacco smoke exposure and ischaemic heart disease: an evaluation of the evidence. BMJ 1997;315:973-80. 3. Kinosian B, Glick H, Garland G. Cholesterol and coronary heart disease: predicting risks by levels and ratios. Ann Intern Med 1994;121:641-7. 4. Kwiterovich PO Jr. The antiatherogenic role of high-density lipoprotein cholesterol. Am J Cardiol 1998;82:Q13-21 [review]. 5. Kannel WB. Office assessment of coronary candidates and risk factor insights from the Framingham study. J Hypertens Suppl 1991;9:S13-9. 6. Gotto AM Jr. Triglyceride as a risk factor for coronary artery disease. Am J Cardiol 1998;1998;82:Q22-5 [review]. 7. Seman LJ, McNamara JR, Schaefer EJ. Lipoprotein(a), homocysteine, and remnantlike particles: emerging risk factors. Curr Opin Cardiol 1999;14:186-91. 8. Megnien JL, Denarie N, Cocaul M, et al. Predictive value of waist-to-hip ratio on cardiovascular risk events. Int J Obes Relat Metab Disord 1999;23:90-7. 9. Law MR, Morris JK. By how much does fruit and vegetable consumption reduce the risk of ischaemic heart disease? Eur J Clin Nutr 1998;52:549-56. 10. Pietinen P, Rimm EB, Korhonen P, et al. Intake of dietary fiber and risk of coronary heart disease in a cohort of Finnish men. The Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study. Circulation 1996;94:2720-7. 11. Albert CM, Hennekens CH, O'Donnell CJ, et al. Fish consumption and risk of sudden cardiac death. JAMA 1998;279:23-8. 12. Hu FB, Stampfer MJ, Rimm E, et al. Dietary fat and coronary heart disease: a comparison of approaches for adjusting for total energy intake and modeling repeated dietary measurements. Am J Epidemiol 1999;149:531-40. 13. Kinosian B, Glick H, Garland G. Cholesterol and coronary heart disease: predicting risks by levels and ratios. Ann Intern Med 1994;121:641-7. 14. Kannel WB. Hazards, risks, and threats of heart disease from the early stages to symptomatic coronary heart disease and cardiac failure. Cardiovasc Drugs Ther 1997;11 Suppl:199-212 [review]. 15. He J, Ogden LG, Vupputuri S, et al. Dietary sodium intake and subsequent risk of cardiovascular disease in overweight adults. JAMA 1999;282:2027-34. 16. Hu FB, Stampfer MJ, Rimm E, et al. Dietary fat and coronary heart disease: a comparison of approaches for adjusting for total energy intake and modeling repeated dietary measurements. Am J Epidemiol 1999;149:531-40. 17. Strandhagen E, Hansson PO, Bosaeus I, et al. High fruit intake may reduce mortality among middle-aged and elderly men. The Study of Men Born in 1913. Eur J Clin Nutr 2000;54:337-41. 18. von Schacky C, Angerer P, Kothny W, et al. The effect of dietary omega-3 fatty acids on coronary atherosclerosis. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1999;130:554-62. 19. Nair SSD, Leitch JW, Falconer J, Garg ML. Prevention of cardiac arrhythmia by dietary (n-3) polyunsaturated fatty acids and their mechanism of action. J Nutr 1997;127:383-93. 20. Theriault A, Chao JT, Wang Q, et al. Tocotrienol: a review of its therapeutic potential. Clin Biochem 1999;32:309-19 [review]. 21. Suarna C, Hood RL, Dean RT, Stocker R. Comparative antioxidant activity of tocotrienols and other natural lipid-soluble antioxidants in a homogeneous system, and in rat and human lipoproteins. Biochim Biophys Acta 1993;1166:163-70. 22. Balz F. Antioxidant vitamins and heart disease. Presented at the 60th Annual Biology Colloquium, Oregon State University, Corvallis, Oregon, February 25, 1999. 23. Wilkinson IB, Megson IL, MacCallum H, et al. Oral vitamin C reduces arterial stiffness and platelet aggregation in humans. J Cardiovasc Pharmacol 1999;34:690-3. 24. Taddei S, Virdis A, Ghaidoni L, et al. Vitamin C improves endotheoium-dependent vasodilation by restoring nitric oxide activity in essential hypertension. Circulation 1998;97:2222-9. 25. Koscielny J, Klendorf D, Latza R, et al. The antiatherosclerotic effect of Allium sativum. Atherosclerosis 1999;144:237-49. 26. Nityanand S, Srivastava JS, Asthana OP. Clinical trials with gugulipid-a new hypolipidemic agent. J Assoc Phys India 1989;37:323-8. 27. Olson BH, Anderson SM, Becker MP, et al. Psyllium-enriched cereals lower blood total cholesterol and LDL cholesterol, but not HDL cholesterol, in hypercholesterolemic adults: Results of a meta-analysis. J Nutr 1997;127:1973-80.