Coronary  Artery Disease ‐ Congestive Heart Failure –Performance Sports Nutrition – Heart Healthy Foods 

and Vitamins What’s Hot and What’s Not    

William D. Salerno, M.DDirector Coronary Care Unit, Hackensack University Medical Center

Clinical Associate Professor of Medicine, UMDNJ

One in Six Teenagers Has Atherosclerotic Lesions

Tuzcu EM et al, Circulation. 2001;103:2705-2710

Coronary Anatomy

Coronary Artery DiseaseThe misunderstood disease … “He just saw the cardiologist, had a stress test, was told he was fine and they found him dead two days later …” 

Up to this degree of stenosis stress test is negative or “NORMAL”

Coronary Thrombus(with a “normal” stress test) 

Glagov’s: Coronary Remodeling

6

Normalvessel

MinimalCAD

Progression

Artery can compensate for up to 40% plaque volume (lumen

size remains constant)

Artery atmaximumexpansion:

lumen narrows

SevereCAD

ModerateCAD

Glagov S et al, N Engl J Med, 1987.

Coronary Remodeling

3.1 mm

3.1 mm

…but the Doctor said I had a “Normal Cath?”

Falk E et al. Circulation 1995;92:657−671.

Ambrose et al.1988

Nobuyoshi et al.1991

Giroud et al.1992

>70%

50−70%

<50%

0

40

80

120

160

200

All

14%

18%

68%

Stenosis prior to MI

MI p

atie

nts

(n)

Which Lesions Progress to MI?

MI p

atie

nts

(n)

0

10

20

30

40

50

60

70

80

90

100

Little et al.1988

“In some respects, the occurrence of symptoms may be regarded more properly as a medical failure than as the initial indication for treatment.”

—William B. Kannel, MDDepartment of MedicineBoston University Medical Center

EBCT Scanner

EBCT SCORES IN FUTURE RISK

Things that you already know …Adult Treatment Panel III

… In a large number of observational studies and their meta‐analyses, individuals who consume less calories, more fruits and vegetables, and less saturated fats tend to have lower risks of CVD… The results of randomized trials of specific components of these dietary changes, however, have been disappointing, based, at least in 

part, on their methodological limitations…

NON‐STATIN DRUGS (Zetia / WelChol) lower cholesterol but no data on myocardial event rate

Nutrient Recommended intake: Saturated fat* <7% of total calories Polyunsaturated fat Up to 10% of total calories Monounsaturated fat Up to 20% of total calories Total fat 25 to 35% of total calories Carbohydrate• 50 to 60% of total calories Fiber 20 to 30 g/day Protein Approximately 15% of total calories Cholesterol <200 mg/day Total calories Δ Balance energy intake and expenditure to maintain desirable body weight and prevent weight gain

* Trans fatty acids are another LDL-raising fat that should be kept at low intake.• Carbohydrates should be derived predominantly from foods rich in complex carbohydrates including grains, especially whole grains, fruits, and vegetables.? Daily energy expenditure should include at least moderate physical activity (contributing approximately 200 kcal/day).Adapted from Adult Treatment Panel III at http://www.nhlbi.nih.gov/.

CONCLUSIONS: A moderate substitution of saturated fatty acids with monounsaturated fatty acids has beneficial effects on lipid metabolism ….long-chain n-3 fatty acids in healthy individuals reduces both fasting

and post-prandial triglyceride concentrations but increases LDL cholesterol, irrespective of the type of diet.

-ALWAYS USE WITH A STATIN IN CVD-

Atherosclerosis. 2003 Mar;167(1):149-58 / Medical Letter 12/14-28-2009

Fish Oil - Omega 3 – good but ?

Vitamins the B’sVitamins, Homocysteine, and Cognition

McMahon JA et al. A controlled trial of homocysteine lowering and cognitive performance. N Engl J Med 2006 Jun 29; 354:2764-72.

…This negative randomized-trial result is disappointing, but it does not definitively refute a possible link between elevated

homocysteine and cognitive dysfunction…

Circulation / March 2010 … Conclusions- Increased intake of folic acid, vitamin B12, and vitamin B6 did not reduce total mortality and had no significant effect on the risk of cardiovascular events in patients with end-stage renal disease.

Don’t Use L‐Arginine After MI

Schulman SP et al. L-arginine therapy in acute myocardial infarction: The Vascular Interaction With Age in Myocardial Infarction (VINTAGE MI) randomized clinical trial. JAMA 2006 Jan 4; 295:58-64.

6-month, single-center, double-blind, randomized trial of L-arginine (titrated up to 3 g three times per day) versus matching placebo in 153 patients (mean age, 60) with ST-segment-elevation MI (STEMI)

L-arginine, when added to standard post-STEMI therapy, did not reduce vascular stiffness or improve LV function

over 6 months and was associated with greater mortality.

Vitamins C and E for the heart?…Despite biological plausibility for the antioxidant effects of

vitamins C and E in preventing cardiovascular disease … randomized studies have ranged from mixed to mostly negative…

-Controlled trial, 14,641 male physicians (mean age, 64) received daily vitamin E (400 IU), vitamin C (500 mg), both, or neither

-Neither vitamin E nor vitamin C supplementation was associated with reductions in cardiovascular events

-Increase in hemorrhagic stroke associated with use of vitamin E

Data do not support the use of either vitamin C or E in the prevention of cardiovascular disease in middle-aged or older men.

Sesso HD et al. Vitamins E and C in the prevention of cardiovascular disease in men: The Physicians’ Health Study II randomized controlled trial. JAMA 2008 Nov 12; 300:2123.

‐placebo‐controlled, double‐blind trial, NYHA class III or IV functional status, ejection fractions <40% 

‐randomized 55 patients to either oral coenzyme Q10 200 mg/day or placebo. 

‐After 6 months of therapy, coenzyme Q10 did not have a significant effect on exercise capacity, ejection fraction or NYHA class. 

Khatta M et al. The effect of coenzyme Q10 in patients with congestive heart failure. Ann Intern Med 2000 Apr 18 132 636-640

Trial for myopathic symptoms, daily supplement of 100 mg coenzyme Q10 … results suggest coenzyme Q10 supplementation is an effective treatment for some patients with muscle aches due to statin treatment. Less than 20 patients.Caso G et al. Effect of coenzyme Q10 on myopathic symptoms in patients treated with statins. Am J Cardiol 2007 May 15; 99:1409‐12.

Coenzyme Q10 has shown promise in management of Parkinson’s and some other chronic diseases and in reducing the cardiotoxicity of anthracyclines (using 100‐200 mg daily)… more data are needed… So far it appears to be safe. Medical Letter Volume 48 (Issue 1229)February 27, 2006 

Wang L et al. Systematic review: Vitamin D and calcium supplementation in prevention of cardiovascular events. Ann Intern Med 2010 Mar 2; 152:315.

…The secondary and observational evidence we do have suggests a possible cardiovascular disease

prevention benefit of vitamin D and no benefit of calcium supplementation…

Vitamin D …looking good …maybe

ResveratrolMECHANISM OF ACTION — increases the activity of some sirtuin enzymes thought to be involved in regulation of molecular mechanisms of aging.

In rodent models of human cancers, resveratrol suppressed the growth oftumors of the skin, breast, gastrointestinal tract, prostate and lung.

Studies in humans are limited. NO GOOD TRIALS YET!

The Medical Letter® Volume 51 (Issue 1321)September 21, 2009

Resveratrol is a phytochemical found in the skin of red grapes and inmany other plants, including berries, plums and peanuts. As aconstituent of red wine, it has been associated with cardioprotectiveeffects. Dietary supplements containing resveratrol are now beingwidely promoted as antioxidants that can prevent age-relateddiseases.

Sweet Things

Diabetics – What We Do KnowType 2 diabetes, with and without MI:

-LDL <70 mg/dL-HDL >40 mg/dL-Triglycerides <150 mg/dL -Pressure goal systolic <130 mmHg-Weight control and exerciseMay be more important than tight glycemic control

Glycemic control and restenosis after percutaneous coronaryinterventions in patients with diabetes mellitus: a report from theInsulin Diabetes Angioplasty study. Diab. Vasc Dis Res. 2009 Apr;6(2):71-9.

CONCLUSION: …Intensified insulintreatment did not influence the rate of restenosis indicating that the

main focus should be on lowering glucose rather thanthe tool to normalize glucose… (HgbA1C ~6.5 in both groups)

Systematic review: glucose control and cardiovascular disease in type 2 diabetes. Ann Intern Med. 2009 Sep 15;151(6):394-403.

CONCLUSION: …Intensive glucose control reduced the risk for some cardiovascular disease outcomes (such as nonfatal myocardial infarction), did not reduce the risk for cardiovascular death or all-cause mortality, and increased the risk for severe hypoglycemia...

Systematic review: Glucose control and cardiovascular disease in type 2 diabetes.Kelly TN et al. Ann Intern Med 2009 Sep 15; 151:394.

…No significant differences were noted for stroke, heart failure, CVD-related mortality, or all-cause mortality… 15 fewer events per 1000 patients during 5 years… Intensive glucose control prevented nonfatal myocardial infarction but not fatal MI, nonfatal stroke, fatal stroke, or peripheral artery disease.

…Intensive glucose control doubled the relative risk for severe hypoglycemia — an absolute excess of 39 events per 1000 patients during 5 years.

The NICE‐SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009 Mar 26; 360:1283.

-randomized more than 6000 critically ill patients , 63% medical, 37% surgical

-intensive glucose control - target glucose 81–108 mg/dL vsconventional glucose control, target glucose level 144–180 mg/dL

-death by 90 days after randomization -- significantly more often in the intensive-control group than in the conventional-control group, 27.5% vs. 24.9%

-no differences between the groups were observed in median number of ICU or hospital days or median days of mechanical ventilation or renal replacement therapy

International society of sports nutrition position stand: caffeine and performance.J Int Soc Sports Nutr. 2010 Jan 27;7(1):5.

1.) Caffeine is effective for enhancing sport performance in trained athletes when consumed in low‐to‐moderate dosages (~3‐6 mg/kg) and overall does not result in further enhancement in performance when consumed in higher dosages (>/= 9 mg/kg). 

2.) Caffeine exerts a greater ergogenic effect when consumed in an anhydrous state as compared to coffee. 

3.) It has been shown that caffeine can enhance vigilance during bouts of extended exhaustive exercise, as well as periods of sustained sleep deprivation. 

4.) Caffeine is ergogenic for sustained maximal endurance exercise, and has been shown to be highly effective for time‐trial performance. 

5.) Caffeine supplementation is beneficial for high‐intensity exercise, including team sports such as soccer and rugby, both of which are categorized by intermittent activity within a period of prolonged duration. 

6.) The literature is equivocal when considering the effects of caffeine supplementation on strength‐power performance, and additional research in this area is warranted. 

7.) The scientific literature does not support caffeine‐induced diuresis during exercise, or any harmful change in fluid balance that would negatively affect performance.

Caffeine impairs myocardial blood flow response to physical exercise in patients with coronary artery disease as well as in age‐matched controls.Cardiac Imaging, University Hospital, Zurich, Switzerland. PLoS One. 2009 May 22;4(5):e5665.

Caffeine decreases exercise‐induced myocardial flow reserve.Cardiovascular Center, Nuclear Cardiology, University Hospital, Zurich, Switzerland.J Am Coll Cardiol. 2006 Jan 17;47(2):405‐10. Epub 2005 Dec 20. 

CONCLUSIONS: In healthy volunteers, a caffeine dose corresponding to two cups of coffee (200 mg) significantly decreased exercise‐induced myocardial flow reserve  at normoxia and was even more pronounced during exposure to altitude.

… data suggest that alcohol effects on lipids and insulin sensitivity may account for a large proportion of the lower risk of CVD/death observed with moderate drinking under the assumption that the alcohol‐CVD association is causal…Circulation   Vol. 120(3), 21 July 2009, pp 237‐244

Some is good, too much is bad and don’t blame me if you end up in the Betty Ford Clinic for alcohol rehab blurting “My cardiologist told me to drink!”

…The problem that we face is that the grafts that are placed in a bypass procedure have an average life span of about 10 years…Some of them will last for five years and some will last for 15 years. So if he had four grafts it is not surprising that one of them would start to fail by now…. REUTERS Feb. 11, 2010