Nutritional Supplements for Promoting Cardiovascular Health

According to the World Health Organization (WHO), cardiovascular disease (CVD) is the leading global cause of death among men and women, accounting for an estimated 17.5 million deaths worldwide each year.¹ This number is expected to surge to more than 23.6 million by 2030.² Additionally, CVD accounts for more deaths than do all forms of cancer combined.² In the United States, an estimated 610,000 individuals die of CVD each year and an estimated 85.6 million are living with some degree of CVD.³

Pharmacists are in a pivotal position to increase awareness among patients regarding the importance of being proactive in their cardiovascular health. Patients should be educated about the modifiable risk factors (eg, history of hypertension, smoking, obesity, diabetes, hyperlipidemia) and the nonmodifiable risk factors (eg, age, gender, ethnicity, genetics/familial history of CVD) and be encouraged to discuss these factors with their primary care provider (PCP).⁴ An estimated 50% of deaths related to CVD are due to major modifiable CVD risk factors.⁴ The WHO states that most cases of CVD can be improved or prevented by addressing lifestyle habits, such as tobacco use, obesity, unhealthy eating habits, sedentary lifestyle, and excessive alcohol use.¹

As point-of-entry health care providers for many patients, pharmacists are likely to encounter patients seeking advice on nutritional supplements marketed for cardiovascular health. These supplements are available as single-entity or combination products in various dosage forms,including tablets, capsules, liquid, and gummies (Table). In addition, some foods are fortified with omega-3 fatty acids and plant sterols, which have been associated with cardiovascular health. Manufacturers of some specialty multivitamin/ mineral supplements market formulations with essential nutrients for cardiovascular health. The most common supplements marketed for promoting cardiovascular health include omega-3 fatty acids, coenzyme Q10 (CoQ10), garlic, red yeast rice, and resveratrol.⁵

OMEGA-3 FATTY ACIDS

Omega-3 fatty acids are essential to proper function of the heart and the brain and to normal growth and development.^5-8 The body needs but cannot produce these fatty acids; therefore, they must be acquired through the diet or supplements.^5-7 Consumption via the diet is optimal; however, many patients may elect to use omega-3 supplements due to their convenience or the inability to consume enough of these fatty acids via diet alone.^5-7

Because of the role of omega-3 fatty acids in cardiovascular protection, the American Heart Association recommends their consumption from fish and plant sources at least twice a week for all individuals.⁷ Commonly used omega-3 supplements are formulated with fish oil, which provides eicosapentaenoic acid, and docosahexaenoic acid (DHA), and flaxseed oil, which provides alpha linolenic acid. Algae oils are a vegetarian source of DHA.^5-8

Patients allergic or hypersensitive to any of these products should avoid their use. Common adverse effects (AEs) include acid reflux, heartburn, indigestion, nausea, diarrhea, and increased burping.^5-8 Gastrointestinal (GI) AEs can be diminished if supplement oils are taken with meals, starting with a low dose that is gradually increased.⁵

The products most likely to interact with omega-3 supplements include aspirin, anticoagulants, antiplatelet agents, and some herbal supplements.⁵ Patients with diabetes should be advised to use these supplements with caution because they may slightly decrease the blood glucose level. Pharmacists should remind patients who take more than 3 g of omega-3 fatty acids to do so only under a physician’s care because excessive intake may cause excessive bleeding or worsen heart rhythm in individuals with arrthymias.⁵

COQ10

CoQ10, also known as ubiquinone, is found in every human cell, with the greatest concentrations in the mitochondria of the heart, liver, pancreas, and kidneys.⁵ CoQ10 has been used in treating cardiovascular conditions, including congestive heart failure, cardiomyopathy, and hypertension; it is also popular for managing AEs of myopathy associated with the use of statin drugs.^5,9,10 However, more research is needed to conclude whether CoQ10 is useful for treating statin myopathy. Currently, there is no research regarding the effectiveness of CoQ10 supplementation for preventing statin myopathy.^5,9,10

The most common AEs of CoQ10 include insomnia, nausea, GI distress, anorexia, headache, heartburn, sensitivity to light, dizziness, rash, dizziness, and irritability.^9,10 The use of CoQ10 should be avoided by women who are pregnant or breast-feeding.⁵ Patients who are taking warfarin should discuss the use of CoQ10 prior to use because potential vitamin K—like procoagulant effects may occur due to CoQ10’s structural similarity to synthetic vita- min K.^5,9,10 Patients taking CoQ10 should have their international normalized ratio monitored until the effects of CoQ10 have been determined.^5,9,10

GARLIC

Garlic supplements have been used to treat hyperlipidemia, hypertension, and type 2 diabetes, as well as to prevent various cancers.^5,11 Garlic supplements are manufactured from dried or fresh bulbs of the Allium sativum plant.⁵ Results from animal studies and in vitro studies show that garlic has hypotensive, hypolipidemic, antiplatelet, and anti-infective properties, and may slightly decrease low-density lipoprotein concentrations and total cholesterol levels.⁵

The most common AEs of garlic include nausea, vomiting, and heartburn, all of which are typically associated with high doses.^5,11 Garlic has antithrombotic effects; to decrease the risk of bleeding, garlic supplements should be discontinued at least 10 to 14 days before surgery.⁵ Patients should be reminded to discuss this issue with their PCP to avoid complications.⁵ Prior to using garlic supplements, patients on warfarin and other platelet-active agents should be advised to consult their PCP.⁵ Study results have shown that the use of garlic supplements may decrease the concentration of saquinavir by approximately 50%; therefore, garlic supplements and saquinavir should not be taken concurrently.⁵

RED YEAST RICE

Red yeast rice, also known as Monascus purpureus, grows on fermented rice and is often used in traditional Chinese medicine.^5,12 Red yeast rice supplements are often used to lower lipid concentrations.^5,12 Monacolin K is a naturally occurring lovastatin analogue of red yeast rice.^5,12 In addition, because red yeast contains chemicals comparable to prescription lovastatin, its use may cause similar AEs, such as liver damage, severe muscle pain, and muscle damage.^5,12 The FDA has determined that red yeast rice products that contain more than trace amounts of monacolin K are unapproved new drugs and cannot be sold legally as dietary supplements.¹²

The most common AEs associated with red yeast rice include allergic reactions, headache, bloating, heartburn, and flatulence.5 In addition, increased liver function test results and rhabdomyolysis have been observed in patients who take red yeast rice supplements; therefore, liver function should be evaluated regularly in these patients.⁵

RESVERATROL

Resveratrol is a polyphenol found in grapes, wine, blueberries, and pistachios.^5,13 Several clinical studies have investigated the link between resveratrol and its cardioprotective effects. Resveratrol has been proposed as a treatment for hyperlipidemia and to prevent fatty liver, diabetes, atherosclerosis, and aging. Its use has not been associated with serum enzyme elevations or with clinically apparent liver injury.^13,14 High dietary intake of resveratrol is linked to lower lipid levels, blood pressure, glucose levels, and heart rate.⁵ To date, there is no conclusive evidence regarding the benefits of using resveratrol supplements, and large-scale studies have not been conducted.⁵ The most common AEs include minor GI upset, nausea, headache, and fatigue; possible supplement—drug interactions include estrogens and anticoagulants.^5,13

PATIENT COUNSELING

During counseling, pharmacists should remind patients to take a proactive role in their cardiovascular health by maintaining a healthy balanced diet (eg, the diet recommended by the American Heart Association) and establishing healthy lifestyle habits (eg, routine exercise, weight loss, smoking cessation, limited alcohol use). Patients who are unsure of their overall risk for hyperlipidemia or who have risk factors for CVD should be encouraged to confer with their PCP for medical evaluation and treatment.

Prior to recommending any supplement marketed for cardiovascular health, it is imperative that pharmacists ascertain the appropriateness of use, and screen patients for potential contraindications and drug—supplement interactions. Patients with preexisting medical conditions or taking medications should always consult their PCP before using any of the supplements discussed here. Patients should be advised that the use of these supplements is not intended to replace any prescription antihyperlipidemia agent or other prescription cardiovascular agent. When in doubt, patients should consult their PCP about the use of these supplements.

Ms. Terrie is a clinical pharmacist and medical writer based in Haymarket, Virginia.

References:

• Cardiovascular disease. World Health Organization website. who.int/mediacentre/factsheets/fs317/en/. Accessed October 5, 2016.
• Heart disease and stroke statistics: at a glance. American Heart Association website. heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_470704.pdf. Accessed October 4, 2016.
• Heart disease fact sheet. CDC website. cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_disease.htm. Accessed October 4, 2016.
• Patel SA, Winkel M, Ali MK, Narayan KV, Mehta NK. Cardiovascular mortality associated with 5 leading risk factors: national and state preventable fractions estimated from survey data. Ann Intern Med. 2015;163(4):245-253. doi: 10.7326/M14-1753.
• McQueen C, Orr K. Natural products. In: Krinsky D, Berardi R, Ferreri S, et al, eds. Handbook of Nonprescription Drugs. 18th ed. Washington, DC: American Pharmacist Association; 2015.
• Omega-3 supplements: introduction. National Center for Complementary and Integrative Health website. https://nccih.nih.gov/health/omega3/introduction.htm . Accessed October 5, 2016.
• Fish and omega-3 fatty acids. American Heart Association website. heart.org/HEARTORG/GettingHealthy/NutritionCenter/HealthyDietGoals/Fish-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp. Accessed October 3, 2016.
• Omega-3 supplements: more information. National Center for Complementary and Integrative Health website. https://nccam.nih.gov/health/omega3/introduction.htm#moreinfo. Accessed October 2, 2016.
• Scott G. Does coenzyme Q10 relieve statin induced myopathy? Medscape website. http://www.medscape.com/viewarticle/709107. Accessed October 5, 2016.
• Coenzyme Q10: in depth. National Center for Complementary and Integrative Health website. http://nccam.nih.gov/health/supplements/coq10. Accessed October 4, 2016.
• Garlic. National Center for Complementary and Integrative Health website. http://nccam.nih.gov/health/garlic/ataglance.htm. Accessed October 4, 2016.
• Red yeast rice. National Center for Complementary and Integrative Health website. https://nccih.nih.gov/health/redyeastrice. Accessed October 2, 2016.
• Resveratrol. United States National Library of Medicine website. https://livertox.nih.gov/Resveratrol.htm. Accessed October 5, 2016.
• Resveratrol. Medline Plus website. https://medlineplus.gov/druginfo/natural/307.html. Accessed October 6, 2016.