Related Terms

• Aneurysm, angina, angioplasty, arterial elasticity, arterial stiffness, arteriosclerosis, atherosclerosis, atherosclerotic lesion, blood pressure, blood vessels, cardiovascular disease, cardiovascular health, cerebrovascular disease, cholesterol, coronary artery disease, EKG, electrocardiograph, endothelial dysfunction, hardening of the arteries, heart, heart attack, heart disease, heart disorders, heart failure, high blood pressure, high cholesterol, hyperlipidemia, hypertension, myocardial infarction, peripheral artery disease, plaque, stroke, transient ischemic attacks.

Background

• In arteriosclerosis, there is a thickening, hardening, and loss of elasticity of the walls of arteries. The name arteriosclerosis is often used interchangeably with the term "atherosclerosis;" however, atherosclerosis is technically a type of arteriosclerosis. The name atherosclerosis comes from the Greek words "athero" (gruel or paste) and "sclerosis" (hardness). The term arteriosclerosis comes from the words "arterial" (artery) and "sclerosis" (hardness).

• Arteries are blood vessels that carry blood from the heart to the rest of the body. Healthy arteries are flexible, strong, and have a high degree of arterial elasticity, or flexibility. As people age, an increase in arterial stiffness is normal. Increased arterial stiffness may restrict blood flow to vital organs and is associated with an increased risk of heart attack and stroke.

• Atherosclerosis results from the accumulation of plaque in artery walls. Plaque is made up of fat, cholesterol (particularly low density lipoprotein (LDL) cholesterol), calcium, and other substances found in the blood. Plaque accumulation causes a narrowing and a loss of elasticity of the arteries. Over time, plaques can grow in size and may partially or totally block the blood's flow through an artery. A build-up of plaque, or a clot that forms if a plaque ruptures, may block an artery, cutting off blood and oxygen supply to vital organs, which may cause a heart attack or stroke. A piece of the clot may also break off and enter the blood stream. Most commonly, the clot will travel to the legs or the lungs. This may result in an obstruction of blood flow, which in the leg, can result in a deep vein thrombosis (DVT), or in the lung, a pulmonary embolism (PE). Although plaques may occur anywhere in the body, they usually cause problems in the heart, brain, and legs.

• Arteriosclerosis may begin early in life and not present any problems or symptoms or even be diagnosed until a plaque has grown so large that it ruptures. However, others experience symptoms such as chest pain, shortness of breath, or leg pain, especially with exercise.

• A plaque deposit may block blood flow to a particular area of the body, which decreases the amount of oxygen reaching that area. The result is that the supply of oxygen does not meet the body's needs. When someone exercises, oxygen demand increases and the heart pumps faster, fulfilling this increased need in healthy patients. In patients with arteriosclerosis, plaque deposits inhibit blood flow, and even though the heart is pumping faster, not enough oxygen reaches the tissues, which is why these symptoms are typically more noticeable during physical activity. The tissues that are normally nourished by the blood carried in the artery do not received oxygen and begin to shut down, causing the tissue to die.

• The endothelium is a thin layer of cells on the inner wall of arteries. Healthy endothelium keeps the inside of arteries toned and smooth, which keeps blood flowing properly. It is believed that endothelial dysfunction, caused by local damage, may trigger plaque formation. Endothelial dysfunction is caused by oxidative stress resulting from excessive levels of free radicals and low levels of antioxidants. Although the endothelium naturally hardens with age, there are some lifestyle factors that may speed up the process. For example, the endothelium may be damaged when a person eats a diet high in cholesterol and fat, has high blood pressure, and/or uses tobacco products. These factors may cause or worsen arteriosclerosis by causing new plaque deposits to form and others to grow larger.

• Plaque formation is the result of an inflammatory process due to endothelial dysfunction. When LDL cholesterol particles invade the endothelium, they become oxidized, which triggers an immune response. Monocytes (white blood cells) attack the LDL particles and engulf them in an attempt to remove them. Instead, they slowly form larger cells, called foam cells, which propagate the immune response. Atherosclerotic lesions occur at the site of plaque deposits. Over time, they grow larger due to cell division, fat build-up, and the formation of connective tissue. The result is hardening and thickening of the arteries, accompanied by restricted blood flow and impaired circulation.

• In most people, atherosclerosis may be prevented by adopting a healthy lifestyle and avoiding certain risk factors. Once atherosclerotic lesions have been detected, medications, lifestyle changes, or possibly surgery may be implemented to prevent disease progression and complications.

Types of the Disease

• Coronary artery disease: When atherosclerotic plaques occur in the arteries of the heart, a person may experience angina. Angina is chest pain that may occur at rest or intensify during physical activity. If the plaque suddenly ruptures and causes blood clots to form, the heart tissue does not receive oxygen and begins to die. The result is a heart attack, or myocardial infarction. According to the National Institutes of Health (NIH), coronary artery disease is the leading cause of death for both men and women in the United States. Coronary artery disease is also used interchangeably with coronary heart disease.

• Cerebrovascular disease: Atherosclerotic plaques may occur in the arteries of the brain. Eventually, the plaque may rupture, which leads to the formation of a blood clot. The clot may block the vessel, cutting off blood and oxygen supply in the brain. This may cause either a transient ischemic attack (temporary without causing permanent damage) or a stroke (which results in tissue death). Strokes may also occur when a plaque ruptures elsewhere in the body, resulting in the formation of a blood clot. A piece of the blood clot may break off (called an embolus) and travel to the brain, occluding (obstructing) an artery and leading to a lack of oxygen and tissue death. Strokes may cause permanent brain damage or even death.

• Peripheral artery disease (PAD): Peripheral artery disease (PAD) is the progressive hardening and narrowing of the arteries due to atherosclerotic plaque formation in the arteries of the lower extremities. A common symptom of PAD is intermittent claudication, which is described as pain, fatigue, discomfort, or numbness in the lower extremities (particularly in the thigh or calf muscles) during exercise that resolves with rest. In more advanced PAD, this lower extremity pain may also occur at rest. The lack of blood flow to the extremities results in poor wound healing, which may sometimes lead to amputations.

Risk Factors

• Age: Some degree of hardening of the arteries is normal as people age, causing an increase in the risk of atherosclerosis. Genetic and lifestyle factors may also cause some degree of hardening of the arteries, which increases the risk of atherosclerosis. In men, the risk increases after age 45. In women, the risk increases after age 55. However, recently there has been an increase in the number of children and youth that are at risk of atherosclerosis, which has been linked to rising childhood obesity rates.

• C-reactive protein (CRP) levels: People with high levels of a protein called C-reactive protein (CRP) in the blood may be at an increased risk of atherosclerosis. High levels of CRP indicate inflammation in the body, which may be caused by damage to the endothelium of the arteries.

• Diabetes: In patients with diabetes, the body has abnormally high blood sugar levels with decreased or a lack of insulin production due to pancreatic dysfunction. Patients with diabetes are at an increased risk for arteriosclerosis.

• Excess alcohol intake: Excessive drinking may have a negative impact on cholesterol levels, raising triglyceride levels and increasing blood pressure. Men who consume more than two alcoholic beverages daily and women who consume more than one alcoholic beverage daily have an increased risk of developing arteriosclerosis.

• Family history: A positive family history of heart disease is a risk factor for developing arteriosclerosis. If a father or first-degree male relative experienced a myocardial infarction or sudden death before the age of 55, or a mother or first-degree female relative experienced a myocardial infarction or sudden death before the age of 65, there is an increased risk of arteriosclerosis.

• High blood pressure: High blood pressure, or hypertension, causes the heart to work extra hard to push blood throughout the body and increases the risk of arteriosclerosis. Although the link between these two diseases is a bit unclear, they are often seen together possibly due to similar risk factors or the shared stressful effects on artery walls. Blood pressure is measured as systolic pressure (the force of the heart pumping) over diastolic pressure (the force of blood entering the heart). Blood pressure below 120/80 millimeters of mercury is considered healthy. There is an increased risk of arteriosclerosis if a patient has a consistent blood pressure of 140/90 or higher or if they are currently taking medication to control their blood pressure. The blood pressure goal for patients with diabetes should be less than 130/80.

• High cholesterol: A diet high in cholesterol and fat, especially saturated fat, may increase the amount of plaque buildup in the arteries. There are different types of cholesterol: low density lipoprotein (LDL), which is sometimes called bad cholesterol, and high density lipoprotein (HDL), sometimes called good cholesterol. The LDL goal changes based on patient-specific risk factors. For patients with a 0-1 risk factor, the LDL goal is less than 160 milligrams per deciliter. The LDL goal for patients with two or more risk factors is less than 130 milligrams per deciliter. The LDL goal for patients with heart disease or a history of diabetes, or a cardiovascular event (such as a heart attack or stroke) is less than 100milligrams per deciliter. The goal for HDL (good cholesterol) is higher than 40 milligrams per deciliter for men and higher than 50 milligrams per deciliter for women. Other cholesterol goals are the same for all patients. Total cholesterol should be less than 200 milligrams per deciliter, and triglycerides should be less than 150 milligrams per deciliter.

• Lack of exercise: A lack of physical activity may worsen other risk factors for atherosclerosis, such as unhealthy blood cholesterol levels, high blood pressure, diabetes, and obesity.

• Obesity: Being overweight contributes to other risk factors for atherosclerosis, such as high blood pressure and diabetes. Obesity is defined as a body mass index (BMI) of over 30 kilograms per square meter and overweight as 25-29.9kilograms per square meter. BMI can be calculated by dividing a patient's weight (in kilograms) by his or her height (in meters squared).

• Poor diet: An unhealthy diet may increase the risk of atherosclerosis. Avoiding certain foods, such as those high in saturated and trans fats, cholesterol, salt, and sugar, may reduce the risk of atherosclerosis.

• Sleep apnea: Sleep apnea is a disorder in which normal breathing stops briefly during periods of sleep. Patients with sleep apnea are often overweight, and therefore have an increased risk of arteriosclerosis as well as high blood pressure, diabetes, and heart disease.

• Smoking: 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 reduces oxygen in the blood and damages the lining of the blood vessels.

Causes

• Atherosclerosis is the progressive accumulation of plaque in artery walls. Plaque is made up of fat, cholesterol (particularly low density lipoprotein (LDL) cholesterol), calcium, and other substances found in the blood. Plaque accumulation causes a narrowing and loss of elasticity of the arteries. Over time, plaques can grow in size and restrict blood flow. Plaque may partially or totally block blood flow through an artery. Although plaques may occur anywhere in the body, they usually cause problems in the heart, brain, and legs.

• It is believed that endothelial dysfunction, caused by damage to the endothelium, triggers plaque formation. The endothelium is a thin layer of cells on the inner wall of arteries. Healthy endothelium keeps the inside of arteries toned and smooth, which keeps blood flowing properly. Endothelial dysfunction is caused by oxidative stress caused by excessive levels of free radicals and low levels of antioxidants. Antioxidants protect molecules, such as DNA, from being damaged by free radicals that are found in the body.

• Although the endothelium naturally hardens with age, there are some lifestyle factors that are believed to speed up the process. For example, the endothelium may be damaged when a person eats a diet high in cholesterol and fat, has high blood pressure, and/or uses tobacco products. These factors may cause or worsen arteriosclerosis by causing new plaque deposits to form or others to grow larger.

• Atherosclerotic lesions occur at the site of plaque deposits. Over time, they grow larger due to cell division, fat build-up, and the formation of connective tissue. The result is hardening and thickening of the arteries, accompanied by restricted blood flow and impaired circulation. The body's immune system responds by trying to attack the foreign matter, thereby causing inflammation, which may further narrow or block arteries. In severe cases, the plaques rupture, causing blood clots to form that may completely block the passage of blood through arteries.

Signs and Symptoms

• General: Atherosclerosis develops gradually. The severity of atherosclerosis depends on the number of risk factors to which the person is exposed. Some people with arteriosclerosis experience no symptoms. However, others experience symptoms such as chest pain, shortness of breath, or leg pain, especially with exercise. A plaque deposit may block blood flow to a particular area of the body, which decreases the amount of oxygen reaching that area. The result is that the supply of oxygen does not meet the body's needs. When someone exercises, oxygen demand increases and the heart pumps faster, fulfilling this increased need in healthy patients. In patients with arteriosclerosis, plaque deposits inhibit blood flow, and even though the heart is pumping faster, not enough oxygen reaches the tissues, which is why these symptoms are typically more noticeable during physical activity. Other people do not experience any symptoms until a plaque suddenly ruptures, causing a blood clot to form inside an artery. If this occurs in the brain, it is called a stroke. If it occurs in the heart, it causes a heart attack. A piece of the clot may also break off and enter the blood stream. Most commonly, the clot will travel to the legs or the lungs. This may result in an obstruction of blood flow, which in the leg, can cause a deep vein thrombosis (DVT), or in the lung, a pulmonary embolism (PE). The tissues that are normally nourished by the blood carried in the artery do not received oxygen and begin to shut down, causing the tissue to die.

• Coronary artery disease: When atherosclerotic plaques occur in the arteries of the heart, a person may experience angina (chest pain). Angina may feel like pressure, burning, or a squeezing pain in the chest. It may also be felt in the shoulders, arms, neck, jaw, or back and gets worse during physical activity or emotional stress. Angina can also occur at rest. Arrhythmias, or abnormal heart rates or rhythms, may also occur.

• Cerebrovascular disease: Atherosclerotic plaques may occur in the arteries of the brain. Eventually, the plaque may rupture, which leads to the formation of a blood clot. The clot may block the vessel, cutting off blood and oxygen supply in the brain. This may cause either a transient ischemic attack (temporary without causing permanent damage) or a stroke (which results in tissue death). Strokes may also occur when a plaque ruptures elsewhere in the body, resulting in the formation of a blood clot. A piece of the blood clot may break off (called an embolus) and travel to the brain, occluding an artery and leading to a lack of oxygen and tissue death. Strokes may cause permanent brain damage or even death. Symptoms may include sudden numbness or weakness in the arms or legs, difficulty speaking or slurred speech, or drooping muscles in the face. A sudden severe headache or blurred vision may also occur.

• Peripheral artery disease (PAD): Peripheral artery disease (PAD) is the progressive hardening and narrowing of the arteries due to atherosclerotic plaque formation in the arteries of the lower extremities, causing poor circulation. A common symptom of PAD is intermittent claudication, which is described as pain, fatigue, discomfort or numbness in the lower extremities (particularly in the thigh or calf muscles) during exercise that resolves with rest. In more advanced PAD, this lower extremity pain can also occur at rest. The lack of blood flow to the extremities results in poor wound healing, which can sometimes lead to amputations. Sometimes atherosclerosis causes erectile dysfunction in men.

Diagnosis

• General: Patients with atherosclerosis may see other doctors in addition to primary care physicians. These specialists may include a cardiologist or vascular physician, whose concentration is in diagnosing and treating heart disease or blood vessel problems. Patients who have experienced a stroke may also see a neurologist.

• Angiography: During angiography, a liquid dye that can be seen on an x-ray is injected through a long, thin tube (catheter) that is fed through an artery, usually in the femoral artery in the thigh, to the arteries in the heart. As the dye travels through the arteries, they become visible on the x-ray, showing whether plaque is blocking any arteries and the severity of that blockage.

• Ankle/brachial Index (ABI): The ankle-brachial index (ABI) is a comparison of the blood pressure in the ankle with the blood pressure in the arm. It is used to diagnose peripheral vascular disease in the arteries of the legs and feet, which may be caused by atherosclerosis. Ideally, the blood pressure in the ankle should be the same as the blood pressure in the arm. If the blood pressure in the ankle is less than that in the arm, it indicates that there is poor circulation to the lower extremities. The value is obtained by dividing the systolic blood pressure reading in the ankle by the blood pressure reading in the arm. An ABI of 0.95-1.2 is generally considered normal, while an ABI greater than 0.80 usually indicates mild peripheral artery disease.

• Blood tests: Blood is drawn to check for abnormal levels of certain fats, cholesterol, sugar, and proteins in the blood that may indicate an increased risk of atherosclerosis. Fasting may be needed before the blood is drawn.

• Chest x-ray: A chest x-ray may be taken to look for signs of heart damage.

• Computed Tomography (CT) scan: A computed tomography (CT) scan creates computer-generated pictures of the heart, brain, or other areas of the body to detect hardening, thickening, and narrowing of large arteries.

• Doppler ultrasound: A Doppler ultrasound device measures blood pressure at various points along an arm or leg. It may be used to detect atherosclerotic lesions and measure blood flow and is particularly helpful in detecting pulmonary embolisms (blockages or blood clots in the artery leading to the lungs) or deep vein thromboses (blood clots or blockages in the legs).

• Echocardiography: Echocardiography uses sound waves to create a moving picture of the heart. It is used to detect injured heart muscle, an abnormal size and shape of the heart, and to look for defective heart chambers and valves.

• Electrocardiogram (EKG): An electrocardiogram (EKG) is a painless procedure that uses electrical signals to test how fast the heart is beating and if the rhythm is normal. An EKG may also provide information about previous or current damage to heart tissue.

• Physical exam: Signs and symptoms of arteriosclerosis that may be detected during a routine physical exam include a weak or absent pulse in the leg or foot, decreased blood pressure in one arm or leg, signs of a bulging artery (aneurysm) in the abdomen or leg, or evidence of poor wound healing, due to restricted blood flow. A doctor may use a stethoscope to listen for abnormal sounds coming from a blocked artery. Such a sound is called a bruit and may indicate poor blood flow, due to plaque build-up.

• Stress testing: During a stress test, the heart is forced to work harder and beat faster by having a patient either exercise or take certain medications. Signs of arteriosclerosis that may occur during a stress test include abnormal changes in heart rate or blood pressure, shortness of breath, chest pain, and abnormal heart rhythms. The heart may be imaged during the procedure to reveal any areas of restricted blood flow.

Complications

• Aneurysms: Aneurysms are bulges in the wall of an artery that may be caused by atherosclerosis. Pain and throbbing in the area of an aneurysm is a common symptom. If an aneurysm bursts, life-threatening internal bleeding may occur. If a blood clot within an aneurysm dislodges, it may block an artery nearby or be carried by the blood to another location and cause a blockage there.

• Cerebrovascular disease: Atherosclerotic plaques may occur in the arteries of the brain. Eventually, the plaque may rupture, which leads to the formation of a blood clot. The clot may block the vessel, cutting off blood and oxygen supply in the brain. This may cause either a transient ischemic attack (temporary without causing permanent damage) or a stroke (which results in tissue death). Strokes may also occur when a plaque ruptures elsewhere in the body, resulting in the formation of a blood clot. A piece of the blood clot may break off (called an embolus) and travel to the brain, occluding an artery and leading to a lack of oxygen and tissue death. Strokes may cause permanent brain damage or even death. Symptoms may include sudden numbness or weakness in the arms or legs, difficulty speaking or slurred speech, or drooping muscles in the face. A sudden severe headache or blurred vision may also occur.

• Coronary artery disease: When atherosclerotic plaques occur in the arteries of the heart, a person may develop coronary artery disease. This may cause angina, which is chest pain that usually intensifies during physical activity but may also occur at rest. If an atherosclerotic plaque suddenly ruptures, a clot forms, and the heart tissue may not receive enough oxygen and begins to die, often causing a heart attack. According to the National Institutes of Health, coronary artery disease is the leading cause of death for both men and women in the United States.

• Peripheral artery disease (PAD): Peripheral artery disease (PAD) is the progressive hardening and narrowing of the arteries due to atherosclerotic plaque formation in the arteries of the lower extremities. A common symptom of PAD is intermittent claudication, which is described as pain, fatigue, discomfort, or numbness in the lower extremities (particularly in the thigh or calf muscles) during exercise that resolves with rest. In more advanced PAD, this lower extremity pain may also occur at rest. The lack of blood flow to the extremities results in poor wound healing, which may sometimes lead to amputations.

Treatment

• Angioplasty and stenting: During angioplasty, a thin tube with an inflatable balloon tip is inserted into an artery in the leg or arm near the blocked or narrowed artery. Blockages are visible on a live x-ray screen. The balloon is inflated, compressing the plaque onto the artery walls. A stent is a mesh tube that is usually left in the artery to prevent it from becoming blocked.

• Aspirin: Patients at risk for atherosclerosis or who have already been diagnosed with the disease may benefit from taking daily anti-platelet medications, such as low dose aspirin, to reduce the risk that blood clots will form in narrowed arteries. Patients should always consult their primary care physician before starting an aspirin regimen. It is generally recommended that patients take one 81 milligram aspirin daily.

• Bile acid sequestrants: These medications are often used in addition to statins and work by forcing the body to use fat stores for bile acid production rather than recycling bile acid, as typically occurs. This leaves less low-density lipoprotein (LDL), or bad cholesterol, in the blood and therefore LDL levels decrease. Examples of such drugs are cholestyramine and colesevelam (Welchol®).

• Bypass surgery: During bypass surgery, a healthy blood vessel is taken from the patient's leg or chest and is used to bypass a segment of an artery that has been blocked by atherosclerosis. Alternatively, a tube made of synthetic fabric may be used.

• Endarterectomy: In some cases, fatty deposits must be surgically removed from the walls of a narrowed artery, a procedure called an endarterectomy.

• Thrombolytic therapy: In thrombolytic therapy, a clot-dissolving drug is inserted into a blocked artery to break up a blood clot that is present there. Thrombolytics are used acutely for the treatment of heart attack and ischemic stroke. Alteplase, reteplase, and streptokinase are examples of thrombolytic medications. These medications can cause severe bleeding, so they are used very cautiously. They are generally avoided in patients with a high risk of bleeding, like the elderly, or patients who recently had surgery.

• Fibrates: Medications such as fenofibrate (Tricor®) and gemfibrozil are mainly used to decrease serum triglyceride levels and to increase high-density lipoprotein (HDL) levels. Fibrates do not have as significant an effect on LDL as other medications. Proper triglyceride and HDL levels are also pivotal for proper cholesterol maintenance.

• HMG-CoA Reductase Inhibitors: Also known as statins, these medications prevent the formation of cholesterol, thereby causing the liver to use LDL from the body. This results in a very effective lowering of serum LDL levels. Examples of statins include simvastatin (Zocor®), atorvastatin (Lipitor®), and rosuvastatin (Crestor®).

• Nicotinic acid: Nicotinic acid or niacin (Niaspan®), also known as vitamin B3, lowers lipid levels by interfering with the synthesis of LDL in the liver. It also potentially increases HDL levels, and may be used for this clinical goal as well.

Integrative Therapies

• Strong scientific evidence:

• Beta-glucan: The sum of existing positive evidence for use of beta-glucan for hyperlipidemia (excess lipids and/or lipoproteins in the blood) is promising. More research is needed to make definitive conclusions.

• Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously in patients with AIDS (Acquired Immunodeficiency Syndrome) or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.

• Beta-sitosterol: Beta-sitosterol is one of the most common dietary phytosterols (plant sterols) found and synthesized exclusively by plants such as in fruits, vegetables, soybeans, breads, peanuts, and peanut products. Many studies in humans and animals have demonstrated that supplementation of beta-sitosterol into the diet decreases total serum cholesterol as well as low-density lipoprotein (LDL) cholesterol and may be beneficial for patients with hypercholesterolemia (high levels of blood cholesterol).

• Caution is advised when taking beta-sitosterol supplements, as numerous adverse effects and drug interactions are possible. Beta-sitosterol supplements are not generally used during pregnancy or breastfeeding unless otherwise advised by a doctor.

• Calcium: Calcium chloride may be given intravenously (IV) by a qualified healthcare professional in cardiac resuscitation, particularly after open-heart surgery, when epinephrine fails to improve weak or ineffective myocardial contractions. Calcium chloride is contraindicated for cardiopulmonary resuscitation (CPR) in the presence of ventricular fibrillation. CPR with calcium chloride should only be done under the supervision of a qualified healthcare professional.

• Calcium chloride is only given in extreme and acute cases and therefore has minor side effects such as fall in blood pressure and a tingling feeling. Due to its administration in a hospital, these side effects will be monitored and are not of concern to a patient.

• Niacin: Niacin, also known as nicotinic acid or vitamin B3, is a well-accepted treatment for high cholesterol. Many studies show that niacin has significant benefits on the levels of high-density lipoprotein (HDL or good cholesterol), with better results than prescription drugs such as statins like atorvastatin (Lipitor®). However, niacin is not as effective at lowering LDL cholesterol or bad cholesterol as statins or fibrates. It is most effective at prescription strength, and therefore must be used at the discretion of a doctor or qualified health professional

• Avoid niacin/vitamin B3 if allergic to niacin or niacinamide. Avoid with a history of liver disease or dysfunction, irregular heartbeat (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: There is strong scientific evidence from human trials that omega-3 fatty acids, obtained from fish or fish oil supplements (EPA + DHA), significantly reduce blood triglyceride (a main constituent of fat and cholesterol) levels. Benefits appear to be dose-dependent. Fish oil supplements also appear to cause small improvements in HDL cholesterol. However, they may also increase LDL cholesterol"). It is not clear if alpha-linolenic acid significantly affects triglyceride levels because there is mixed evidence regarding hypertriglyceridemia from fish oils.

• 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 in patients with bleeding disorders, diabetes, low blood pressure, or drugs, and herbs and supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single six-ounce meal weekly and in young children to less than two ounces weekly. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces weekly of other fish types. Women who might become pregnant are advised to eat seven ounces or less weekly of fish with higher levels of methylmercury or up to 14 ounces weekly of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

• Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of several species in the genus Plantago, including the English plantain (Plantago ovate). Psyllium contains a high level of soluble dietary fiber and is the chief ingredient in many commonly used bulk laxatives, such as Metamucil® and Serutan®. Psyllium is well studied as a cholesterol lowering agent with generally modest reductions in blood levels of total cholesterol and LDL cholesterol. Effects have been observed following eight weeks of regular use. Psyllium does not appear to have significant effects on HDL cholesterol or triglyceride levels. Because only small reductions in total cholesterol and LDL have been observed, people with high cholesterol should discuss the use of more potent agents with their health care provider.

• Avoid if allergic or hypersensitive to psyllium, ispaghula, or any member of the genus Plantago. Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, and previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or long-term psyllium exposure who have not manifested allergic or hypersensitive symptoms. Prescription drugs should be taken one hour before or two hours after psyllium. Adequate fluid intake is needed when taking psyllium-containing products. Use cautiously with blood thinners, antidiabetic agents, carbamazepine, lithium, potassium-sparing diuretics, salicylates, tetracyclines, nitrofurantoin, calcium, iron, vitamin B12, other laxatives, tricyclic antidepressants (amitriptyline, doxepin, and imipramine), antigout agents, anti-inflammatory agents, hydrophilic agents, and chitosan. Use cautiously in patients with diabetes and kidney dysfunction. Use cautiously if pregnant or breastfeeding.

• Red yeast rice: Since the 1970s, human studies have reported that red yeast lowers blood levels of total cholesterol, LDL cholesterol, and triglyceride levels. Other products containing red yeast rice extract can still be purchased, mostly over the Internet. However, these products may not be standardized and effects are not predictable. Therefore, for effectively lowering high cholesterol, evidence better supports the use of prescription drugs such as statins.

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

• Soy: Numerous human studies report that adding soy protein to the diet can moderately decrease blood levels of total cholesterol and LDL cholesterol. Small reductions in triglycerides may also occur, while HDL cholesterol) does not seem to be significantly affected. 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 remains controversial. It is not known 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 from high cholesterol, such as heart attack or stroke.

• 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 is 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, a product 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 not known 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 like warfarin should check with a doctor and pharmacist before taking soy supplementation.

• Good scientific evidence:

• Arginine: Early evidence from several studies suggests that arginine taken by mouth or by injection may improve exercise tolerance and blood flow to the arteries of the heart. Benefits have been shown in some patients with coronary artery disease and chest pain (angina). However, more research is needed to confirm these findings and to develop safe and effective doses.

• Avoid if allergic to arginine, or in patients with a history of stroke, liver, or kidney disease. Avoid if pregnant or breastfeeding. Use with caution if taking blood-thinning drugs (like warfarin) and blood pressure drugs, herbs, or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in diabetic patients taking prescription drugs to control blood sugar levels.

• Avocado: Avocados added to the diet may lower total cholesterol, LDL (bad cholesterol), and increase HDL (good cholesterol) and triglyceride levels. Additional studies are needed before a strong recommendation can be made for high cholesterol.

• Avoid if allergic or hypersensitive to avocado, banana, chestnut, or natural rubber latex. Use cautiously with anticoagulants (like warfarin). Avoid with monoamine oxidase inhibitors (MAOIs). Doses greater than found in a normal diet are not recommended if pregnant or breastfeeding. Some types of avocado may be unsafe when breastfeeding.

• Barley: The Food and Drug Administration (FDA) has announced that whole grain barley and barley-containing products are permitted to claim to reduce the risk of coronary heart disease (CHD). To qualify for the health claim, the barley-containing foods must provide at least 0.75 gram of soluble fiber per serving of the food.

• Several small, randomized studies suggest that high fiber barley, barley bran flour, and barley oil elicit small reductions in serum cholesterol levels by increasing cholesterol excretion. Barley β-glucan extracts vary in their functionality with respect to cholesterol reduction. At least one barley β-glucan concentrate, Barliv™ barley Betafiber, has demonstrated the ability to lower cholesterol in a human clinical trial. There is good evidence from existing research to support the use of barley along with a cholesterol-lowering diet in mild cases of high cholesterol. Larger and longer studies are warranted to more rigorously confirm the effects of barley on hyperlipidemia.

• Use cautiously in all patients due to possible risk of contamination with fungi. Use cautiously in children. Use cautiously in patients taking hypoglycemic agents, due to possible additive properties. Use cautiously in patients taking cardiac agents, as hordenine in the root of germinating barley is a sympathomimetic (substance that mimics the effects of the sympathetic nervous system). Fiber may reduce gastrointestinal transit and may, therefore, reduce the absorption of various orally administered agents. Avoid use in patients with celiac disease. Gluten found in barley may worsen this condition.

• Betaine anhydrous: Overall, betaine supplementation has shown significant reductions in both fasting and postmethionine load homocysteine. However, additional studies are needed to better understand the effects of betaine on hyperhomocysteinemia, a medical condition in which patients have an abnormally high amount of homocysteine in the blood, which is associated with an increased risk of other artery or cardiovascular disease.

• Avoid if allergic/hypersensitive to betaine anhydrous or cocamidopropylbetaine, a form of betaine. Use cautiously with kidney disease, obesity, and psychiatric conditions. Avoid if pregnant or breastfeeding.

• Carob: 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 better understand the effects of carob on high cholesterol (high cholesterol).

• Avoid if allergic/hypersensitive to carob (Ceratonia siliqua), its constituents, or any plants in the Fabaceae family, including tamarind. Avoid with metabolic disorders, chromium, cobalt, copper, iron, or zinc disorder/deficiency, kidney disorders, or acute diarrhea. Avoid in underweight infants. Use cautiously in patients with anemia, known allergy to peanuts and other nuts, complications with powdered, bulk forming laxative drinks, diabetes, or hyperlipidemia. Use cautiously if taking oral herbs or drugs. Use cautiously in hypouricemic (abnormally low level of uric acid in the blood) patients. Avoid if pregnant or breastfeeding.

• Chia: Early studies in animals and humans suggest that diets containing chia seed may decrease risk factors for cardiovascular disease. Evidence suggests that the benefits of Salba® (a name brand chia product) in humans are similar to those of other whole grains. Further study is needed.

• There is limited safety data on chia. Avoid if allergic or sensitive to chia, sesame, or mustard seed. Use cautiously with low blood pressure or bleeding disorders. Use cautiously if taking anti-cancer, antioxidant, blood pressure-lowering, or blood thinning agents, or agents that are broken down in the liver. Avoid if pregnant or breastfeeding.

• Chitosan: Evidence from several trials suggests that chitosan may have a beneficial effect on hyperlipidemia by lowering total and LDL bad cholesterol while raising HDL good cholesterol levels. This appears especially true when combined with a hypocaloric diet. However, the studies reporting the largest benefits used chitosan in combination with other active ingredients, which makes a causal statement for chitosan impossible. Future effectiveness studies of chitosan are needed to evaluate relative effectiveness and safety of this substance alone compared to other interventions and determine whether chitosan my act in synergy with other substances. In addition, if effectiveness is firmly established, optimum dosage needs to be determined.

• Avoid if allergic or sensitive to chitosan or shellfish. Use cautiously in patients with diabetes or bleeding disorders. Use cautiously if taking drugs, herbs, or supplements that lower blood sugar or increase the risk of bleeding. Chitosan may decrease absorption of fat and fat-soluble vitamins from foods. Chitosan is not recommended during pregnancy or breastfeeding.

• Coleus: Coleus species have been used in traditional Asian medicine for several indications. Since the 1970s, research was predominantly concentrated on forskolin, a root extract of Coleus forskohlii. A small number of studies suggest that forskolin may improve cardiovascular function. Larger studies are needed.

• Coleus is generally regarded as safe, although long-term safety data are lacking. Avoid in patients with a known allergy or hypersensitivity to Coleus forskohlii and related species. Rash may occur in sensitive individuals. Inhalation of forskolin may cause sore throat, upper respiratory tract irritation, mild-to-moderate cough, tremor, or restlessness. Coleus eye drops may produce a milky covering over the eyes. Use cautiously in patients with heart disease, asthma, thyroid disorders, diabetes, a history of bleeding, hemostatic (internal blood stopping) disorders or drug-related hemostatic problems, low blood pressure, or in patients at risk for hypotension. Discontinue use in patients at least two weeks prior to surgical or dental procedures, due to risk of bleeding. Avoid in patients with active bleeding. Avoid during pregnancy.

• Cordyceps: Cordyceps 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 in patients with diabetes, bleeding disorders, or if taking anticoagulant medications, with prostate conditions, if taking immunosuppressive medications, or if on hormonal replacement therapy or oral contraceptives. Avoid with myelogenous-type (relating to bone marrow) cancers. Avoid if pregnant or breastfeeding.

• Gamma oryzanol: Gamma oryzanol seems to reduce total cholesterol, LDL, HDL, and triglycerides. Additional study is needed to establish gamma oryzanol's effect on hyperlipidemia.

• 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, herbs that alter blood sugar levels, immunomodulators, luteinizing hormone or luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering drugs, thyroid drugs, herbs, or supplements. Use cautiously in patients with diabetes, hypothyroidism, hypoglycemia (low blood sugar levels), hyperglycemia and high cholesterol. Avoid if pregnant or breastfeeding.

• Garlic: Multiple studies in humans have reported small reductions in total blood cholesterol and LDL cholesterol over short periods of time (4-12 weeks) with use of garlic. It is not clear if there are benefits for hyperlipidemia after this amount of time. Effects on HDL good cholesterol are not clear. 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, chive). Avoid if there is a history of bleeding problems, asthma, diabetes, low blood pressure, or thyroid disorders. Stop using supplemental garlic two weeks before dental/surgical/diagnostic procedures and avoid using immediately after such procedures to avoid bleeding problems. Avoid supplemental doses if pregnant or breastfeeding.

• Ginseng: Ginseng appears to have antioxidant effects that may benefit patients with heart disorders. Some studies suggest that ginseng also reduces oxidation of LDL or bad cholesterol and brain tissue. Better studies are needed.

• 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 ginseng formulations.

• Globe artichoke: Early human studies suggest that artichoke extracts may have lipid lowering effects. More research is needed in this area.

• Use cautiously if allergic/hypersensitive to members of the Asteraceae or Compositae family (e.g., chrysanthemums, daisies, marigolds, ragweed, arnica), due to possible cross-reactivity. Use cautiously in patients with cholelithiasis, or biliary/bile duct obstruction, or kidney disease. Avoid if pregnant or breastfeeding.

• L-carnitine: Evidence from human studies suggests that L-carnitine and L-propionyl-carnitine (propionyl-L-carnitine) are effective in reducing symptoms of 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 in patients with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birthweight 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 decreases blood levels of cholesterol and lipoprotein (a), which may reduce the risk of atherosclerosis (hardening of the arteries). Niacin is also very effective at increasing HDL cholesterol (good cholesterol). However, niacin may increase homocysteine levels, which may have the opposite effect. Overall, scientific evidence supports the use of niacin in combination with other drugs, such as statins, (but not alone) to decrease cholesterol and slow the progression 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 in patients with a history of liver disease or 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, fish oil, alpha-linolenic acid: 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 not clear 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 concerning the effects of fish oil on primary cardiovascular disease prevention.

• 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 in patients with bleeding disorders, diabetes, low blood pressure or drugs, herbs, and supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single six-ounce meal weekly and in young children to less than two ounces weekly. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces weekly of other fish types. Women who might become pregnant are advised to eat seven ounces or less weekly of fish with higher levels of methylmercury or up to 14 ounces weekly of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

• Pantethine: Numerous trials have examined the effects of oral pantethine on hyperlipidemia. Reductions in total cholesterol, 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 with caution in patients with bleeding disorders. Avoid if pregnant or breastfeeding.

• Peony: Dandi Tablet is a traditional Chinese medicine (TCM) formula containing peony; in the TCM paradigm or concept, Dandi Tablet is used for activating blood circulation. Additional high-quality research is needed to evaluate the use of this formulation for lipid lowering effects and for CHD prevention or treatment.

• Avoid if allergic or sensitive to peony. Avoid in patients with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.

• Policosanol: Policosanol is a cholesterol-lowering natural mixture of higher aliphatic primary alcohols, isolated and purified from sugar cane wax. The effects of policosanol supplementation on exercise-electrocardiogram (ECG) testing responses have been studied in individuals with coronary heart disease. Beneficial changes were noted in functional capacity, rest and exercise angina (chest pain), cardiac events, and maximum oxygen uptake. Although this represents early yet compelling evidence, further research is needed before a clear conclusion can be reached.

• Caution is advised when taking policosanol, as adverse effects and drug interactions are possible. Policosanol supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

• Sweet almond: Early studies in humans and animals report that for high cholesterol, whole almonds may lower total cholesterol and LDL/bad cholesterol and raise HDL/good cholesterol). It is not clear what dose may be safe or effective.

• Avoid if allergic or hypersensitive to almonds or other nuts. Use cautiously in patients with heart disease, diabetes, or low blood sugar. Use cautiously if taking cardiovascular agents, including antilipemics (cholesterol lowering drugs), antidiabetics, estrogens, phytoestrogens, and fertility agents. Use cautiously if pregnant or breastfeeding.

• Yoga: There is some evidence to support the use of yoga as an adjunct therapy in the prevention of coronary artery disease. Yoga was once part of a comprehensive program of lifestyle changes demonstrated to lessen blockages in coronary arteries, angina episodes, and cardiac events. Yoga appears to improve a number of cardiovascular disease risk factors, including blood pressure, plasma cholesterol, and blood sugar among healthy volunteers. Lower fibrinogen levels and increased fibrinolytic activity may lower the risk of myocardial infarction (heart attack).

• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses in patients with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously in patients 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 (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

• Zinc: There is some evidence that zinc may improve cholesterol ratio of HDL (good cholesterol) versus LDL (bad cholesterol), a positive effect. Well-designed human studies are needed before a conclusion can be made about the use of zinc for high cholesterol.

• Zinc is generally considered safe when taken at the recommended doses. Avoid zinc chloride since studies have not been done on its safety or effectiveness. Avoid in patients with kidney disease. Use cautiously if pregnant or breastfeeding.

• Unclear or conflicting scientific evidence:

• Acupuncture: Some research has suggested that acupuncture might help reduce distress and symptoms of angina pectoris, but this has not been consistently shown in other studies.

• Needles must be sterile in order to avoid disease transmission. Avoid in patients with valvular heart disease, infections, bleeding disorders or drugs that increase the risk of bleeding (anticoagulants), medical conditions of unknown origin, or neurological disorders. Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously in patients with pulmonary disease (e.g., asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or those with a history of seizures. Avoid electroacupuncture (in which electric currents pass through acupuncture needles) in patients with arrhythmia (irregular heartbeat) or with pacemakers.

• Alfalfa: Reductions in blood levels of total cholesterol and low-density lipoprotein (LDL/bad cholesterol) have been reported in animal studies and in a small number of human cases. High-density lipoprotein (HDL/good cholesterol) did not change in these cases. Although this evidence is promising, better research is needed before a firm conclusion can be reached about the use of alfalfa for hyperlipidemia (excess lipids or lipoproteins in the blood) or atherosclerosis.

• Avoid if allergic to alfalfa, clover, or grass. Avoid in patients with a history of lupus. Avoid before any surgery/dental/diagnostic procedures that may have a risk of bleeding, and avoid use immediately after these procedures. Use cautiously in patients with a history of stroke, hormone conditions (breast tenderness, breast cancer, ovarian cancer, menstrual problems), diabetes, low blood sugar levels, thyroid disease, gout, blood clots, seizures, liver disease, or kidney disease. Use cautiously in patients taking blood sugar-altering medications, aspirin or any aspirin products, ibuprofen, and blood thinners (e.g., warfarin). Use cautiously if operating heavy machinery or driving. Alfalfa may be contaminated with dangerous bacteria (e.g., E. coli, Salmonella, or Listeria). Avoid if pregnant or breastfeeding.

• Amalaki: Indian gooseberry (Emblica officinalis), also known as amalaki, is a small-to-medium-sized deciduous tree native to India and the Middle East. In addition to its medicinal uses, the fruits are often eaten raw and used as ingredients for various Indian recipes. Based on human research, raw amalaki may improve serum cholesterol levels in patients with hyperlipidemia. However, there is not enough scientific evidence to form clear conclusions about its safety or effectiveness in humans.

• Avoid with known allergy/hypersensitivity to amalaki (Emblica officinalis Linn, Phyllanthus emblica L.), its constituents, or members of the Phyllanthus family. Other members of the Phyllanthus family include Phyllanthus acidus (Otaheite gooseberry), Phyllanthus acuminatus (Jamaican gooseberry tree), Phyllanthus mirabilis, Phyllanthus niruri (Chanca piedra), and Phyllanthus urinaria (chamberbitter). Use cautiously in patients with low iron levels, those taking anticoagulants (blood thinners) or anti-platelet drugs, in patients with low blood sugar levels, and those with decreased immune system function. Avoid in pregnant or breastfeeding women, due to a lack of available scientific evidence.

• Amaranth oil: Amaranth plus a low-sodium, heart-healthy diet decreased cholesterol and blood pressure in patients with coronary heart disease (CHD). However, additional evidence is needed before a recommendation can be made in this area.

• Amaranth is generally considered safe. Avoid if allergic or sensitive to amaranth. Use cautiously in patients with diabetes, low blood sugar, low blood pressure, immune system disorders, or kidney disorders. Use cautiously if pregnant or breastfeeding.

• American hellebore: Isolated jervine alkaloids found in American hellebore have been studied for cardiovascular dysfunction. Additional studies are needed before a firm recommendation can be made.

• Avoid if allergic/hypersensitive to plants in the lily family (Liliaceae) or to American hellebore or any related species of Veratrum (false hellebores). Use cautiously in patients with cardiovascular disease, cardiac dysfunction, -irregular heartbeats, hemodynamic instability, and compromised kidney function. Use cautiously if taking drugs excreted by the kidney, diuretics, asthma medications, or blood pressure medications. Avoid if pregnant or breastfeeding.

• Aortic acid: Glycosaminoglycans, which include mesoglycan, are structural components of cardiovascular vessels and organs. Mesoglycan is also known as aortic acid because it is commonly extracted from calf aorta. Early study indicates that mesoglycan may reduce blood vessel thickening. However, additional research is needed regarding the use of this agent for atherosclerosis.

• Due to the heparin sulfate content of mesoglycan, patients with an allergy to heparin or heparinoid derivatives should use caution. Use cautiously in patients with coagulation (blood clotting) disorders or if taking anticoagulation therapy. Use cautiously in patients with hypertension (high blood pressure) or if taking antihypertensive drugs. Avoid if pregnant or breastfeeding.

• Arabinogalactan: It is unclear what effect arabinogalactan has on blood cholesterol levels, including triglycerides, in patients with high cholesterol. Limited early studies did not show an effect of arabinogalactan in patients with normal cholesterol levels. More studies are needed.

• Avoid if allergic or sensitive to arabinogalactan or larch. People who are exposed to arabinogalactan or larch dust may have irritation of the eyes, lungs, or skin. Use cautiously in people with diabetes, digestive problems, or immune system disorders, and in people who consume a diet that is high in fiber or low in galactose. Arabinogalactan should not be used during pregnancy or breastfeeding.

• Arginine: Although there is good evidence for increased exercise tolerance, further studies are needed to confirm findings of decreased heart damage post myocardial infarction (MI). Studies suggest that arginine supplementation after MI (heart attack) may decrease heart damage, but further research is needed to confirm these findings. Arginine-supplemented blood cardioplegic solution may provide heart protection during coronary artery bypass grafting (CABG). Some research also suggests that arginine may help treat or prevent high cholesterol.

• Avoid if allergic to arginine, or in patients with a history of stroke, liver, or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (e.g., warfarin) and blood pressure drugs, herbs, or supplements with similar effects. Check blood potassium levels. L-arginine may worsen symptoms of sickle cell disease. Caution is advised in patients taking prescription drugs to control sugar levels.

• Ashwagandha: In a case series, 12 patients were administered powdered roots of ashwagandha by mouth for 30 days. The authors reported significant decreases in serum total cholesterol levels, triglycerides, LDL, and very low density lipoproteins (VLDL). Additional evidence is needed to better determine the effectiveness of ashwagandha for high cholesterol.

• 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 an ashwagandha trial.There are few reports of adverse effects associated with ashwagandha, but there are also few human trials using ashwagandha, and most do not report the doses or standardization/preparation used.Avoid in patients with peptic ulcer disease. Ashwagandha may cause abortions based on anecdotal reports. Avoid if pregnant, trying to become pregnant, or breastfeeding.

• Astaxanthin: There is not enough evidence to recommend or discourage the use of astaxanthin for hyperlipidemia prevention. More research is needed to make a conclusion.

• Avoid if allergic/hypersensitive to astaxanthin or related carotenoids, including canthaxanthin, or in patients with hypersensitivity to an astaxanthin algal source, such as Haematococcus pluvialis. Use cautiously if taking 5-alpha-reductase inhibitors for the treatment of benign prostate hypertrophy (BPH) such as dutasteride and finasteride, antihypertensive agents, antihistamines such as cetirizine dihydrochloride and azelastine, cytochrome P450 metabolized agents, menopause agents or oral contraceptives, or Helicobacter pylori agents. Use cautiously in patients with high blood pressure, parathyroid disorders, and osteoporosis. Avoid in patients with hormone-sensitive conditions, immune disorders, or if taking immunosuppressive therapies. Avoid in patients with a history of visual changes while taking astaxanthin and with low eosinophil levels. Avoid if pregnant or breastfeeding.

• Astragalus: Astragalus products are derived from the roots of Astragalus membranaceus or related species, which are native to China. 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 about the use of astragalus for CHD.

• Caution is advised when taking astragalus supplements, as adverse effects and drug interactions are possible. Astragalus supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

• Ayurveda: Abana is a combination herbal and mineral formulation traditionally used in Ayurveda for heart health and cardiac disease. Early studies report that abana may reduce the frequency and severity of angina. 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. Ayurvedic herbs can interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before taking these herbs.

• Beet: Increased dietary fiber intake is recommended based on findings that support its antilipedemic effects and potential benefits for reducing the risk of cardiovascular disease. Beet pulp and pectin have been studied and used as sources of dietary fiber in humans. Research suggests that cholesterol-lowering effects of sugar beet fiber may be partially due to the activity of byproducts produced in the large intestine as a result of fermentation by colonic bacteria. Human studies have evaluated the effects of beet fiber for hyperlipidemia. More research is needed in this area.

• Avoid in cases of allergy or hypersensitivity to any part of the beet plant, including the beet root and leaves, beet fiber, or other members of the Chenopodiaceae family.

• Berberine: Berberine may reduce triglycerides, serum cholesterol, and LDL cholesterol. Higher quality trials are needed before berberine's effects for hyperlipidemia can be established. Berberine is a compound that is present in the herb goldenseal.

• Avoid if allergic or hypersensitive to berberine, to plants that contain berberine [Hydrastis canadensis (goldenseal), Coptis chinensis (coptis or goldenthread), Berberis aquifolium (Oregon grape), Berberis vulgaris (barberry), and Berberis aristata (tree turmeric)], or to members of the Berberidaceae family. Avoid in newborns, due to the potential for an increase in free bilirubin (which may cause jaundice), and the development of kernicterus. Use cautiously in patients with cardiovascular disease, gastrointestinal disorders, hematologic disorders, leucopenia, kidney disease, liver disease, respiratory disorders, cancer, hypertyraminemia, diabetes, or hypotension. Use cautiously in children, due to a lack of safety information. Use cautiously in individuals with high exposure to sunlight or artificial light. Use cautiously if taking for longer than eight weeks, due to theoretical changes in bacterial flora in the gut. Use cautiously if taking anticoagulants, antihypertensives, sedatives, anti-inflammatories, medications metabolized by CYP P450 3A4 including cyclosporin, or any prescription medications. Avoid if pregnant or breastfeeding.

• Beta glucan: Depending on the type of study performed, there is both strong and weak evidence for the use of beta glucan in the treatment of arteriosclerosis or associated conditions. Evidence suggests that beta glucan may protect against abnormal endothelial function induced by high fat meals. Diabetes, hyperlipidemia (high cholesterol), and hypertension (high blood pressure) data are also promising. Further study is needed regarding cardiovascular disease. Early research suggests that treatment with beta glucan may be effective for heart protection during CABG.

• Avoid if allergic or hypersensitive to beta-glucan. When taken by mouth, beta-glucan is generally considered safe. Use cautiously in patients with Acquired Immunodeficiency Syndrome (AIDS) or AIDS-related complex (ARC). Avoid using particulate beta-glucan. Avoid if pregnant or breastfeeding.

• Betaine anhydrous: Depending on the type of study performed, there is both strong and weak evidence for the use of betaine anhydrous in the treatment of arteriosclerosis or associated conditions. Overall, betaine supplementation has shown significant reductions in both fasting and postmethionine load homocysteine. However, additional studies are needed to better understand the effects of betaine on hyperhomocysteinemia (high levels of homocysteine in the blood).

• Avoid if allergic/hypersensitive to betaine anhydrous or cocamidopropylbetaine, a form of betaine. Use cautiously in patients with kidney disease, obesity, and psychiatric conditions. Avoid if pregnant or breastfeeding.

• Bilberry: Bilberry (Vaccinium myrtillus), also known as the European blueberry, is widely used as an antioxidant for general health. Bilberry has been used traditionally to treat heart disease and atherosclerosis (hardening of the arteries). There is some laboratory research in this area, but no clear information in humans.

• Caution is advised when taking bilberry supplements, as adverse effects, including an increase in bleeding, and drug interactions are possible. Bilberry supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

• Biotin: A combination of biotin and chromium may help lower cholesterol and decrease the risk of developing atherosclerosis in patients with diabetes. However, other research of biotin alone found that biotin did not affect cholesterol, glucose, or insulin levels, but did decrease triglyceride levels. More research with biotin alone is needed to better determine its effects on cardiovascular disease risk in patients with diabetes.

• Avoid if hypersensitive to constituents of biotin supplements.

• Black tea: There is mixed 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; therefore, it is proposed to be beneficial against blocked arteries in the heart. The long-term effects of tea consumption on heart attack prevention and cardiovascular risk factors, such as cholesterol levels and atherosclerosis, are not fully understood. Other research suggests that drinking black tea regularly does not affect plasma homocysteine levels or blood pressure. Black tea may also increase heart rate because it contains caffeine, which is a stimulant.

• Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution in patients with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of sudden infant death syndrome (SIDS). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk and caffeine ingestion by infants can lead to sleep disturbances or insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.

• Borage seed oil: Borage seed oil, also known as gamma linolenic acid, may decrease plasma triglyceride levels and increase HDL concentration. However, more research is needed to better define borage's effects on hyperlipidemia.

• Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously in patients with bleeding disorders or taking warfarin or other anticoagulant/ antiplatelet (blood thinning) agents. Use cautiously in patients with epilepsy or taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid if pregnant or breastfeeding.

• Carrageenan: The hypolipidemic effect of carrageenan has been investigated in clinical studies. Total cholesterol and triglyceride levels were both significantly reduced following the consumption of an experimental diet containing carrageenan-enriched foods. Further human studies are needed before carrageenan can be recommended for hyperlipidemia.

• Use cautiously in patients with, or at risk for, cancer, gastrointestinal disorders, immune disorders, inflammatory disorders, bleeding disorders, low blood pressure, or diabetes. Use cautiously in combination with any oral medication, as the fiber in carrageenan may impair the absorption of oral medications.

• Chamomile: 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 before a firm conclusion can be made concerning its use for cardiovascular conditions.

• Avoid if allergic to chamomile. Anaphylaxis, throat swelling, skin allergic reactions, and shortness of breath have been reported. Chamomile eyewash may cause allergic conjunctivitis (pinkeye). Stop use two weeks before surgery/dental/diagnostic procedures, due to bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating machinery. Avoid if pregnant or breastfeeding.

• Chondroitin sulfate: Several studies in the early 1970s assessed the use of oral chondroitin for the prevention of subsequent coronary events in patients with a history of heart disease or heart attack. Although favorable results were reported, due to methodological weaknesses in this research and the widespread current availability of better proven drug therapies for patients in this setting, a recommendation cannot be made for the use of this agent in coronary artery disease (CAD).

• Use cautiously if allergic or hypersensitive to chondroitin sulfate products and with shellfish allergy. Use cautiously in patients with bleeding disorders and if taking blood thinners like warfarin (Coumadin®). Avoid with prostate cancer or increased risk of prostate cancer. Avoid if pregnant or breastfeeding.

• Chromium: Studies show mixed results in using chromium to treat cardiovascular disease or high cholesterol. A few studies show that chromium may lower cholesterol, but other studies show no effects. Many natural medicine experts and textbooks do not recommend chromium for treating high cholesterol over more proven therapies.

• Trivalent chromium appears to be safe because side effects are rare or uncommon. However, hexavalent chromium may be poisonous (toxic). Avoid if allergic to chromium, chromate, or leather. Use cautiously in patients with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, stroke, and in patients who are taking medications for these conditions. Use cautiously if driving or operating machinery. Use cautiously if pregnant or breastfeeding.

• Cinnamon: The use of cinnamon for bacterial angina has been reviewed. However, well-designed trials are needed before a firm conclusion can be made.

• Avoid if allergic or hypersensitive to cinnamon, its constituents, members of the Lauraceae family, or balsam of Peru. High levels of cinnamon may contain coumarin. Use cautiously if prone to atopic reactions, if taking cytochrome P450 metabolized agents, anticoagulants (blood thinners), insulin or blood sugar-altering medications, antibiotics, medications that affect the immune system, medications that lower cholesterol, agents toxic to the liver, or cardiovascular agents. Avoid if pregnant or breastfeeding.

• Coenzyme Q10 (CoQ10): Early small human studies suggest that CoQ10 may reduce angina and improve exercise tolerance in people with clogged heart arteries. There is mixed evidence from research on the use of CoQ10 in patients with dilated or hypertrophic cardiomyopathy. There is not enough scientific evidence to recommend for or against the use of CoQ10 in patients with CHD, heart attack, or hypertriglyceridemia.

• Allergy associated with CoQ10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures, due to bleeding risk, and do not use immediately after these procedures. Use cautiously in patients with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners), antiplatelet drugs (e.g., aspirin, warfarin, clopidogrel (such as Plavix®), or drugs that affect blood pressure, blood sugar, cholesterol, or thyroid function. Avoid if pregnant or breastfeeding.

• Conjugated linoleic acid: Conjugated linoleic acid (CLA) is a fatty acid that is naturally found in beef and dairy products. Most CLA dietary supplements are made from safflower oil. However, CLA is also found in other vegetable oils, including hydrogenated soybean oil. Early evidence suggests that CLA supplementation may have beneficial effects on blood lipids for patients with hyperlipidemia. Additional study is needed in this area before a conclusion can be made. Use cautiously in patients with skin sensitivities, diabetes, gastrointestinal problems, immune conditions, and bleeding disorders. Use cautiously in patients taking medications that lower cholesterol or blood pressure levels, medications that affect blood sugar, or when taking any of the following: antibiotics, antidepressants, anti-cancer agents, anti inflammatory agents, anti-obesity agents, appetite stimulants, calcium salts, cardiovascular agents, corticosteroids, agents for skin conditions, exercise performance enhancers, gastrointestinal agents, agents that stimulate or suppress the immune system, neurologic agents, and osteoporosis agents. Avoid in pregnant or breastfeeding women, due to a lack of available scientific evidence.

• Copper: The effect of copper intake or blood copper levels on cholesterol, atherosclerosis (cholesterol plaques in arteries), or cardiovascular disease remains unclear. Studies in humans are mixed, and further research is needed.

• Avoid if allergic/hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid in patients with hypercupremia (too much copper in the blood), occasionally observed in disease states including cutaneous leishmaniasis, sickle-cell disease, unipolar depression, breast cancer, epilepsy, measles, Down syndrome, and controlled fibrocalculous pancreatic diabetes (a unique form of type 2 diabetes mellitus). Avoid in patients with genetic disorders affecting copper metabolism such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid in patients with HIV/AIDS. Use cautiously with water containing copper concentrations greater than six milligrams per liter. Use cautiously with anemia, arthralgias and myalgias. Use cautiously if taking oral contraceptives. Use cautiously if at risk for selenium deficiency. The U.S. recommended dietary allowance (RDA) is 1,000 micrograms for pregnant women. The U.S. RDA is 1,300 micrograms for nursing women.

• Corydalis: Corydalis may be of benefit for angina pectoris. More studies are needed.

• Corydalis is generally considered safe. Avoid if allergic or sensitive to corydalis. Avoid if taking sedative or hypnotic drugs, drugs that treat abnormal heart rhythms (including bepridil), pain relievers, and anti-cancer drugs. Avoid if pregnant or breastfeeding.

• Creatine: Early studies have evaluated the effect of creatine on hyperlipidemia, ischemic heart disease, and MI. More human studies are needed before a conclusion can be made.

• Avoid if allergic to creatine or if taking diuretics such as hydrochlorothiazide and furosemide (Lasix®). Use cautiously in patients with asthma; diabetes; gout; kidney, liver, or muscle problems; stroke; or a history of these conditions. Avoid dehydration. Avoid if pregnant or breastfeeding.

• Danshen: 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), myocarditis, and hyperlipidemia. Early studies suggest that danshen may improve blood levels of cholesterol (lowering LDL or bad cholesterol and triglycerides and raising HDL or good cholesterol). Large high-quality studies are needed.

• Avoid if allergic or hypersensitive to danshen. Use cautiously in patients with changed immune states, irregular heartbeat, compromised liver function, or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery/dental/diagnostic procedures, due to bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking blood thinners (anticoagulants), digoxin, or antihypertensives including angiotensin-converting enzyme (ACE) inhibitors such as captopril, or Sophora subprostrata root or herba serissae. Avoid in patients with bleeding disorders, low blood pressure, and following cerebral ischemia. Avoid if pregnant or breastfeeding.

• DHEA (dehydroepiandrosterone): Early studies report possible benefits of dehydroepiandrosterone (DHEA) supplementation in patients with cholesterol plaques in their arteries. There is mixed scientific evidence regarding the use of DHEA supplements in patients with heart failure. Other therapies are better proven in this area, and patients with heart failure or other types of cardiovascular disease should discuss treatment options with a cardiologist.

• Avoid if allergic to DHEA. Avoid in patients with a history of seizures. Use cautiously in patients with adrenal or thyroid disorders or with anticoagulants, drugs, herbs or supplements for diabetes, heart disease, seizure, or stroke. Stop use two weeks before surgery/dental/diagnostic procedures, due to bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

• Dill: Although early study in rats showed cholesterol-lowering properties of dill powder, a clinical trial in humans did not suggest that dill had a significant cholesterol-lowering effect. Of note, an increase in triglycerides was observed with dill treatment in this clinical trial. More well-designed trials are needed before a conclusion can be made.

• Use cautiously in patients with elevated triglycerides, in patients with diabetes or those using blood sugar-lowering agents, and in patients using central nervous system (CNS) depressants, as concurrent use with dill may theoretically increase the risk of sedation. Avoid in patients with known allergy/hypersensitivity to dill, its constituents, or members of the Apiaceae (Umbelliferae) family.

• Dong quai: There is not enough evidence to support the use of Dong quai for the treatment of CAD. More studies are needed.

• Although Dong quai is accepted as being safe as a food additive in the United States and Europe, its safety in therapeutic doses is unknown. Long-term studies of side effects are lacking. Avoid if allergic/hypersensitive to Dong quai or members of the Apiaceae / Umbelliferae family (e.g., anise, caraway, carrot, celery, dill, parsley). Avoid long-term exposure to sunlight or ultraviolet light. Use with caution in patients with bleeding disorders or if taking drugs that may 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 before dental or surgical procedures. Avoid if pregnant or breastfeeding.

• Elderberry and elder flower: Reliable human evidence is currently unavailable evaluating elder alone as a treatment for hyperlipidemia. Early studies report that elderberry juice may decrease serum cholesterol concentrations and increase LDL or bad cholesterol 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 better proven therapies, and patients are advised to discuss with their primary healthcare provider before using elderberry for treatment of high cholesterol.

• Avoid if allergic to elder or to plants related to honeysuckle. Reports exist of allergies from contact with fresh elder stems. Use with caution in patients with diabetes, high blood pressure, or urinary problems, or with drugs used for any of these conditions. Use cautiously in patients taking anti-inflammatory agents, diuretics, and laxatives. Avoid if pregnant or breastfeeding.

• Fenugreek: There is not enough evidence to support the use of fenugreek as an agent for hyperlipidemia. Additional research is needed in this area.

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

• Flaxseed and flaxseed oil: It has been proposed that flaxseed, and its lignan complex, may exert a beneficial effect on plaque formation or cardiovascular outcomes from atherosclerosis, based on suggested antioxidant and lipid-lowering properties. There is a small number of high-quality direct human data in this area. However, there is promising evidence regarding the role of n-3 polyunsaturated fatty acids (PUFA) and alpha-linolenic acid (ALA) (present in flaxseed) for improving outcomes in individuals with CAD. Despite this evidence, it remains unclear if flaxseed supplementation improves human cardiovascular endpoints, and dosing regimens are not established.

• Many poor-quality human studies have administered flaxseed products and measured effects on hyperlipidemia, with mixed results. There is a lack of well-designed human trials in this area, thus, strong evidence-based recommendations cannot be made at this time.

• 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 large amounts of flaxseed by mouth and mix with plenty of water or liquid. Avoid flaxseed with a history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Use cautiously in patients with a history of a bleeding disorder or if taking drugs that increase bleeding risk (like anticoagulants) and non-steroidal anti-inflammatory drugs. Also use with caution in patients with high triglyceride levels, diabetes, mania, seizures, or asthma. Avoid if pregnant or breastfeeding. Avoid in patients with prostate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods.

• Folate: Early data suggests that folic acid lowers homocysteine levels and might reduce the risk of cardiovascular disease and hyperhomocysteinemia. Large, randomized controlled trials are needed before a firm conclusion can be drawn.

• Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents (inserted slender tubes), or with anemia and seizure disorders. Folate is likely safe if breastfeeding and is highly recommended for pregnant women.

• Gamma oryzanol: 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 for prevention of restenosis after coronary angioplasty.

• Avoid if allergic/hypersensitive to gamma oryzanol, its components, or rice bran oil. Use cautiously if taking anticoagulants (blood thinners), CNS depressants , growth hormone, drugs, herbs that alter blood sugar levels, immunomodulators, luteinizing hormone or luteinizing hormone-releasing hormone, prolactin, cholesterol-lowering or thyroid drugs, herbs, or supplements. Use cautiously in patients with diabetes, hypothyroidism, low blood sugar levels, hyperglycemia and high cholesterol. Avoid if pregnant or breastfeeding.

• Garlic: Depending on the type of study performed, there is both strong and weak evidence for the use of garlic in the treatment of arteriosclerosis or associated conditions. Early research in humans suggests that deposits of cholesterol in blood vessels may not grow as quickly in people who take garlic. It is not clear if this is due to the ability of garlic to lower cholesterol levels, or to other effects of garlic on atherosclerosis.

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

• Ginger: Ginger may lower cholesterol levels in patients with hyperlipidemia. More studies are needed before a strong conclusion can be drawn.

• Avoid if allergic to ginger or other members of the Zingiberaceaefamily (such as red ginger, Alpinia purpurata, shell ginger, Alpinia zeru, green cardamom, and balsam of Peru). Avoid with therapy aimed at preventing the blood from clotting (anticoagulation therapy). Avoid large quantities of fresh cut ginger if diseases of the intestines (such as inflammatory bowel disease or a history of intestinal obstruction) are present. Use cautiously prior to surgery, with ulcers of the stomach or intestines, gallstones, heart disease, and diabetes. Use cautiously long-term and in underweight patients. Use cautiously if taking heart medications or sedatives, and if driving or operating heavy machinery. Use cautiously with drugs that affect serotonin, drugs that affect the function of the immune system, estrogen, CNS depressants, antiseizure medications, antibiotics, metronidazole, nifedipine, and cyclosporine. Use cautiously if pregnant or breastfeeding.

• Ginkgo: Animal and limited human data suggest a role of ginkgo in heart blood flow. More research is needed to better understand the effects of ginkgo on cardiovascular disease.

• Avoid if allergic or hypersensitive to members of the Ginkgoaceaefamily. If allergic to mango rind, sumac, poison ivy, oak, or cashews, an allergy to ginkgo is possible. Avoid with blood thinners such as aspirin or warfarin (Coumadin®), due to an increased risk of bleeding. Ginkgo should be stopped two weeks before surgical procedures. Ginkgo seeds are dangerous and should be avoided. Skin irritation and itching may also occur, due to ginkgo allergies. Do not use ginkgo in supplemental doses if pregnant or breastfeeding.

• Ginseng: Several studies from China report that ginseng in combination with various other herbs may reduce symptoms of CAD. Low-quality studies have evaluated various doses of Panax ginseng to reduce cholesterol levels in patients with hyperlipidemia. One study found no significant benefit in postmenopausal women. Benefit was found in another study in an unknown population using a dose of 2g Panax ginseng extract three times daily. More studies with quality methodologies and doses would be helpful to ascertain the effects of Panax ginseng.

• Caution is advised when taking ginseng supplements, as adverse effects and drug interactions are possible. Patients should be cautious if taking ginseng with warfarin or other medications that increase the risk of bleeding. Ginseng may also interact with cyclosporine, metronidazole, nifedipine, phenytoin, and benzodiazepines. Ginseng supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor.

• Goldenseal: In limited available clinical study, berberine (a compound present in goldenseal) reduced triglycerides, serum cholesterol, and LDL cholesterol. However, HDL cholesterol was not affected. Higher quality trials are needed to better determine the role of goldenseal in patients with high cholesterol.

• Use cautiously in patients with cardiovascular disease, bleeding disorders, diabetes, gastrointestinal disorders, increased bilirubin levels, or glucose-6-phosphate deficiency. Use cautiously during pregnancy. Goldenseal is not recommended during breastfeeding, due to a lack of sufficient data.

• Grape seed: Historical statistics suggest that wine may reduce the risk of heart disease and may be of benefit for high cholesterol. Animal studies suggest that grape seed may decrease cholesterol deposits in blood vessels and may reduce the amount of injury to heart muscle during a heart attack.

• Avoid if allergic or hypersensitive to grapes or other grape compounds. Use cautiously if taking blood thinners such as warfarin, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or anti-platelet agents. Use cautiously in patients with bleeding disorders or if taking drugs that may increase the risk of bleeding. Use cautiously with drugs processed using the liver's cytochrome P450 enzyme system. Use cautiously with blood pressure disorders or if taking ACE inhibitors. Avoid with disorders that increase the risk of bleeding or with active bleeding disorders (stomach ulcers, bleeding into the brain, etc.). Avoid if pregnant or breastfeeding.

• Grapefruit: 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/hypersensitive to grapefruit or its constituents. Use cautiously if taking cytochrome P450 3A4 substrates, such as blood thinners, heart medications, anticonvulsants, antidepressants, antihistamines, blood pressure medications, benzodiazepines, calcium channel blockers, caffeine, corticosteroids, diabetes medications, erectile dysfunction medications, estrogens, immune modulators, HMG-CoA reductase inhibitors, macrolide antibiotics, or protease inhibitors. Use cautiously if drinking red wine, tonic water, or if smoking. Use cautiously with a history of liver cirrhosis, kidney stones, gastric bypass surgery, and diabetes. Use cautiously if pregnant or breastfeeding.

• Green tea: There is evidence that regular intake of green tea may lower cholesterol levels and reduce the risk of cardiovascular conditions, like heart attack or atherosclerosis. Laboratory studies, animal studies, and limited human research suggest possible benefits of green tea for high cholesterol and hypertriglyceridemia. Better human evidence is necessary in this area.

• Avoid if allergic or hypersensitive to caffeine or tannins. Use cautiously in patients with diabetes or liver disease. Caution is advised when taking green tea supplements, as adverse effects and drug interactions are possible. Green tea supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

• Guggul: Prior to 2003, the majority of scientific evidence suggested that guggul elicits significant reductions in serum total cholesterol, LDL, and triglycerides, as well as elevations in HDL. However, most published studies were small and methodologically flawed. In August 2003, a well-designed trial reported small but significant increases in serum LDL levels associated with the use of guggul compared to placebo. No significant changes in total cholesterol, HDL, or triglycerides were measured. These results are consistent with two previously published case reports. Although this provides early evidence against the effectiveness of guggul for high cholesterol, further study is needed before a definitive conclusion can be reached for the use of this therapy for hyperlipidemia, due to the precedent of prior research and historical use.

• 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: Reductions in levels of serum triglycerides, total cholesterol, VLDL, and LDL have been observed in animals following the administration of gymnema. The mechanism may by via a decrease in the synthesis or an increase in the metabolism of cholesterol, or through decreased intestinal fat absorption. One study of gymnema in patients with type 2 diabetes reported decreased cholesterol and triglyceride levels as a secondary outcome. Further study is needed to better determine the effectiveness of gymnema for hyperlipidemia.

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

• Hawthorn: Hawthorn (Crataegus spp.), a flowering shrub of the rose family, has an extensive a history of use in cardiovascular disease dating back to the 1st Century. Increased blood flow to the heart and better heart performance has been observed in animals when given hawthorn supplements. Clinical research indicates that hawthorn may be effective in decreasing the frequency or severity of anginal symptoms. Hawthorn has not been tested in the setting of concomitant drugs such as beta-blockers or ACE-inhibitors, which are often the standard-of-care. At this time, there is not enough evidence to recommend or discourage the use of hawthorn in patients with angina.

• Caution is advised when taking hawthorn supplements, as adverse effects and drug interactions are possible. Hawthorn supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor.

• 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 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 with antibiotics. Potentially harmful contaminants (e.g., C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.

• Horny goat weed: Horny goat weed is traditionally used to treat cardiovascular diseases, like atherosclerosis. Early study suggests that horny goat weed may improve symptoms associated with ischemic cardio-cerebral vascular diseases. However, additional study is needed before a conclusion 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 anticoagulant or anti-platelet (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 if pregnant or breastfeeding.

• Kudzu: Kudzu (Pueria lobota) is well known to people in the Southeastern United States as an invasive weed, but it has been used in Chinese medicine for centuries. Kudzu has a long a history of use in the treatment of cardiovascular disease, including acute MI, and heart failure. A small number of poorly designed trials found kudzu to reduce the frequency of angina events in human subjects. Overall, available studies have been methodologically weak.

• Caution is advised when taking kudzu supplements, as adverse effects including drug interactions are possible. Kuzdu supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

• Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Case studies report that breathing techniques used in Kundalini yoga may help people with angina pectoris reduce symptoms and the need for medication. 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 as follows: one breath per minute of respiratory exercise with slow inspiration for 20 seconds, breath retention for 20 seconds, and slow expiration for 20 seconds. This occurs for 31 consecutive minutes. The technique was found to stabilize the heart's electrical wave patterns, which may have value for maintaining cardiovascular health.

• Avoid exercises that involve stoppage of breath in patients with heart or lung problems, insomnia, poor memory or concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Use cautiously in patients 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: There is mixed information from several human studies regarding the effects of Lactobacillus acidophilus-enriched dairy products in patients with high cholesterol. It may lower blood levels of total cholesterol or LDL (bad cholesterol).

• Avoid 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, such as corticosteroids, because of the risk of infection. Use cautiously in patients 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 may use antacids (e.g., famotidine (Pepcid®), esomeprazole (Nexium®)) to decrease the amount of acid in the stomach one hour before taking Lactobacillus acidophilus.

• L-carnitine: Although early research is promising, there is not enough available evidence to recommend for or against the use of L-carnitine for hyperlipoproteinemia (high levels of lipoprotein and cholesterol in blood) or myocardial infarction. Additional study is needed in this area.

• Avoid with known allergy or hypersensitivity to carnitine. Use cautiously in patients with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis, and diabetes. Use cautiously in low birthweight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

• Lemongrass: Early research has not shown any effect of lemongrass in patients with high cholesterol. More research is needed in this area.

• Avoid if allergic/hypersensitive to lemongrass, its constituents, or any members of the Poaceae family. Use cautiously if taking antidiabetic or cardiac medications, or with medications metabolized by cytochrome P450. Use cautiously in patients with liver conditions. Avoid if pregnant or breastfeeding.

• Lutein: Currently, there is not enough available evidence to recommend or discourage the use of lutein for atherosclerosis. 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: 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: There is evidence 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 on cholesterol levels are reliable and meaningful.

• There is a risk of nutritional deficiencies with use of a macrobiotic diet. However, this can be avoided with appropriate menu planning. Use cautiously in patients with cancer or other medical conditions without expert planning or supplementation. Avoid in children or adolescents without professional guidance or appropriate supplementation. Avoid in pregnant or lactating women, due to potential deficiencies, unless properly supplemented.

• Magnesium: Magnesium has been studied for acute MI, cardiac arrest, and CAD. Study results are mixed and additional research is needed.

• Use cautiously in patients with bleeding disorders, or in those taking anticoagulants or anti-platelet agents, anti-diabetic agents, or antihypertensive agents. Use intravenous magnesium sulfate with extreme caution in patients with eclampsia. Avoid in patients with atrioventricular heart block, kidney failure, or severe kidney disease. Avoid intravenous magnesium in women with toxemia (toxic substances in the blood) during the first few hours of labor.

• Meditation: There is currently not enough evidence that meditation has any clinical effects in cardiovascular disease. More studies are needed to determine whether meditation may have benefits and whether specific techniques might be more effective than others. Meditation may offer general benefits for mood and stress, which are likely to aid in cardiac care. However, more studies are needed to recommend meditation as a specific treatment during cardiac rehabilitation. Transcendental Meditation®, along with other therapies, has been reported to be of benefit for older patients with atherosclerosis, particularly in those with apparent CHD.

• Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professional(s) before starting a program of meditation, and should explore how meditation may or may not fit in with their current treatment plan. Avoid in patients with a risk or a history of seizures. The practice of meditation should not delay the time to diagnosis or treatment with better proven techniques or therapies, and should not be used as the sole approach to illnesses.

• Melatonin: Melatonin is a hormone produced in the brain by the pineal gland from the amino acid tryptophan. The synthesis and release of melatonin are stimulated by darkness and suppressed by light, suggesting the involvement of melatonin in circadian rhythm and regulation of diverse body functions. Levels of melatonin in the blood are highest prior to bedtime.

• One clinical trial found that melatonin when used with zinc and the diabetes drug, metformin, may improve diabetes-related complications such as an impaired lipid profile. However, there is also evidence that melatonin will increase cholesterol levels. More research is needed to clarify mixed results.

• Milk thistle: Milk thistle has been used medicinally for more than 2,000 years, most commonly for the treatment of liver and gallbladder disorders. A flavonoid complex called silymarin can be extracted from the seeds of milk thistle and is believed to be the biologically active component. The terms milk thistle and silymarin are often used interchangeably. Although animal and laboratory research suggests cholesterol-lowering effects of milk thistle, human studies have provided unclear results. Further studies are needed before a firm recommendation can be made.

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

• Music therapy: Music therapy may improve cardiac conditions and may have effects on heart rate and breathing rate. Additional research is needed. Music therapy is generally known to be safe.

• Nopal: Nopal may aid in reducing hyperlipidemia, although there is currently not enough evidence to make a strong recommendation for this condition.

• Avoid if allergic/hypersensitive to nopal (Opuntia spp.), any of its 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 if immunosuppressed or with impaired liver function. Avoid if pregnant or breastfeeding. It is recommended that oral doses of dried nopal be taken with at least eight ounces (250 milliliters) of water.

• Omega-3 fatty acids: Early studies report reductions in angina pectoris (chest pain) associated with fish oil intake. Some research also reports that regular intake of fish or a fish oil supplements reduces the risk of developing 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. Although some studies suggest benefits for secondary cardiovascular disease prevention, others do not.

• 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, and herbs or supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single six-ounce meal weekly, and in young children to less than two ounces weekly. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces weekly of other fish types. Women who might become pregnant are advised to eat seven ounces or less weekly of fish with higher levels of methylmercury or up to 14 ounces weekly of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

• 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 early study of AHT in a small number of patients with a history of a heart attack. A decrease in total cholesterol and LDL(bad cholesterol) was reported. However, this research was not well designed. Better research is needed before a firm conclusion can be reached for the use of ozone therapy in patients with cardiovascular disease.

• Autohemotherapy has been associated with transmission of viral hepatitis, and with a possible case of dangerously lowered blood cell counts. Consult a qualified health professional before undergoing any ozone-related treatment.

• Pantethine: Data has shown that pantethine exhibits lipid-modulating effects. Additional human studies are needed regarding the use of pantethine for heart disease.

• Avoid if allergic or hypersensitive to pantethine or any component of the formulation. Use with caution in patients with bleeding disorders. Avoid if pregnant or breastfeeding.

• Pantothenic acid: 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 high cholesterol, with compelling early 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.

• Peony: Dandi Tablet is a traditional Chinese medicine (TCM) formula containing peony; in the TCM paradigm (concept), Dandi Tablet is used for activating blood circulation. Additional high-quality research is needed to evaluate the use of this formulation for lipid lowering effects and for CHD prevention or treatment.

• Avoid if allergic or sensitive to peony. Avoid in patients with bleeding disorders or if taking drugs, herbs, or supplements that increase bleeding risk. Use cautiously with estrogen-sensitive cancers or if taking drugs, herbs, or supplements with hormonal activity. Avoid if pregnant or breastfeeding.

• Physical therapy: 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 studies are needed to make a firm recommendation for the use of physical therapy for cardiovascular conditions.

• Not all physical therapy programs are suited for everyone, and patients should discuss their medical history with a qualified healthcare professional before beginning any treatments. Physical therapy may aggravate pre-existing conditions. 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. Physical therapy has been used in pregnancy and although reports of major adverse effects are lacking in the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician/gynecologist before initiation.

• Policosanol: Policosanol has been used to treat high cholesterol. However, some newer research suggests that policosanol may not be as beneficial as previously thought.

• Avoid if allergic or hypersensitive to policosanol. Use cautiously if taking aspirin or blood pressure medications. Use cautiously with high blood pressure. Use cautiously if pregnant or breastfeeding.

• Pomegranate: Early study results of pomegranate for atherosclerosis are mixed. Consumption of a juice containing a combination of fruits, including pomegranate, was found to have a beneficial effect on high cholesterol. Additional studies are needed to confirm these early findings.

• Avoid if allergic or hypersensitive to pomegranate. Avoid in cases of 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 the supervision of a qualified healthcare professional. Use cautiously in patients with liver damage or disease. Pomegranate supplementation may be unsafe during pregnancy when taken by mouth. The bark, root, and fruit rind may cause menstruation or uterine contractions. Avoid if breastfeeding, due to a lack of scientific data.

• Prayer: Prayer may have far reaching healing effects that are hard to study. Early 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.

• Prayer is not recommended as the sole treatment approach for potentially serious medical conditions, and should not delay the time until consultation with a healthcare professional or to receive established therapies. Sometimes religious beliefs come into conflict with standard medical approaches and require an open dialog between patients and caregivers. Based on clinical study, patients who were certain that they were receiving intercessory prayer had a higher incidence of complications following cardiac bypass surgery than those who did not know prayers were being said for them..

• Probiotics: There is limited evidence suggesting probiotics may help reduce LDL or bad cholesterol, a risk factor for cardiovascular disease, in overweight people. These findings are tentative and more evidence is needed to arrive at firm conclusions. Some examples of probiotics include lactobacillus, saccharomyces boulardii, and acidophilus.

• Probiotics are generally considered safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

• Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional, such as a psychiatrist, psychologist, clinical social worker, licensed counselor, or other trained practitioner. Its purpose is the exploration of thoughts, feelings, and behaviors to facilitate problem solving or achieving higher levels of functioning. Alexithymia, or the inability to verbally express one's feelings, may influence the course of CHD. Educational sessions and group psychotherapy may decrease the incidence of alexithymia and CHD.

• Psychotherapy is not always sufficient to resolve mental or emotional conditions. Psychiatric medication is sometimes needed. The reluctance to seek and use appropriate medication may contribute to the worsening of symptoms or the increased risk for poor outcomes. In order to be successful, psychotherapy requires considerable personal motivation and investment in the process. This includes consistent attendance and attention to treatment recommendations provided by the practitioner. Not all therapists are sufficiently qualified to work with all problems. The client or patient should seek referrals from trusted sources and should also inquire of the practitioner's training and background before committing to work with a particular therapist. Some forms of psychotherapy evoke strong emotional feelings and expression. This may be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with post-partum depression, but is not a substitute for medication, which may be needed in severe cases.

• Pycnogenol: Pycnogenol® may reduce LDL/bad cholesterol levels and increase HDL/good cholesterol levels. Due to mixed data, further studies are necessary before a clear conclusion can be drawn on the use of Pycnogenol® for high cholesterol.

• Avoid if allergic/hypersensitive to pycnogenol, its components, or members of the Pinaceae family. Use cautiously in patients with diabetes, low blood sugar levels, or bleeding disorders. Use cautiously if taking cholesterol-lowering drugs, medications that may increase the risk of bleeding, antihypertensive medications, or immune stimulating/inhibiting drugs. Avoid if pregnant or breastfeeding.

• Qi gong: There is some evidence suggesting that practicing Qi gong (a Chinese system similar to meditation or yoga, of physical and mental training for health, martial arts, and emotional well-being), may be used in the treatment of angina and atherosclerosis. More studies would lead to a better understanding of this technique.

• Qi gong is generally considered to be safe in most people when learned from a qualified instructor. Use cautiously with psychiatric disorders. In cases of potentially serious conditions, Qi gong should not be used as the only treatment instead of more proven therapies, and should not delay the time it takes to see an appropriate healthcare provider.

• Quercetin: Quercetin is one of the almost 4,000 bioflavonoids (antioxidants) that occur in foods of plant origin, such as red wine, onions, green tea, apples, berries, and brassica vegetables (cabbage, broccoli, cauliflower, 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 CHD. 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 may occur. Avoid if pregnant or breastfeeding.

• Red clover: Red clover has been shown to improve the flow of blood through arteries and veins. However, it has not been clearly shown to have beneficial effects on high cholesterol. Due to mixed study results, further research is needed in this area before a recommendation can be made.

• Avoid if allergic to red clover or other isoflavones. Use cautiously if taking hormone replacement therapy (HRT) or birth control pills, or have a history of a bleeding disorder, breast cancer, or endometrial caner. Avoid if pregnant or breastfeeding.

• Red yeast rice: Red yeast rice is the product of yeast (Monascuspurpureus) grown on rice, and is served as a dietary staple in some Asian countries. It contains several compounds collectively known as Monacolins, substances known to inhibit cholesterol synthesis. One of these, Monacolin K, is a potent inhibitor of HMG-CoA reductase, and is also known as lovastatin (Mevacor®). Early evidence reports that taking red yeast riceby mouth may improve blood flow and may be effective for the treatment of CHD.

• Caution is advised when taking red yeast rice supplements, as adverse effects and drug interactions are possible. Red yeast rice supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor. Red yeast rice should not be used in people with liver problems or in heavy alcohol users.

• Reishi: Reishi (Ganoderma lucidum) is a fungus (mushroom) that grows wild on decaying logs and tree stumps.Reishi has been used in TCM for more than 4,000 years to treat liver disorders, high blood pressure, arthritis, and other ailments. A reishi supplement was reported to improve major symptoms of CHD such as angina (chest pain), palpitations (irregular heart beats), shortness of breath, high blood pressure, and high cholesterol in patients. Long-term studies are needed to evaluate the effectiveness and safety of reishi in CHD.

• Caution is advised when taking reishi supplements, as adverse effects, including bleeding, and drug interactions are possible. Reishi supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor.

• Relaxation therapy: 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. Better research is needed before a firm conclusion can be reached on the use of this therapy for heart attack risk reduction.

• Avoid in patients with psychiatric disorders like schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses like 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 used as an antioxidant in various health conditions, including cardiovascular disease. Laboratory animal studies suggest resveratrol helps restore blood flow to the heart. Well-designed human studies using resveratrol are needed.

• Caution is advised when taking resveratrol supplements, as adverse effects, including an increase in bleeding, and drug interactions are possible. Resveratrol supplements should not be used if pregnant or breast feeding unless otherwise directed by a doctor.

• Rhubarb: Rhubarb has been examined for its 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 still needed.

• 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, not enough liver function, ileus (intestinal obstruction), irritable bowel syndrome, menstruation, pre-eclampsia, kidney disorders, ulcerative colitis, and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under the age of 12, due to water depletion. Use cautiously in patients with bleeding disorders, cardiac conditions, coagulation therapy, constipation, a history of kidney stones, and 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 be used by both Western and TCM systems for angina pectoris and CAD. More high-quality studies are needed to establish the effect of safflower yellow injection. Limited available evidence suggests that safflower oil may be of benefit for atherosclerosis, familial hyperlipidemia, and high cholesterol. More studies are needed before a firm conclusion can be made.

• 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, and skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.

• Scotch broom: Scotch broom herb has been taken by mouth traditionally for a variety of conditions related to the heart and blood circulation. These include abnormal heart rhythms (arrhythmias), fast heart rate (tachycardia), swelling in the legs (peripheral edema), water in the lungs (pulmonary edema, congestive heart failure), and low blood pressure (hypotension). Sparteine, which can be extracted from Scotch broom, may affect the electrical conductivity of the 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 conditions should be evaluated and supervised by a licensed healthcare professional.

• Avoid if allergic or hypersensitive to Scotch broom or any of its constituents, including sparteine. Smoking or taking the flower/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 have developed in children from sucking on the flowers of the related species, French broom. Small amounts of Scotch broom may be safe in otherwise healthy individuals. Use in foods as a flavoring or coloring agent is generally considered safe. Medical supervision is recommended when using this herb. Scotch broom seeds have been used as a coffee substitute, which may carry a significant risk of toxicity. Avoid if pregnant or breastfeeding.

• Sea buckthorn: Sea buckthorn (Hippophae) may help to improve cardiovascular disease. More, higher 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 ACE inhibitors, anticoagulants and antiplatelet agents (blood thinners), antineoplastics (anticancer agents), cyclophosphamide, or farmorubicin. Avoid higher doses than those typically found in food if pregnant or breastfeeding.

• Selenium: 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 and Chagas' disease). However, most cases of cardiomyopathy are not due to low selenium levels and therefore selenium may not always be helpful. It has been suggested that low selenium levels may be a risk for coronary heart disease, although this remains unclear. 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 sensitive to products containing selenium. Avoid with a history of nonmelanoma 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.

• Shea butter: Inhuman studies, shea butter/oil was shown to prevent increases in lipids and factor VII coagulant concentrations that occur after eating. Additional trials with larger sample sizes are needed to confirm shea butter's proposed lipid-lowering effects.

• Avoid in patients taking anticoagulants. Avoid in individuals with a latex allergy as anecdotal information suggests that some shea butter formulations may contain latex.

• Soy: Further investigation is needed before a conclusion can be made about the use of soy for cardiovascular disease.

• 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 is 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 not known if soy or soy isoflavones share the same side effects as estrogens, e.g., the 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 such as warfarin should check with a doctor and pharmacist before taking soy supplementation.

• Spirulina: In animal studies, spirulina has been found to lower blood cholesterol and triglyceride levels. Early poor-quality studies in humans suggest a similar effect. Better research is needed before a firm conclusion can be drawn about the use of spirulina for high cholesterol.

• Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously in patients with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; and if consuming a high-protein diet. Avoid in children and if pregnant or breastfeeding.

• Squill: Currently, there is not enough available evidence to recommend or discourage the use of squill for CAD. 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 calcium levels. Use cautiously with cardioglycosides. Avoid if pregnant or breastfeeding.

• Tai chi: There is evidence that suggests the practice of 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; therefore, additional research is needed before a firm conclusion can be drawn about the use of this technique for cardiovascular disease or cardiovascular rehabilitation.

• 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 better proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

• Taurine: Taurine may offer benefit to individuals with high cholesterol. More study is needed to make a conclusion. Taurine is an amino acid and it is unlikely that there are allergies related to this constituent.

• However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, coagulation disorders, potential for mania, or epilepsy. Avoid consumption of energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients, then consuming alcohol or exercising. Use cautiously if pregnant or breastfeeding because taurine is a natural component of breast milk.

• Transcutaneous electrical nerve stimulation (TENS): Several small, brief studies report benefits of transcutaneous electrical nerve stimulation (TENS) on angina. However, most studies were conducted during the late 1980s and early 1990s, and were not well designed or reported. New drugs for heart disease have been developed since these studies were conducted, and people with heart disease or chest pain are advised to seek immediate medical attention from a licensed physician.

• Avoid with implantable devices such as defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Use cautiously with decreased sensation, like neuropathy, and with seizure disorders. Avoid if pregnant or breastfeeding.

• Thiamin (Vitamin B1): Thiamin has been studied as a way to help widen arteries that are too narrow. Regular intake of thiamin might help slow the progression of atherosclerosis. However, additional research is needed.

• Avoid if allergic or hypersensitive to thiamin. Rare hypersensitivity/allergic reactions have occurred with thiamin supplementation. Skin irritation, burning, or itching may rarely occur at injection sites. Large doses may cause drowsiness or muscle relaxation. Thiamin appears safe if pregnant or breastfeeding. Use cautiously if pregnant or breastfeeding.

• Thymus extract: Early evidence suggests that thymus extract may increase left ventricular function, exercise tolerance, and survival. Additional study is needed regarding the use of thymus extract for cardiomyopathy.

• 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" since most are derived from bovine sources. 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) herb combinations have been found to improve some markers of coronary heart disease. The TCM of Liqi Kuanxiong Huoxue combined with conventional treatment has been reported to reduce symptoms of stable and unstable angina. Additional 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, heavy metal, or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.

• Tribulus: Early research suggests that tribulus (Tribulus terrestris) may be beneficial to patients with CHD. 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 in patients with enlarged prostate, prostate cancer, and diabetes. Use cautiously if taking steroids, blood pressure medication like beta-blockers and calcium channel blockers, or digoxin. Avoid if pregnant or breastfeeding.

• Turmeric: Early studies suggest that turmeric may lower levels of LDL (bad cholesterol) and total cholesterol in the blood. Better human studies are needed before a conclusion can be made for the use of turmeric for high cholesterol.

• Avoid if allergic or hypersensitive to turmeric, curcumin, yellow food colorings, or plants belonging to the Zingiberaceae (ginger) family. Use cautiously in patients with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, low blood sugar levels, or gallstones. Use cautiously with blood thinners such as warfarin (Coumadin®), and blood sugar-altering medications. Avoid in large amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.

• Vitamin B12: Some evidence suggests that folic acid plus vitamin B12 and pyridoxine daily can decrease the rate of restenosis (reblocking of arteries) in patients treated with balloon angioplasty. However, 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 for patients receiving coronary stents.

• Hyperhomocysteinemia (high homocysteine levels in the blood) is a risk factor for coronary, cerebral, and peripheral atherosclerosis, recurrent thromboembolism, deep vein thrombosis, MI (heart attack), and ischemic stroke. Folic acid, pyridoxine (vitamin B6), and vitamin B12 supplementation may reduce total homocysteine levels; however, this reduction does not seem to help with secondary prevention of death or cardiovascular events such as stroke or MI 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 human studies of vitamin B12 supplementation alone are needed before a conclusion can be made on the use of vitamin B12 for high cholesterol.

• Avoid vitamin B12 supplements if allergic or hypersensitive to cobalamin, cobalt, or any other vitamin B12 product ingredients. Avoid with coronary stents (mesh tubes that hold clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the recommended dietary allowance (RDA). There is not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.

• Vitamin B6: There are mixed 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 conclusion can be made.

• High homocysteine levels in the blood (hyperhomocysteinemia) are a risk factor for cardiovascular disease, blood clotting abnormalities, MI (heart attack), 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 not clear if lowering homocysteine levels results in reduced cardiovascular morbidity and mortality. Until definitive data is available, the current recommendation is to screen 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.

• Avoid vitamin B6 products if sensitive or allergic to any of their ingredients. 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 RDA. Use cautiously if pregnant or breastfeeding.

• Vitamin C (ascorbic acid): Due to its antioxidant properties, vitamin C has been used in patients with ischemic heart disease. Early data suggest that vitamin C may have a benefit on blood flow in the heart but more research is needed to confirm these findings.

• Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken at 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 during pregnancy or breastfeeding. It is not clear if vitamin C supplements in doses higher than Dietary Reference Intake (DRI) recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.

• Vitamin D: There is insufficient evidence regarding the use of vitamin D 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. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken at recommended doses.

• Vitamin E: Vitamin E has been evaluated in patients with angina, atherosclerosis and high cholesterol in numerous laboratory, population, andhuman studies. 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 these conditions. Further research is warranted before a clear conclusion can be drawn.

• Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously in patients with bleeding disorders or if taking blood thinners. Avoid greater than recommended amounts in pregnant and breastfeeding women.

• White horehound: An early study showed that white horehound may lower cholesterol and triglyceride blood levels and may be of benefit for patients with atherosclerosis. Further research is needed to confirm these results.

• Avoid if allergic or hypersensitive to white horehound or any member of the Lamiaceae (mint) family. White horehound is generally considered safe when used to flavor foods. Use cautiously in patients with diabetes, high/low/unstable blood pressure, high levels of sodium in the blood, irregular heartbeats, or gastrointestinal disease (such as ileus, atony, or obstruction). Use cautiously with diuretics (drugs that increase urine production). Avoid if pregnant or breastfeeding.

• Wild yam: Animal studies have shown that wild yam may reduce the absorption of cholesterol from the gut and may be of benefit for patients with hyperlipidemia. Early studies in humans have shown changes in the levels of certain sub-types of cholesterol, including decreases in LDL or bad cholesterol and triglycerides, as well as increases in HDL or good cholesterol. More studies are needed in this area.

• Avoid if allergic or hypersensitive to wild yam or any member of the Dioscorea plant family. Use cautiously with a history of hormone-sensitive conditions (such as fibroids, endometriosis, or cancer of the breast, uterus, or ovary), asthma, blood clots, stroke, low blood sugar, or diabetes. Use cautiously if taking hormone replacement therapy, birth control pills, or blood sugar-altering agents. Avoid if pregnant or breastfeeding.

• Yucca: A blend of partially purified Yucca schidigera and Quillaja saponaria extracts may reduce cholesterol levels in patients with high cholesterol. However, additional studies are needed in this area, especially on yucca monotherapy.

• Avoid if allergic or hypersensitive to yucca (Yucca schidigera), its constituents, or members of the Agavaceae family (such as agave). Use cautiously if taking antihyperlipidemic (cholesterol-lowering) agents. Avoid if pregnant or breastfeeding.

• Fair negative scientific evidence:

• Acacia: There is early evidence that acacia may not be helpful for high 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 family. 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: 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 (AHA) 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.

• Chelation therapy: Evidence does not support the use of ethylenediamine tetraacetic acid (EDTA) chelation therapy in heart disease even though there is strong popular interest in this use.

• Use cautiously in individuals taking warfarin, individuals with osteoporosis or other bone deficiency conditions, and individuals with serious deficiencies of essential minerals that may be further depleted by chelation (would require replacement).

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

• Avoid if allergic to plants in the Onagraceae family (willow's herb, 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.

• Glucosamine: Glucosamine does not appear to alter low density lipoprotein (LDL) cholesterol or high density lipoprotein (HDL) cholesterol levels in patients with chronic joint pain or high cholesterol.

• Avoid if allergic or hypersensitive to shellfish or iodine. Some reports suggest a link between glucosamine/chondroitin products and asthma. Use caution with diabetes or a history of bleeding disorders. Avoid if pregnant or breastfeeding.

• Guided imagery: Therapeutic guided imagery may be used to help individuals relax and focus on images associated with personal issues they are confronting. Early human research does not report benefits of guided imagery in congestive heart failure.

• Guided imagery is usually intended to supplement medical care, not replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety, or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified healthcare provider before practicing guided imagery.

• Omega-3 fatty acids, fish oil, alpha-linolenic acid: Although fish oil may reduce triglycerides, beneficial effects in patients with high cholesterol have not been demonstrated.

• 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 in patients with bleeding disorders, diabetes, low blood pressure, or drugs, herbs, and supplements that treat any such conditions. Use cautiously before surgery. The Environmental Protection Agency (EPA) recommends that intake be limited in pregnant/nursing women to a single six-ounce meal weekly, and in young children to less than two ounces weekly. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration (FDA) recommends that pregnant/nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces weekly of other fish types. Women who might become pregnant are advised to eat seven ounces or less weekly of fish with higher levels of methylmercury or up to 14 ounces weekly of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

• Relaxation therapy: Early 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 like 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 better proven techniques.

• Vitamin C (ascorbic acid): Vitamin C does not appear to be of benefit for heart disease prevention.

• Avoid if allergic or sensitive to vitamin C product ingredients. 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 (DRI) recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.

• Vitamin E: Vitamin E does not appear to be of benefit for heart disease prevention.

• Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously in patients with bleeding disorders or if taking blood thinners. Avoid taking more than the recommended daily level in pregnant and breastfeeding women.

Prevention

• Alcohol consumption: In some studies, moderate use of alcohol (particularly red wine) has been linked with increasing levels of high density lipoprotein (HDL) cholesterol. Men should have no more than two drinks containing alcohol a day. Women should have no more than one drink containing alcohol a day. Excessive drinking can have a negative impact on cholesterol levels, actually raising triglyceride levels and increasing blood pressure.

• 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 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 in addition to many risk factors or disease states, an LDL level below 70 milligrams per deciliter of blood is optimal. There are several different types of cholesterol-lowering agents that may be prescribed to help maintain healthy cholesterol levels. The statins are considered first-line therapy, are most commonly used, and include medications such as simvastatin, lovastatin, and rosuvastatin. Fibrates are also used to lower cholesterol, such as gemfibrozil and fenofibrate. Niacin is another cholesterol-lowering medication. Bile acid sequesterants, such as cholestyramine, are also used, but generally less frequently than other therapy options.

• Cholesterol screenings: Everyone age 20 years and older should have his or her cholesterol measured at least once every five years and more often if additional risk factors apply.

• Diet: 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 permitted to claim to reduce the risk of coronary artery disease.

• Exercise: Exercise may lower blood pressure, increase HDL levels (good cholesterol), and improve the overall health of blood vessels and the heart. It also helps control weight, control diabetes, and reduce stress. Thirty minutes of daily exercise is normally recommended.

• High blood pressure (hypertension) control: A healthy blood pressure should ideally be a systolic reading of less than 120 and a diastolic reading of less than 80 (less than 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 high blood pressure, such as diuretics, angiotensin-converting enzyme (ACE) inhibitors, and angiotensin receptor blockers, may also be used. High blood pressure is defined as a consistent systolic blood pressure of 140 or higher, a diastolic blood pressure of 90 or higher, or both (greater than 140/90).

• Platelet inhibitors: It is recommended that men over the age of 50 and women over the age of 60 with at least one additional risk factor (some of which include diabetes, smoking, high blood pressure, hyperlipidemia, a strong family history of heart disease), be initiated on an aspirin regimen of one 81 milligram tablet once daily for prevention of a heart attack or ischemic stroke (due to a clot cutting off blood and oxygen supply to the brain). However, it is recommended to use the lowest dose of aspirin possible to minimize the risk of bleeding, ulcers, and hemorrhagic strokes (due to bleeding in the brain). Aspirin is usually used first line as a platelet inhibitor (prevent platelet clumping). Other platelet inhibitors that may be used in patients who cannot take aspirin, 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. Similar to aspirin, there is an increased risk of gastrointestinal bleeding with all platelet inhibitors.

• Smoking cessation: Nicotine constricts blood vessels and forces the heart to pump harder. A build-up of carbon monoxide reduces oxygen in the blood and damages the lining of the blood vessels. Therefore, individuals may decrease their risk of arteriosclerosis by not smoking.

• Stress management: Stress may cause an increase in blood pressure along with increasing the blood's tendency to clot. Chronic stress may 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 may be vital to keeping a heart healthy.

• 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, two of the major risk factors for developing atherosclerosis.

Author Information

• This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

Natural Standard developed the above evidence-based information based on a thorough systematic review of the available scientific articles. For comprehensive information about alternative and complementary therapies on the professional level, go to www.naturalstandard.com. Selected references are listed below.

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