Various health organizations promote the importance of maintaining cardiovascular health because cardiovascular disease (CVD) is the leading cause of death among both men and women in the United States and the number of individuals with CVD continues to escalate annually.

A host of nutritional supplements are marketed for the promotion of cardiovascular health and for their protective effects against CVD. Pharmacists are in a pivotal position to guide patients in the proper selection and use of these nutritional supports and to provide patients with key information regarding measures to improve or maintain cardiovascular health.

The nutritional supplements marketed to promote cardiovascular health are available in single-entity or combination products in a variety of dose formulations, including capsules, liquids, and gummies (Online Table 1). Some foods are even fortified with omega-3 fatty acids and plant sterols. In recent years, many manufacturers of multivitamin/mineral supplements have marketed formulations specifically for cardiovascular health. Some of the newest cardiovascular health supplements on the market include TruHeart Heart Health Formula (Bayer), which contains plant sterols, vitamin D3, and coenzyme Q10 (CoQ10), and Vitafusion Multivites Plus Heart Support (Church & Dwight Co Inc). The most common ingredients marketed for the promotion of cardiovascular health include omega fatty acids, plant sterols, CoQ10, and garlic.

TABLE 1: DIETARY SUPPLEMENTS MARKETED FOR CARDIOVASCULAR HEALTH

Omega-3 Fatty Acid Supplements

AlphaBetic Omega-3 EPA+DHA Fish Oil Diabetic Nutrients

Coromega Omega-3 Squeeze Packets

Finest Nutrition Omega-3 Krill Oil

Iceland Health Omega-3 plus Vitamin D3

Natrol Omega-3 Fish Oil

Natrol Omega-3 Flax Seed Oil

Natrol Omega 3-6-9 Complex Fish, Flax and Borage Oil

N

ature Made Triple Omega

Nature’s Bounty Dual Spectrum Omega-3 Krill and Fish Oil

Nature’s Bounty Fish Oil

Nature’s Bounty Odorless Double Strength Fish Oil

Nature’s Way Super Fisol Fish Oil

Nordic Naturals Omega-3 Purified Fish Oil

Schiff’s MegaRed Omega-3 Krill Oil

Solgar Omega 3 Fish Oil

Sundown Naturals Triple Omega 3-6-9

Twin Lab Omega-3 Fish Oil

Vitafusion Omega-3 EPA/DHA

Vitamin Products That Contain Plant Sterols or Omega-3 Fatty Acids and/or CoQ10

Centrum Cardio

Emergen-C Heart Health

One A Day VitaCraves Gummies Plus Omega-3 DHA

TruHeart Heart Health Formula

Vitafusion MultiVites Plus Heart Support

Garlic Supplements

Garlique

Kyolic Aged Garlic Extract

Nature Made Odor Control Garlic

Nature’s Bounty Odorless Garlic

Nature’s Way Garlic Bulb

Co-Enzyme Q10 Supplements

Natrol CoQ-10

Nature Made CoQ 10

Nature’s Bounty Co Q-10

Sundown Naturals Co Q-10

Windmill CoQ 10

Vitafusion CoQ10

Cholesterol-Lowering Supplements

Natrol Cholesterol Balance Beta Sitosterol

Nature Made CholestOff Plus

Plant Sterol Products

CholestaPRO Natural Cholesterol Reduction

Windmill Rx Premium Plant Sterol Cholesterol Control Formula

Natrol Cholesterol Balance

Vitafusion CholestorWell

Omega Fatty Acids

Omega-6 and omega-3 polyunsaturated fatty acids have an important role in heart and brain function as well as in normal growth and development.¹ Polyunsaturated fatty acids are “essential” fats that the body needs but cannot produce, so sources must be acquired via dietary means or supplements.¹

Consuming omega-3 fatty acids through dietary means is the optimal method; however, many patients elect to use omega-3 dietary supplements due to their convenience or to the individual’s inability to consume enough omega-3 fatty acids through diet alone. The American Heart Association recommends the consumption of omega-3 fatty acids from fish and plant sources at least twice a week for all individuals.² Omega-3 dietary supplements are commonly formulated with fish oil, which provides eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and flaxseed oil, which provides alpha linolenic acid (ALA). Algae oils are a vegetarian source of DHA.

Patients with allergy or hypersensitivity to any of these oils should avoid use of these supplements. Common adverse effects associated with fatty acid nutritional supplements include acid reflux/ heartburn/indigestion, nausea, diarrhea, and increased burping.^3,4 Gastrointestinal (GI) side effects can be minimized if fish oils are taken with meals and if doses are started low and increased gradually.³

Plant Sterols

Various studies have investigated the benefits of plant sterols (phytosterols), a naturally occurring plant-based ingredient that has been proved to lower lowdensity lipoprotein (LDL) cholesterol levels, thus possibly decreasing the risk for CVD.^5-7 The most common plant sterols include beta-sitosterol, campesterol,and stigmasterol.^6,7 Sitostanol, which is a saturated derivative of sitosterol, is the most common plant stanol.⁶ Plant sterols and stanols are chemically related and structurally similar to cholesterol and have been shown to decrease total and LDL cholesterol by decreasing both dietary and biliary cholesterol absorption via the displacement of cholesterol from the micelles, thus resulting in decreased solubility of cholesterol in the intestine.^6,7

Adverse effects regarding the consumption of the plant stanol/sterol ester— containing fats are reported rarely. There has been some concern regarding observations of decreased levels of plasma alpha- plus beta-carotene, alpha-tocopherol, and/or lycopene due to the consumption of foods containing both stanol esters and sterol esters.⁷ Further investigation is needed to establish long-term safety of recommended doses of stanols and sterols and to evaluate the potential bioavailability of nutrients in foods, beverages, and supplements as well as their effects.⁷

Coenzyme Q10

CoQ10 is found in every human cell, with the greatest concentrations in the mitochondria of the heart, liver, pancreas, and kidneys.⁸ This supplement has been used in the treatment of various cardiovascular conditions, including congestive heart failure, cardiomyopathy, and hypertension. It is also popular for managing the adverse effects of statin drugs such as myopathy.^9,10 More research is needed to determine whether CoQ10 is useful for treating statin myopathy; no research has been published regarding its effectiveness for the prevention of statin myopathy.^8-10

The most common adverse effects of CoQ10 supplements include insomnia, nausea, GI distress, anorexia, headache, dizziness, rashes, and irritability.^8,10

Garlic

Garlic supplements have been used to treat hyperlipidemia, hypertension, and other medical conditions such as type 2 diabetes mellitus; garlic is also used to prevent various types of cancer.^11,12

Garlic supplements are manufactured from dried or fresh bulbs of the Allium sativum plant. Results from both animal studies and in vitro studies have shown that garlic has hypotensive, hypolipidemic, and antiplatelet properties.^11,12

The most common adverse effects associated with garlic supplements include nausea, vomiting, and heartburn; these effects typically occur with megadoses.^11,12 Body odor and halitosis are common complaints among individuals using these supplements, but odorless formulations are available.^11,12

The Pharmacist’s Role

Before recommending any cardiovascular supplements, patients, especially those taking medications for other conditions, should consult with their primary health care provider to establish the appropriateness of using these supplements to avoid potential contraindications or drug interactions (Online Table 2). In addition, patients should be advised that these supplements should not be used as a replacement for prescription antihyperlipidemic agents or other cardiovascular medications. Patients at risk for hyperlipidemia or those with risk factors for CVD should be encouraged to consult their primary health care provider for medical evaluation and treatment. During counseling, patients should be reminded that eating a healthy, balanced diet and establishing lifestyle habits, such as exercising routinely, maintaining a healthy weight, quitting smoking, and limiting the use of alcohol, are some of the best defenses against CVD. Patients should be encouraged to take a proactive role in their health.

TABLE 2: KEY INFORMATION AND COUNSELING TIPS ABOUT DIETARY SUPPLEMENTS MARKETED FOR CARDIOVASCULAR HEALTH

Omega Fatty Acids

· Pharmacists should remind patients who ingest more than 3 g of omega-3 fatty acids in supplement form to do so only under a physician’s care because high intakes may result in excessive bleeding or worsen heart rhythm in individuals with arrthymias.^3,4

· Patients should be advised that vitamin E is added to many commercial fish oil products because prolonged use of fish oil supplements may cause vitamin E deficiency.^3,4 Regular use of vitamin E—enriched products may lead to elevated levels of this fat-soluble vitamin, so patients should be monitored by their physicans.³

· The drugs that most commonly interact poorly with omega-3 fatty acid supplements include aspirin, anticoagulants, antiplatelet agents, and some herbal supplements.^3,4 In addition, caution should be exercised by diabetic patients because these supplements may decrease blood glucose levels slightly.^3,4

CoQ10

^· Daily doses range from 100 to 200 mg. The structure of CoQ10 is comparable to that of the synthetic form of vitamin K (menaquinone) and may have some procoagulant effects similar to vitamin K.^3,8 Therefore, patients taking warfarin should discuss the use of CoQ10 supplements prior to using them.

· CoQ10 may interact with some chemotherapeutic agents and certain antihypertensive

agents.^3,8,10

· The use of this supplement is contraindicated in both pregnant and lactating women due to lack of clinical information regarding its safety in this patient population.^3,8,10

Garlic

^· Because of their antithrombotic effects, garlic supplements should be discontinued at least 7 to 10 days before undergoing any surgical procedure. Patients should be reminded to discuss this with their physicians. ³

^· Because of potential bleeding risks, patients on warfarin or other platelet-active agents as well as those using ginkgo supplements should be advised to consult their primary health care provider prior to using garlic supplements.³

· Studies have reported that the use of garlic supplements may decrease the concentration of the agent saquinavir by an estimated 50%; therefore, use of garlic supplements and agents such as those to treat HIV typically should be avoided.^3,4

· Research shows that garlic may decrease blood pressure by as much as 7% or 8% in people with hypertension.^3,11,12 Other studies report promising, modest, short-term effects of garlic supplements on lipid and antithrombotic factors; however, more research is needed.^3,11,12

Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia.

References

1. Fish oil. Medline Plus website. www.nlm.nih.gov/medlineplus/druginfo/natural/patient-fishoil.html. Reviewed August 21, 2014. Accessed November 5, 2014.

2. Fish and omega-3 fatty acids. American Heart Association website. www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Fish-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp. Updated May 14, 2014. Accessed November 5, 2014

3. McQueen C, Orr K. Natural products. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs, 17th ed. Washington, DC: American Pharmacists Association; 2012.

4. Omega-3 supplements: An introduction. National Center for Complementary and Alternative Medicine website. http://nccam.nih.gov/health/omega3/introduction.htm#moreinfo. Updated June 2014. Accessed November 5, 2014.

5. Phytochemicals and cardiovascular disease. American Heart Association website. www.heart.org/HEARTORG/GettingHealthy/NutritionCenter/Phytochemicals-and-Cardiovascular-Disease_UCM_306020_Article.jsp. Updated March 18, 2014. Accessed November 5, 2014.

6. Jones PJ, AbuMweis SS. Phytosterols as functional food ingredients: linkages to cardiovascular disease and cancer. Curr Opin Clin Nutr Metab Care. 2009;12(2):147-151.

7. Lichtenstein AH, Deckelbaum RJ. AHA science advisory. Stanol/sterol ester-containing foods and blood cholesterol levels. A statement for healthcare professionals from the Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism of the American Heart Association. Circulation. 2001;103(8):1177-1179.

8. Coenzyme Q-10. Medline Plus website. www.nlm.nih.gov/medlineplus/druginfo/natural/938.html. Reviewed October 21, 2011. Accessed November 5, 2014.

9. Scott GN. Does coenzyme Q10 relieve statin induced myopathy? Medscape website. www.medscape.com/viewarticle/709107. Accessed October 24, 2014. 10. Coenzyme Q10 (CoQ10): What you need to know. National Center for Complementary and Alternative Medicine website. http://nccam.nih.gov/health/supplements/coq

10. Accessed November 5, 2014.

11. Garlic. Medline Plus website. www.nlm.nih.gov/medlineplus/druginfo/natural/300.html#Effectiveness. Reviewed August 21, 2014. Accessed November 5, 2014.

12. Garlic. National Center for Complementary and Alternative Medicine website. http://nccam.nih.gov/health/garlic/ataglance.htm. Updated April 2012. Accessed November 5, 2014.