Heart disorders (heart disease)

Strong scientific evidence :

Beta-glucan: Beta-glucan is a fiber that comes from the cell walls of algae, bacteria, fungi, yeasts, and plants. Numerous trials have examined the effects of oral beta-glucan on cholesterol. Small reductions in total and low density lipoprotein (LDL) cholesterol ("bad" cholesterol) have been reported. Little to no significant changes have been noted to occur on triglyceride levels or high density lipoprotein (HDL) cholesterol ("good" cholesterol) levels.

Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucans are generally considered safe. Use cautiously with AIDS or AIDS-related complex (ARC).Avoid using particulate insoluble beta-glucan, as preliminary evidence suggests intravenous beta-glucans in the microparticulate form may cause serious side effects including hepatosplenomegaly (enlargement of both the liver and the spleen).. Avoid if pregnant or breastfeeding.

Beta-sitosterol: Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads, peanuts, and peanut products. It is also found in bourbon and oils. Many human and animal studies have found that supplementation of beta-sitosterol into the diet decreases total serum cholesterol, as well as low-density lipoprotein (LDL or "bad") cholesterol.

Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma, breathing disorders, diabetes, primary biliary cirrhosis (chronic liver disease), ileostomy (operation that makes it possible for stool to leave the body), neurodegenerative disorders, diverticular disease (bulging of the colon), short bowel syndrome, celiac disease, or sitosterolemia (lipid metabolic disorder). Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.

Calcium: Calcium is the most abundant mineral in the human body. Calcium chloride may be given intravenously (IV or through a vein) by a qualified healthcare professional in cardiac resuscitation, particularly after open-heart surgery, when epinephrine fails to improve weak or ineffective heart contractions. Calcium chloride helps increase heart contractions. Calcium chloride should not be used for cardiac resuscitation with ventricular fibrillation. CPR with calcium chloride should only be done under 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 high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or 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, also known as vitamin B3 or nicotinic acid, is a well-accepted treatment for high cholesterol. Multiple studies show that niacin (not niacinamide) has significant benefits on levels of high-density cholesterol (HDL or "good cholesterol"). Niacin has been shown to produce better results than prescription drugs, such as "statins." There are also benefits on levels of low-density cholesterol (LDL or "bad cholesterol"), although these effects are less dramatic. A combination therapy with niacin and a statin may help decrease low-density lipoproteins levels. Individuals should check with their physicians and/or pharmacists before starting niacin.

Avoid if allergic to niacin or niacinamide. Avoid with a history of liver disease, liver 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: Omega-3 fatty acids are found in fish oil and certain plant/nut oils. Fish oil contains both docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Multiple human trials report small reductions in blood pressure with intake of omega-3 fatty acid. DHA may have greater benefits than EPA. However, high intake of omega-3 fatty acids per day may be necessary to obtain clinically relevant effects, and at this dose level, there is an increased risk of bleeding. Therefore, a qualified healthcare provider should be consulted prior to starting treatment with supplements.

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 (increases) in high-density lipoprotein ("good cholesterol"). However, increases (worsening) in low-density lipoprotein levels (LDL/"bad cholesterol") are also observed. It is unclear if alpha-linolenic acid significantly affects triglyceride levels, and there is conflicting evidence in this area. The American Heart Association has published recommendations for EPA + DHA. Because of the risk of bleeding from omega-3 fatty acids, a qualified healthcare provider should be consulted prior to starting treatment with supplements.

While omega-3 fatty acids from both plants (ALA) and fish (EPA+DHA) have been shown to reduce C-reactive protein (CRP) in some studies, others have failed to show an effect. There is growing evidence that reducing CRP is beneficial towards favorable cardiovascular outcomes, although additional research is pending in this area.

Several well-conducted randomized controlled trials report that in people with a history of heart attack, regular consumption of oily fish or fish oil/omega-3 supplements reduces the risk of non-fatal heart attack, fatal heart attack, sudden death, and all-cause mortality. Most patients in these studies were also using conventional heart drugs, suggesting that the benefits of fish oils may add to the effects of other therapies.

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 if taking drugs, herbs, or supplements that treat any such conditions. Use cautiously before surgery. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).

Policosanol: Policosanol is a natural mixture of alcohols derived from plant based waxes that has been shown to lower cholesterol. Policosanol has been used and recommended to treat high cholesterol (hypercholesterolemia). Numerous studies have analyzed the effects of policosanol on cholesterol levels and have found benefits. At this time, the evidence supporting the efficacy of this agent is compelling, although greater acceptance in the U.S. market may await additional larger studies.

Avoid if allergic or hypersensitive to policosanol. Use cautiously if taking nitrates, aspirin, or drugs that lower cholesterol or blood pressure. Avoid if pregnant or breastfeeding.

Psyllium: Psyllium, also known as ispaghula, comes from the husks of the seeds of Plantago ovata. Psyllium is well studied as a lipid-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, people with high cholesterol should discuss the use of more potent agents with their healthcare providers. Effects have been observed in adults and children, although long-term safety in children is not established.

Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Prescription drugs should be taken one hour before or two hours after psyllium. Use cautiously if pregnant or breastfeeding because psyllium may lower blood sugar levels.

Red yeast rice: Red yeast rice (RYR) is the product of yeast (Monascus purpureus) grown on 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. However, these products may not be standardized and effects are unpredictable. For lowering 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: Soy is a subtropical plant, native to southeastern Asia. This member of the pea family (Fabaceae) grows from one to five feet tall and forms clusters of three to five pods, each containing two to four beans per pod. 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 it remains controversial. It is unknown 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 such as heart attack or stroke.

Avoid if allergic to soy. The effects of high doses of soy or soy isoflavones in humans are unclear, and therefore, are not recommended. There has been one case report of vitamin D deficiency rickets in an infant nursed with soybean milk that was not specifically designed for infants. People who experience intestinal irritation from cow's milk may experience intestinal damage or diarrhea from soy. It is unknown if soy or soy isoflavones share the same side effects as estrogens, such as 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 should check with their doctors before taking soy supplements. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific evidence of safety in these subgroups.

Good scientific evidence :

Avocado: Avocados are fruits, not vegetables, and are a nutritious source of potassium. Avocados contain no sodium or cholesterol. 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.

Avoid if allergic or hypersensitive to avocado, banana, chestnut, or natural rubber latex. Use cautiously if taking anticoagulants (e.g. warfarin). Avoid if taking monoamine oxidase inhibitors (MAOIs). Pregnant and breastfeeding women should not consume more avocado than is in a normal diet. Some types of avocado may be unsafe when breastfeeding.

Barley: Barley is a cereal used as a staple food in many countries. It is commonly used as an ingredient in baked products and soup in Europe and the United States. Barley malt is used to make beer, and it is also used as a natural sweetener called malt sugar or barley jelly sugar. Several small studies suggest that high-fiber barley, barley bran flour, and barley oil elicit small reductions in serum cholesterol levels by increasing cholesterol excretion. 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 lasting benefits.

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 heart disease (CHD). To qualify for the health claim, the barley-containing foods must provide at least 0.75 grams of soluble fiber per serving of the food.

Avoid if allergic or hypersensitive to barley flour or beer. Barley appears to be well tolerated in non-allergic, healthy adults in recommended doses for short periods of time, as a cereal or in the form of beer. Use cautiously with diabetes, asthma, or arrhythmia (irregular heartbeat). Contamination of barley with fungus has occurred. Traditionally, women have been advised against eating large amounts of barley sprouts during pregnancy. Infants fed with a formula containing barley water, whole milk, and corn syrup have developed malnutrition and anemia, possibly due to vitamin deficiencies.

Betaine anhydrous: Betaine is found in most microorganisms, plants, and marine animals. It is also found naturally in many foods, most highly concentrated in beets, spinach, grain, and shellfish. Homocystinuria is a severe form of hyperhomocysteinemia caused by genetic defects in homocysteine-metabolizing genes. Patients with severely elevated homocysteine due to a genetic deficiency can use betaine treatment, in combination with other vitamins and diet restrictions, to reduce the risk of vascular events. Betaine anhydrous has been shown to reduce circulating levels of homocysteine in the body. Further studies are needed to determine whether betaine supplementation can lower heart disease risks in the general population.

Overall, betaine supplementation has also shown significant reductions in both fasting and postmethionine load homocysteine. However, additional studies are needed to make a strong recommendation.

Avoid if allergic or hypersensitive to betaine anhydrous or a type of betaine called cocamidopropylbetaine. Use cautiously with kidney disease, obesity, or psychiatric conditions. Avoid if pregnant or breastfeeding.

Carob: Carob (Ceratonia siliqua) is a leguminous evergreen tree of the family Leguminosae (pulse family). 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 confirm these findings.

Avoid if allergic or hypersensitive to carob (Ceratonia siliqua), its constituents, or any plants in the Fabaceae family, including tamarind. Avoid with metabolic disorders, kidney disorders, acute diarrhea, or with deficient levels of chromium, cobalt, copper, iron, or zinc. Avoid in underweight infants. Use cautiously with anemia, known allergy to peanuts or other nuts, diabetes, or hyperlipidemia (high cholesterol). Use cautiously if taking oral herbs or drugs. Use cautiously in hypouricemic patients. Avoid if pregnant or breastfeeding.

Coleus: The root extract of coleus is known as forskolin. Forskolin may improve cardiovascular function in patients with cardiomyopathy (enlarged heart). However, additional study is needed to confirm these findings.

Avoid if allergic to Coleus forskohlii and related species. Use cautiously with diabetes, thyroid disorders, heart disease, asthma, low blood pressure, or if at risk of developing low blood pressure. Use cautiously with a history of bleeding, homeostatic disorders, or drug-related homeostatic problems. Use cautiously if taking asthma medications (e.g. bronchodilators), anticoagulants, anti-thrombotic agents, or anti-platelet medications. Do not use two weeks before and immediately after surgical or dental procedures that have bleeding risks. Avoid if pregnant or breastfeeding.

Cordyceps: Cordyceps is a fungus found mainly in China, Nepal, and Tibet. Cordyceps supplements may lower total cholesterol and triglyceride levels, although these changes may not be permanent or long lasting. Longer studies with follow up are needed to determine the long-term effects of cordyceps on hyperlipidemia.

Avoid if allergic or hypersensitive to cordyceps, mold, or fungi. Use cautiously with diabetes, bleeding disorders, or prostate conditions. Use cautiously if taking anticoagulants, immunosuppressants, hormonal replacement therapy, or birth control pills. Avoid with myelogenous types of cancers. Avoid if pregnant or breastfeeding.

Gamma oryzanol: Gamma oryzanol is found in rice bran oil, and it has also been extracted from corn and barley oils. Preliminary evidence indicates that gamma oryzanol may help treat hyperlipidemia. Gamma oryzanol seems to reduce total cholesterol, LDL ("bad" cholesterol), HDL ("good cholesterol"), and triglycerides. Additional study is needed to establish gamma oryzanol's effect on hyperlipidemia (high cholesterol).

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

Garlic: The garlic bulb is made of many cloves that are wrapped in a paper-thin, white skin. It is used both medicinally and as a spice in food. Multiple studies in humans have reported small reductions in total blood cholesterol and low-density lipoproteins ("bad cholesterol") over four to 12 weeks. It is unclear if there are benefits after this amount of time. Effects on high-density lipoproteins ("good cholesterol") are unclear. 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 (e.g. hyacinth, tulip, onion, leek, or chive). Avoid with a history of bleeding problems, asthma, diabetes, low blood pressure, or thyroid disorders. Stop using supplemental garlic two weeks before and immediately after dental/surgical/diagnostic procedures to avoid bleeding problems. Use cautiously if taking anticoagulants. Avoid in supplemental doses if pregnant or breastfeeding.

Globe artichoke: Globe artichoke (Cynara scolymus) is a species of thistle. The edible part of the plant is the base of the artichoke head in bud, harvested well before any fruit develops. Preliminary human study suggests that cynarin and artichoke extracts may reduce serum cholesterol and triglyceride levels. However, additional study is needed to a make a strong recommendation.

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

L-carnitine: L-carnitine is an amino acid that is made in the muscles and liver. Evidence from clinical trials suggests that L-carnitine and L-propionyl-carnitine (propionyl-L-carnitine) are effective in reducing symptoms of chest pain (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, 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 is a B-complex vitamin found in a many foods, such as liver, poultry, fish, nuts, and dried beans. It is needed for the nervous system and gastrointestinal tract function. Vitamin B3 is made up of niacin (nicotinic acid) and niacinamide. Niacin decreases blood levels of cholesterol and lipoprotein (a), which may reduce the risk of atherosclerosis ("hardening" of the arteries). However, niacin can also 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.

Avoid niacin/vitamin B3 if allergic to niacin or niacinamide. Avoid with a history of liver disease, liver 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: Omega-3 fatty acids are found in fish oil and certain plant/nut oils. Fish oil contains both docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). 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 unclear 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 that classify people by their risk of developing heart disease are necessary before a firm conclusion can be drawn.

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 if taking drugs, herbs, or supplements that treat any such conditions. Use cautiously before surgery. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).

Pantethine: Pantethine is a natural compound. It is the active form of pantothenic acid. Numerous trials have examined the effects of oral pantethine on lipid levels. 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 cautiously with bleeding disorders. Avoid if pregnant or breastfeeding.

Policosanol: Policosanol is a mixture of higher aliphatic primary alcohols, isolated and purified from sugar cane wax that is known for its cholesterol-lowering effects. Policosanol has been used to treat high cholesterol levels and numerous studies have analyzed the effects of policosanol on cholesterol levels. Although these studies have produced promising results, most human studies have been conducted in Cuba and many have been conducted by the same author(s). At this time, the evidence supporting the efficacy of policosanol is compelling, although greater acceptance in the U.S. market may await completion of a large, well-conducted randomized trial in the United States.

Avoid if allergic or hypersensitive to policosanol. Use cautiously if taking nitrates, aspirin, or drugs that lower cholesterol or blood pressure. Avoid if pregnant or breastfeeding.

Sweet almond: The almond tree is native to Western Asia and North Africa, but it is now grown in most temperate regions. The sweet almond is a popular and nutritious food. There is initial positive evidence from human studies to support the use of almonds in the diet to lower serum lipids. There are supporting data from animal studies. Proposed mechanisms include the presence of monounsaturated fats in raw almonds, or direct effects on low-density lipoprotein (LDL) receptors. Further study is warranted in this area to establish dosing guidelines and degree of benefit.

Avoid if allergic or hypersensitive to almonds or other nuts. Use cautiously with a history of swollen joints, asthma, hair loss, or diabetes. Avoid if pregnant or breastfeeding.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Yoga addresses physical, mental, intellectual, emotional, and spiritual dimensions towards an overall harmonious state of being. Several human studies suggest that yoga is helpful in people with heart disease. However, it is unclear if yoga reduces the risk of heart attack or death or if yoga is better than any other form of exercise therapy or lifestyle/dietary change. Therefore, yoga may be a useful addition to standard therapies (such as medications for blood pressure or cholesterol) in people at risk for heart attacks, but further research is necessary before a strong recommendation can be made.

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, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. 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. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Zinc: Zinc formulations have been used since ancient Egyptian times to enhance wound healing. Zinc may improve serum cholesterol levels in hemodialysis patients. 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 recommendation can be made.

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. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used since studies cannot rule out the possibility of harm to the fetus.

Unclear or conflicting scientific evidence :

Acupuncture: Acupuncture is commonly used throughout the world. According to Chinese medicine theory, the human body contains a network of energy pathways through which vital energy, called "chi," circulates. These pathways contain specific "points" that function like gates, allowing chi to flow through the body. Needles are inserted into these points to regulate the flow of chi. Illnesses and symptoms are caused by problems in the circulation of chi through the pathways. Some research has suggested that acupuncture might help reduce distress and symptoms of chest pain (angina), but this has not been consistently shown in other studies.

Acupuncture has been found to be superior to medication (Shenmai injection) for low pulse pressure syndrome. More studies are needed before a firm conclusion can be drawn.

It remains unknown whether acupuncture is an effective treatment for heart disease.

Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. 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 because therapy may interfere with the device.

Alfalfa: Alfalfa has a long history of dietary and medicinal use. Alfalfa is usually taken by eating part of the plant. Several studies in animals report reductions in cholesterol plaques of the arteries after use of alfalfa. Well-designed research in humans is needed to determine if alfalfa is an effective treatment for atherosclerosis.

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.

Avoid if allergic to alfalfa, clover, or grass. Avoid with a history of lupus, thyroid disease, gout, blood clots, seizures, liver disease, or kidney disease. Use cautiously with stroke, hormonal conditions (e.g. breast tenderness, breast cancer, ovarian cancer, or menstrual problems), or diabetes. Avoid if taking drugs that increase the risk of bleeding (e.g. aspirin, aspirin products, or warfarin) or ibuprofen. Do not use two weeks before and immediately after any surgery/dental/diagnostic procedures that may have bleeding risks. Alfalfa may be contaminated with dangerous bacteria (e.g. E. coli, salmonella, or listeria). Avoid if pregnant or breastfeeding.

American hellebore: American hellebore is a plant native to the swampy areas and moist meadows of the eastern and western United States. Isolated jervine alkaloids found in American hellebore have been studied for cardiovascular and kidney dysfunction. Additional study is needed before a firm recommendation can be made.

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

Aortic acid: Aortic extract is typically manufactured from the hearts of animals, usually sheep, cows, or pigs. There are many substances, including aortic acid in this extract. There are several constituents in aortic acid, but mesoglycan has been studied the most. Mesoglycan is a structural aspect of cardiovascular vessels and organs. One preliminary study indicates that mesoglycan supplements may reduce blood vessel thickening. However, additional research is needed in this field.

There are currently no reported allergic reactions available. Due to the heparin sulfate content of mesoglycan, patients who are allergic to heparin or heparinoid derivatives should use aortic acid cautiously. Use cautiously with blood disorders or if taking anticoagulation therapy. Use cautiously with high blood pressure or if taking antihypertension drugs. Avoid if pregnant or breastfeeding.

Arginine: There is initial evidence from several studies that arginine taken by mouth or by injection improves exercise tolerance and blood flow in the arteries of the heart. Benefits have been shown in some patients with coronary artery disease and chest pain (angina). A small randomized, controlled clinical trial studied the effects of a medical food bar enriched with L-arginine and a combination of other nutrients in the management of chronic stable angina. The authors found that this arginine-rich medical food, when used with traditional therapy, improves vascular function, exercise capacity, and aspects of quality of life in these patients. However, further research is needed to confirm these findings and to establish doses that may be safe and effective.

An L-arginine supplement, called "blood cardioplegic solution," is proposed to have protective properties for the heart. A randomized, controlled clinical trial using this solution in patients undergoing heart surgery (coronary artery bypass grafting) reports improved heart protection. Further research is needed before a firm conclusion can be drawn.

Study results of arginine supplementation after heart attack (myocardial infarction) are mixed. Further research is needed before a recommendation can be made. A cardiologist and pharmacist should be consulted prior to initiation of arginine therapy.

Avoid with known allergy or hypersensitivity to arginine. Use cautiously with peripheral vascular disease, high blood pressure, alcohol-induced liver cirrhosis, or 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.

Ashwagandha: Ashwagandha (Withania somnifera) is a small, grayish, erect evergreen shrub that grows to about four to five feet tall, with small greenish flowers and fruits that become orange-red when ripe. Decreases in serum total cholesterol levels, triglycerides, low-density lipoprotein (LDL), and very low-density lipoproteins (VLDL) have been reported with ashwagandha use. Further research is needed before a strong recommendation can be made.

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 one 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, according to anecdotal reports. Avoid if pregnant or breastfeeding.

Astaxanthin: Astaxanthin can be found in microalgae, yeast, salmon, trout, krill, shrimp, crayfish, crustaceans, and the feathers of some birds. There is insufficient evidence to recommend for or against the use of astaxanthin for LDL oxidation prevention. More research is needed to make a firm conclusion.

Avoid if allergic/hypersensitive to astaxanthin or related carotenoids (e.g. canthaxanthin). Use cautiously if taking 5-alpha-reductase inhibitors, hypertensive agents, asthma medications, menopause agents, birth control pills, Helicobacter pylori agents, or drugs that are broken down by the liver. Use cautiously with hypertension, parathyroid disorders, or 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: In traditional Chinese medicine (TCM), astragalus is commonly found in mixtures with other herbs. 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.

Avoid if allergic to astragalus, peas, or any related plants. Avoid with a history of Quillaja bark-induced asthma. Avoid if taking anticoagulants (e.g. aspirin or warfarin) or herbs or supplements with similar effects. Avoid with inflammation (swelling), fever, stroke, organ transplant, or autoimmune diseases. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously if taking blood sugar drugs, diuretics, or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.

Ayurveda: Ayurveda is a form of natural medicine that originated in ancient India more than 5,000 years ago. Ayurveda is an integrated system of techniques that uses diet, herbs, exercise, meditation, yoga, and massage or bodywork to achieve optimal health on all levels. In India, Ayurveda involves the eight principal branches of medicine: pediatrics, gynecology, obstetrics, ophthalmology, geriatrics, otolaryngology (ear, nose, and throat), general medicine, and surgery. Abana is a combination herbal and mineral formulation traditionally used in Ayurveda for cardiovascular health. Its main ingredients are Terminalia arjuna, Withania somnifera, Terminalia chebula, Phyllanthus emblica, Nardostachys jatamansi, Tinosporia cordifolia, Glycyrrhiza glabra, Zingiber officinale, and Nepeta hindostana. Early studies report that abana may reduce the frequency and severity of chest pain (angina). Other studies suggest that abana may improve cardiac function, but further research is needed before a firm conclusion can be made.

Arjuna (Terminalia arjuna) is a type of bark powder traditionally used as an anti-ischemic and cardio protective agent in high blood pressure and ischemic heart diseases. It may be a safe and effective anti-angina agent comparable to isosorbine mononitrate (ISMN) and better tolerated. However, further research is needed before a recommendation can be made, and angina should be treated by a qualified healthcare provider.

Evidence suggests that carotid intima-media thickness (IMT), a measure of atherosclerosis, may be reduced with a comprehensive program including diet, exercise, stress reduction, and a combination herbal formula (Maharishi Vedic Medicine), particularly in patients with a marked congenital heart disease (CHD) risk.

Evidence indicates that Ayurveda's comprehensive purification and detoxification regime, known as panchakarma, in heart disease patients may lead to increased VIP (a vasodilator), acute reduction in total cholesterol, reduction in lipid peroxide (a measure of free radical damage), and a significant reduction in anxiety.

A study of Arjuna (Terminalia arjuna), a type of bark powder that is traditionally used as an anti-ischemic and cardio protective agent in hypertension and ischemic heart diseases, found evidence that it may reduce cholesterol and lipid peroxide levels as well as have significant antioxidant action that is comparable to vitamin E in coronary heart disease patients. Further research is needed before a firm conclusion can be drawn.

There is preliminary evidence that the herb guggulu (Commiphora), administered as a purified gum, may reduce serum cholesterol and serum triglyceride levels, increase HDL, and decrease LDL levels. More studies are needed to validate this use.

Ayurvedic herbs can interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before taking. 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. Use guggul cautiously with peptic ulcer disease and avoid taking with sour food, alcohol, and heavy exercise. Mahayograj guggul should not be taken for long periods of time. Pippali (Piper longum) should be taken with milk and avoided with asthma. Avoid sweet flag and amlaki (Emblica officinalis) at bedtime. Avoid Terminalia hebula (harda) if pregnant. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages, and medical conditions that require surgery.

Berberine: Berberine is a bitter-tasting, yellow, plant alkaloid with a long history of medicinal use in Chinese and Ayurvedic medicine. Berberine may reduce triglycerides, serum cholesterol, and LDL cholesterol. Higher quality trials are needed before berberine's cholesterol-lowering effect can be established.

Avoid if allergic or hypersensitive to berberine, to plants that contain berberine (e.g. goldenseal, coptis, goldenthread, Oregon grape, barberry, or tree turmeric), or to members of the Berberidaceae family. Use cautiously with heart disease, gastrointestinal disorders, blood disorders, leucopenia (abnormally low level of white blood cells), kidney disease, liver disease, lung disorders, cancer, hypertyraminemia (high levels of tyramine), diabetes, or low blood pressure. Use cautiously in children due to lack of safety information. Use cautiously with high exposure to sunlight or artificial light. Use cautiously for longer than eight weeks. Use cautiously if taking anticoagulants, antihypertensives, sedatives, anti-inflammatories, or medications that are broken down by the liver. Avoid if pregnant or breastfeeding. Avoid in newborns.

Beta-glucan: Beta-glucan is a fiber that comes from the cell walls of algae, bacteria, fungi, yeast, and plants. 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 in this area.

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

Bilberry: Bilberry is an herb made from the berries of a small deciduous shrub. Bilberry has been used traditionally to treat heart disease and atherosclerosis. There is some laboratory research in this area, but there is no clear information in humans.

Avoid if allergic to plants in the Ericaceae family or to anthocyanosides (a component of bilberry). Avoid with a history of low blood pressure, heart disease, bleeding, diabetes, blood clots, or stroke. Avoid if pregnant or breastfeeding. Stop use two weeks before and immediately after surgeries/dental or diagnostic procedures with bleeding risks.

Black tea: Black tea is made from the dried leaves of Camellia sinensis, a perennial evergreen shrub. 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 blockage of arteries in the heart. The long-term effects of tea consumption on heart disease risk factors, such as cholesterol levels, blood pressure, and atherosclerosis, are unknown. One study reports that regular ingestion of black tea does not alter plasma homocysteine concentrations.

Avoid if allergic or hypersensitive to caffeine or tannin. Skin rash and hives have been reported with caffeine ingestion. Use cautiously with diabetes. Use cautiously 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/insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. If breastfeeding mothers consume black tea, it may lead to anemia, decreased iron metabolism, and irritability in their infants

Borage seed oil: Borage (Borago officinalis) is an herb native to Syria that has spread throughout the Middle East and Mediterranean. Borage flowers and leaves may be eaten, and borage seeds are often pressed to produce oil that is very high in gamma-linolenic acid (GLA). Hyperlipidemia means that there are excess levels of fats in the blood. These fats can be triglycerides or cholesterol. Hyperlipidemia is often associated with an increased risk of heart disease and strokes. Gamma linolenic acid may decrease plasma triglyceride levels and increase HDL-cholesterol concentration. However, more research is needed to define borage's effects on lipid levels in the blood.

Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously with bleeding disorders or epilepsy. Use cautiously if taking anticoagulants (e.g. warfarin or aspirin) or anticonvulsants. Avoid if immunocompromised. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil's GLA. Avoid if breastfeeding.

Chamomile: Chamomile is an herb that has an apple-like smell and taste. Chamomile is a common tea. 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 to determine if chamomile can help treat or prevent heart disease.

Avoid if allergic to chamomile or any related plants, such as aster, chrysanthemum, mugwort, ragweed, or ragwort. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.

Chondroitin sulfate: Chondroitin sulfate is manufactured from natural sources (e.g. shark, beef cartilage, or bovine trachea) or by artificial means. Several studies have assessed the use of oral chondroitin for the prevention of subsequent coronary events in patients with a history of heart disease or heart attack (myocardial infarction). A recommendation cannot be made in this area until further well-designed clinical trials are available.

Use cautiously if allergic or hypersensitive to chondroitin sulfate products. Use cautiously with bleeding disorders or if taking blood-thinners, such as warfarin. Avoid if pregnant or breastfeeding.

Coenzyme Q10: Coenzyme Q10 (CoQ10) is produced by the human body. It is needed for the basic functioning of cells. Preliminary small human studies suggest that CoQ10 may reduce chest pain (angina) and improve exercise tolerance in people with clogged heart arteries. Better studies are needed before a firm recommendation can be made.

There is conflicting evidence from research on the use of CoQ10 in patients with dilated or hypertrophic cardiomyopathy. Better research is needed in this area before a recommendation can be made.

There is preliminary human study of CoQ10 given to patients within three days after a heart attack. Better research is needed before a firm conclusion can be drawn.

Several studies suggest that the function of the heart may be improved after major heart surgeries, such as coronary artery bypass graft (CABG) or valve replacement, when CoQ10 is given to patients before or during surgery. Better studies are necessary before a recommendation can be made.

There are no reported allergies associated with Coenzyme Q10 supplements. However, rash and itching have been reported rarely. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke. Use cautiously if taking anticoagulants (blood thinners) or anti-platelet drugs, blood pressure drugs, blood sugar drugs, cholesterol drugs, or thyroid drugs. Avoid if pregnant or breastfeeding.

Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains fruits, shellfish, avocado, beef, and animal organs. The effects of copper intake or blood copper levels on cholesterol, atherosclerosis (cholesterol plaques in arteries), or coronary artery disease remain unclear. Studies in humans are mixed, and further research is needed in this area.

Avoid if allergic or hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid with a high amount of copper in the blood (hypercupremia), genetic disorders affecting copper metabolism (e.g. Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis), or HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6 milligrams per liter. Use cautiously with anemia (low red blood cell count), arthralgias (painful joints), or myalgias (muscle pain). Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).

Creatine: Creatine is an amino acid that is produced in the muscles. There is early evidence that heart muscle may recover better and more rapidly after open-heart surgery if intravenous creatine is administered during the operation. Further study is needed before a recommendation can be made.

There is limited research on the use of creatine to reduce high cholesterol, and the results from different studies disagree with each other (with some trials noting reductions in total cholesterol and triglyceride levels). It remains unclear what effect creatine has on lipids. Additional studies are needed before a clear conclusion can be drawn.

There is early evidence that intravenous creatine following a heart attack may be beneficial to heart muscle function, and may prevent ventricular arrhythmias (irregular heartbeat). Further study is needed before a recommendation can be made in this area.

It has been reported that use of creatine phosphate may have a favorable effect on mental deterioration in "cardio-cerebral syndrome" following heart attacks in the elderly.

Avoid if allergic to creatine or if taking diuretics. Use cautiously with asthma, diabetes, gout, kidney, liver problems, muscle problems, stroke, or with a history of these conditions. Avoid dehydration while taking creatine. Avoid if pregnant or breastfeeding.

Danshen: Danshen (Salvia miltiorrhiza) is widely used in traditional Chinese medicine (TCM), often in combination with other herbs. 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), or myocarditis. Danshen may have effects on blood clotting, and therefore, may be unsafe when combined with other drugs used in patients with heart disease. Patients should check with their physicians and pharmacists before combining danshen with prescription drugs.

Avoid if allergic or hypersensitive to danshen. Use cautiously if taking sedatives, hypolipidemics, cardiac glycosides, CYP-metabolized agents, nitrate ester, steroidal agents, or some anti-inflammatories (e.g. ibuprofen). Use cautiously with altered immune states, arrhythmia, compromised liver function, or a history of glaucoma, stroke, or ulcers. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin, or hypotensives, including ACE inhibitors (e.g. captopri), or Sophora subprostrata root or herba serissae. Avoid with bleeding disorders or low blood pressure. Avoid use after cerebral ischemia. Avoid if pregnant or breastfeeding.

DHEA: DHEA (dehydroepiandrosterone) is naturally produced by the adrenal glands. 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 heart disease should discuss treatment options with their cardiologists.

Avoid if allergic to DHEA. Avoid with a history of seizures. Use cautiously with adrenal or thyroid disorders. Use cautiously if taking anticoagulants or drugs, herbs, or supplements that treat diabetes, heart disease, seizures, or stroke. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures with bleeding risks. Avoid if pregnant or breastfeeding.

Dong quai: Dong Quai (Angelica sinensis), also known as Chinese angelica, has been used for thousands of years in traditional Chinese, Korean, and Japanese medicine. There is insufficient evidence to support the use of Dong quai for the treatment of heart disease.

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. There are no reliable long-term studies of side effects available. Avoid if allergic/hypersensitive to Angelic radix or members of the Aplaceael or Umbelliferae families. Avoid prolonged exposure to sunlight or ultraviolet light. Use cautiously with bleeding disorders or if taking drugs that increase the risk of bleeding. Use cautiously with diabetes, glucose intolerance, or hormone sensitive conditions (e.g. breast cancer, uterine cancer or ovarian cancer). Do not use two weeks before or immediately after dental or surgical procedures with bleeding risks. Avoid if pregnant or breastfeeding.

Elder: European elder grows up to 30 feet tall. It is native to Europe, but it has been naturalized to the Americas. There is no reliable human evidence currently available evaluating elder alone as a treatment for high cholesterol. Early study reports that elderberry juice may decrease serum cholesterol concentrations and increase low-density lipoprotein (LDL) 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 providers before using elderberry for treatment of high cholesterol.

WARNING: Cyanide toxicity is possible. Berries (elderberries) must be cooked to prevent nausea or cyanide toxicity. Avoid if allergic to elder or to plants related to honeysuckle. Some reports exist of allergies from contact with fresh elder stems. Use cautiously with diabetes, high blood pressure, urinary problems, or if taking drugs used for any of these conditions. Use cautiously if taking anti-inflammatories, diuretics, or laxatives. Avoid if pregnant or breastfeeding.

Fenugreek: Fenugreek has been used in Indian and Chinese medicine to help with labor and digestion. There is insufficient evidence to support the use of fenugreek as a hyperlipidemic agent.

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

Flaxseed and flaxseed oil: Flaxseed and flaxseed oil/linseed oil are rich sources of the essential fatty acid alpha-linolenic acid (omega-6). Alpha-linolenic acid is a building block in the body for omega-3 fatty acids. Flaxseed oil should be refrigerated at all times. People who have had a heart attack are reported to benefit from diets rich in alpha-linolenic acid, which is found in flaxseed. Good studies that examine the effect of flaxseed on heart disease in humans are not available. It is unclear whether flaxseed supplementation alters the course of heart disease.

In laboratory and animal studies, flaxseed and flaxseed oil are reported to lower blood cholesterol levels. Effects on blood triglyceride levels in animals are unclear, with increased levels in some research, and decreased levels in other research. Human studies in this area report mixed results, with decreased blood levels of total cholesterol and low-density lipoprotein ("bad cholesterol") in some studies, but no effect in other studies. Most human research has not been well-designed, and further research is needed before a recommendation can be made.

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 with prostate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods. Avoid large amounts of flaxseed by mouth and mix plenty of water or liquid. Avoid flaxseed (not flaxseed oil) with a history of esophageal stricture, ileus (loss of bowel motility), gastrointestinal stricture or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis (bowel inflammation), or inflammatory bowel disease. Avoid topical flaxseed in open wounds or abraded skin surfaces. Use cautiously with a history of a bleeding disorders, high triglyceride levels, diabetes, mania, seizures, or asthma. Use cautiously if taking drugs that increase the risk of bleeding or nonsteroidal anti-inflammatory drugs (NSAIDs). Avoid if pregnant or breastfeeding.

Folate: Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food, and folic acid is the synthetic form of this vitamin. Elevated homocysteine levels may be a marker of heart disease. Preliminary data suggest that folic acid lowers homocysteine levels and might reduce the risk of vascular disease (cardiac, peripheral, or cerebral). However, folic acid does not seem to help with secondary prevention of death or cardiovascular events, such as stroke or heart attack, in people with existing coronary artery disease (CAD) or prior stroke. Large randomized controlled trials are needed before a firm conclusion can be drawn.

Avoid if allergic or hypersensitive to folate or any of the product ingredients. It is recommended that pregnant women consume 400 micrograms daily in order to reduce the risk of the fetus developing a defect. Folate is likely safe if breastfeeding.

Gamma oryzanol: Gamma oryzanol occurs in rice bran oil and has been extracted from corn and barley oils as well. 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 on restenosis.

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, luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering drugs, thyroid drugs, or herbs or supplements with similar effects. Use cautiously with diabetes, hypothyroidism, hypoglycemia (low blood sugar), hyperglycemia (high blood sugar), or high cholesterol. Avoid if pregnant or breastfeeding.

Garlic: The garlic bulb is made of many cloves that are wrapped in a paper-thin, white skin. It is used both medicinally and as a spice in food. Preliminary research in humans suggests that deposits of cholesterol in blood vessels may not grow as quickly in people who take garlic. It is unclear if this is due to the ability of garlic to lower cholesterol levels or to other effects of garlic.

Familial hypercholesterolemia is a genetic disorder in which very high cholesterol levels run in families. Research in children with an inherited form of high cholesterol suggests that garlic does not have a large effect in lowering cholesterol levels in these patients.

It is unclear if garlic prevents future heart attacks in people who have already had heart attacks. The effects of garlic on cholesterol levels may be beneficial in such patients.

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

Ginseng: The roots of this slow-growing plant have been valued in Chinese medicine. Several studies from China report that ginseng in combination with various other herbs may reduce symptoms of coronary artery disease. Without further evidence of the effects of ginseng specifically, a firm conclusion cannot be reached.

Low-quality studies have studied various doses of Panax ginseng to reduce cholesterol levels. Further research is warranted in this area.

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 the ginseng formulation.

Goldenseal: Goldenseal is one of the five top-selling herbal products in the United States. Berberine, a compound isolated from goldenseal, may lower cholesterol and triglycerides with a mechanism of action different from that of statin drugs.

Avoid if allergic or hypersensitive to goldenseal or any of its constituents, such as berberine or hydrastine. Use cautiously with bleeding disorders, diabetes, or low blood sugar. Avoid if pregnant or breastfeeding.

Grapefruit: Grapefruit pectin supplementation may inhibit hypercholesterolemia (high cholesterol). 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 to grapefruit. Grapefruit may interact with prescription drugs, herbs, or supplements. Use cautiously if taking anticoagulants, anti-platelet drugs, antiarrhythmics, anticonvulsants, antidepressants, antihistamines, antihypertensives, benzodiazepines, channel blockers, caffeine, corticosteroids, erectile dysfunction medications, estrogens, immune modulators, HMG-CoA reductase inhibitors, macrolide antibiotics, protease inhibitors, or drugs that are broken down by the liver. Use cautiously if drinking red wine or tonic water. Use cautiously when smoking or with liver cirrhosis or if at risk for kidney stones. Use cautiously in patients that have undergone gastric bypass surgery. Use cautiously if pregnant or breastfeeding.

Green tea: Green tea is made from the dried leaves of Camellia sinensis, an evergreen shrub. There is early suggestive evidence that regular intake of green tea may reduce the risk of heart attack or atherosclerosis (clogged arteries). Further well-designed clinical trials are needed before a recommendation can be made in this area.

Laboratory studies, animal studies, and limited human research suggest possible effects of green tea on cholesterol and triglyceride levels. Better human evidence is necessary in this area.

Avoid if allergic or hypersensitive to caffeine or tannin. Use cautiously with diabetes or liver disease.

Guggul: Guggul (gum guggul) is a resin produced by the mukul mirth tree. 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, recent 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.

Avoid if allergic to guggul. Avoid with a 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: Gymnema is found in India and some parts of Africa. It is commonly used in Ayurvedic medicine. Preliminary research in people with type 2 diabetes reports decreased cholesterol and triglyceride levels. Better evidence is needed before a clear conclusion can be drawn.

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

Hawthorn: Hawthorn, a flowering shrub of the rose family, has an extensive history of use for heart disease, dating back to the first century. Hawthorn has not been tested in the setting of concomitant drugs, such as beta-blockers or ACE-inhibitors, which are often considered to be standard-of-care. At this time, there is insufficient evidence to recommend for or against hawthorn for coronary artery disease or angina.

Avoid if allergic to hawthorn or to members of the Crataegus species. Avoid with a history of low blood pressure, irregular heartbeat, asthma, low blood pressure when standing, or insomnia. Use cautiously in elderly patients. Avoid if pregnant or breastfeeding.

Honey: In general, the evidence supporting the use of honey to treat high cholesterol 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 the 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 if taking antibiotics. Potentially harmful contaminants (e.g. C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously if pregnant or breastfeeding.

Horny goat weed: Horny goat weed has been traditionally used to treat cardiovascular disease. Early study suggests that horny goat weed may improve symptoms associated with ischemic cardio-cerebral vascular diseases. However, additional study is needed before a firm recommendation 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 anticoagulants 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 in patients with fire from yin deficiency (people with too much "yang" or heat, masculinity, and activity, based on Chinese philosophy). Avoid if pregnant or breastfeeding.

Kudzu: Kudzu has a long history of use in the treatment of cardiovascular (heart) disorders, including angina (chest pain), acute myocardial infarction (heart attack), and heart failure. Preliminary studies have suggested that kudzu may reduce the frequency of angina events in human subjects. More research is needed in this area.

Avoid if allergic or hypersensitive to Pueraria lobata or members of the Fabaceae/Leguminosae family. Use cautiously if taking anticoagulants/anti-platelet and blood pressure lowering agents, hormones, antiarrhythmics, benzodiazepines, bisphosphonates, diabetes medications, drugs that are metabolized by the liver's cytochrome P450 enzymes, mecamylamine, neurologic agents, or methotrexate. No well-designed studies on the long-term effects of kudzu are available. Avoid if pregnant or breastfeeding.

Kundalini yoga: Kundalini yoga is one of many traditions of yoga, which share common roots in ancient Indian philosophy. Kundalini yoga incorporates multiple modalities, including physical postures, chanting, mediation, breathing exercises, and visualization. One case series report suggests that breathing techniques used in Kundalini Yoga may help people with angina pectoris reduce symptoms and need for medication. Formal clinical trials are needed to explore this application of Kundalini yoga before a conclusion can be made regarding efficacy.

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 a one breath per minute respiratory exercise with slow inspiration for 20 seconds, breath retention for 20 seconds, and slow expiration for 20 seconds, for 31 consecutive minutes. The technique was found to stabilize the heart's electrical wave patterns, which may have preventive value in heart health. More studies are needed to determine whether this exercise has tangible effects on heart-related problems

Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, poor memory, or poor concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. 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: Lactobacilli are bacteria that normally live in the human small intestine and vagina. There is conflicting information from several human studies regarding the effects of Lactobacillus acidophilus-enriched dairy products on lowering blood levels of total cholesterol or low-density lipoprotein ("bad cholesterol").

Patients may have difficulty tolerating if allergic to dairy products containing L. acidophilus. Avoid with a history of an injury or illness of the intestinal wall, immune-disease, or heart valve surgery. Avoid with prescription drugs, (e.g. 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 (e.g. famotidine (Pepcid®) or esomeprazole (Nexium®)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

L-carnitine: Although preliminary evidence is promising, there is insufficient available evidence to recommend for or against the use of carnitine for hyperlipoproteinemia.

Currently there is insufficient evidence to support the use of carnitine for myocardial infarction (heart attack). Additional study is needed in this area.

Despite strong arguments of animal and human studies that congestive heart disease is associated with a fall in myocardial free carnitine, the number of well-organized studies demonstrating the efficacy of carnitine supplementation is small. Presently there is not enough strong evidence supporting the use of carnitine for this condition. Further well-designed clinical trials are required before recommendations can be made.

Overall, the data is mixed in terms of benefits of L-carnitine for exercise performance. Until confirmed, L-carnitine can not be recommended for increased exercise endurance. Some preliminary evidence suggests effects of L-carnitine on lactate and pyruvate levels, as well as respiratory quotient changes.

Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, or 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.

Lemongrass: Lemongrass oil is an essential oil used in deodorants, herbal teas, skin care products, fragrances, insect repellents, and for aromatherapy. Early research has not shown any effect of lemongrass on serum cholesterol. However, more research is warranted in this area.

Avoid if allergic/hypersensitive to lemongrass, its constituents, or any members of the Poaceae family. Use cautiously if taking diabetic drugs, heart medications, or drugs that are broken down by the liver. Use cautiously with liver conditions. Avoid if pregnant or breastfeeding.

Lutein: Lutein and zeaxanthin are found in high levels in foods, such as green vegetables, egg yolk, kiwi fruit, grapes, orange juice, zucchini, squash, and corn. Currently, there is insufficient available evidence to recommend for or against the use of lutein for atherosclerosis (hardening of the arteries). 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: Lycopene is a carotenoid found tomatoes, and it is also present in human serum, liver, adrenal glands, lungs, prostate, colon, and skin. 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: Macrobiotics is a popular approach to diet that stresses vegetarianism and consumption of whole, healthy foods. There is evidence from one study suggesting 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 are reliable and meaningful.

There is a risk of nutritional deficiencies. However, this can be avoided with appropriate menu planning. Use cautiously with cancer or other medical conditions without expert planning or supplementation. Not recommended in children or adolescents without professional guidance or appropriate supplementation. Not recommended in pregnant or breastfeeding women due to potential deficiencies, unless properly supplemented.

Meditation: Various forms of meditation have been practiced for thousands of years throughout the world. Transcendental meditation®, along with other therapies, has been reported to help attenuate atherosclerosis in older people, particularly in those with apparent cardiovascular disease. Further research is needed to confirm any potential benefits from meditation alone.

Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and should explore how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnose or treat the condition with more proven techniques or therapies. Meditation should not be used as the sole approach to illnesses.

Milk thistle: Although animal and laboratory research suggest that milk thistle has cholesterol-lowering effects, human studies have provided unclear results. Further studies are necessary before a recommendation can be made.

Use cautiously if allergic to plants in the aster family (Compositea or Asteraceae), daisies, artichoke, common thistle, or kiwi. Use cautiously with diabetes. Avoid if pregnant or breastfeeding.

Nopal: Traditionally, nopal, or prickly pear, has both food and medicinal uses. Preliminary studies in animal models suggest a hypolipidemic effect of nopal. However, further studies are warranted in this area to draw a firm conclusion.

Avoid if allergic/hypersensitive to nopal (Opuntia spp.), any of their 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, rhinitis (runny or congested nose), or asthma. Avoid with immunosuppression or impaired liver function. Avoid if pregnant or breastfeeding.

The nopal plant should be handled cautiously, as it is covered in long sharp spines and shorter soft-appearing barbs of glochids, which may be painful and difficult to remove once they are imbedded in the skin. Oral doses of dried nopal should be taken with at least eight ounces of water.

Omega-3 fatty acids: Omega-3 fatty acids are found in fish oil and certain plant/nut oils. Fish oil contains both docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Preliminary studies report reductions in angina associated with fish oil intake. Better research is necessary before a firm conclusion can be drawn.

Some research reports that regular intake of fish or fish oil supplements reduces the risk of developing atherosclerotic plaques 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.

There is limited study of the use of fish oils in patients after undergoing coronary artery bypass grafting (CABG). Additional evidence is necessary before a firm conclusion can be drawn in this area.

Several randomized controlled trials have evaluated whether omega-3 fatty acid intake reduces blockage of arteries in the heart following balloon angioplasty (percutaneous transluminal coronary angioplasty/PTCA). The evidence in this area remains inconclusive.

It remains unknown if alpha linolenic acid can help prevent heart disease in patients who do not have a history of heart disease.

Several randomized controlled trials have examined the effects of alpha-linolenic acid in people with a history of heart attack. Although some studies suggest benefits, others do not. Additional research is necessary before a conclusion can be drawn in this area.

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. Pregnant and breastfeeding women should not consume doses that exceed the recommended dietary allowance (RDA).

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. The researchers concluded that AHT had a beneficial effect on blood lipid metabolism, provoking the activation of antioxidant protection system. However, this research was not well-designed. Better information is necessary before a firm conclusion can be reached.

Autohemotherapy has been associated with transmission of viral hepatitis, and with a possible case of dangerously lowered blood cell counts. Insufflation of the ear carries a risk of tympanic membrane ("ear drum") damage, and colon insufflation may increase the risk of bowel rupture. Consult a qualified health professional before undergoing any ozone-related treatment.

Pantethine: Pantethine is a natural compound. It is the active form of pantothenic acid. Data have shown that pantethine exhibits lipid-modulating effects. Additional human study is needed.

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

Pantothenic acid: Pantothenic acid (vitamin B5) is found in many foods, including, meats, liver, kidney, fish/shellfish, chicken, vegetables, legumes, yeast, eggs, and milk. 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 this purpose, 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.

Physical therapy: The goal of physical therapy, or physiotherapy, is to improve mobility, restore function, reduce pain, and prevent further injury. Physical therapy has been studied to improve peak oxygen consumption, work rate, general cardiovascular health, and distance walked during six minutes. In particular, 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.

Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with their qualified healthcare professionals before beginning any treatments. Based on the available literature, physical therapy appears generally safe when practiced by a qualified physical therapist; however, complications are possible. 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. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

Pomegranate: Preliminary study of pomegranate for atherosclerosis is mixed. Pomegranate juice may decrease serum angiotensin converting enzyme (ACE) activity and lower blood pressure in elderly hypertensive (high blood pressure) patients. However, additional study is warranted to confirm these 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, distant healing: 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. Better-quality research is necessary before a firm conclusion can be drawn.

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.

Probiotics: Probiotics are beneficial bacteria that are sometimes called friendly germs. They help maintain a healthy intestine and aid in digestion. They also help keep harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. There is limited evidence suggesting probiotics may help reduce low density lipoproteins (LDL) cholesterol, a risk factor for cardiovascular disease, in overweight people. These findings are tentative and more evidence is needed to arrive at firm conclusions.

One study suggests probiotic supplementation might reduce blood pressure and some biochemical risk factors for cardiovascular disease (leptin and fibrinogen). This implies a possible protective effect against atherosclerosis. However, more studies are needed to confirm such effects.

There is conflicting evidence regarding the effects of probiotic-enriched dairy products on lowering blood levels of total cholesterol or low-density lipoprotein ("bad cholesterol"). More studies are needed.

Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional. The patient explores thoughts, feelings, and behaviors to help with problem solving. 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 alexithymia and reduce cardiac events.

Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expression.

Pycnogenol: Pycnogenol® is the patented trade name for a water extract of the bark of the French maritime pine (Pinus pinaster ssp. atlantica), which is grown in coastal southwestern France. 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.

Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously with diabetes, hypoglycemia (low blood sugar), or bleeding disorders. Use cautiously if taking hypolipidemics (cholesterol-lowering medications), medications that may increase the risk of bleeding, hypertensive (high blood pressure) medications, or immune stimulating or inhibiting drugs. Avoid if pregnant or breastfeeding.

Quercetin: Quercetin is a major flavonol (antioxidant) that occurs in foods of plant origin, such as red wine, onions, green tea, apples, berries, and vegetables from the mustard family (e.g. cabbage, broccoli, cauliflower, or 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 can occur. Avoid if pregnant or breastfeeding due to a lack of evidence.

Red clover: Red clover is a legume that has plant-based chemicals that are similar to estrogen. Because estrogens have been reported to decrease low-density lipoproteins (LDL) and increase high-density lipoproteins (HDL), some effort has been undertaken to discern the effects of red clover isoflavones, which appear to possess estrogenic activity, on lipid metabolism. To date, the available evidence of red clover's effects on lipid levels in humans remains inconclusive. Further research is warranted in this area.

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

Red yeast rice: Red yeast rice (RYR) is the product of yeast (Monascus purpureus) grown on rice. Preliminary evidence shows that taking Monascus purpureus by mouth may result in cardiovascular benefits and improved blood flow. Additional study is needed before a firm recommendation can be made.

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

Reishi mushroom: Based on positive laboratory evidence, a clinical trial was conducted to evaluate the effect of Ganopoly® on coronary heart disease in humans. Ganopoly® treatment improved the major symptoms (e.g. angina, palpitations, or shortness of breath), decreased abnormal ECG appearance, decreased blood pressure, and decreased cholesterol levels in these patients. Long-term studies are needed to evaluate the efficacy and safety of Ganopoly® before it may be recommended for CHD. The authors are closely related to the manufacturer of Ganopoly®.

Avoid if allergic or hypersensitive to any constituents of Ganoderma lucidum or any member of its family. Use cautiously with diabetes, blood disorders (including hemophilia), low blood pressure, or ulcers. Avoid if pregnant or breastfeeding.

Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. 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 heart attacks suggests that fewer future heart attacks may occur when relaxation is regularly practiced. However, only a small number of patients have been studied, and better research is necessary before a firm conclusion can be reached.

Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses, such as 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 naturally found in over 70 plant species, nuts, grapes, pine trees, and red wine. The effects of resveratrol cannot be adequately assessed from trials using foods, wine or combination products containing resveratrol and other substances. Well-designed clinical trials of resveratrol alone are needed before a recommendation can be made.

Avoid if allergic or hypersensitive to resveratrol, grapes, red wine, or polyphenols. Resveratrol is generally considered safe. It is commonly found in food and beverages. Use cautiously with bleeding disorders and abnormal blood pressure. Use cautiously if taking drugs that are broken down by the liver, digoxin, or digoxin-like drugs. Avoid if pregnant or breastfeeding.

Rhubarb: Two very different uses of the rhubarb plant have been examined for their effects on high cholesterol. 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 to evaluate the impact of both uses of rhubarb.

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, kidney disorders, ulcerative colitis, or urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children younger than age 12 due to water depletion. Use cautiously with bleeding disorders, cardiac conditions, coagulation therapy, constipation, or with a 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 symptoms of angina pectoris (chest pain) and coronary artery disease. More high-quality studies with safflower are needed to establish the effect of safflower yellow injection.

Limited available evidence suggests that safflower oil may increase oxidation of low-density lipoproteins (LDL) and lower thiobarbituric acid reactive substances (TBARS) when compared to fish oil. Additional study is needed in this area.

Safflower oil has lowered high blood pressure and coagulation in patients with chronic cor pulmonale, although there is limited available evidence in this area. Additional study is needed.

Ingestion of certain lipids is known to affect various serum lipid levels. Preliminary evidence suggests that ingestion of safflower oil may reduce serum cholesterol levels. Additional study is needed.

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, immunosuppressants, or pentobarbital. Use cautiously with diabetes, hypotension, inadequate liver function, hypercoagulability, or skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.

Scotch broom: Scotch broom (Cytisus scoparius), also referred to as broom, is a woody plant native to Europe that is now common across western Canada and California. 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, fast heart rate, swelling in the legs, fluid in the lungs caused by congestive heart failure), and low blood pressure..

The scotch broom flower has been taken by mouth traditionally for tachycardia and to reduce leg swelling by increasing urination (diuretic), as well as for damage to the heart muscle (cardiomyopathy) and for poor circulation.

There is a scientific basis for some of these uses, due to the presence in scotch broom herb and flower of small amounts of the alkaloid sparteine. 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 disorders should be evaluated and supervised by a licensed healthcare professional.

Medical supervision is recommended when using this herb. 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.

Sea buckthorn: Sea buckthorn (Hippophae rhamnoides) is found throughout Europe and Asia, particularly eastern Europe and central Asia. Two studies have been conducted using different aspects of Hippophae to improve cardiovascular conditions. More high-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, anti-platelet agents, antineoplastic agents, cyclophosphamide, or farmorubicin. Avoid higher doses than food amounts if pregnant or breastfeeding.

Selenium: Selenium is a mineral found in soil, water, and some foods. 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). However, most cases of cardiomyopathy are not due to low selenium levels, and therefore selenium may not be helpful.

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 hypersensitive to products containing selenium. Avoid with a history of non-melanoma 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.

Soy: Dietary soy protein has not been shown to affect long-term cardiovascular outcomes such as heart attack or stroke. Research does suggest cholesterol-lowering effects of dietary soy, which in theory may reduce cardiovascular risk. Soy has also been studied for blood pressure-lowering and blood sugar-reducing properties in people with type 2 diabetes, although the evidence is not definitive in these areas. Further investigation is needed before a recommendation can be made.

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 are 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 unknown if soy or soy isoflavones share the same side effects as estrogens (e.g. increased risk of blood clots). The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast cancer or prostate cancer. Other hormone-sensitive conditions, such as endometriosis, may also be worsened. Patients taking blood-thinning drugs, such as warfarin, should check with their doctors before taking soy supplementation.

Spirulina: The term spirulina refers to a large number of cyanobacteria, or blue-green algae. 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.

Avoid if allergic or hypersensitive to spirulina or blue-green algae. Avoid with phenylketonuria. Avoid 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 a history of high potassium or high calcium levels. Use cautiously if taking cardioglycosides. Avoid if pregnant or breastfeeding.

Tai chi: Tai chi techniques aim to address the body and mind as an interconnected system. 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. Additional research is needed before a firm conclusion can be drawn.

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: An amino acid, called taurine, may offer benefit to individuals fed a high-fat and high-cholesterol diet. More study is needed to make a firm recommendation.

It is unlikely that there are allergies related to taurine. However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously with high VLDL cholesterol, hypertriglyceridemia, a history of low blood pressure, coagulation disorders, potential for mania, or epilepsy. Use cautiously if taking hypolipidemic medications, or hypotensive, hypoglycemic, antiplatelet, or anticoagulant medications. Do not take taurine with alcohol or exercise. Use cautiously if pregnant or breastfeeding.

Thymus extract: Thymus extracts for nutritional supplements are usually derived from young calves (bovine). Preliminary evidence suggests that thymus extract may increase left ventricular function, exercise tolerance, and survival. Additional study is needed in this area.

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): Traditional Chinese medicine (TCM) herbal formulas have been reported to reduce symptoms of stable and unstable angina. However, research designs have been weak and more studies of better design are needed before recommendations can be made.

TCM herb combinations have been found to improve some markers of coronary heart disease. 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 ephedra (ma huang). Avoid ginseng if pregnant or breastfeeding.

Tribulus: Tribulus terrestris is a ground-hugging plant with spiny fruit that grows in tropical and sub-tropical climates. Preliminary research suggests that tribulus 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: Turmeric is a perennial plant native to India and Indonesia that is often used as a spice in cooking. 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 recommendation can be made.

Avoid if allergic or hypersensitive to turmeric (curcumin), yellow food colorings, or plants belonging to the Curcuma and Zingiberaceae (ginger) families. Use cautiously with a history of bleeding disorders, immune system deficiencies, liver disease, or gallstones. Use cautiously if taking anticoagulants. Use cautiously if pregnant or breastfeeding.

Vitamin B12: Vitamin B12 is a water-soluble vitamin, and it is commonly found in many foods, including fish, shellfish, meats, and dairy products. 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 to patients receiving coronary stents.

Hyperhomocysteinemia (high homocystein levels in the blood) is a risk factor for coronary, cerebral, and peripheral atherosclerosis, recurrent thromboembolism, deep vein thrombosis, myocardial infarction, and ischemic stroke. Elevated homocysteine levels may be a marker instead of a cause of vascular disease. However, it is unclear if lowering homocysteine levels results in reduced cardiovascular morbidity and mortality. 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 drawn.

Avoid vitamin B12 supplements if allergic or hypersensitive to cobalamin, cobalt, or any other product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the recommended dietary allowance (RDA).

Vitamin B6: Vitamin B6 (pyridoxine) is required for the body to produce serotonin and norepinephrine. 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 recommendation can be made.

High homocysteine levels in the blood (hyperhomocysteinemia) are a risk factor for cardiovascular disease, blood clotting abnormalities, myocardial infarction, 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 unclear 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.

Investigation of more renal transplant recipients undergoing longer treatment with vitamin B6 is needed as study results conflict.

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).

Vitamin D: Vitamin D is found in many foods, including fish, eggs, fortified milk, and cod liver oil. Further research is needed to determine if vitamin D is an effective treatment 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. Individuals with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, or histoplasmosis have an increased risk of experiencing toxic effects. Vitamin D is generally considered safe for pregnant women.

Vitamin E: Vitamin E has been suggested and evaluated in patients with angina, although possible benefits remain unclear. Further evidence is necessary before a clear conclusion can be drawn. Patients with known or suspected angina should be evaluated by their physicians.

Vitamin E has been proposed to have a role in preventing or reversing atherosclerosis by inhibiting oxidation of low-density lipoprotein ("bad cholesterol"). Several population studies have suggested that a high dietary intake of vitamin E and high blood concentrations of alpha-tocopherol are associated with lower rates of heart disease. However, while the Cambridge Heart Antioxidant Study supported this hypothesis, the more recent prospective Heart Outcomes Prevention Evaluation (HOPE) study did not. This area remains controversial.

It has been suggested that hemodialysis patients may be under increased oxidative stress, and therefore may benefit from the chronic use of antioxidants (particularly for the reduction of risk of heart disease). There is some research on the use of high-dose chronic vitamin E in dialysis patients for heart disease prevention, although benefits or risks remain unclear in this population. Recent concern has been raised that regular use of high-dose vitamin E supplements may actually increase the risk of death (from "all causes") by a small amount, although this remains an area of controversy and active investigation. Additional research is necessary in this area before a firm conclusion can be reached.

The effects of vitamin E on cholesterol levels and atherosclerosis have been studied 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 lowering lipids. Further research is warranted before a clear conclusion can be drawn.

Avoid if allergic or hypersensitive to vitamin E. For short periods of time, vitamin E supplementation is generally considered safe if taken at doses lower than the recommended dietary allowance (RDA). Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders.

White horehound: Early study shows that white horehound may lower cholesterol and triglyceride blood levels. Further research is needed to confirm these results.

Avoid if allergic or hypersensitive to white horehound or any member of the Lamiaceaefamily (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 diseases. Use cautiously if taking diuretics. Avoid if pregnant or breastfeeding.

Wild yam: Animal studies have shown that wild yam can reduce absorption of cholesterol from the gut. 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"). However, no changes in the total amount of blood cholesterol have been found. More studies are needed in this area.

Avoid wild yam if allergic or hypersensitive to wild yam or any member of the Dioscorea plant family. Use cautiously with a history of hormone-sensitive conditions (e.g. breast cancer or endometrial cancer), asthma, blood clots, stroke, or diabetes. Avoid if pregnant or breastfeeding.

Yucca: A blend of partially purified Yucca schidigera and Quillaja saponaria extracts may reduce cholesterol levels in hypercholesterolemic patients. 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 cholesterol-lowering agents. Avoid if pregnant or breastfeeding.

Fair negative scientific evidence :

Acacia: Current available scientific evidence suggests that acacia does not effectively lower cholesterol.

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 families. 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: Beta-carotene is a member of the carotenoids, which are very colorful (red, orange, yellow), fat-soluble compounds. There is some concern that when antioxidant vitamins, including beta-carotene, are used together they might have harmful effects in patients after angioplasty. Additional research is needed to determine the effect of beta-carotene specifically. Supplements containing these vitamins should be avoided immediately before and following angioplasty without the recommendation of a qualified healthcare professional.

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.

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

Avoid if allergic to plants in the Onagraceae family (e.g. willow's herb or 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.

Guided imagery: Guided imagery refers to a number of techniques, including metaphor, storytelling, fantasy, game playing, dream interpretation, drawing, visualization, active imagination, and direct suggestion using imagery. A combination of masked prayer, music, imagery, and touch therapy did not significantly improve the clinical outcome after elective catheterization or percutaneous coronary intervention in a recent study.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem.

Omega-3 fatty acids: Omega-3 fatty acids are found in fish oil and certain plant/nut oils. Fish oil contains both docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA). Although fish oil is able to reduce triglycerides, beneficial effects on blood cholesterol levels have not been demonstrated. Fish oil supplements appear to cause small improvements in high-density lipoprotein ("good cholesterol"); however, increases (worsening) in low-density lipoprotein levels ("bad cholesterol") are also observed. Fish oil does not appear to affect C-reactive protein (CRP) levels.

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. Pregnant and breastfeeding women should not take doses that exceed the recommended dietary allowance (RDA).

Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. 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.

Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses such as 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.

Vitamin C (ascorbic acid): Vitamin C (ascorbic acid) is a vitamin that the body needs to form collagen in bones, cartilage, muscle, and blood vessels. Vitamin C does not appear to lower cholesterol levels or reduce the risk of heart attacks. Effects on cholesterol plaques in heart arteries (atherosclerosis) remain unclear, and some studies suggest possible beneficial vasodilation (artery opening) properties. Based on the current scientific evidence, vitamin C is generally not recommended for this use. People at risk of heart attacks should speak with their healthcare providers to consider preventive measures such as aspirin.

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 E: Numerous studies of vitamin E oral supplementation have suggested no benefits in the prevention of cardiovascular disease, and there is recent evidence to suggest that regular use of high-dose vitamin E increases the risk of death (from "all causes") by a small amount. These conclusions have been criticized by some experts.

Avoid if allergic or hypersensitive to vitamin E. For short periods of time, vitamin E supplementation is generally considered safe when taken in doses that do not exceed the recommended dietary allowance (RDA).

Strong negative scientific evidence :

Chelation (EDTA) therapy: During chelation therapy, EDTA (ethylenediamine tetraacetic acid), usually in combination with vitamins, trace elements, and iron supplements, is injected into the vein as a treatment for a variety of diseases. Chelation has been suggested as a treatment for clogged arteries ("atherosclerosis"), and has been recommended as a therapy to delay the time until heart surgery is necessary. However, recent scientific research reports that chelation is not helpful in these situations. The American Heart Association does not recommend chelation therapy for arteriosclerotic heart disease. Research is ongoing in this area.

Avoid with heart disease, liver disease, kidney disease, immune system disorders, bleeding disorders, or if taking drugs that increase the risk of bleeding. Avoid if pregnant or breastfeeding due to potential toxic effects.

High blood pressure (hypertension) control: One of the most important things that can be done to prevent coronary artery disease (CAD) and heart attack is to reduce high blood pressure. Blood pressure should be a systolic reading of 120 and a diastolic reading of 80 (120/80 millimeters of mercury). 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 also be used.

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

Platelet inhibitors: In otherwise healthy men who are older than 50 years, 325 milligrams of aspirin every other day helps prevent heart attack (at a rate of two men per 1,000), but not stroke. In otherwise healthy women older than 45 years, a 100 milligram dose of aspirin every other day prevents ischemic stroke (at a rate of three women per 1,000) but not heart attack (myocardial infarction). Platelet inhibitors, or antiaggregants (prevent platelet clumping), such as aspirin may increase 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 heart attack) 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. Therefore, individuals can decrease their risk of heart disease by not smoking.

Flu shots: Flu shots for patients with chronic cardiovascular disease are now used routinely. This is because patients with cardiovascular disease have an increased risk of dying from the flu.

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. Chronic stress can lead to an increase in the release of the stress hormone cortisol from the adrenal glands. Researchers believe that this increase in cortisol leads to increased blood pressure. Managing stress can be vital to keeping a heart healthy.

Diet: Eat healthy foods. A 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.

Alcohol consumption: In some studies, moderate use of alcohol (particularly red wine) has been linked with increasing levels of HDL cholesterol. No more than two glasses of red wine (four ounces each) should be consumed daily for heart protection. Excessive drinking can have a negative impact on cholesterol levels, actually raising triglyceride levels and increasing blood pressure.

Cholesterol screenings: Everyone age 20 and older should have their cholesterol measured at least once every five years.