Related Terms

• Androgen, angina, angina pectoris, angiogenesis, angiogram, arcus senilis, arteriogram, atherosclerosis, blood clot, cholesterol, computerized tomography angiography (CTA), coronary artery bypass graft surgery (CABG), coronary heart disease (CHD), cortisol, C-reactive protein, diabetes, dyslipidemia, embolus, endothelium, enhanced external counter pulsation (EECP), estrogen, high-density lipoprotein (HDL), homocysteine, hypercholesterolemia, hyperlipidemia, hyperlipoproteinemia, lipid disorder, lipid panel, lipid profile, lipoprotein, low-density lipoprotein (LDL), magnetic resonance imaging (MRI), myocardial infarction, obesity, percutaneous transluminal coronary angioplasty(PTCA) platelet, peripheral artery disease (PAD), plaque, Raynaud's disease, saturated fats, silent ischemia, soluble fiber, sterol, stress test, therapeutic lifestyle changes (TLC), thrombus, trans fats, transient ischemic attacks (TIAs),triglyceride, unsaturated fats, very-low-density lipoprotein (VLDL), xanthelasma, xanthoma.

Background

• High cholesterol, or hypercholesterolemia, is a condition in which there are unhealthily high levels of cholesterol in the blood. It is also called dyslipidemia, hyperlipidemia, and lipid disorder.

• Too much cholesterol in the blood is a major risk for heart disease, which may lead to a heart attack, heart failure (not being able to pump enough blood to the body), and death. igh cholesterol levels are also a risk factor for stroke (a lack of blood and oxygen to the brain), which causes nerve damage.

• Cholesterol is a soft, waxy, fat-like substance found in the bloodstream and cells of the body. Cholesterol synthesis is a naturally occurring process that functions to produce membranes for all cells in the body, including those in the brain, nerves, muscles, skin, liver, intestines, and heart. Cholesterol is also converted into steroid hormones, such as androgens and estrogens (the male and female sex hormones) and the adrenal hormones (cortisol, corticosterone, and aldosterone). In the liver, cholesterol is the precursor to bile acids that aid in the digestion of food, especially fats. Cholesterol is also used in making vitamin D.

• The body obtains cholesterol in two ways, producing the majority of it in the body and consuming the rest in the diet in the form of animal products, such as meats, poultry, fish, eggs, butter, cheese, and whole milk. Plant foods, like fruits, vegetables, and grains, do not contain cholesterol. Fat that occurs naturally contains varying amounts of saturated and unsaturated fat.

• High cholesterol can cause the formation and accumulation of plaque deposits in the arteries. Plaque is composed of cholesterol, other fatty substances, fibrous tissue, and calcium, normal substances in the blood that become deposited on the artery walls if the blood does not flow properly. When plaque builds up in the arteries, it results in atherosclerosis (hardening of the arteries) or coronary heart disease (CHD). Atherosclerosis can lead to plaque ruptures and blockages in the arteries, which increase the risk for heart attack, stroke, and death, as well as circulation problems, such as Raynaud's disease and high blood pressure.

• The development of plaques and blockages in the arteries involves several steps. When the endothelium (the innermost lining of the arteries) is damaged by oxidation, cholesterol particles, proteins, and other substances are deposited into the damaged wall and form plaques. More cholesterol and other substances are incorporated into the plaque, and the plaque grows, narrowing the artery. Over time, plaque deposits may grow large enough to interfere with blood flow through the artery (this is called a blockage). When coronary arteries (the arteries supplying the heart with blood) are blocked, angina (chest pain) may occur; when arteries in the legs are blocked, leg pain or cramping may occur; and when arteries supplying the brain with blood are blocked, stroke may occur.

• The platelets collecting on the plaque deposit form a clot as they try to rush by but get caught, because the lining of the artery is rough and the platelets are sticky. Then the clot can break off and travel through the body, getting lodged in vessels of the leg or brain and less commonly the lungs. If a plaque ruptures or tears, a thrombus (blood clot) may develop. If a blood clot completely blocks blood flow through a coronary artery, myocardial infarction (heart attack) occurs; if an artery supplying blood to the brain is completely blocked, stroke occurs.

• Blood clots (called emboli) can break loose and travel through the bloodstream and lodge in blood vessels in other parts of the body, including the lungs, heart, brain, and legs. A thromboembolus is when the blood clot lodges in vessels.

• According to current estimates, 71.3 million people in America have one or more forms of heart disease. High cholesterol affects about 20% of adults over the age of 20 in the United States. The highest prevalence occurs in women between the ages of 65 and 74. The World Health Organization (WHO) reports that high cholesterol contributes to 56% of cases of coronary heart disease worldwide and causes about 4.4 million deaths each year.

• Generally, people who live in countries where blood cholesterol levels are lower, such as Japan, have lower rates of heart disease. Countries with very high cholesterol levels, such as Finland, have very high rates of coronary heart disease. However, some populations with similar total cholesterol levels have very different heart disease rates, suggesting that other factors (such as diet, heredity, and smoking) also influence risk for coronary heart disease.

• Evidence is accumulating that eating more carbohydrates, especially simpler, more refined carbohydrates such as white breads, sugar, and pasta, may increase levels of triglycerides in the blood, lower high-density lipoprotein (HDL, or "good") cholesterol, and increase low-density lipoprotein (LDL, or "bad") cholesterol. Thus a low-fat diet, which often means a higher carbohydrate intake, may actually be an unhealthy change.

Types of Cholesterol

• Saturated fats: Saturated fats are solid at room temperature, Foods that contain a high proportion of saturated fat are butter, lard, coconut oil, cottonseed oil and palm oil, dairy products (such as cream and cheese), meat, skin, and some prepared foods. People with diets high in saturated fat are reported to have an increased incidence of atherosclerosis (hardening of the arteries) and coronary heart disease. Saturated fats are popular with manufacturers of processed foods because they are less vulnerable to rancidity and are generally more solid at room temperature than unsaturated fats.

• Unsaturated fats: Unsaturated fats are liquid at room temperature. Unsaturated fats include monounsaturated and polyunsaturated fats. Monounsaturated fat remains liquid at room temperature but may start to solidify in the refrigerator. Foods high in monounsaturated fat include olive, peanut, and canola oils. Avocados and most nuts also have high amounts of monounsaturated fat. Polyunsaturated fat is usually liquid at room temperature and in the refrigerator. Foods high in polyunsaturated fats include vegetable oils, such as safflower, corn, sunflower, soy, and cottonseed oils. The use of monounsaturated and polyunsaturated fats instead of saturated fat can help to lower blood cholesterol levels.

• Trans fats: Trans-fatty acids (trans fats) are a type of unsaturated fat. Trans fat is formed when liquid vegetable oils go through a chemical process called hydrogenation, in which hydrogen is added to make the oils more solid. Hydrogenated vegetable fats are utilized in food production because they allow longer shelf life and give food desirable taste, shape and texture. Trans fat can be found in shortenings (e.g., Crisco®), margarine, cookies, crackers, snack foods, fried foods (including fried fast food), doughnuts, pastries, baked goods, and other foods processed with partially hydrogenated oils. Some trans fat is found naturally in small amounts in dairy products and some meats. The primary health risk associated with trans fat consumption is an increased risk of coronary heart disease (CHD). Effective January 1, 2006, the U.S. Food and Drug Administration (FDA) requires food companies to list trans fat content separately on the nutrition facts panel of all packaged foods.

• Lipoproteins: Cholesterol and other fats cannot dissolve in the blood. They have to be transported to and from the cells by special carriers called lipoproteins. There are two main types of lipoproteins, including low-density lipoprotein (LDL, or "bad") cholesterol and high-density lipoprotein (HDL, or "good") cholesterol. Another type, very-low-density lipoprotein (VLDL) is converted to LDL in the bloodstream. Each form of lipoprotein contains a specific combination of cholesterol, protein, and triglyceride (a blood fat). VLDL cholesterol contains the highest amount of triglyceride.

• Too much LDL cholesterol can block the arteries, increasing the risk of heart attack and stroke. LDL takes cholesterol into the bloodstream, and HDL takes it back to the liver for storage. It is also believed that HDL removes excess cholesterol from plaque in arteries, thus slowing the buildup. Studies suggest that high levels of HDL cholesterol reduce the risk of heart attack.

• Lipoprotein (a) (Lp(a)) cholesterol: Lp(a) is a lipoprotein (fat-protein molecule) found in the body that is a genetic variation of LDL cholesterol. A high level of Lp(a) is an important risk factor for developing fatty deposits in arteries. The way increased Lp(a) contributes to disease is not understood, but Lp(a) may attract substances that increase inflammation, such as interleukins (IL-1, IL-6, TNF-alpha) and prostaglandins (PG2), leading to the buildup of fatty deposits.

• Triglycerides: Triglycerides are the body's storage form for fat. Most triglycerides are found in adipose (fat) tissue. Some triglycerides circulate in the blood to provide fuel for muscles to work. Extra triglycerides are found in the blood after eating a meal, when fat is being sent from the intestines to fat tissue for storage. People with high triglyceride levels often have high LDL cholesterol and low HDL cholesterol levels. Many people with heart disease also have high triglyceride levels. People with diabetes or who are overweight are also likely to have high triglyceride levels.

Risk Factors and Causes

• Diet: Saturated fat and cholesterol in foods makes total cholesterol and low-density lipoprotein (LDL) levels rise. Cholesterol is consumed in the diet in the form of animal products, such as meats, poultry, fish, eggs, butter, cheese and whole milk. Plant foods, like fruits, vegetables, and grains, do not contain cholesterol. Fat that occurs naturally contains varying amounts of saturated and unsaturated fat.

• Weight: Being overweight may increase "bad" cholesterol levels and is a risk factor for heart disease. Losing weight may help lower LDL, triglyceride, and total cholesterol levels, as well as raise high-density lipoprotein (HDL) levels. Individuals with a large waist measurement (more than 40 inches for men and more than 35 inches for women) are at high risk for heart disease.

• Physical activity: A lack of physical activity is a risk factor for heart disease. Exercise helps strengthen the heart and blood vessels. Exercising regularly can help lower LDL ("bad") cholesterol and raise HDL ("good") cholesterol levels. Being physically active for at least 30 minutes on most, if not all, days may help reduce the risk of developing high cholesterol and coronary heart disease.

• Age and gender: Cholesterol levels rise with age, due to various factors, including hormonal changes, diet, and general health. Before the age of menopause, women have lower total cholesterol levels than men of the same age. After the age of menopause, women's LDL levels tend to rise due to hormonal imbalances. As a rule, women have higher HDL cholesterol levels than men do. The female sex hormone estrogen tends to raise HDL cholesterol, which may help explain why premenopausal women are usually protected from developing heart disease. Estrogen production is highest during the childbearing years (20s to 40s). Women also tend to have higher triglyceride levels. As people get older and/or gain weight, their triglyceride and cholesterol levels tend to rise. Evidence reports that the atherosclerotic process (buildup of fatty plaque in arteries) begins in childhood and progresses slowly into adulthood. Then it often leads to coronary heart disease, the single leading cause of death in the United States. Eating patterns and genetics affect blood cholesterol levels in children and increase the risk of developing heart disease later in life.

• Heredity: Genetics partially determine how much cholesterol is produced endogenously. High blood cholesterol can run in families. If a parent or sibling developed heart disease before age 55, high cholesterol levels place an individual at a greater-than-average risk of developing heart disease.

• Smoking: Cigarette smoking damages the walls of blood vessels through a process called oxidation, making them prone to build up fatty deposits. Smoking may also lower levels of HDL cholesterol.

• High blood pressure: Increased pressure on the blood vessel walls damages arteries, which can speed the accumulation of plaque.

• Diabetes: High blood sugar contributes to high LDL cholesterol and low HDL cholesterol. High blood sugar can also damage the lining of the arteries, making it easier for plaque (protein, fat, and cholesterol) to deposit.

• Others: Nephrotic syndrome (kidney disease), hypothyroidism (low thyroid levels), anorexia nervosa (an eating disorder), and Zieve's syndrome (a condition that causes high cholesterol during withdrawal from long-term alcohol abuse) can all contribute to high cholesterol.

Signs and Symptoms

• High cholesterol does not lead to specific symptoms unless it has been chronic (long-term). High cholesterol levels may lead to specific physical findings such as xanthoma (thickening of tendons due to accumulation of cholesterol), xanthelasma (yellowish patches around the eyelids), and arcus senilis (white discoloration of the outer edges of the cornea due to cholesterol deposits).

• A high level of blood cholesterol causes the arteries to narrow and can slow, or even block, blood flow to the heart. This reduced blood supply prevents the heart from receiving enough oxygen. Chronic (long-term) high cholesterol can lead to atherosclerosis (hardening of the arteries), angina (chest pain), heart attack, transient ischemic attacks (TIAs, or temporary lack of blood flow and oxygen to the brain), cerebrovascular accidents or strokes (lack of blood and oxygen in the brain), and peripheral artery disease (PAD).

Diagnosis and Screening

• Recommendations for cholesterol screening and treatment have been provided by the National Institutes of Health (NIH) and are summarized in the National Cholesterol Education Program (NCEP). The guidelines recommend that all adults have their cholesterol levels checked at least once every five years. Patients with coronary heart disease or other forms of atherosclerosis are at the highest risk for heart attack and stroke (lack of blood and oxygen to the brain). These patients may benefit the most from cholesterol-reduction therapy and should have a full lipid profile (lipid panel) performed annually. This includes measuring total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and triglycerides. Very-low-density lipoproteins (VLDL) and lipoprotein (a) (Lp(a)) levels can also be taken. For the most accurate measurements, there is no eating or drinking anything (other than water) for 9-12 hours before the blood sample is taken.

• There is no formula to determine what cholesterol level is considered "safe" and what cholesterol level requires treatment for each individual. General recommendations are based on ongoing research regarding future risk for heart attack. In a person with established coronary heart disease, the risk for heart attack (or subsequent heart attack) and death is much higher, so even mildly elevated cholesterol levels must be treated aggressively.

• Total cholesterol levels: The total blood cholesterol will fall into one of three categories, including desirable (less than 200mg/dL, or milligrams per deciliter), borderline high-risk (200-239mg/dL), and high-risk (240mg/dL and above).

• If the total cholesterol is less than 200mg/dL, the risk of heart attack risk is relatively low, unless there are other risk factors, such as smoking, a previous heart attack, or high blood pressure.

• If the total cholesterol level is 200-239mg/dL, individuals are classified as borderline high-risk. About one-third of American adults are in this group, whereas almost one-half of adults have total cholesterol levels below 200mg/dL. Not every person whose cholesterol level is in the 200-239mg/dL range is at increased risk.

• If the total cholesterol level is 240mg/dL or more, an individual is at high risk of heart attack and stroke. In general, people who have a total cholesterol level of 240mg/dL have twice the risk of coronary heart disease as people whose cholesterol level is 200mg/dL. About 20% of the U.S. population has high blood cholesterol levels.

• Lipoprotein levels: LDL, or "bad" cholesterol, is a major risk factor for developing atherosclerosis (hardening of the arteries) and coronary artery disease (CAD). LDL levels are reported in several categories. An LDL level below 100mg/dL is best for people at risk for heart disease. If an individual is at very high risk for heart disease, such as having had a previous heart attack, an LDL level less than 70mg/dL is optimal. LDL levels can also be near optimal (100-129mg/dlL, borderline high (130-159mg/dL), high (160-189mg/dlL, or very high (190mg/dL and above).

• HDL ("good") cholesterol protects against heart disease, so for HDL, higher numbers are better. A level less than 40mg/dL is low and is considered a major risk factor for developing heart disease. HDL levels of 60mg/dL or more help to lower the risk for developing heart disease.

• Triglyceride levels: High levels of triglycerides can increase heart disease risk. Levels that are borderline high (150-199mg/dL) or high (200mg/dL or more) may need treatment.

• Children: Total cholesterol levels in children and adolescents (2-19 years old) are classified as acceptable (less than 170mg/dL), borderline (170-199mg/dL), and high (200mg/dL and greater). LDL cholesterol levels for children are classified as acceptable (less than 110mg/dL, borderline (110-129mg/dL), and high (130mg/dL or greater).

Complications

• Possible complications of high cholesterol include atherosclerosis (hardening of the arteries), coronary artery disease (CAD) or coronary heart disease (CHD), stroke (lack of blood flow to the brain), heart attack, and death. As discussed, high cholesterol levels can lead to plaque deposits in blood vessels. Plaque is composed of cholesterol, other fatty substances, fibrous tissue, and calcium, normal substances in the blood that become deposited on the artery walls if the blood does not flow properly. Over time, plaque deposits may grow large enough to interfere with blood flow through the artery (this is called a blockage). When the coronary arteries (the arteries supplying the heart with blood) are blocked, angina (chest pain) may occur; when arteries in the legs are blocked, leg pain or cramping may occur; and when arteries supplying the brain with blood are blocked, stroke may occur.

Treatment

• The main goal of cholesterol-lowering treatment is to lower low-density lipoprotein (LDL) levels enough to reduce the risk of developing heart disease or having a heart attack. The higher the risk, the lower the LDL goal should be. There are two main ways to lower cholesterol, including therapeutic lifestyle changes (TLC) and drug therapy. TLC includes a cholesterol-lowering diet (called the TLC diet), physical activity, and weight management. TLC is for anyone whose LDL is above his or her target number and goal. Drug treatment with cholesterol-lowering drugs can be used together with TLC treatment to help lower LDL. Prevention of elevated cholesterol is started if the individual is at risk for high cholesterol levels or heart disease, or if a previous heart attack or stroke has occurred.

• Category I, highest risk: In those with highest risk, the LDL goal is less than 100mg/dL. They will begin the TLC diet to reduce high risk even if the LDL is below 100mg/dL. If the LDL level is 100mg/dL or above, drug treatment will be started at the same time as the TLC diet. If the LDL level is below 100mg/dL, drug treatment may also be started together with the TLC diet if the doctor finds the risk is very high, for example, if the individual has had a recent heart attack or has both heart disease and diabetes.

• Category II, next highest risk: The LDL goal is less than 130mg/dL. If the LDL level is 130mg/dL or above, treatment with the TLC diet should be started. If the LDL level is 130mg/dL or more after three months on the TLC diet, drug treatment should be started along with the TLC diet. If the LDL level is less than 130mg/dL, individuals should follow the heart-healthy diet for all Americans, which allows a little more saturated fat and cholesterol than the TLC diet.

• Category III, moderate risk: The LDL goal is less than 130mg/dL. If the LDL level is 130mg/dL or above, the TLC diet is started. If the LDL is 160mg/dL or more after having tried the TLC diet for three months, drug treatment may be started along with the TLC diet. If the LDL is less than 130mg/dL, the heart-healthy diet for all Americans (low saturated fat and cholesterol) is used.

• Category IV, low-to-moderate risk: The LDL goal is less than 160mg/dL. If the LDL level is 160mg/dL or above, the TLC diet is started. If the LDL level is still 160mg/dL or more after three months on the TLC diet, drug treatment may be started along with the TLC diet to lower LDL, especially if the LDL level is 190mg/dL or more. If the LDL level is less than 160mg/dL, the heart-healthy diet for all Americans is used.

• Diet: Individuals with high risk associated with developing heart disease will be started on the therapeutic lifestyle changes (TLC) diet. The TLC diet is a low-saturated-fat, low-cholesterol eating plan that calls for less than 7% of calories to come from saturated fat (such as in animal products) and less than 200 milligrams of dietary cholesterol daily. The TLC diet recommends only enough calories to maintain a desirable weight and avoid weight gain. If the LDL level is not lowered enough by reducing saturated fat and cholesterol intakes, the amount of soluble fiber, such as psyllium, oat bran, and beta-glucan, in the diet can be increased (in cereals, breads, and supplements), thereby helping to raise HDL levels and lower LDL levels. Certain food products that contain plant sterols (a cholesterol-lowering component in many plants) can also be added to the TLC diet to boost its LDL-lowering power. Examples include cholesterol-lowering margarines (containing Benecol®, a plant sterol) and sterol supplements in capsule and tablet form. Plant sterols are found naturally in fruits, vegetables, nuts, seeds, cereals, legumes (beans), and vegetable oils (particularly soybean oil).

• Weight management: When the body mass index (BMI, or fat content) is greater than 25, an individual is considered overweight. BMI uses an equation based on height and weight to determine the level of obesity. Losing weight can help lower LDL levels and is especially important for those with a cluster of risk factors that includes high triglyceride and/or low HDL levels.

• Physical activity: Regular physical activity (at least 30 minutes on most, if not all, days) is recommended for those that can tolerate exercise. Taking a brisk 30-minute walk, 3-4 times per week, can positively impact cholesterol levels. Patients with chest pain and/or known or suspected heart disease should talk to their doctor before beginning any exercise program. Exercise can help raise HDL and lower LDL and is especially important for those with high triglyceride and/or low HDL levels who are overweight with a large waist measurement. Individuals with a large waist measurement (more than 40 inches for men and more than 35 inches for women) are at high risk for heart disease.

• Medication therapy: There are several medications that may help lower cholesterol, including total cholesterol, lipoproteins, and triglycerides. Medications can reduce LDL ("bad") cholesterol levels by 20-40%. They also can modestly increase HDL ("good") cholesterol levels, usually by about 5-10%. Available drugs include 5-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (HMG-CoA reductase inhibitors), bile acid-binding resins, cholesterol absorption inhibitors, fibrates, and niacin.

• 5-Hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (HMG-CoA reductase inhibitors, or statins): Statins have significantly advanced the treatment of high cholesterol. Statins block a substance (HMG-CoA reductase) that the liver needs to make cholesterol. This decreases cholesterol in hepatocytes (liver cells), which causes the liver to remove cholesterol from the blood, thereby lowering cholesterol levels. Statins may also help the body reabsorb cholesterol from accumulated deposits on artery walls, potentially reversing coronary artery disease. Commonly prescribed statins include atorvastatin (Lipitor®), fluvastatin (Lescol®), lovastatin (Mevacor®), pravastatin (Pravachol®), rosuvastatin calcium (Crestor®), and simvastatin (Zocor®). Statins may also be added to blood pressure-lowering drugs for use in protection from coronary heart disease (e.g., Caduet®, a combination of atorvastatin (Lipitor®) and amlodipine (Norvasc®)). Results from statin treatment should be seen after several weeks, with a maximum effect in 4-6 weeks. After about 6-8 weeks, a doctor will check the LDL cholesterol levels while the individual is on the statin. Serious side effects are rare, and they include liver problems and muscle soreness, pain, and weakness. If this happens, or if there is brown urine present, contact a doctor immediately. Although rare, muscle breakdown, known as rhabdomyolysis, can occur. This is a medical emergency, and a doctor should be contacted immediately. Other recent updates that are being added to safety labels are memory loss, confusion, forgetfulness, possible elevation in blood sugar, and type 2 diabetes.

• Bile-acid-binding resins (sequestrants): The liver uses cholesterol to make bile acids, a substance needed for digestion. The medications cholestyramine (Prevalite®, Questran®), colesevelam (WelChol®), and colestipol (Colestid®) lower cholesterol indirectly by binding to bile acids (this is called sequestrant therapy). This causes the liver to use excess cholesterol to make more bile acids, which reduces the level of cholesterol in the blood. Bile acid sequestrant powders must be mixed with water or fruit juice and must be taken once or twice (rarely, three times) daily with meals. Tablets must be taken with large amounts of fluids to avoid stomach and intestinal problems. Sequestrant therapy may produce a variety of symptoms, including constipation, bloating, nausea, and gas. Although sequestrants are not absorbed, they may interfere with the absorption of other medicines if taken at the same time. Other medications should be taken at least one hour before or 4-6 hours after taking the sequestrant.

• Cholesterol absorption inhibitors: The small intestine absorbs cholesterol from the diet and releases it into the bloodstream. The drug ezetimibe (Zetia®) helps reduce blood cholesterol by limiting the absorption of dietary cholesterol. Zetia® can cause headaches, nausea, fever, and muscle weakness. Zetia® by itself lowers LDL cholesterol levels similarly to statins, but when combined with a statin, Zetia® works better to control elevated LDL levels. There is a combination of ezetimibe and simvastatin on the market, called Vytorin®.

• Fibrates: The medications fenofibrate (Lofibra®, TriCor®) and gemfibrozil (Lopid®) decrease triglycerides by reducing the liver's production of very-low-density lipoprotein (VLDL) cholesterol and by speeding up the removal of triglycerides from the blood. VLDL cholesterol contains mostly triglycerides. Some people taking fibrates may have side effects such as stomach or intestinal discomfort. Fibrates may increase the likelihood of developing gallstones and can increase the effect of medications that thin the blood. The dose of fibrates should be reduced if kidney function declines.

• Niacin: Niacin, also known as nicotinic acid or vitamin B3, decreases triglycerides by limiting the liver's ability to produce low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) cholesterol. There are two types of niacin: immediate-release and extended-release (or slow-release). Niacin can reduce LDL cholesterol levels by 10-20%, reduce triglycerides by 20-50%, and raise HDL cholesterol levels by 15-35%. A common and troublesome side effect of immediate-release niacin is flushing or hot flashes, which are the result of blood vessels opening wide. The causes of this flushing are not well known. Most people develop a tolerance to flushing, which can sometimes be decreased by taking the drug during or after meals or by the use of aspirin 30 minutes prior to taking niacin; a doctor will guide the individual. The extended-release form (Niaspan®) may cause less flushing than the other forms. Individuals will be started on regular niacin therapy to see how well it is tolerated, then the individual can be started on the extended-release products if needed. Blood pressure may also be reduced while taking niacin. Niacin can cause a variety of gastrointestinal symptoms, including nausea, indigestion, gas, vomiting, diarrhea, and the irritation of peptic ulcers.

• Other: If there are other symptoms of coronary heart disease (CHD) besides high cholesterol, other medications may be used to decrease the risk of stroke (lack of blood and oxygen to the brain) and heart attack. These include platelet inhibitors (which "thin" the blood) such as aspirin (81-325 milligrams daily, which may cause bleeding) or Plavix® (clopidogrel), beta-blockers (these decrease the heart rate and blood pressure, reducing the heart's demand for oxygen, and may cause fatigue) such as metoprolol (Lopressor®, Toprol®), nitroglycerin (which increases the oxygen available to the heart by dilating coronary arteries, and which may cause headache), calcium channel blockers (which slow the heart rate and dilate coronary blood vessels, and which may cause slow heart rate) such as amlodipine (Norvasc®) or diltiazem (Cardizem®), angiotensin-inhibiting drugs or ACE inhibitors (which dilate blood vessels and increase oxygen to the heart, and which may cause cough) such as lisinopril (Prinivil®, Zestril®) or ramipril (Altace®), and statins or HMG-CoA reductase inhibitors (which help lower cholesterol levels and may cause liver problems or muscle pain) such as atorvastatin (Lipitor®) or lovastatin (Mevacor®). Interventional procedures may also be used to treat CHD, including balloon angioplasty (percutaneous transluminal coronary angioplasty (PTCA)) and stent (a wire mesh that opens blocked blood vessels) placement. Coronary artery bypass graft (CABG) surgery may be required to restore normal blood flow to the heart. CABG is a serious surgery, with complications including infection, lowered immunity, memory loss, "fuzzy" thinking, and even death.

Integrative Therapies

• Strong scientific evidence:

• Beta-glucan: The sum of existing positive evidence for use of beta-glucan for hyperlipidemia 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 with AIDS 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 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 of benefit for patients with hypercholesterolemia (high levels of blood cholesterol).

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

• Folate: Homocysteine is considered a significant risk factor for cardiovascular disease, and levels of homocysteine are modified by B vitamins, including folate.

• Avoid if allergic or hypersensitive to folate or any of the product ingredients. Use cautiously in those receiving coronary stents and those with anemia and seizure disorders. It is suggested that pregnant women consume 400 micrograms daily in order to reduce the risk of the fetus developing a defect. Folate is likely safe if breastfeeding.

• Garlic: Multiple studies in humans have reported small reductions in total blood cholesterol and low-density lipoprotein ("bad") cholesterol with use of garlic over short periods of time (4-12 weeks). Effects on high-density lipoprotein ("good") cholesterol are unclear. This remains an area of controversy.

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

• Konjac glucomannan: Glucomannan supplementation significantly reduced cholesterol levels in human research, according to a meta-analysis and randomized controlled trials. By definition, a soluble fiber is one that has a high water-holding capacity and forms viscous solutions when dissolved in water. It is thought that soluble fibers interfere with the transport of cholesterol and bile acids. Further evidence is required on safety in a population with high cholesterol as well as the potential for interaction with antilipemic agents.

• Avoid when used by patients allergic to Amorphophallus konjac, its constituents, or any component of the formulation. When used by pregnant and lactating women, due to a lack of safety data. When used in patients with diabetes or those using antidiabetic agents, as glucomannan may interfere with glucose control. Also use caution in people with thyroid disorders, and those using immunomodulatory agents, fat-soluble vitamins, or antihypertensive agents. Increased consumption of dietary fibers is thought to have the potential to modify the bioavailability of other agents, including prescription and nonprescription drugs, herbs, and supplements. Separating the ingestion of any fiber supplement by two hours from other foods, pharmaceutical agents, herbal products, or dietary supplements is recommended.

• Niacin: Niacin is a well-accepted treatment for high cholesterol. Multiple studies show that for high cholesterol, niacin has significant benefits on levels of high-density (HDL, or "good") cholesterol, with better results than prescription drugs such as statins like atorvastatin (Lipitor®).

• Avoid niacin or vitamin B3 if allergic to niacin or niacinamide. Avoid in those with history of liver disease or dysfunction, arrhythmia (irregular heartbeats), 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 from fish or fish oil supplements (EPA + DHA) significantly reduce blood triglyceride levels. Benefits appear to be dose dependent. It is not clear if alpha-linolenic acid significantly affects triglyceride levels, and there is conflicting evidence in this area.

• Avoid if allergic or hypersensitive to fish, nuts, linolenic acid, or omega-3 fatty acid products that come from fish or nuts. Avoid during active bleeding. Use cautiously in those with bleeding disorders, diabetes, low blood pressure, or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The U.S. Environmental Protection Agency (EPA) recommends that intake be limited in pregnant and nursing women to a single six-ounce meal per week, and in young children to less than two ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant and nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

• Plant sterols: Many studies in humans and animals have demonstrated that supplementation of beta-sitosterol into the diet decreases total serum cholesterol and low-density lipoprotein (LDL) cholesterol in patients with hypercholesterolemia (high levels of blood cholesterol).

• Their use is likely unsafe in patients with known allergy or hypersensitivity to plant sterols or stanols, or to plant sources from which plant sterols or stanols are isolated (e.g., pine, soy). Also, they are likely unsafe when used in patients with advanced breast cancer treated with tamoxifen, as plant sterols have been shown to be inconsistently increased in serum. Use caution in patients with asthma or other respiratory diseases, diabetes mellitus, primary biliary cirrhosis, ileostomy, a history of gallstones, neurodegenerative disorders, diverticular disease, short bowel syndrome, celiac disease, or sitosterolemia, and in those taking antiplatelet agents or hormonal agents.

• Psyllium: Psyllium, also referred to as ispaghula, is derived from the husks of the seeds of Plantago ovata. 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 seen in blood levels of total cholesterol and low-density lipoprotein ("bad") cholesterol. Effects have been observed following eight weeks of regular use. Psyllium does not appear to have significant effects on high-density lipoprotein ("good") cholesterol or triglyceride levels. Because only small reductions have been observed (total cholesterol and LDL), people with high cholesterol should discuss the use of more potent agents with their healthcare provider.

• Avoid if allergic or hypersensitive to psyllium, ispaghula, or English plantain (Plantago lanceolata). Avoid in patients with esophageal disorders, gastrointestinal atony, fecal impaction, gastrointestinal tract narrowing, swallowing difficulties, or previous bowel surgery. Avoid ingestion of psyllium-containing products in individuals with repeated or prolonged 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 required 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 those 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, low-density lipoprotein (LDL, or "bad") 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 their effects are not predictable. For lowering high cholesterol, there is better evidence for using prescription drugs such as lovastatin.

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

• Soy: Numerous human studies report that adding soy protein to the diet can moderately decrease blood levels of total cholesterol and low-density lipoprotein ("bad") cholesterol. Small reductions in triglycerides may also occur, while high-density lipoprotein ("good") cholesterol does not seem to be significantly altered. Some scientists have proposed that specific components of soybean, such as the isoflavones genistein and daidzein, may be responsible for the cholesterol-lowering properties of soy. However, this has not been clearly demonstrated in research and remains controversial. It is not known if products containing isolated soy isoflavones have the same effects as regular dietary intake of soy protein.

• Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there are limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore high doses 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 colitis (intestinal irritation) 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, like 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 in arteries of the heart. Benefits have been shown in some patients with coronary artery disease. However, more research is needed to confirm these findings and to develop safe and effective doses.

• Avoid in those allergic to arginine, or in those with a history of stroke or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution in those taking blood-thinning drugs (like warfarin or Coumadin®) or blood pressure drugs or 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.

• Avocado: Avocados added to the diet may lower total cholesterol, LDL ("bad") cholesterol, HDL ("good") cholesterol, and triglycerides. Additional research is needed before a strong recommendation can be made concerning 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 those found in a normal diet are not recommended if pregnant or breastfeeding. Some types of avocado may be unsafe when breastfeeding.

• Barley: 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 beta-glucan extracts vary in their functionality with respect to cholesterol reduction. At least one barley beta-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 hypercholesterolemia. 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. Fiber may reduce gastrointestinal transit and can, therefore, reduce the absorption of various orally administered agents. Avoid use in patients with celiac disease. Gluten found in barley may exacerbate this condition.

• Beans: In human and animal research, beans have been found to lower total cholesterol, LDL cholesterol, and triglycerides, and increase HDL cholesterol. In vitro, pinto beans and black beans were found to bind bile acids, which the authors suggested may play a role in cholesterol and lipid-lowering effects in those that have hypercholesterolemia, as well as reducing plaque formation in the arteries. Well-designed clinical trials are needed before further conclusions may be drawn.

• Beans are likely unsafe when consumed raw or improperly cooked, as there are multiple reports of poisoning incidents, or when used in patients with known allergy or hypersensitivity to Phaseolus vulgaris, its constituents, or other members of the Fabaceae family. Use caution in patients with gout, folate deficiency, vitamin B12 deficiency, and low blood pressure.

• Betaine anhydrous: Homocystinuria is a severe form of hyperhomocysteinemia caused by genetic defects in homocysteine-metabolizing genes, most commonly the cystathionine beta-synthase (CBS) gene. Patients with severely elevated homocysteine due to a genetic deficiency can use betaine treatment, in combination with other vitamins and diet restrictions, to reduce the risk of vascular events. Further studies are needed to determine whether betaine supplementation can lower cardiovascular risk in the general population.

• Hyperhomocysteinemia is a complication found in 80% of end-stage renal failure patients and may contribute to the progression of atherosclerosis among these patients. The effect of betaine supplementation on reducing homocysteine concentrations in this population has only been studied in addition to folic acid. Additional research investigating betaine alone is needed to make a firm conclusion.

• Avoid if allergic or hypersensitive to betaine anhydrous or cocamidopropylbetaine, a form of betaine. Use cautiously in those with renal 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 hypercholesterolemia (high cholesterol).

• Avoid if allergic or hypersensitive to carob (Ceratonia siliqua), its constituents, or any plants in the Fabaceae family, including tamarind. Avoid in those with metabolic disorders; a chromium, cobalt, copper, iron, or zinc disorder or deficiency; renal 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 in those taking oral herbs or drugs. Use cautiously in hypouricemic 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® in humans are similar to those of other whole grains. Further research is needed.

• There are limited safety data on chia. Avoid if allergic or sensitive to chia, sesame, or mustard seed. Use cautiously in those with low blood pressure or bleeding disorders. Use cautiously in those taking anticancer, 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, including serum lipid profiles, and lowering total and LDL cholesterol while raising HDL (high-density lipoprotein) 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 efficacy trials of chitosan should evaluate the relative efficacy and safety of this substance alone compared to other interventions and determine whether chitosan my act in synergy with other substances. In addition, if efficacy is firmly established, the optimum dosage needs to be determined.

• Avoid if allergic or sensitive to chitosan or shellfish. Use cautiously in those with diabetes or bleeding disorders. Use cautiously in those 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: A small number of studies suggest that forskolin may improve cardiovascular function in patients with cardiomyopathy. However, these trials are small and of poor quality. Larger studies are needed before a conclusion can be made.

• Avoid in individuals with a known allergy or hypersensitivity to Coleus forskohlii and related species. Rash may occur in sensitive individuals.

• 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 those with diabetes, bleeding disorders, or prostate conditions, or in those taking immunosuppressive medications or anticoagulant medications, hormonal replacement therapy, or oral contraceptives. Avoid anticoagulant medications with myelogenous-type cancers. Avoid if pregnant or breastfeeding.

• DHA: The effects of omega-3 fatty acids on reducing the risk of cardiovascular events are well known. However, the effect of DHA monotherapy on cardiovascular events has been studied to a lesser extent. Despite the triglyceride-lowering and HDL-increasing effects of DHA, some studies suggest that DHA may negatively increase total cholesterol and LDL cholesterol levels. The use of DHA should be monitored by health professionals in certain at-risk individuals. Further research is required before firm conclusions may be drawn in this field.

• Avoid in patients with known allergy or hypersensitivity to fish, fish oils, or any marine products.

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

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

• Globe artichoke: Preliminary human research suggests that cynarin and artichoke extracts may have lipid-lowering effects. More research is needed in this area.

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

• Guggul: Guggulipid supplements have been taken for high cholesterol. Early scientific studies suggest that guggulipid may be effective in reducing levels of total cholesterol, triglycerides, and LDL (low-density lipoprotein, or "bad") cholesterol and in raising levels of HDL (high-density lipoprotein, or "good") cholesterol. Some conflicting evidence exists. Additional high-quality trials are needed.

• Use cautiously in patients with gastrointestinal disorders. Use cautiously in patients using agents that affect the cardiovascular system, agents that are processed by the liver's cytochrome P450 system, agents that increase the risk of bleeding, agents that lower blood sugar, antiarthritics, antibacterials, antibiotics, anticancer agents, anti-inflammatory herbs, antiobesity agents, antioxidants, cholesterol-lowering agents, hormonal agents, lipid-lowering agents, osteoporosis agents, red yeast rice, or thyroid agents. Avoid in large amounts in patients using estrogens. Avoid if pregnant or trying to become pregnant. Guggul is not suggested for use in breastfeeding women, due to a lack of available scientific evidence. Avoid with known allergy or sensitivity to guggul (Commiphora mukul), any of its components, or other members of the Burseraceae family. Skin reactions and shortness of breath have been reported.

• L-carnitine: Evidence from clinical trials suggests that L-carnitine and L-propionyl-carnitine (propionyl-L-carnitine) are effective in reducing symptoms of angina (chest pain). Carnitine may not offer further benefit when patients continue conventional therapies. Additional research is needed to confirm these findings.

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

• Lecithin: Studies suggest that lecithin, when given together with plant compounds known as sterols, improves the sterols' beneficial effect on cholesterol levels. Additional research is needed before a conclusion can be made.

• Lecithin is generally well tolerated. Avoid in those with known allergy or hypersensitivity to lecithin, egg, or soy.

• Niacin: Niacin decreases blood levels of cholesterol and lipoprotein (a), which may reduce the risk of atherosclerosis ("hardening" of the arteries). However, niacin also can increase homocysteine levels, which may have the opposite effect. Overall, the scientific evidence supports the use of niacin in combination with other drugs (but not alone) to decrease cholesterol and slow the process of atherosclerosis. More research is needed in this area before a firm conclusion can be drawn.

• Avoid niacin and vitamin B3 if allergic to niacin or niacinamide. Avoid with history of liver disease or dysfunction, arrhythmia (irregular heartbeats), heart disease, blood clotting, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout, or diabetes. Avoid if pregnant or breastfeeding.

• Pantethine: Numerous trials have examined the effects of pantethine taken by mouth on hyperlipidemia. Reductions in total cholesterol, low-density lipoprotein (LDL), and triglycerides have occurred. However, additional research 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 those with bleeding disorders. Avoid if pregnant or breastfeeding.

• Phytoestrogens: Evidence suggests that certain populations that consume large amounts of soy protein have lower cardiovascular morbidity and mortality. Soy protein has been reported to reduce serum lipid levels by up to 10%. Preliminary evidence suggests that soy protein is superior to isoflavones isolated from red clover for reduction of serum lipid levels. Additional research is needed in this area.

• Phytoestrogens are likely safe when consumed in amounts commonly found in foods. Some experts advise against use of soy-based formulas by infants not sensitive to cow's milk, due to estrogenic components in the formula. Use cautiously in patients with bleeding disorders or those taking agents that may increase the risk of bleeding, in patients with diabetes or hypoglycemia or those taking agents that affect blood sugar, in patients taking hormone replacement therapy or birth control pills, in patients with thyroid disorders, in men, in females trying to become pregnant, in children, and in patients taking lipid-lowering medications. Avoid in patients with estrogen-dependent tumors or endometrial hyperplasia, in women who are pregnant or breastfeeding, and in those with known allergy or sensitivity to the plant from which the phytoestrogen is derived.

• 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-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 compelling evidence, further research is necessary before a clear conclusion can be reached.

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

• Ribose: Some evidence suggests that ribose may be beneficial to individuals with heart disease. Further research is needed in this field.

• Use cautiously in people with diabetes, low blood sugar, kidney disorders, or gastrointestinal disorders; in those prone to headaches; and in those taking blood sugar-lowering agents. Avoid in pregnant or breastfeeding women. Avoid in those with known allergy or sensitivity to ribose.

• Sweet almond: Early studies in humans and animals report that for high cholesterol, whole almonds may lower total cholesterol and low-density lipoprotein (LDL, or "bad") cholesterol and raise high-density lipoprotein (HDL, or "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 those with heart disease, diabetes, or low blood sugar. Use cautiously in those taking cardiovascular agents (including antilipemics), antidiabetics, estrogens, phytoestrogens, or fertility agents. Use cautiously if pregnant or breastfeeding.

• Yoga: There is intermediate evidence to support the use of yoga as an adjunct therapy in the prevention of coronary artery disease. Yoga was one 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.

• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Some inverted poses should be avoided in those 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 those 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 during pregnancy.

• Unclear or conflicting scientific evidence:

• Acupuncture: Some research has suggested that acupuncture might help reduce distress and symptoms of angina (chest pain), but this has not been consistently shown in other studies. Acupuncture has been found to be superior to medication (Shenmai injection) for low pulse pressure syndrome, a cardiovascular condition. More studies are needed before a firm conclusion can be drawn. It also remains unclear if acupuncture is an effective treatment for rehabilitation of the heart.

• Acupuncture does not usually cause serious side effects. There have been reports of dizziness and rapid, involuntary eye movements after acupuncture. Needles must be sterile in order to avoid disease transmission or infections (most practitioners now use disposable needles). Acupuncture should only be performed by qualified healthcare professionals. Acupuncture should be avoided in those with the following conditions: valvular heart disease, known bleeding disorders, use of anticoagulants (blood thinners), pregnancy (may induce unwanted labor and possible miscarriage), systemic or local infection, pain of unknown medical origin, medical condition of unknown origin such as dermatologic lesions, and neurologic disorders (e.g., severe polyneuropathy or paraplegia, or following certain forms of neurosurgery), as well as on areas that have received radiation therapy.

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

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

• Amalaki: According to human research, raw amalaki may improve serum cholesterol levels. However, there is not enough scientific evidence to form clear conclusions about its safety or effectiveness in humans.

• Avoid with known allergy or hypersensitivity to amalaki (Emblica officinalis, Phyllanthus emblica), its components, or members of the Phyllanthus family. Other members of the Phyllanthus family include Otaheite gooseberry, Jamaican gooseberry tree, chanca piedra, and chamberbitter. Avoid if pregnant or breastfeeding, due to a lack of scientific evidence. Use cautiously in patients with low blood sugar levels or low iron levels, in patients taking blood thinners, and in patients with decreased immune system function.

• Amaranth oil: Amaranth plus a low-sodium, heart-healthy diet decreased cholesterol and blood pressure in patients with coronary heart disease. 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 those 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 research is needed before a firm recommendation can be made.

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

• Aortic acid: Mesoglycan is a structural aspect of cardiovascular vessels and organs. Preliminary research indicates that mesoglycan may reduce blood vessel thickening. However, additional research is needed regarding the use of this agent for atherosclerosis.

• Due to the heparan sulfate content of mesoglycan, patients with an allergy to heparin or heparinoid derivatives should use caution. Use cautiously in those with coagulation (blood) disorders or those taking anticoagulation therapy. Use cautiously in those with hypertension (high blood pressure) or those taking antihypertension 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 research 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: Some research suggests that arginine may help treat or prevent high cholesterol.

• Avoid in those allergic to arginine, or with a history of stroke or liver or kidney disease. Avoid if pregnant or breastfeeding. Use caution if taking blood-thinning drugs (like warfarin or Coumadin®) or 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 for 30 days by mouth. The authors reported significant decreases in serum total cholesterol levels, triglycerides, low-density lipoproteins (LDL), and very-low-density lipoproteins (VLDL). Additional evidence is required to better determine the effectiveness of ashwagandha for hypercholesterolemia.

• 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 few human trials using ashwagandha, and most do not report the doses or standardization or preparation used.Avoid in those with peptic ulcer disease. Ashwagandha may cause abortions, according to anecdotal reports. Avoid if pregnant or breastfeeding.

• Astaxanthin: There is insufficient evidence to recommend for or against the use of astaxanthin for hyperlipidemia prevention. More research is needed to make a conclusion.

• Avoid in those allergic or hypersensitive to astaxanthin or related carotenoids, including canthaxanthin, or those with hypersensitivity to an astaxanthin algal source, such as Haematococcus pluvialis. Use cautiously in those taking 5-alpha-reductase inhibitors, hypertensive agents, asthma medications, such as cetirizine dihydrochloride and azelastine, cytochrome P450-metabolized agents, menopause agents or oral contraception, or Helicobacter pylori agents. Use cautiously in those with hypertension, parathyroid disorders, or osteoporosis. Avoid in those with hormone-sensitive conditions or immune disorders, and in those taking immunosuppressive therapies. Avoid in those with previous experience of visual changes while taking astaxanthin and with low eosinophil levels. Avoid if pregnant or breastfeeding.

• Astragalus: There are several human case reports of reduced symptoms and improved heart function with use of astragalus, although these are not well described. High-quality human research is necessary before a conclusion can be drawn about the use of astragalus for coronary heart disease.

• Caution is advised when taking astragalus supplements, as adverse effects including 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. There is preliminary evidence that the herb guggul (Commiphora) may reduce serum cholesterol, serum triglyceride, and LDL levels, and increase HDL levels. More studies are needed to validate the use of guggul for high cholesterol.

• 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.

• Barley: The Food and Drug Administration (FDA) has announced that whole grain barley and barley-containing products are allowed to claim that they reduce the risk of coronary heart disease (CHD). To qualify for the health claim, the barley-containing foods must provide at least 0.75 gram of soluble fiber per serving of the food. Supplementation with different types of barley beta-glucan has been shown to have small effects on cardiovascular disease markers in humans. Further research is necessary in this area.

• Avoid in those with known allergy or sensitivity to barley flour or to beer made with barley, its constituents, or members of the Poaceae family. Life-threatening allergic reactions and other adverse effects have been reported from drinking beer made with malted barley. Patients with allergy or sensitivity to grass pollens, rice, rye, oats, or wheat may also react to barley. Avoid use in patients with celiac disease. Use cautiously in all patients. Use caution in patients with diabetes or hypoglycemia, and in those taking agents that lower blood pressure, blood sugar, or cholesterol, or agents that stimulate the heart and blood flow.

• Bay leaf: Bay leaf may have beneficial effects on glucose, total cholesterol, LDL ("bad") cholesterol, HDL ("good") cholesterol, and triglyceride levels in patients with type 2 diabetes. Additional research is needed in this area.

• Use caution when whole bay leaves are ingested with food. Caution is advised in patients with bleeding disorders, diabetes, or low blood sugar, or in those taking agents for any of these conditions. Use caution in patients using sedatives and in pregnant or breastfeeding women. Avoid if allergic or sensitive to bay (Laurus nobilis), its constituents, or related plants in the Lauraceae, Compositae, or Asteraceae families.

• Beans: Bean intake was found to be inversely associated with cardiovascular disease (CVD) in a cohort study. Well-designed clinical trials are needed before a conclusion may be drawn.

• Beans are likely unsafe when consumed raw or improperly cooked, as there are multiple reports of poisoning incidents, and when used in patients with known allergy or hypersensitivity to Phaseolus vulgaris, its constituents, or other members of the Fabaceae family. Use caution in patients with gout, folate deficiency, vitamin B12 deficiency, or low blood pressure.

• Beer: Although moderate beer drinking is associated with improved cardiovascular risk reduction, further research on the mechanisms is required before conclusions can be made.

• Avoid in patients using methotrexate or sedatives, in patients with liver disease or those using agents that may affect the liver, in patients with known allergies or addictions to alcohol or ingredients in beer, in children, and in pregnant or breastfeeding women. Use cautiously at high levels in all patients, if driving or operating heavy machinery, in patients with high or low blood pressure or those taking agents that may affect blood pressure, in patients with bleeding disorders or those taking agents that may affect the risk of bleeding, in patients taking agents that are processed by the liver, in those with diabetes or low blood sugar or those taking agents that may affect blood sugar, in postmenopausal women, in patients with gastrointestinal disorders, in obese patients, in patients using diuretics, in those at risk for electrolyte imbalances or those using agents that may affect electrolytes, in patients at risk for carpal tunnel syndrome, in patients with nerve pain, in patients prone to migraines, in patients with asthma, in patients trying to become pregnant or taking fertility agents, in men and those receiving testosterone therapy, in patients with osteoporosis, and in patients with gout.

• Beet: Increased dietary fiber intake is recommended, based on findings that support its antilipemic 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 the cholesterol-lowering effects of sugar beet fiber may be partially due to the activity of by-products produced in the large intestine as a result of fermentation by colonic bacteria. Clinical trials have evaluated the effects of beet fiber for hyperlipidemia. More research is needed in this area.

• Avoid in those with an allergy or hypersensitivity to any part of the beet plant, including the beet root, beet 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.

• 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 potential for increase in free bilirubin, jaundice, and development of kernicterus. Use cautiously in those 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 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 gut flora. 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: Evidence suggests that reductions in endothelial function induced by a high-fat meal may be prevented when a high-fat meal is taken along with a beta-glucan-containing cereal or vitamin E. Further research is needed regarding the effect of beta-glucan on cardiovascular disease.

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

• Betaine anhydrous: Limited evidence from human trials suggests betaine supplementation increases total cholesterol, LDL cholesterol, and triglycerides, which may offset any benefit in coronary heart disease (CHD) risk received through homocysteine lowering. However, the increase in cholesterol is relatively small. More study is warranted to confirm these results.

• Avoid if allergic or hypersensitive to betaine anhydrous or cocamidopropylbetaine, a form of betaine. Use cautiously in those with renal 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 there is 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 diabetics. However, other research of biotin alone found that biotin did not affect cholesterol, glucose, or insulin levels, but that it did decrease triglyceride levels. More research with biotin alone is needed.

• Individuals with hypersensitivity to constituents of biotin supplements should avoid these products. Use cautiously in patients taking anticonvulsants, antibiotics, agents that are processed by the liver, or isotretinoin (Roaccutane®). Use cautiously in pregnant or breastfeeding women.

• Black seed: In human studies, Nigella sativa oil was shown to slightly decrease plasma triglycerides and to slightly increase HDL cholesterol in patients with various allergies. In an open study, the oil reduced total and LDL cholesterol. Further research is required before conclusions can be drawn.

• Avoid in those with known allergy or sensitivity to black seed, its constituents, black seed oil, or to members of the Ranunculaceae family. Avoid in patients who are pregnant, breastfeeding, or trying to conceive. Use cautiously in patients with immune disorders, in patients with bleeding disorders or those taking agents that may increase the risk of bleeding, in patients with diabetes or low blood sugar and those taking agents that affect blood sugar, in patients with low blood pressure and those taking agents that affect blood pressure, in patients at risk for gastrointestinal side effects, in those taking drugs for epilepsy or those taking cholesterol-lowering drugs, or if driving or operating heavy machinery.

• Black tea: There is conflicting evidence from a small number of studies examining the relationship of tea intake with the risk of heart attack. Tea may reduce the risk of platelet aggregation or endothelial dysfunction, proposed to be beneficial against 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 increase heart rate.

• Avoid if allergic or hypersensitive to caffeine or tannins. Skin rash and hives have been reported with caffeine ingestion. Use caution with diabetes. Use caution if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants can lead to sleep disturbances 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.

• Blueberry: The effect of blueberries on cardiovascular disease risk factors is not clear, due to a lack of well-designed research. Further research is required.

• Avoid in patients with known allergy or hypersensitivity to blueberries, its constituents, or members of the Ericaceae family.

• Borage seed oil: Gamma-linolenic acid, a component in high concentrations in borage seed oil, may decrease plasma triglyceride levels and increase HDL cholesterol concentration. However, more research is needed to better define borage's effects on hyperlipidemia.

• Avoid in those 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 or antiplatelet (blood-thinning) agents. Use cautiously in patients with epilepsy or those taking anticonvulsants. Avoid in patients with compromised immune systems or similar immunological conditions. Avoid if pregnant or breastfeeding.

• Brewer's yeast: A variety of effective and safe doses of brewer's yeast have been used in clinical trials to lower serum lipids and increase HDL in diabetic or hyperlipidemic patients. Five to 20 grams of brewer's yeast containing 23-48 micrograms of chromium has been used for 8-12 weeks, resulting in a significant decrease in the mean levels of triglycerides and increases in the mean levels of HDL cholesterol, as well as serum and urinary chromium.

• Avoid when used in individuals with an allergy to brewer's yeast or possibly other yeasts. When used in patients with Crohn's disease, as brewer's yeast has been shown to exacerbate the disease. When used in patients taking monoamine oxidase inhibitors (MAOIs), due to the potential for hypertensive crisis, as brewer's yeast contains high levels of tyramine.

• Buckwheat: There is conflicting evidence regarding the effects of buckwheat on blood lipids. More evidence is required before conclusions can be made.

• Avoid in those with known allergy or hypersensitivity to buckwheat, its constituents, or members of the Polygonaceae family. Avoid nonfood parts of the buckwheat plant in pregnant women. Use cautiously in patients with celiac disease, diabetes, or hypoglycemia. Use cautiously in those using agents that lower blood glucose, cholesterol, or blood pressure, or that increase sensitivity to light.

• Cabbage: Consumption of Brassica vegetables, particularly cabbage, has been shown to have antihyperlipidemic effects in hypercholesterolemic persons. Further research is needed before a conclusion can be made.

• Avoid in pregnant or breastfeeding women in amounts above those normally found in food. Avoid in individuals with a known allergy or sensitivity to Brassica or to any of its constituents, or to cabbage, mustard, peach, or mugwort pollen. Use cautiously in patients with bacterial infection of the intestines, chronic headache, diamine oxidase deficiency, intolerance of histamine-rich foods, irritable bowel syndrome, lactose intolerance, or pre-existing thyroid conditions. Use with caution in patients with diabetes or hypoglycemia or those taking agents that affect blood sugar, and in patients with bleeding disorders or those taking agents that may increase the risk of bleeding.

• Calcium: A review of the effects of calcium on myocardial infarction (heart attack) and cardiovascular events suggested a statistically nonsignificant increased risk for stroke, and a statistically significant increased risk for myocardial infarction with calcium use. Other researchers, however, have pointed out multiple flaws with this review and that more evidence is needed. A prospective analysis of the effects of calcium supplementation in postmenopausal women in Finland appeared to increase the risk of coronary heart disease (CHD). A pooled analysis of cohort studies suggested a lack of increased risk of stroke with consumption of milk products.

• Avoid in those allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid in those with hypercalcemia (high levels of calcium in the blood), hypercalciuria (high levels of calcium in urine), hyperparathyroidism (high levels of parathyroid hormone), bone tumors, digitalis toxicity, ventricular fibrillation (ventricles of the heart contracting in an unsynchronized rhythm), kidney stones, kidney disease, or sarcoidosis (inflammation of lymph nodes and various other tissues). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously in those with achlorhydria (absence of hydrochloric acid in gastric juices) or arrhythmia (irregular heartbeat). Calcium appears to be safe in pregnant or breastfeeding women; a healthcare provider can determine the appropriate dosing during pregnancy and breastfeeding.

• Carrageenan: The hypolipidemic effect of carrageenan has been investigated in clinical research. Total cholesterol and triglyceride levels were both significantly reduced following the consumption of an experimental diet containing carrageenan-enriched foods. Further clinical trials are required 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.

• Cashew: There is conflicting evidence regarding the effects of a high-cashew diet on patients with metabolic syndrome. Additional larger, better-controlled trials are needed before any conclusions can be made.

• Avoid in pregnant or breastfeeding women or those with known allergy or sensitivity to cashew (Anacardium occidentale), its pollen or constituents, other members of the Anacardiaceae family, or related species. Use cautiously in patients with allergy to marking-nut tree (Semecarpus anacardium), mango, sweet pepper, pistachio, pectin, almond, Brazil nut, hazelnut, or walnut.

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

• Chocolate: Some research suggests that a diet high in flavonoids may help protect against heart disease. However, more high-quality studies are needed before a conclusion can be drawn. Several studies suggest that eating cocoa butter or chocolate may lower cholesterol. More research is needed before a conclusion can be drawn.

• Avoid in those with known allergy or sensitivity to chocolate, cocoa, any of its components (including caffeine), or members of the Sterculiaceae family. Chocolate contains relatively high levels of caffeine.

• 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 more proven drug therapies for patients in this setting, a recommendation cannot be made for use of this agent for coronary artery disease.

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

• Chromium: Studies show conflicting 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 those with diabetes, liver problems, weakened immune systems (such as HIV/AIDS patients or organ transplant recipients), depression, Parkinson's disease, heart disease, or 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 (chest pain) has been reviewed. Preliminary research suggests that cinnamon may be useful in the treatment of features of metabolic syndrome in prediabetic subjects. 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 in those prone to atopic reactions or those 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): There is not enough scientific evidence to recommend for or against the use of CoQ10 in patients with hypertriglyceridemia.

• Allergy associated with Coenzyme Q10 supplements has not been reported, although rash and itching have been reported rarely. Stop use two weeks before surgery or dental or diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Use caution in those with a history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or those using anticoagulants (blood thinners) or antiplatelet drugs (like aspirin), warfarin, clopidogrel (like Plavix®), blood pressure, blood sugar, cholesterol, or thyroid drugs. Avoid if pregnant or breastfeeding.

• Conjugated linoleic acid: Some, but not all, human studies showed a decrease in blood pressure with CLA treatment. Additional research is needed to investigate the possible cardiovascular effects of CLA. To date, there is a lack of human evidence to suggest that supplementation with CLA has a positive outcome with regard to hypercholesterolemia.

• Insufficient evidence is available on allergy or sensitivity to conjugated linoleic acid (CLA). Use cautiously in children and pregnant or breastfeeding women, as safety has not been systematically studied in these populations.

• 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 or hypersensitive to copper. Avoid use of copper supplements during the early phase of recovery from diarrhea. Avoid in those with hypercupremia, 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 secondary diabetes mellitus). Avoid in those with genetic disorders affecting copper metabolism such as Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis. Avoid in those 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 in those taking oral contraceptives. Use cautiously in those at risk for selenium deficiency. The U.S. recommended dietary allowance (RDA) is 1,000 micrograms for pregnant women and 1,300 micrograms for nursing women.

• Corydalis: Corydalis may be of benefit in chest pain caused by clogged arteries called angina. More studies are needed to determine if corydalis is effective for this use.

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

• Creatine: Early studies have evaluated the effect of creatine on hyperlipidemia. More clinical trials are needed before a conclusion can be made.

• Avoid in those allergic to creatine or those taking diuretics (like hydrochlorothiazide or furosemide (Lasix®)). Use caution in those 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, angina (cardiac chest pain), 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 in those allergic or hypersensitive to danshen. Use cautiously in those with altered immune states, arrhythmia, compromised liver function, or a history of glaucoma, stroke, or ulcers. Stop use two weeks before surgery or dental or diagnostic procedures with a bleeding risk, and do not use immediately after these procedures. Use cautiously if driving or operating heavy machinery. Avoid if taking anticoagulants (blood thinners), digoxin or hypotensives, including ACE inhibitors such as captopril, or Sophora subprostrata root or herba Serissae. Avoid in those with bleeding disorders or low blood pressure and following cerebral ischemia. Avoid if pregnant or breastfeeding.

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

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

• Dill: Some evidence has suggested possible cholesterol-lowering properties of dill, although this has not been well studied in humans. Preliminary human research has shown a lack of significant effect of dill on cholesterol levels and an increase in triglycerides with dill treatment. More research is needed before a definitive conclusion can be made.

• Avoid in those with known allergy or hypersensitivity to dill (Anethum graveolens), its components, or members of the Apiaceae (Umbelliferae) family. An inflammatory skin reaction, following contact with light-sensitizing compounds in dill and long-wave ultraviolet light, has been documented. Hives from contact with dill has been reported. Avoid in pregnant or breastfeeding women in amounts above those normally found in food, due to a lack of sufficient scientific evidence.

• Docosahexaenoic acid: Despite the triglyceride-lowering and HDL-increasing effects of DHA, some studies suggest that DHA may increase total cholesterol and LDL cholesterol levels. The use of DHA should be monitored by health professionals in certain at-risk individuals. Further research is required before firm conclusions may be drawn in this field.

• Avoid in patients with known allergy or hypersensitivity to fish, fish oils, or any marine products. Use with caution in patients taking anticoagulants or antiplatelets.

• Dong quai: There is insufficient evidence to support the use of dong quai for the treatment of coronary artery disease. 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 medicinal doses is not known. Long-term studies of its side effects are lacking. Avoid in those allergic or hypersensitive to dong quai or members of the Apiaceae or Umbelliferae family (like anise, caraway, carrot, celery, dill, and parsley). Avoid with prolonged exposure to sunlight or ultraviolet light. Use caution in those with bleeding disorders or those taking drugs that may increase the risk of bleeding. Use cautiously in those with diabetes, glucose intolerance, or hormone-sensitive conditions (like 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 research reports that elderberry juice may decrease serum cholesterol concentrations and increase low-density lipoprotein (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 more 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 caution in those with diabetes, high blood pressure, or urinary problems, or those taking drugs used for any of these conditions. Use caution with anti-inflammatories, diuretics, and laxatives. Avoid if pregnant or breastfeeding.

• Fenugreek: There is insufficient 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 or dental or diagnostic procedures with a bleeding risk, and do not use immediately after these procedures. Use cautiously in those with asthma, diabetes, or a history of ulcers or stroke. Avoid if pregnant. Children should not take doses larger than those commonly found in foods.

• Flaxseed and flaxseed oil: 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 its purported antioxidant and lipid-lowering properties. There is a scarcity 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 coronary artery disease (CAD). Despite this evidence, it remains unclear if flaxseed supplementation improves human cardiovascular endpoints, and dosing regimens are not established.

• Multiple 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, and thus strong evidence-based recommendations cannot be made at this time.

• Flaxseed has been well tolerated in studies for up to four months. Avoid in those 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 in those with a history of esophageal stricture, ileus, gastrointestinal stricture, or bowel obstruction. Avoid in those with a history of acute or chronic diarrhea, irritable bowel syndrome, diverticulitis, or inflammatory bowel disease. Use cautiously in those with a history of a bleeding disorder or those using drugs that increase bleeding risk (like anticoagulants and nonsteroidal anti-inflammatories (like aspirin, warfarin, and Advil®)), high triglyceride levels, diabetes, mania, seizures or asthma. Avoid if pregnant or breastfeeding. Avoid in those with prostate cancer, breast cancer, uterine cancer, or endometriosis. Avoid ingestion of immature flaxseed pods.

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

• Avoid in those allergic or hypersensitive to folate or any folate product ingredients. Use cautiously in those receiving coronary stents and in those with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms of folate daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

• Gamma-aminobutyric acid: There is limited evidence that gamma-aminobutyric acid is effective for treating atherosclerosis. Available evidence supporting this use is found in a Russian study conducted in 1980.

• Use cautiously in people with cancer; in people driving or operating heavy machinery; or in people taking or consuming 5-HTP, coffee, fermented foods, GABA-enriched plant products, hop, kava, L-arginine, lemon balm, magnesium, passionflower, phosphatidylserine, skullcap, tea, valerian, vitamin B6, or zinc. Avoid in people with bleeding disorders, cancer, fatigue, liver disorders, liver failure, menstrual disorders, mood disorders, problems with breathing, problems with hormones, seizures or other neurological disorders, or stomach disorders. Avoid in people who take or consume alcohol, barbiturates, benzodiazepines, beta-carbolines, chloride channel blockers (picrotoxin), dopaminergic agents, epilepsy medications, GABA transporter (GAT) inhibitors, gabapentin, neuroactive steroids, pregabalin, valproate, or vigabatrin. Avoid using GABA in high doses. Avoid if pregnant or breastfeeding.

• Gamma-oryzanol: Gamma-oryzanol has been used to reduce restenosis (the return of blood vessel blockages after treatment) after coronary dilation, in combination with ticlopidine and probucol. Although restenosis was not affected by any of the treatments, research with gamma-oryzanol alone is needed to establish its effect on restenosis.

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

• Garlic: Preliminary 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 in those allergic or hypersensitive to garlic or other members of the Liliaceae (lily) family (like hyacinth, tulip, onion, leek, and chive). Avoid in those with history of bleeding problems, asthma, diabetes, low blood pressure, or thyroid disorders. Stop using supplemental garlic two weeks before dental, surgical, or diagnostic procedures, and avoid using immediately after such procedures to avoid bleeding problems. Use cautiously in those with history of peptic ulcer disease. Avoid in supplemental doses if pregnant or breastfeeding.

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

• Avoid if allergic to ginger or other members of the Zingiberaceaefamily (like red ginger, Alpinia purpurata, shell ginger, Alpinia zeru, green cardamom, and balsam of Peru). Avoid with anticoagulation therapy (therapy aimed at preventing the blood from clotting). Avoid large quantities of fresh cut ginger in those with diseases of the intestines (such as inflammatory bowel disease) or a history of intestinal obstruction. Use cautiously prior to surgery and in those with ulcers of the stomach or intestines, gallstones, heart disease, and diabetes. Use cautiously long-term and in underweight patients. Use cautiously in those taking heart medications or sedatives and in those driving or operating heavy machinery. Use cautiously with drugs that affect the serotonin system, drugs that affect the function of the immune system, estrogen, central nervous system 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 in those allergic or hypersensitive to members of the Ginkgoaceaefamily. In those allergic to mango rind, sumac, poison ivy or oak or cashews, allergy to ginkgo is possible. Skin irritation and itching may also occur due to ginkgo allergies. Avoid with blood thinners (like 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. 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 coronary artery disease. 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 but used a dose of 500 milligrams. Benefit was found in another study in an unknown population using a dose of two grams of 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, including drug interactions, are possible. Ginseng supplements should not be used if pregnant or breastfeeding unless otherwise directed by a doctor.

• Goldenseal: In limited available clinical research, berberine 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 hypercholesterolemia.

• Use cautiously in patients with cardiovascular disease, bleeding disorders, diabetes, gastrointestinal disorders, increased bilirubin levels, or glucose-6-phosphate deficiency. Use cautiously during pregnancy.

• Grape seed: Historical statistics suggest that wine may reduce the risk of heart disease and may be of benefit for hypercholesterolemia. 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 in those allergic or hypersensitive to grapes or other grape compounds. Use cautiously in those taking blood thinners such as warfarin, aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), or antiplatelet agents. Use cautiously in those with bleeding disorders or in those taking drugs that may increase the risk of bleeding. Use cautiously with drugs processed using the liver's cytochrome P450 enzyme system. Use cautiously in those with blood pressure disorders or in those taking ACE inhibitors. Avoid in those 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 research is needed in this area.

• Avoid if allergic or hypersensitive to grapefruit or its constituents. Use cautiously if taking cytochrome P450 3A4 substrates, 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 or tonic water, or if smoking. Use cautiously in those with liver cirrhosis or diabetes, in those at risk for kidney stones, and in those who have undergone gastric bypass surgery. Use cautiously if pregnant or breastfeeding.

• Green coffee: Coffee consumption is associated with increased cardiovascular disease risk factors, such as increased blood pressure and plasma homocysteine. Significant increases in plasma homocysteine were observed in subjects consuming high doses of chlorogenic acid for a short duration (two grams daily for one week); however, improved vasoreactivity and blood pressure occurred in patients administered lower doses (up to 140 milligrams daily for 1-4 months). Further studies are warranted to determine the optimal dosing of green coffee extract and/or chlorogenic acid for cardiovascular disease risk.

• Avoid use in pregnant or lactating women, due to a lack of safety data. Avoid in individuals with castor bean allergies or known allergies to green coffee, due to multiple reports of occupational allergies in green coffee workers.

• 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 (clogged arteries). Laboratory studies, animal studies, and limited human research suggest possible benefits of green tea for hypercholesterolemia and hypertriglyceridemia. Better human evidence is necessary in this area.

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

• Gymnema: Reductions in levels of serum triglycerides, total cholesterol, very-low-density lipoprotein (VLDL), and low-density lipoprotein (LDL) have been observed in animals following the administration of gymnema. The mechanism may by via a decrease in the synthesis or increase in the metabolism of cholesterol, or through decreased intestinal fat absorption. One study of gymnema in type 2 diabetes patients reported decreased cholesterol and triglyceride levels as a secondary outcome. Further research 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 has not been tested in the setting of concomitant drugs such as beta-blockers or ACE inhibitors, which are often considered to be standard-of-care. At this time, there is not enough evidence to recommend for or against hawthorn for coronary artery disease or angina (chest pain).

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

• Honey: In general, the evidence supporting the use of honey to treat hypercholesterolemia is weak. Additional research 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 (like C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.

• Hops: Limited evidence suggests that hop extract may decrease oxidative stress and markers of cardiovascular risk and inflammation. Further research is needed in this area before a conclusion can be made.

• Some evidence suggests that hops in combination with other agents may be effective for metabolic syndrome. Further research is needed to determine the effects of hops alone.

• Use cautiously in combination with central nervous system (CNS) depressants, sedatives, or antipsychotics, or if driving or operating heavy machinery. Use cautiously in those with hormone-sensitive conditions (e.g., breast cancer, uterine cancer, cervical cancer, prostate cancer, or endometriosis) or in those taking hormonal agents (e.g., contraceptives or fertility agents). Use cautiously in those with diabetes or low blood sugar, or in those taking agents that affect blood sugar. Use cautiously in patients with autoimmune disorders or in those taking agents that affect the immune system. Use cautiously in those taking agents broken down by the liver. Use cautiously if pregnant or breastfeeding. Avoid in those allergic to hops, its constituents, pollen, members of the Cannabaceae family, peanuts, chestnuts, or bananas.

• Horny goat weed: Horny goat weed is traditionally used to treat cardiovascular diseases, like atherosclerosis. Early research suggests that horny goat weed may improve symptoms associated with ischemic cardio-cerebral vascular diseases. However, additional research is needed before a conclusion can be made.

• Avoid if allergic or hypersensitive to horny goat weed (Epimedium grandiflorum), its constituents, or related plants in the Berberidaceae family. Use cautiously in those with tachyarrhythmia, decreased blood pressure, frequent nosebleeds, musculoskeletal disorders, bipolar disorder, immune function disorders, homocysteine disorders, hypothyroid conditions, and cardiovascular disease. Use cautiously in those taking anticoagulant or antiplatelet (blood thinning) medications, antihypertensive (blood pressure) medications, antidepressants (MAOIs), interleukins, or cholesterol-lowering medications. Avoid in those with hormone-sensitive conditions or in those taking estrogen or oral contraception. Avoid if pregnant or breastfeeding.

• Hydroxymethylbutyrate (HMB): In preliminary research, HMB supplementation was found to reduce cardiovascular disease risk factors. HMB lowered total and low-density lipoprotein (LDL) cholesterol and reduced systolic blood pressure. Well-designed clinical trials are needed to confirm these findings.

• Avoid in individuals with known allergy or hypersensitivity to HMB.

• Inositol nicotinate: Limited research suggests that inositol nicotinate may have beneficial effects in patients with high cholesterol. Additional research is needed before a conclusion can be made.

• Avoid in patients with liver disease or stomach ulcers, in patients using carbamazepine, in pregnant or breastfeeding women, or in patients with known allergy or sensitivity to inositol nicotinate, niacin, or any of their constituents. Caution is advised in patients with diabetes or blood sugar disorders, blood pressure disorders, bleeding disorders, or cardiovascular conditions, and in those taking drugs that may affect blood sugar or blood pressure, increase the risk of bleeding, or lower lipids or cholesterol.

• Isoflavones: Preliminary evidence suggests that isoflavones, as a component part of soy protein isolate, reduce low-density lipoprotein (LDL) cholesterol. In contrast, purified soy isoflavones are suggested as having little effect on LDL cholesterol levels. Additional research in this area is needed to clarify the existing controversy in prior results.

• Avoid in those with known allergy or hypersensitivity to soy, soy-based products, or isoflavone products. Avoid higher-than-normal dietary amounts in children and pregnant or breastfeeding women. Avoid in patients with breast and other estrogen-associated cancers. Use cautiously in those taking hormonal agents (such as estrogens, or estrogen-like agents) or cholesterol-lowering agents. Use cautiously in patients with bleeding disorders, diabetes or hypoglycemia, low or high blood pressure, or thyroid disorders, and in those taking agents to treat any of these conditions.

• Kefir: Preliminary evidence suggests that kefir may be beneficial to patients with high cholesterol levels. Further studies are needed before conclusions can be drawn.

• Use cautiously in people who are lactose intolerant, alcoholics, or pregnant or breastfeeding women. Use cautiously in high doses in children. Avoid in those with known allergy or sensitivity to dairy products.

• Krill: Krill oil was shown to lower total cholesterol, LDL cholesterol, and total cholesterol:HDL ratio levels compared to fish oil in randomized, placebo controlled trials. However, until more trials with large sample sizes are conducted, no firm conclusions can be made.

• Use caution in patients with known allergy or hypersensitivity to seafood, including those with allergies to shellfish.

• 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 history of use in the treatment of cardiovascular disease, including acute myocardial infarction, 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: Limited evidence suggests that breathing techniques used in Kundalini yoga may help people with angina pectoris (chest pain) reduce symptoms and the need for medication. Formal clinical trials are needed to explore this application of Kundalini yoga before a conclusion can be made regarding efficacy.

• A specific breathing technique of Kundalini yoga reputed to help prevent heart attacks was examined in one study to determine its effects on heart function. The technique is a respiratory exercising using one breath per minute, with slow inspiration for 20 seconds, breath retention for 20 seconds, and slow expiration for 20 seconds, for 31 consecutive minutes. The technique was found to stabilize the heart's electrical wave patterns, which may have preventive value in heart health. More studies are needed to determine whether this exercise has tangible effects on heart-related problems.

• The postures used in Kundalini yoga are generally considered to be safe in healthy individuals when practiced appropriately, and have been well tolerated in studies with few side effects. However, some yoga positions and postures should not be used by people with certain conditions or illnesses. People 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 should avoid some poses. Any yoga should be supervised by a well-qualified teacher.

• L-carnitine: Although preliminary research is promising, there is insufficient available evidence to recommend for or against the use of carnitine for hyperlipoproteinemia (high levels of lipoprotein and cholesterol in blood). Additional research is needed in this area.

• Avoid in those with known allergy or hypersensitivity to carnitine. Use cautiously in those 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 in those taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

• Lecithin: Limited research suggests that soy lecithin may have a beneficial effect on blood vessel health. Further research is needed before a conclusion can be made.

• Lecithin is generally well tolerated. Avoid in those with known allergy or hypersensitivity to lecithin, egg, or soy.

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

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

• Lignans: There is limited scientific evidence that lignans may be taken to prevent or treat cardiovascular disease or hypercholesterolemia

• Lignans may be unsafe when used in patients with known allergy or hypersensitivity to lignans, flaxseed, sesame seeds, or any plants that produce them. Use cautiously in patients with insulin disorders, or in those using anticoagulants, central nervous system (CNS) depressants, diuretics, immunomodulators, or antibiotics.

• Lutein: Currently, there is insufficient available evidence to recommend for or against the use of lutein for atherosclerosis. Additional research is needed in this area.

• Avoid if allergic or hypersensitive to lutein or zeaxanthin. Use cautiously in those 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 its 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 those 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 myocardial infarction, cardiac arrest, and coronary artery disease. Study results are mixed, and additional research is needed.

• Use cautiously in patients with bleeding disorders, or in those taking anticoagulant or antiplatelet agents, antidiabetic agents, or antihypertensive agents. Use intravenous magnesium sulfate with extreme caution in patients with eclampsia. Avoid in patients with atrioventricular heart block, renal failure, or severe renal disease. Avoid intravenous magnesium in women with toxemia 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 cardiovascular heart disease.

• Use cautiously in those 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 those with a risk of seizures. The practice of meditation should not delay the time to diagnosis or treatment with more proven techniques or therapies, and it should not be used as the sole approach to illnesses.

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

• Melatonin is generally considered safe in recommended doses for short-term use. Use cautiously in those with seizures, underlying major depression or psychotic disorders, high cholesterol, diabetes, blood sugar disorders, glaucoma, blood pressure disorders, or bleeding disorders, and in patients using medications for any of these conditions. Use cautiously in patients using anesthetics, cytochrome P450 inhibitors, methamphetamine, or nifedipine (a calcium channel blocker), and in children with a history of enuresis. Avoid in patients using central nervous system (CNS) depressants, including benzodiazepines and alcohol. Avoid in women who are pregnant or are attempting to become pregnant. Avoid with known allergies to melatonin or related products.

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

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

• Monterey pine: Heart tissue can be damaged by oxidants. Antioxidant-rich plants such as Monterey pine may help protect the heart against the damaging effects of oxidants. Early human research showed that a dietary supplement containing Monterey pine extract and vitamin C was safe and well tolerated, and that it may have heart-health benefits. However, other research produced conflicting results. Further research is required before a conclusion can be made.

• Avoid during pregnancy or breastfeeding. Avoid in those with known allergy or hypersensitivity to Monterey pine, its components (such as pollen), airborne allergens, or members of the Pinaceae family. Use cautiously in patients taking blood pressure-lowering agents or those with blood pressure disorders, and in patients with high blood levels of fats or cholesterol.

• 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.

• Mustard: In human research, mustard oil consumption in the diet of patients with a heart attack resulted in a decrease in further heart problems. In further dietary research, consumption of mustard oil, as well as other foods (vegetables, legumes, walnuts, almonds, whole grains, and soybean oil), resulted in a reduced risk of heart attack and deaths due to heart problems. Additional research is needed in this area.

• In human research, inclusion of mustard oil in the diet resulted in little benefit in terms of cholesterol levels. Additional research is needed in this area.

• People with a known allergy or hypersensitivity to mustard and other members of the Brassicaceae family (e.g., cabbage, cauliflower, turnip, Chinese cabbage, rapeseed, radish, or horseradish), nuts, legumes, corn, Rosaceae fruit, mugwort pollen, turnip rape, Brazil nut, peach, melon, or cashews should avoid mustard and mustard oil. Also, children with sensitivities to cow's milk, egg, wheat, and pollens (birch, timothy, or mugwort), should avoid mustard, as they are more likely to react to mustard and rapeseed. Both local (e.g., skin) and whole-body reactions, such as anaphylaxis, are possible. Respiratory (e.g., nose, sinus, and lung) reactions are also possible.

• N-acetyl cysteine (NAC): Results of studies on the effect of NAC on angina (chest pain) are mixed. Further well-designed clinical trials are needed before a conclusion may be made. NAC has been investigated for its potential to protect against heart damage following coronary artery bypass grafting (CABG).

• The clinical effects of NAC are unclear. Further research is required before firm conclusions may be made. High blood levels of homocysteine may increase the risk of heart disease. Preliminary human research showed that NAC decreased homocysteine levels in patients with high blood levels of homocysteine, in patients with kidney disease, and in healthy people. It is unclear if NAC decreases the risk of heart disease. Well-designed studies are required before conclusions may be made in this area. Results of different studies investigating the effect of NAC on reducing levels of certain blood lipids conflict. Further evidence is required before a conclusion may be made.

• Avoid with known allergy or hypersensitivity to N-acetyl cysteine (NAC) and related substances. Avoid in doses greater than 30 grams daily. Avoid in pregnant or breastfeeding women.

• Nopal: Nopal may aid in reducing hyperlipidemia, although there is currently insufficient evidence to make a strong recommendation for this condition.

• Avoid in those allergic or hypersensitive to nopal (Opuntia spp.), any of its constituents, or members of the Cactaceae family. Use cautiously in those taking medications that alter blood sugar, cholesterol, or blood pressure. Use cautiously in those with thyroid dysfunction, rhinitis (runny or congested nose), or asthma. Avoid in those with immunosuppression or 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, fish oil, alpha-linolenic acid: Preliminary studies have reported reductions in angina (chest pain) associated with fish oil intake. Some research has reported that regular intake of fish or fish oil supplements reduces the risk of developing atherosclerotic plaques in the arteries of the heart, while other research has reported no effects. Evidence suggests that people who have low levels of EPA and DHA may have an increased risk of developing acute coronary syndrome (ACS) (a type of heart disease). Clinical trials suggest that supplementation with omega-3 fatty acids has positive benefits in terms of reduced cardiovascular disease mortality and total mortality.

• Although there is strong scientific evidence from human trials that omega-3 fatty acids from fish or fish oil supplements (EPA plus DHA) significantly reduce blood triglyceride levels, fish oil may increase (worsen) low-density lipoprotein (LDL, or "bad") cholesterol levels.

• Avoid if allergic or hypersensitive to fish, nuts, linolenic acid, or omega-3 fatty acid products that come from fish or nuts. Avoid during active bleeding. Use cautiously in those with bleeding disorders, diabetes, low blood pressure, or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. The U.S. Environmental Protection Agency (EPA) recommends that intake be limited in pregnant and nursing women to a single six-ounce meal per week, and in young children to less than two ounces per week. For farm-raised, imported, or marine fish, the U.S. Food and Drug Administration recommends that pregnant and nursing women and young children avoid eating types with higher levels of methylmercury and less than 12 ounces per week of other fish types. Women who might become pregnant are advised to eat seven ounces or less per week of fish with higher levels of methylmercury or up to 14 ounces per week of fish types with about 0.5 parts per million (such as marlin, orange roughy, red snapper, or fresh tuna).

• Onion: Research in humans found that onion may have an effect on blood serum triglyceride, beta-lipoprotein cholesterol, and phospholipid levels. More research is needed in this area to confirm these results. Early evidence suggests that consumption of onions and other vegetables belonging to the Allium genus may reduce the risk of heart attack. More well-designed studies are needed before a conclusion can be made.

• Avoid in individuals with a known allergy or hypersensitivity to onion (Allium cepa) or its constituents. In some individuals, handling onion bulbs has caused skin rash, painful tingling in the fingers, or a reddening of the skin. Use cautiously in patients with gastrointestinal disorders, high cholesterol, or cancer, or in patients taking p-glycoprotein substrates, cyclosporine, or agents processed by the liver's cytochrome P450 enzyme system.

• Oregano: In early research, an aqueous distillate of Origanum onites resulted in improvements in heart disease risk factors, such as reduction of cholesterol and C-reactive protein levels. More research is needed.

• Use caution in those with diabetes, bleeding disorders, or low blood pressure.Use caution in patients using mineral (zinc, iron, copper) supplements, central nervous system depressants, or agents that affect the immune system. Pregnant or breastfeeding women should not consume oregano at doses above those normally found in food. Avoid if allergic or hypersensitive to oregano or other herbs from the Lamiaceae family, including hyssop, basil, marjoram,mint, sage, and lavender.

• Ozone therapy: Autohemotherapy (AHT) is a technique that withdraws blood from the body, mixes it with ozone gas, and then injects it back into the body through a vein or muscle. There is limited preliminary study of AHT in a small number of patients with history of a heart attack. A decrease in total cholesterol and low-density lipoproteins ("bad") cholesterol was reported. However, this research was not well designed. Better research is necessary 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.

• Palm oil: Preliminary evidence suggests that palm oil may help prevent atherosclerosis. Further studies are needed in this field. Research results regarding the effects of palm oil on cholesterol levels are mixed. Further studies are needed in this field.

• Avoid oxidized palm oil. Avoid use of large doses of palm oil in pregnant women. Avoid with known allergy or sensitivity to Elaeis guineensis, its constituents, or members of the Arecaceae family. Mild allergic symptoms have been reported. Avoid in patients allergic to coconut, due to similarities in allergens. Use cautiously in patients with diabetes or low blood sugar and in those using agents that affect blood sugar. Use cautiously in patients taking drugs, herbs, or supplements that affect blood pressure. Use cautiously in patients with bleeding disorders or those taking agents that may increase the risk of bleeding or blood clotting. Use cautiously in patients with abnormal cholesterol levels, gastrointestinal sensitivities, liver problems, or heart disease.

• 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 preliminary evidence in humans.

• Avoid in those allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid in those 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, Dandi Tablet is used for purportedly tonifying Shen and activating blood circulation. Additional high-quality research is required to evaluate the use of this formulation for lipid-lowering effects and for coronary heart disease prevention or treatment.

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

• Phosphatidylcholine: Preliminary research suggests that phosphatidylcholine may reduce clofibrate-induced increases in low-density lipoprotein (LDL, or "bad") cholesterol. Additional research is needed before a conclusion can be made.

• Avoid in those with known allergy or sensitivity to phosphatidylcholine. Avoid in pregnant and or breastfeeding women, due to a lack of safety data.

• 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 research is 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 the available literature, caution is advised nonetheless. All therapies during pregnancy and breastfeeding should be discussed with a licensed obstetrician or 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 in those allergic or hypersensitive to policosanol. Use cautiously in those taking aspirin or blood pressure medications. Use cautiously in those with high blood pressure. Use cautiously if pregnant or breastfeeding.

• Polydextrose: In early research, polydextrose has been shown to have effects on triglyceride and cholesterol concentrations. Additional research is needed.

• Avoid in people with a known allergy or sensitivity to polydextrose. Use cautiously in people with gastrointestinal problems, diarrhea, pancreatic problems, kidney disease, skin conditions, diabetes, or low blood sugar, or in those using agents that affect blood sugar or lipid levels.

• Pomegranate: Preliminary research 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 in those allergic or hypersensitive to pomegranate. Avoid in those with diarrhea or high or low blood pressure. Avoid taking pomegranate fruit husk with oil or fats to treat parasites. Pomegranate root or stem bark should only be used under the supervision of a qualified healthcare professional. Use cautiously in those with liver damage or disease. Pomegranate supplementation can be unsafe during pregnancy when taken by mouth. The bark, root, and fruit rind can cause menstruation or uterine contractions. Avoid if breastfeeding, due to a lack of scientific data.

• Potassium: It has been reported that the favorable impact of diets rich in fruit and vegetables on heart health may be due to the potassium supplied by these foods. Studies performed in humans have found that a high dietary potassium intake may cause a decrease in the risk of coronary heart disease and cardiovascular disease. Further research is warranted.

• Avoid in patients with kidney dysfunction, hyperkalemia, potassium retention, oliguria, azotemia, anuria, crush syndrome, severe hemolytic reactions, adrenocortical insufficiency (including untreated Addison's disease), adynamical episodica hereditaria, acute dehydration, heat cramps, or early postoperative oliguria (except during gastrointestinal drainage). Avoid in patients on dialysis (instead, adjust dialysate potassium levels). Avoid in patients taking potassium-sparing diuretics (such as triamterene, amiloride, or spironolactone), drugs with anticholinergic properties, sodium polystyrene sulfonate (Kayexalate®), antimuscarinics, or opioid analgesics. Avoid with known allergy or hypersensitivity to potassium.

• Prayer: Prayer may have far-reaching healing effects that are hard to study. Initial studies in patients with heart disease reported variable effects on the severity of illness, complications during hospitalization, procedure outcome, and death rates when intercessory prayer is used.

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

• Probiotics: There is limited evidence suggesting probiotics may help reduce low-density lipoprotein (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.

• 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.

• Progesterone: Limited studies suggest that progesterone combined with estrogen may lower cholesterol in menopausal women. However, the benefits of progesterone alone are not yet determined. More evidence is needed before a conclusion can be made.

• Use cautiously in people with heart conditions (such as low blood pressure) or depression, or in those taking agents that may affect levels of serotonin, agents that may affect levels of dopamine, blood pressure-lowering agents, estrogen therapy, gonadotropin-releasing hormone, opioids, paclitaxel, or drugs that cause drowsiness (such as sedatives). Avoid in those allergic or sensitive to progesterone.

• 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 behavior for the purpose of problem solving or achieving higher levels of functioning. Alexithymia, or the inability to express one's feelings, may influence the course of coronary heart disease (CHD). Educational sessions and group psychotherapy may decrease the incidence of alexithymia and coronary heart disease.

• 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 worsening of symptoms or 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 can be disturbing for people with serious mental illness or some medical conditions. Psychotherapy may help with postpartum depression but is not a substitute for medication, which may be needed in severe cases.

• Pycnogenol®: Pycnogenol® may reduce low-density lipoprotein (LDL, or "bad") cholesterol levels and increase high-density lipoprotein (HDL, or "good") cholesterol levels. Due to conflicting data, further studies are necessary before a clear conclusion can be drawn on the use of Pycnogenol® for high cholesterol.

• Avoid if allergic or hypersensitive to Pycnogenol®, its components, or members of the Pinaceae family. Use cautiously in those with diabetes, hypoglycemia, or bleeding disorders. Use cautiously in those taking hypolipidemics, medications that may increase the risk of bleeding, hypertensive medications, or immune-stimulating or -inhibiting drugs. Avoid if pregnant or breastfeeding.

• Pyruvate: Results are mixed with respect to the effect of pyruvate on blood lipid levels. In a study of individuals consuming a high-fat diet, pyruvate reduced levels of total cholesterol and LDL cholesterol. This did not occur in subjects consuming a low-cholesterol, low-fat diet. Further well-designed research is required in this field before conclusions may be drawn.

• Avoid with known allergy or hypersensitivity to pyruvate or its constituents.

• Qi gong: There is some evidence suggesting that Qi gong may be used in the treatment of angina (chest pain) 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 in those 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 it 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 coronary heart disease. Antioxidant and cholesterol-lowering effects have been 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 infections 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 conflicting research 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 with hormone replacement therapy (HRT) or birth control pills, and in those with a history of a bleeding disorder, breast cancer, or endometrial caner. Avoid if pregnant or breastfeeding.

• Red yeast rice: Preliminary evidence reports that taking red yeast riceby mouth may improve blood flow and may be effective for the treatment of coronary heart disease.

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

• Reishi: Reishi (Ganoderma lucidum) is a fungus (mushroom) that grows wild on decaying logs and tree stumps. Reishi has been used in traditional Chinese medicine 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 coronary heart disease 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 efficacy and safety of reishi in coronary heart disease.

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

• Relaxation therapy: Early research in patients with angina (chest pain) has reported that relaxation may reduce anxiety, depression, the frequency of angina episodes, the need for medication, and physical limitations. Early research on relaxation techniques in people who have had a heart attack suggests that fewer future heart attacks may occur when relaxation is regularly practiced. Relaxation techniques have been associated with reduced pulse rate, systolic blood pressure, and diastolic blood pressure; lower perception of stress; and enhanced perception of health. Further research is needed to confirm these results.

• Most relaxation techniques are noninvasive and are generally considered safe in healthy adults. Serious adverse effects have not been reported. It is theorized that anxiety may actually increase in some individuals using relaxation techniques and that autogenic discharges (sudden, unexpected emotional experiences, including pain, heart palpitations, muscle twitching, crying spells, or increased blood pressure) may occur rarely. Scientific evidence is limited in these areas. People with psychiatric disorders such as schizophrenia or psychosis should use relaxation techniques only when recommended by their primary psychiatric healthcare provider. It is sometimes suggested by practitioners that techniques requiring inward focusing may intensify depressed mood, although scientific evidence is limited in this area.

• Resveratrol: Resveratrol is used as an antioxidant in various health conditions, including cardiovascular disease. Laboratory animal studies suggest that resveratrol helps restore blood flow to the heart. Well-designed clinical trials in humans 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 breastfeeding unless otherwise directed by a doctor.

• Rhubarb: Rhubarb has been examined for its effects on hypercholesterolemia. In one study, a combination product containing rhubarb (Rheum palmatum) seemed to lower cholesterol. In another study, rhubarb (Rheum rhabarbarum) stalk fiber also seemed to lower cholesterol. However, large, high-quality studies using rhubarb as a monotherapy are needed.

• Avoid if allergic or 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 in those with atony, colitis, Crohn's disease, dehydration with electrolyte depletion, diarrhea, hemorrhoids, insufficient liver function, intestinal obstruction or ileus, irritable bowel syndrome, menstruation, pre-eclampsia, renal disorders, ulcerative colitis, and urinary problems. Avoid handling rhubarb leaves, as they may cause contact dermatitis. Avoid rhubarb in children under age 12, due to water depletion. Use cautiously in those with bleeding disorders, cardiac conditions, constipation, a history of kidney stones, or thin or brittle bones. Use cautiously in those taking coagulation therapy, antipsychotic drugs, or oral drugs, herbs, or supplements (including calcium, iron, and zinc). Avoid if pregnant or breastfeeding.

• Riboflavin: Low riboflavin status may be associated with increased homocysteine levels in the blood. Riboflavin is commonly included in B vitamin supplements to reduce blood homocysteine levels in individuals with high homocysteine. Further studies are needed to clarify the relationship between riboflavin and homocysteine levels.

• Reports of allergy or anaphylaxis associated with riboflavin supplementation are rare. Avoid in those with known allergy or sensitivity to riboflavin. Riboflavin supplementation has been associated with rare reports of allergy or anaphylaxis (a life-threatening allergic reaction).

• Safflower: Safflower yellow injection may improve both Western and traditional Chinese medicine symptoms for angina pectoris (chest pain) and coronary artery disease. 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 hypercholesterolemia. More research is needed before a firm conclusion can be drawn.

• Avoid in those allergic or hypersensitive to safflower, Carthamus tinctorius, safflower oil, daisies, ragweed, chrysanthemums, marigolds, or any related constituents. Use parenteral (injected) safflower oil emulsions cautiously in newborns. Use cautiously in those taking anticoagulants (blood thinners) or antiplatelet drugs, immunodepressants or pentobarbital. Use cautiously in those with diabetes, hypotension, inadequate liver function, hypercoagulability, or skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.

• Savory: Savory (Satureja khuzestanica) capsules, used together with standard drugs, significantly improved the amount of cholesterol and fat in the blood of people with diabetes and high cholesterol. Additional research is needed before conclusions can be made.

• Avoid in those with known allergy or sensitivity to savory, its constituents, or members of the Lamiaceae family. Savory may cause allergic skin reactions. Use cautiously in patients with blood pressure or bleeding disorders, or in patients with diabetes.

• Scopolamine: In clinical research, a single transdermal therapeutic system (TTS) patch (Ciba Consumer Pharmaceuticals), applied behind the ear for 24 hours, safely increased cardiac parasympathetic activity and short-term heart rate variability after acute myocardial infarction (heart attack).

• Avoid in patients with a known allergy or hypersensitivity to scopolamine, atropine, belladonna, hyoscyamine, anticholinergic drugs, or any component of the transdermal system.

• Scotch broom: Scotch broom herb has been taken by mouth traditionally for a variety of conditions related to the heart or blood circulation. These include arrhythmias (abnormal heart rhythms), tachycardia (a fast heart rate), peripheral edema (swelling in the legs), pulmonary edema or congestive heart failure (water in the lungs), and hypotension (low blood pressure). Sparteine may affect the electrical conductivity of heart muscle (similar to type 1A antiarrhythmic drugs such as quinidine). However, there is limited evidence in humans, and it is not clear if sparteine found in the plant form has clinically meaningful effects. These potential properties of scotch broom may be dangerous in individuals with heart disease or those 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 or above-ground parts of scotch broom by mouth may not be safe, due to the presence of toxic alkaloids. Poisoning of livestock grazing on scotch broom has been reported. Nausea and vomiting has 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 may help improve heart conditions and lower the amount of cholesterol and other lipids in the blood of some people, but more research is needed.

• Avoid in those allergic or hypersensitive to sea buckthorn, its constituents, or members of the Elaeagnaceae family. Use cautiously in those taking angiotensin-converting enzyme (ACE) inhibitors, anticoagulant and antiplatelet agents (blood thinners), antineoplastics (anticancer agents), or cyclophosphamide or farmorubicin. Avoid higher doses than common food amounts if pregnant or breastfeeding.

• Selenium: Studies of the effects of selenium intake and supplementation on cardiovascular disease have yielded inconsistent findings. Better-designed trials are needed before a conclusion can be made.

• Selenium is a trace element, and hypersensitivity is unlikely. Avoid in those with known allergy or hypersensitivity to products containing selenium.

• Sesame: Overweight or obese men and women who took 25 grams of sesame daily for five weeks had significantly increased levels of sesame lignans in their systems. However, they did not experience any improvement in markers of heart disease risk, such as blood pressure or the level of lipids (fats) in the blood. Based on this limited evidence, sesame is not recommended for this condition.

• In preliminary research, supplementing the diet with sesamin, a lignan found in sesame, has been shown to decrease total cholesterol and LDL, or "bad," cholesterol in humans. However, another study showed that sesame oil had no effect on cholesterol. Additional studies are needed.

• Avoid injecting drugs solubilized in sesame oil unless directed by a doctor. Avoid in medicinal (nonfood) amounts during pregnancy and breastfeeding. Avoid in those with known allergy or sensitivity to sesame or any of its constituents, or poppy seed, nuts (such as almonds, walnuts, or peanuts), buckwheat, soybeans, kiwi, or flour. Obtain sesame only from trusted sources, due to the risk of contamination.

• Shea butter: In clinical trials, shea butter or oil was shown to lower increases in postprandial lipids and postprandial factor VII coagulant concentrations. 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: Dietary soy protein has not been shown to affect long-term cardiovascular outcomes, such as heart attack or stroke. Soy has also been studied for blood pressure-lowering and blood sugar-reducing properties in people with type 2 diabetes, although the evidence is not definitive in these areas. In women with suspected cardiac ischemia, high levels of the soy isoflavone genistein have been associated with blood vessel problems. Further investigation is needed before a conclusion can be made.

• Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there are limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore high doses 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 colitis (intestinal irritation) 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, like 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.

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

• Avoid in those allergic or hypersensitive to spirulina or blue-green algae. Use cautiously in those with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, or osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or 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 insufficient available evidence to recommend for or against the use of squill for coronary artery disease. Additional research is needed.

• Avoid in those allergic or hypersensitive to Urginea maritima or members of the Liliaceae family. Avoid in those with heart, stomach, or intestine problems. Avoid in those with a history of high potassium or high calcium levels. Use cautiously with cardioglycosides. Avoid if pregnant or breastfeeding.

• Sulfur: Limited evidence suggests that sulfur water from the Wiesław spring in Busko-Solec, Poland, improved fat and cholesterol levels and clotting profiles in patients with atherosclerosis (hardening of the arteries). Further studies need to be performed to determine if sulfur was indeed the active agent in this spring water.

• Use cautiously in patients with bleeding disorders or those taking drugs that may increase the risk of bleeding. Use cautiously in infants. Use cautiously in patients with kidney disease, sensitive skin, or gastrointestinal sensitivities. Use caution with sulfur products taken by mouth. Use cautiously in patients with an allergy or hypersensitivity to sulfonamides. Use heated sulfur baths and concentrated sulfur products cautiously. Avoid using or storing sulfur products near a heat source or other chemicals. Avoid topical sulfur on irritated skin. Avoid the use of concentrated sulfur on the skin. Avoid getting sulfur products near the eyes. Avoid inhaling sulfur products. Avoid sulfur preparations in pregnant or breastfeeding patients. Avoid in individuals with a known allergy or hypersensitivity to sulfur.

• Sunflower oil: Limited research suggests that sunflower oil, which contains a high level of unsaturated fat, may have a beneficial effect on cardiovascular disease risk factors, including blood cholesterol levels. Additional studies are needed before a conclusion can be made.

• Use cautiously in patients with bleeding disorders and those taking drugs, herbs, or supplements that may increase the risk of bleeding. Use cautiously in patients with diabetes or hypoglycemia and in those taking drugs, herbs, or supplements that affect blood sugar. Use cautiously in obese individuals. Use cautiously in those with autoimmune immune disorders and those taking agents that may affect the immune system. Use levels higher than those commonly found in the diet cautiously in pregnant or breastfeeding women. Avoid in those with known allergy or hypersensitivity to Helianthus annuus, it constituents, other members of the Asteraceae family, or members of the Compositae family.

• Tai chi: There is evidence that suggests that tai chi decreases blood pressure and cholesterol as well as enhances quality of life in patients with chronic heart failure. Most studies have used elderly Chinese patients as their population. Additional research is needed before a firm conclusion can be drawn.

• Avoid in those with severe osteoporosis or joint problems or acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.

• Taurine: Taurine may offer benefit to individuals with hypercholesterolemia. More research 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, the 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.

• TENS: Several small, brief studies report benefits of transcutaneous electrical nerve stimulation (TENS) on angina pectoris (chest pain). 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.

• TENS is generally reported as being well tolerated. Skin irritation and redness are the most common adverse reactions, occurring in up to one-third of patients. Hives, welts, or contact dermatitis (allergic skin reactions) may occur with the use of electrodes and electrode paste. Electrical burns may occur with excess use or improper technique. Due to the risk of burns, TENS should be used cautiously in people with decreased sensation, such as with neuropathy. TENS should not be used in patients with implantable devices such as defibrillators, pacemakers, intravenous infusion pumps, or hepatic artery infusion pumps. Electrical shocks or device malfunction may occur.

• 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.

• Thiamine is generally considered safe and relatively nontoxic. Rare hypersensitivity or allergic reactions have occurred with thiamine supplementation. Skin irritation, burning, or itching may rarely occur at injection sites. Large doses may cause drowsiness or muscle relaxation. Use cautiously if pregnant or breastfeeding with doses higher than the U.S. recommended daily allowance (RDA). Use cautiously in patients with low blood pressure or a slow heart rate, or in those taking blood pressure-lowering agents or vasodilators (blood vessel-widening agents). Avoid use of thiamine at levels higher than those commonly found in available marketed products, unless under the advice of a healthcare practitioner. Avoid in patients with known allergy or hypersensitivity to any components in thiamine supplements.

• Thymus extract: Preliminary evidence suggests that thymus extract may increase left ventricular function, exercise tolerance, and survival. Additional research is needed in this area.

• Avoid in those allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously, due to the potential for exposure to the virus that causes "mad cow disease." Avoid use in those with an organ transplant or other forms of allografts or xenografts. Avoid in those receiving immunosuppressive or hormonal therapy, and those with thymic tumors, myasthenia gravis (a neuromuscular disorder), or untreated hypothyroidism. Avoid if pregnant or breastfeeding, as thymic extract increases human sperm motility and progression.

• Tocotrienols: There is mixed clinical evidence on the role of tocotrienols in reducing cholesterol levels. Additional high-quality clinical studies are needed before a firm conclusion can be drawn.

• Avoid in those with known allergy or hypersensitivity to sources of vitamin E, tocopherols, tocotrienols, or products containing these compounds. Skin reactions such as contact dermatitis and eczema have been reported with topical vitamin E preparations, such as ointments or vitamin E containing-deodorants.

• Traditional Chinese medicine (TCM): TCM herb combinations have been found to improve some markers of coronary heart disease. The traditional Chinese method of Liqi Kuanxiong Huoxue combined with conventional treatment has been reported to reduce symptoms of stable and unstable angina (chest pain). More studies of better design are needed before conclusions can be made.

• Chinese herbs can be potent and may interact with other herbs, foods, or drugs. Consult a qualified healthcare professional before taking. There have been reports of manufactured or processed Chinese herbal products being tainted with toxins or heavy metal or not containing the listed ingredients. Herbal products should be purchased from reliable sources. Avoid ma huang, which is the active ingredient in ephedra. Avoid ginseng if pregnant or breastfeeding.

• Tribulus: Preliminary research suggests that tribulus (Tribulus terrestris) may be beneficial to patients with coronary heart disease. Additional research is needed to further evaluate its clinical effectiveness.

• Avoid if allergic or hypersensitive to Tribulus terrestris or the members of the Zygophyllaceae family. Use cautiously in those with enlarged prostate or prostate cancer, or diabetes. Use cautiously in those taking steroids, blood pressure medication like beta-blockers, calcium channel blockers, or digoxin. Avoid if pregnant or breastfeeding.

• Turmeric: Early studies suggest that turmeric may lower levels of low-density lipoprotein ("bad") cholesterol and total cholesterol in the blood. Better human studies are needed before a 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 those with a history of bleeding disorders, immune system deficiencies, liver disease, diabetes, hypoglycemia, or gallstones. Use cautiously with blood thinners, such as warfarin (like Coumadin®), and blood sugar-altering medications. Avoid in medicinal amounts if pregnant or breastfeeding. Turmeric should be stopped prior to scheduled surgery.

• Vitamin B6: Hyperhomocysteinemia (high homocysteine levels in the blood) is a risk factor for cardiovascular disease, blood clotting abnormalities, atherosclerosis, myocardial infarction (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 are available, the current recommendation is screening of 40 year-old men and 50 year-old women for hyperhomocysteinemia. Decreased pyridoxine concentrations are also associated with increased plasma levels of C-reactive protein (CRP). CRP is an indicator of inflammation that is associated with increased cardiovascular morbidity in epidemiologic studies. In a large, long-term study, a combination pill containing folic acid, vitamin B6, and vitamin B12 did not reduce the risk of cardiovascular disease in high-risk women. More high-quality studies are needed.

• Some people seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Overall, pyridoxine is generally considered safe in adults and children when used appropriately at recommended doses. Adverse reactions to preservatives in high-dose pyridoxine hydrochloride intravenous injections are possible. Use with caution in patients with low blood pressure, bleeding disorders, cardiovascular disorders, gastrointestinal conditions, or blood sugar disorders such as diabetes or hypoglycemia (or in patients taking drugs for any of these conditions), or in patients taking agents for Parkinson's disease. Avoid if allergic or sensitive to any ingredient in vitamin B6 products. Avoid excessive dosing (doses higher than 200 milligrams daily). Avoid high doses during pregnancy or lactation.

• Vitamin B12: Some evidence suggests that vitamin B12 in combination with fish oil might be superior to fish oil alone when used daily to reduce total serum cholesterol and triglycerides. Well-designed clinical trials of vitamin B12 supplementation alone are needed before a conclusion can be 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 in those with coronary stents (mesh tubes that hold clogged arteries open) and Leber's disease. Use cautiously in those undergoing angioplasty and those 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 breastfeeding.

• Vitamin C: According to studies in humans, vitamin C supplementation may have beneficial effects in patients with high cholesterol. More research is needed in this area. 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 this finding.

• Use with caution in patients with cancer, glucose-6-phosphate dehydrogenase deficiency, anemia and related conditions, kidney stones, or sickle cell disease, or after angioplasty. Use with caution in patients taking antibiotics, anticancer agents, HIV medications, barbiturates, estrogens, fluphenazine, or iron supplements. Use parenteral (injected) vitamin C cautiously. Avoid in patients with known allergy or sensitivity to any vitamin C product ingredients. Avoid high doses of vitamin C in patients with cirrhosis, gout, renal tubular acidosis, paroxysmal nocturnal hemoglobinuria, or kidney failure, or in those taking agents that may damage the kidneys.

• Vitamin D: There is insufficient evidence regarding the use of vitamin D for hyperlipidemia. The effects of vitamin D, alone or in combination with other agents, on lipid parameters have been inconsistent. Further research is needed to evaluate the effects of vitamin D alone or in combination with calcium on lipids before a conclusion can be made.

• 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 in those with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

• Vitamin E: Vitamin E has been evaluated in patients with angina (chest pain), atherosclerosis, and high cholesterol in numerous laboratory, population, and clinical trials. It remains unclear if there are clinically meaningful benefits, and it is not known what the effects of vitamin E are compared to (or in combination with) other agents that have been clearly demonstrated as beneficial for these conditions. Further research is warranted before a clear conclusion can be drawn.

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

• Vitamin K: A relationship between vitamin K intake and reduced cardiovascular disease risk cannot be confirmed at this time. Further research is needed.

• Conditions that interfere with absorption of vitamin K may lead to deficiency, and these include short bowel syndrome, cystic fibrosis, malabsorption (various causes), pancreas or gallbladder disease, persistent diarrhea, sprue, and ulcerative colitis. Use cautiously in patients with skin or gastrointestinal conditions, in pregnant women, and in those taking lipid-lowering drugs. Injection into the muscle or vein should only be done by a healthcare professional. Many serious side effects have occurred after injection. Avoid in patients with known allergy or hypersensitivity to vitamin K. Avoid supplemental vitamin K in patients using warfarin or other blood-thinning agents unless otherwise directed by a healthcare professional. Avoid use of vitamin K3 supplements or menadiol.

• Whey protein: Early research suggests that whey protein may aid in reducing the risk of heart disease. However, further research is required before conclusions can be made.

• Avoid in patients with known allergy or hypersensitivity to milk or milk products.

• White horehound: Early research shows 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 family (mint family). White horehound is generally considered safe when used to flavor foods. Use cautiously in those with diabetes; high, low, or unstable blood pressure; high levels of sodium in the blood; irregular heartbeats; or gastrointestinal disease (like 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 can 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 subtypes of cholesterol, including decreases in low-density lipoprotein (LDL, or "bad") cholesterol and triglycerides and increases in high-density lipoprotein (HDL, or "good") cholesterol. More studies are needed in this area.

• Avoid in those allergic or hypersensitive to wild yam or any member of the Dioscorea plant family. Use cautiously in those 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 hypercholesterolemia. However, additional research is needed in this area, with yucca studied alone.

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

• Zinc: Zinc may improve blood cholesterol levels in hemodialysis patients. There is some evidence that zinc may improve the ratio of HDL ("good") cholesterol to LDL ("bad") cholesterol, which would be considered a positive effect. Well-designed clinical trials are needed before a conclusion can be made.

• Use cautiously in patients with bleeding disorders, diabetes, or low blood sugar levels, or in patients taking agents for these conditions. Use cautiously in patients with high cholesterol or blood fats, a high risk of developing heart disease, various skin disorders, gastrointestinal disorders, liver disease, genitourinary conditions, blood disorders, neurological disorders, pulmonary or respiratory disorders, immune disorders, or kidney disease. Use cautiously in patients taking antidepressants, potassium-sparing diuretics, antibiotics (particularly tetracyclines and quinolones), iron, penicillamine, thyroid hormones, or copper. Avoid in patients who are homozygous for hemochromatosis (a metabolic disorder involving the deposition of iron-containing pigments in the tissues and characterized by bronzing of the skin, diabetes, and weakness) or with a known allergy or hypersensitivity to zinc compounds. Avoid use of intranasal Zicam®.

• Fair negative scientific evidence:

• Acacia: There is preliminary evidence that acacia may not be helpful for hypercholesterolemia.

• Acacia is generally considered safe when taken in the amounts typically found in foods. Avoid in those allergic to acacia, pollen, or any members of the Fabaceae or Leguminosae family. Use cautiously in those taking amoxicillin or iron. Use cautiously in those with gastrointestinal disorders, respiratory disorders, or pinkeye. Acacia may prevent the body from absorbing drugs, and tannins from acacia may increase the risk of certain cancers. Avoid if pregnant or breastfeeding.

• Acidophilus: Some studies suggest that L. acidophilus, when used together with other probiotics, may aid in the treatment of high levels of cholesterol and other fats in the blood. Additional research is needed before a firm conclusion can be made.

• Lactose-sensitive people may develop abdominal discomfort or other adverse effects from L. acidophilus-containing products, due to very small amounts of lactose left over from the manufacturing process. Avoid in patients with milk allergies.

• 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 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.

• Calcium: Cardiopulmonary resuscitation is the restoration of cardiac output and pulmonary ventilation following cardiac arrest and apnea, using artificial respiration and manual closed-chest compression or open-chest cardiac massage. Per the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science, routine administration of calcium for the treatment of cardiac arrest is no longer advised. Variable results have been observed in trials, and a beneficial effect on survival is lacking with the use of calcium.

• Avoid in individuals with a known allergy or hypersensitivity to calcium supplements or any of their ingredients. Dairy products contain lactose, and dairy products are a common food source of calcium, but some people are lactose intolerant. Lactose intolerance may cause cramping, bloating, gas, and diarrhea. Lactose intolerance affects the population in varying degrees. Avoid calcium supplementation in those who are very sensitive to any component of a calcium-containing supplement, or who have hypercalcemia (high levels of calcium in the blood). Conditions causing hypercalcemia include sarcoidosis (inflammation in the lymph nodes and other organs), hyperparathyroidism (high levels of parathyroid hormone), and hypervitaminosis D (high levels of vitamin D).

• Chelation therapy: Evidence does not support the use of 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 (and would require replacement).

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

• Avoid in those allergic to plants in the Onagraceae family (willow's herb, enchanter's nightshade) or gamma-linolenic acid. Avoid in those 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 LDL or HDL levels in patients with chronic joint pain or hypercholesterolemia.

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

• Guided imagery: Masked prayer, music, imagery, and touch (combined) therapy did not significantly improve clinical outcomes after elective catheterization or percutaneous coronary intervention in a recent study.

• Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified healthcare 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 in those with physical symptoms that can be brought about by stress, anxiety, or emotional upset, because imagery may trigger these symptoms. Those feeling unusually anxious while practicing guided imagery, or those with a history of trauma or abuse, should speak with a qualified healthcare provider before practicing guided imagery.

• Sunflower oil: Limited research suggests that fats found in sunflower oil may not have an effect on the stability of atherosclerotic plaques (hardening of the arteries). Additional research is needed before a conclusion can be made.

• Use cautiously in patients with bleeding disorders and those taking drugs, herbs, or supplements that may increase the risk of bleeding. Use cautiously in patients with diabetes or hypoglycemia and in those taking drugs, herbs, or supplements that affect blood sugar. Use cautiously in obese individuals. Use cautiously in those with autoimmune immune disorders and those taking agents that may affect the immune system. Use levels higher than those commonly found in the diet cautiously in pregnant or breastfeeding women. Avoid in those with known allergy or hypersensitivity to Helianthus annuus, it constituents, other members of the Asteraceae family, or members of the Compositae family.

• 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 (a bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding. It is not clear if vitamin C supplements in doses higher than Dietary Reference Intake recommendations are safe for pregnant or breastfeeding women. Vitamin C is naturally found in breast milk.

• Strong negative scientific evidence:

• Arginine: Until potential safety issues are addressed, L-arginine should be avoided by myocardial infarction patients.

• Use caution in patients with bleeding disorders or those taking drugs that may increase the risk of bleeding. Use caution in patients with diabetes or hypoglycemia or those taking agents that affect blood sugar. Use caution in patients with impaired kidney function, those at risk for high blood potassium (including those with diabetes), or those using drugs that elevate potassium levels (including potassium-sparing diuretics and potassium supplements). Avoid in those with low blood pressure or those using blood-pressure lowering agents, in patients with asthma or breast cancer, in those with or at risk for a history of heart attack, and in those using nitrates or spironolactone. Avoid in pregnant or breastfeeding women. Avoid in those with known allergy or sensitivity to arginine.

Prevention

• Dietary modification: Minimize cholesterol and fat intake, especially saturated fat, which raises cholesterol levels more than any other substance. Cholesterol and saturated fats are found primarily in foods derived from animals, such as meats and dairy products. Dietary guidelines for reducing cholesterol and fat consumption include eating lean fish, poultry, and meat (remove the skin from chicken and trim the fat from beef before cooking); avoiding commercially prepared and processed food (cakes, cookies, and doughnuts) and breaded fried foods; increasing the intake of fruits, vegetables, breads, cereals, rice, legumes (beans, peas); and using skim or 1% milk and cooking oils that are high in unsaturated fat (corn, olive, canola, and safflower oils). Healthcare professionals recommend eating fish, including salmon, tuna, and herring, which are high in omega-3 fatty acids, and therefore proposed to have a heart-protective action. Eggs do contain cholesterol but may be eaten without negative effects on cholesterol levels.

• Weight loss: Excess weight contributes to high cholesterol. Losing 5% of one's total body weight can have a significant impact on lowering total cholesterol levels. Fad diets such as the Atkins diet may not give a person the balance of nutrients needed for a healthy heart and body. Exercising and eating the right foods in moderation help to increase weight loss.

• Smoking cessation: Quitting smoking can improve HDL cholesterol levels, decrease blood pressure, and reduce the risk of a heart attack. Within one year after stopping, the risk of heart disease is half that of a smoker. Within 15 years of stopping, the risk of heart disease is similar to that of someone who has never smoked.

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

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

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.

1. American Heart Association. www.americanheart.org.

2. Boekholdt SM, Sandhu MS, Day NE, et al. Physical activity, C-reactive protein levels and the risk of future coronary artery disease in apparently healthy men and women: the EPIC-Norfolk prospective population study. Eur J Cardiovasc Prev Rehabil. 2006;13(6):970-6. View Abstract

3. Duffey KJ, Gordon-Larsen P, Jacobs DR Jr, et al. Differential associations of fast food and restaurant food consumption with 3-y change in body mass index: the Coronary Artery Risk Development in Young Adults Study. Am J Clin Nutr. 2007;85(1):201-8. View Abstract

4. Harris WS, Assaad B, Poston WC. Tissue omega-6/omega-3 fatty acid ratio and risk for coronary artery disease. Am J Cardiol. 2006 Aug 21;98(4A):19i-26i. Epub 2006 May 30. View Abstract

5. National Heart, Lung, and Blood Institute. www.nhlbi.nih.gov.

6. National Institutes of Health. www.nlm.nih.gov.

7. Natural Standard: The Authority on Integrative Medicine. www.naturalstandard.com.

8. U.S. Food and Drug Administration. www.fda.gov.