FitSugar

The Most Unhealthy Chinese Restaurant Foods: Part Two

FitSugar — Tue, 29 Apr 2008 11:00:00 -0700

I already told you about a few unhealthy Chinese food menu items that are heavy hitters in terms of calories, fat, and sodium and you may have been thrilled that your favorite dish was not on there. Unfortunately, there's more.

In case you missed it, Newsweek talked to Jayne Hurley and Bonnie Liebman , authors of Chinese Restaurant Food: Wok Carefully. They shared their take on the most unhealthy Chinese food menu items. I wanted to make sure you don't miss the highlights:

Lemon chicken: A plate of lemon chicken contains 1,400 calories, two-thirds of a day's fat, and no vegetables. "It's like eating three McDonald's McChicken sandwiches and a 32-ounce Coke," Hurley says.
General Tso's chicken: General Tso's chicken features breaded, deep-fried chicken chunks that are then soaked in sauce; Hurley and Liebman found that one plate has about 1,300 calories and half a day's worth of saturated fat.
Barbecued spare ribs: These "appetizers" pack a punch - one plate of spare ribs carries two-thirds of a day's worth of saturated fat and 600 calories. That's the same amount of calories as in two pork chops, Hurley says. Dumplings, steamed or pan-fried, are much more health friendly, she says.

So eat Chinese food at your own risk, I know I will be - sometimes a girl's just gotta have her General Tso's.

Source

The Most Unhealthy Restaurant Chinese Foods: Part One

FitSugar — Mon, 28 Apr 2008 03:30:00 -0700

The other day, out of the blue, I was having a bit of a craving for Chinese food. This is unusual for me, but I was thinking of indulging myself. Then I read a nutritional dissection of the cuisine in Newsweek by Jayne Hurley and Bonnie Liebman, the authors of Chinese Restaurant Food: Wok Carefully. Their take on the most unhealthy Chinese food menu items certainly had me rethinking my decision to indulge – or at least stick to steamed meals with sauces on the side. Here are highlights:

Fried rice and lo mein: "Those dishes are basically three quarters of a day's calories, and you're just getting four or five cups of white rice or white noodles with oil and a sprinkling of vegetables," Hurley says. They're especially dangerous because they're often served alongside people's main orders, she says, and deliver "not much more than a smattering of vegetables or protein from the meat."
Chow fun: This dish is made of wider rice noodles and might taste more healthy than lo mein, but it's not. "The noodles are thicker, but they're going to do the same damage to your belly and blood pressure as the lo mein," Hurley says.
Crispy (orange) beef: Many meat-based menu items simply offer "hunks of fried meat," Hurley says. "What you're getting is three quarters of a pound of deep-fried meat, garnished with vegetables," she says. The same goes for sweet and sour pork.

So there you have it. This is not to say that you shouldn’t eat Chinese food, because sometimes you need some take-out and a fortune cookie. Just try steer clear of the high-calorie, high-sodium, high-fat items like those listed above.

Source

All You Can Eat - Recession Buster or Fat Maker?

FitSugar — Thu, 29 Oct 2009 03:00:15 -0700

Taybarns restaurant is introducing a new dining concept to the English - all you can eat. It's nothing we haven't seen in the United States. We have all-you-can-eat baked potato and pizza bars, endless breadsticks and salad, and the kind of buffets that would make Elvis weep if he was still kickin' it in Vegas.

The Taybarns message is clear: "Enjoy as much as you like, as many times as you like. All for one fixed price!" That fixed price gives you a 111-foot counter filled with pizza, Chinese food, carving stations, fry stations, desserts, and more. The English are going crazy for the buffet-style chain, and while neighboring restaurants continue to close, Taybarns is on the up.

During tough economic times, giving people the most bang for their buck seems like a smart business model, but at what cost? As reported by the BBC, not everyone likes Taybarns. They think the chain encourages unhealthy eating habits and will cause England's collective waistline to expand.

It's a common argument, and one that's been batting around in the US for some time. Is it the fault of (insert any fast food giant here), or does the responsibility fall on the individual? Does walking into Taybarns rob a human of their free will, and why isn't healthy food more accessible to the masses?

Vitamins

FitSugar — Wed, 08 Oct 2008 17:35:00 -0700

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Cancer

Growing evidence suggests that vitamins and micronutrients, especially from foods, may play important roles in the prevention or treatment of certain cancers:

One study found that the risk of prostate cancer risk dropped as consumption of vegetables high in vitamin C, such as broccoli and bell peppers, rose.
A diet high in cruciferous vegetables has been found to reduce the risk of kidney cancer; low consumption of cruciferous vegetables increases the risk.

On the other hand, high amounts of folic acid (a B vitamin) may be associated with colorectal cancer, and beta-carotene supplements are associated with increased lung cancer risk in smokers and people exposed to asbestos.

Macular Degeneration

In 2007, the National Eye Institute recommended that people with intermediate or advanced macular degeneration in one eye take a vitamin formula shown to reduce the risk of macular degeneration in the other eye by 25%. The formula contains vitamin C, vitamin E, beta-carotene, and zinc.

Osteoporosis

Vitamin K is widely used in Japan to treat osteoporosis, and studies suggest it also may be effective in treating rheumatoid arthritis.

Heart Disease

Although people with high levels of homocysteine are prone to developing blood clots in their arteries and veins, a 2007 study found that lowering homocysteine with B vitamins and folic acid does not reduce the incidence of deep vein thrombosis (DVT). A 2007 trial in adults with stable coronary artery disease found that lowering homocysteine levels 33% with folic acid and other B vitamins had no effect on arterial inflammation, meaning that lower levels were unlikely to offer protection against heart attack or stroke.

Introduction

Vitamins do not share a common chemistry, but they do share certain characteristics. They are all organic nutrients that are necessary in small amounts for normal metabolism and good health. Your diet or supplements provide most vitamins. The body can manufacture only three vitamins (D, K, and the B vitamin biotin) from nondietary sources. Unlike carbohydrates, fats, and proteins, vitamins are not sources of energy. Instead, vitamins are chemical partners for the enzymes involved in the body's metabolism, cell production, tissue repair, and other vital processes.

Vitamins are either fat soluble or water soluble. The fat-soluble vitamins, which include A, D, E, and K, are absorbed by the body using processes that closely parallel the absorption of fat. They are stored in the liver and used up by the body very slowly. The water-soluble vitamins include C and the B complex vitamins. The body uses these vitamins very quickly. Excess amounts are eliminated in urine.

The Recommended Daily Allowance (RDA) for vitamins, set by the Food and Nutrition Board of the National Academy of Sciences-National Research Council, has been used for years as a guide for determining the amount of vitamins needed for a healthy diet. The RDA refers to an estimate of the average daily requirement. It is not completely adequate, however, for informing people about the amounts of vitamins they may need.

The RDA is gradually being enhanced using a new standard called the Dietary Reference Intake (DRI). The DRI is based on the following ratings, which will eventually appear on labels:

The recommended daily allowance (RDA). This is the current rating on most vitamins.
The estimated average requirement (EAR). This is the amount adequate for 50% of all people, which will be put on labels when it can be calculated.
Adequate intake (AI). This is an amount that will be used if there is insufficient data to calculate the EAR.
Tolerable upper intake level (UL). This is the maximum dose likely to be safe in nearly all individuals. It will be included on labels if this amount is known.

Food and supplement labels now typically list the Daily Value (DV). This is the percentage of the amount of a nutrient that experts believe a person needs in their daily diet. On food labels it is usually based on one serving size for a person who takes in 2,000 calories a day.

Regulation of dietary supplements by the U.S. Food and Drug Administration (FDA) is a complex issue.

Labels on vitamins and other dietary supplements now include nutrient information and list all ingredients, including identifying parts of plants from which ingredients may be taken. Unlike the labels for drugs, however, labels for vitamins and supplements may not claim to prevent or treat any specific disease. Labels for vitamins and supplements include one of the following:

Health claim -- description of how the substance may reduce the risk of a health-related condition
Nutrient claim -- description of the amount of the nutrient in the product or
Structure or function claim -- description of how the product may affect organs or systems of the body, without claiming to prevent or treat specific disease

The quality of dietary supplements depends on the manufacturer and is not ensured by FDA. The U.S. government does not require that supplements be standardized, meaning that the amounts or quality of nutrients may vary depending on the batch. So, more expensive supplements are not necessarily better than the less expensive ones. Government regulations are in the process of catching up to the boom in the supplement industry. In the meantime, some companies voluntarily adhere to rigorous quality controls, while others do not.

The U.S. Pharmacopeia (USP), an independent organization that sets quality standards for drugs, has also implemented standards for vitamins. Consumers may look for the USP label on products of companies that adhere to these standards. USP verification means the following:

What is in the bottle matches what is listed on the label.
There are no harmful levels of contaminants.
The supplement will be absorbed properly into the body.
It has been produced according to good manufacturing standards.

Before selling any supplement introduced after 1994, manufacturers must submit information as to why the product is considered safe for people. The FDA may refuse to allow it on the market if it finds the evidence insufficient. The FDA does not require manufacturers to provide any scientific evidence that dietary supplements are safe and effective before a product is sold (unlike drugs, which must be proven both safe and effective through clinical trials). If a supplement causes side effects in people once it is for sale, the government may place restrictions on the supplement or withdraw it from the market. The FDA may also withdraw products from the market if their labels are misleading or false.

About 30% of Americans take at least one vitamin or mineral supplement daily. In a large study that examined the death rates of 11,000 people, however, there was no difference in mortality rate between those who took vitamin supplements and those who didn't. Most people who have a healthy diet do not need vitamins, but there are some exceptions.

Pregnant and Breast-Feeding Women. Women who are pregnant or who are breast-feeding generally need additional vitamins. Vitamins B6, B12, and folic acid are particularly important. Women who are vegetarians must be sure to avoid deficiencies, which can harm their offspring. Folic acid reduces the risk for neural tube defects and possibly facial abnormalities, such as cleft palate. Studies also show that low folate levels during pregnancy are associated with low birth weight, a risk factor for the development of cardiovascular disease in adulthood. Multivitamins that contain folic acid also appear to be somewhat protective. A woman's best approach is to take extra folic acid plus multivitamin supplements (which have additional benefits), starting them before becomming pregnant.

The human body stores several years' worth of vitamin B12, so nutritional deficiency of this vitamin is extremely rare. Although, people who follow a strict vegetarian diet and do not consume eggs or dairy products may require vitamin B12 supplements.

Pregnant women with healthy diets may have low folate levels and need to take supplements. Requirements are as follows:

The recommended daily allowance (RDA) for folic acid prior to conception and during pregnancy is 400 mcg.
During breast-feeding 260 - 280 mcg is recommended.

The following vitamins may have some value for pregnant women:

Choline, another vitamin B, is also essential for pregnant (450 mg) and nursing women (550 mg). Choline plays a key role in brain development. Not getting enough during pregnancy can lead to memory and cognitive defects in the baby. Choline supplements can also lessen the cognitive defects of prenatal alcohol exposure.
Vitamin B6 may help improve morning sickness.
Vitamin C may reduce the risk of urinary tract infections during pregnancy.
Vitamin D may help prevent preeclampsia.
One study also suggested that if pregnant women took vitamin K supplements, their infants might not need the required injection of this vitamin after birth, but supplements of vitamin K during pregnancy are not currently recommended.

Some women have low vitamin A reserves in their liver. It is important to note, however, that too much vitamin A significantly increases the risk for birth defects. Daily amounts of 10,000 IU (international units) of vitamin A in supplements and food (an amount not far above the RDA level) can pose a danger. Experts recommend that pregnant women take in no more than 8,000 IU per day and avoid eating liver.

Infants and Children. Infants who are breast-fed by healthy mothers receive enough vitamins except, in some cases, vitamins K and D. Human milk has low levels of K, and the newborn's immature intestinal tract may not produce enough of the baby's own supply. Most babies are given an injection of this vitamin at birth. Infants being breast-fed by malnourished women or those who lack sufficient exposure to sunlight may be deficient in vitamin D. In these cases, supplements of 200 - 300 IU are recommended. Formulas are required to contain sufficient vitamins and minerals. One study suggests that vitamin supplements for infants under 1 year of age may help protect them from developing type 1 diabetes later on. Beyond infancy, most American children receive all the vitamins they need from their diet unless they are living in severely deprived circumstances.

Smokers. Smoking interferes with absorption of several vitamins, importantly vitamins C and D. In one study nearly 25% of female smokers and 31% of male smokers were deficient in vitamin C. Smoking can interfere with the metabolims of vitamin D, resulting in poor muscle function. Taking high doses of antioxidant vitamins, however, may actually be harmful in smokers, especially beta carotene. Instead of taking supplements, most smokers should be sure their diets are rich in fresh fruits and vegetables and whole grains. Of course, smoking cessation is the most important intervention of all.

Click the icon to see an image of sources for vitamin C.

Alcoholics. Alcoholics often suffer from multiple vitamin deficiencies. The most dangerous deficiencies are from vitamins B1 (thiamin), folic acid, B6 (pyridoxine), B2 (riboflavin), and vitamin C. Low levels of B6 are associated with increased risk of colorectal cancer in men who drink large amounts of alcohol.

Overweight Adults. Overweight and obesity causes many problems that often result in metabolic syndrome or type 2 diabetes. Evidence suggests that isoflavones can help regulate cholesterol levels and reduce body weight and fat mass. Because some medications used to control blood sugar levels reduce folic acid and vitamin B12, some people may need vitamin supplements.

People Who Have Had Gastric Bypass Surgery. Vitamin deficiency is a recognized complication of gastric bypass surgery. Women, African-Americans of both sexes, and adults who have had laparoscopic Roux-en-Y bypass surgery are at highest risk. The deficiency is treated with water-soluble vitamin supplements.

Strict Vegetarians. Strict vegetarians need supplements of vitamin B12, unless they get enough of it from fortified cereals and other grain products.

Dieters and Vegetarians. People on weight-reduction diets with less than 1,000 calories a day should probably take a multivitamin and should also check regularly with a physician.

Vegetarians may need riboflavin, vitamin B12, and vitamin D supplements. Vegans, who do not eat dairy or eggs as well as meat, may be at further risk for vitamin A deficiencies if they do not also have plenty of dark colored fruits and vegetables. Those who eat eggs and dairy products need only watch their iron levels.

Deficiencies in vegetarian children may be particularly harmful. (One study, for example, reported that adolescents who had been on macrobiotic diets before age 6 and were deficient in vitamin B12 scored lower on psychological tests.) Pregnant and breast-feeding women who are vegetarians must be sure to have sufficient vitamins. Of special note, maternal deficiencies in vitamin B12 may cause delayed growth and neurologic problems in their newborns.

Click the icon to see an image of sources for vitamin D.

Older Adults. Deficiencies of vitamins and important minerals have been observed in almost a third of elderly people. Often their dietary habits slip and they fail to eat balanced meals regularly. Multiple drug regimens may prevent absorption of some vitamins. Elderly people, particularly if they are not exposed to sunlight, may be deficient in vitamin D. They also may have low levels of important B vitamins. (Older adults showing signs of dementia should be checked for B12 deficiencies as well as other disorders causing mental disturbances.) One study reported that the immune systems of elderly people may benefit from higher levels of vitamin E than the daily recommended dosage. It should be noted, however, that metabolism slows down as a person ages, and in elderly people it takes the liver longer to eliminate drugs and vitamins from the body. The effect of some vitamin supplements, therefore, may be intensified. Dosage levels of vitamin A, for instance, which might be harmless in a younger adult, could be toxic in an elderly patient. Nevertheless, experts are increasingly recommending extra vitamin and mineral supplements for older people.

People Who Need to Avoid Sunlight. People who need to avoid sunlight or are housebound, and whose diet is low in foods that contain vitamin D should take supplements. People with darker skin are at higher risk for deficiencies than those with whiter skin. (Note: vitamin D is toxic in high doses, and no one should exceed the recommended daily intake of vitamin D except under the direction of a physician.)


Benefits	Essential for growth, bone development, night vision, reproduction, and healthy skin.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)	Vitamin A RDA and Upper Limit (when toxicity is risk) are the following: For children: 1,000 IU ages one to three (upper limit is 2,000 IU); 1,333 IU ages 4 - 8 (upper limit is 3,000 IU); and 2,000 IU for 9 - 13 (upper limit is 5,665 IU). For nonpregnant women: 2,330 IU ages 14 through adulthood. (Upper limit is 9,335 IU for ages 14 - 18 and 10,000 IU for women over 19.) For pregnant women: 2,500 IU for pregnant women under 18; 2,565 IU for pregnant women over 19. (Upper limit is 9,335 IU for ages 14 - 18 and 10,000 IU for women over 19. It should be noted that some experts recommend 8,000 IU as the upper limit during pregnancy.) Warning: Use of the topical acne medication tretinoin, a vitamin A derivative, during pregnancy can cause birth defects. For nursing women: 4,000 IU for nursing mothers under 18; 4,335 IU for nursing mothers over 19. (Upper limit is 9,335 IU for ages 14 - 18 and 10,000 IU for women over 19.) For men: 3,000 IU ages 14 - 18; 3,000 IU for ages 19 and above. (Upper limit is 10,000 IU.) Note: In determining the daily vitamin A allowance, experts also take note of provitamins, such beta carotene, that convert to vitamin A. Some experts recommend 3 - 6 mg of beta-carotene. Vitamin A is also now being measured with a new unit called the Retinol Activity Equivalent (RAE or RE). One RE is equal to 1 mcg. Retinol is the most active form of vitamin A and it is also converted in the liver from carotenoids. One RE is equal to 12 mcg of beta-carotene or 24 mcg of alpha-carotene or beta-cryptoxanthin).
Foods containing the vitamin	Animal products, such as liver, dairy products, eggs, and fish liver oil. Provitamin A carotenoids are also found in dark red, green, and yellow vegetables and fruits. Requires some dietary fat to be absorbed.
Effects of deficiencies	Skin disorders, severe diarrhea, and eye damage. In less developed countries severe deficiencies cause blindness in 250,000 children each year. Diets low in vitamin A may also increase the risk of developing cancer. Low dietary intake of vitamin A has been associated with impaired lung function in children.
People at risk for deficiencies	Preschool children and any child with inadequate intake of protein, calories, and zinc. Iron deficiency may also impair metabolism of vitamin A. People with asthma. People with serious disorders in the intestine, liver or pancreas, such as cystic fibrosis, steatorrhea, biliary obstruction, inflammatory bowel disease, cirrhosis, and others. People who have undergone Roux-en-Y gastric bypass surgery. Vegans (vegetarians who do not eat eggs and dairy). Such individuals should be sure to have plenty of deep-colored fruits and vegetables. People who abuse alcohol. It should be noted, however, that people with alcoholism may be at risk for vitamin A deficiency, but a combination of high-dose vitamin A and alcohol may cause toxic effects in the liver. Healthy adults usually have a year's store of vitamin A in the liver, so temporary nutritional deficiencies or problems with fat absorption are unlikely to cause serious vitamin A deficiency problems.
Toxicities	Very toxic when taken in high-dose supplements for long periods of time. Symptoms of overdose include dizziness, nausea, vomiting, headache, skin damage, mental disturbances, and, in women, infrequent periods. Can affect almost every part of the body, including eyes, bones, blood, skin, central nervous system, liver, and genital and urinary tracts. Severe toxicity can cause blindness and may even be life threatening. In children, chronic overdose can cause fluid on the brain and as well as adult complications. High consumption of vitamin A may also increase the risk of gastric cancer and the risk of osteoporosis and fractures in both men and women. Pregnant women who take amounts not much higher than RDA levels increase the risk for birth defects in their children. Liver damage can occur in children who take RDA-approved adult levels over prolonged periods of time or in adults who take as little as five times the RDA-approved amount for 7 - 10 years.


	B Vitamins: General Information	Vitamin B1 (thiamin)
Benefits	The B vitamins have a wide and varied range of functions in the human body. Most B vitamins are involved in the process of converting blood sugar into energy.	Essential for converting blood sugar into energy and is involved in metabolic activities in nerves, heart, and muscles and in the production of red blood cells.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)		RDA is 1.2 mg per day for men and 1.1 mg for women.
Foods containing the vitamin		Best source is pork and good sources are dried fortified cereals, oatmeal, corn, nuts, cauliflower, and sunflower seeds. Supplements for people with normal diets and health are unnecessary.
Effects of deficiencies	Deficiencies are uncommon in the U.S., but when they occur, they usually involve several B vitamins, since many of them come from the same food groups.	Severe vitamin B1 deficiency is known as beriberi. It can cause visual disturbances, paralysis, staggering, loss of sensation in the legs and feet, psychosis, and congestive heart failure.
People at risk for deficiencies	Alcohol interferes with these vitamins, and some of the physical and mental problems that alcoholics experience may be attributed to a deficiency of B vitamins. Elderly people are also at risk for deficiencies because of inadequate diets and potential interference with B-vitamin absorption by medications. Deficiencies can occur in severely malnourished people or in those receiving long-term dialysis or intravenous feeding. Vegetarians may be at risk.	See general vitamin B description.
Toxicities	Because the B vitamins are water-soluble and eliminated in the urine, toxic reactions from oral administration of most of them are extremely rare. (Exceptions are niacin and B6.) It should be noted that substances known as B15 (pangamic acid) and B17 (laetrile) are neither vitamins nor nutrients; both chemicals are highly dangerous and have no proven nutritional or health value.	No toxic effects have been reported from thiamin.


	Vitamin B2 (riboflavin)	Vitamin B3 (niacin) also known as nicotinic acid	Vitamin B5 (Pantothenic Acid)
Benefits	Important in the production of energy.	Helps break down blood sugar for energy. Acts as a vasodilator, widening blood vessels and increasing blood flow. May be prescribed for improving cholesterol levels.	Important for metabolism of fats, carbohydrates, and proteins, as well as production of steroid hormones and other important chemicals.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)	DRI is 1.7 mg.	DRI is 20 mg.	Adequate intake (AI) is 4 - 7 mg.
Foods containing the vitamin	Liver, dried fortified cereals, dairy products, fish. Some dark green vegetables. Supplements for people with normal diets and health are unnecessary.	Mackerel, swordfish, chicken, veal, dried fortified cereals, pork, salmon, and beef liver. Supplements are unnecessary in people with normal health and diets.	Whole grains, beans, milk, eggs, and liver. Supplements are unnecessary in people with normal health and diets.
Effects of deficiencies	Deficiencies affect the skin and mucous membranes and can cause cracks on the lips or corners of the mouth, eczema of the face and genitals, a burning sensation on the tongue, eye irritation. May contribute to anemia when iron levels are low and contribute to elevated levels of homocysteine, a heart risk factor.	Deficiency causes pellagra; symptoms can include eczema, intestinal and stomach distress, depression, headache, thinning of the hair, and excess saliva production.	Deficiency is unlikely except in company with other B vitamin deficiencies. Symptoms include abdominal distress, burning sensation in the heels, and sleep problems.
People at risk for deficiencies	See general vitamin B description.	Alcoholics and any malnourished persons.	Alcoholics and any malnourished persons.
Toxicities	Until recently, no toxic effects had been reported even from large doses of riboflavin. However, one study indicated that high consumption of vitamin B2 might increase the risk of stomach cancer. More research is needed. (In the same study, vitamins B1, B3, and B6 were protective.)	Even mildly high doses of niacin can cause hot flushing of the face and shoulders, headache, itchiness, and stomach problems. Some report heart disturbances and temporarily lowered blood pressure. Large doses may produce ulcers, gout, diabetes, and liver damage, which are usually reversed when high doses are discontinued.	Although no toxicity has been reported in humans, high dosages have caused liver damage in rats.


	Vitamin B6 (pyridoxine)	Vitamin B12 (cobalamin)
Benefits	Has an effect on over 60 proteins in the body, importantly, those that play a role in the nervous system, in red and white blood cell production, and in heart disease.	Essential for the production of blood cells, manufacturing genetic material, and for healthy functioning of the nervous system. New evidence suggests that high levels of B12 may protect against colon and rectal cancer.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)	RDA is 1.3 mg in adults under 50 and 1.7 mg for older men and 1.5 for older women. (Some experts recommend 3 to 6 mg for people who need heart protection.) Upper limit is 100 mg for adults.	RDA is 2.4 mcg in men and nonpregnant women, 2.6 mcg in pregnant women, and 2.8 mcg in nursing mothers.
Foods containing the vitamin	Meats, oily fish, poultry, whole grains, dried fortified cereals, soybeans, avocados, baked potatoes with skins, watermelon, plantains, bananas, peanuts, and brewer's yeast.	The only natural dietary sources are animal products, including meats, dairy products, eggs, and fish (clams and oily fish are very high in B12). Like other B vitamins, however, B12 is added to commercial dried cereals.
Effects of deficiencies	Increased levels of homocysteine, associated with heart disease and possibly Alzheimer's disease. Skin problems and nervous system disorders, including impaired memory and concentration. Increased risk for kidney stones. One study found a correlation between vitamin B6 deficiency and inability to conceive or carry a child to term. In unborn children, some evidence shows that lack of vitamin B6, in addition to vitamin B12 and folic acid, may be responsible for defects such as cleft lip and palate and spina bifida. Supplementation with these vitamins is advised during pregnancy. Note: People who have been taking more than 50 mg for some time and stop suddenly are at risk for a so-called rebound deficiency. When people stop, they should taper off slowly.	Deficiencies elevate homocysteine, a possible risk factor for heart disease and Alzheimer's disease. Increased risk of bone fractures. Abnormal gaits in the elderly. May cause severe depression, memory loss, instability, disorientation, and decreased reflexes, and possibly hearing loss. Children who are deficient may experience growth failure. Deficiencies in pregnant and breast-feeding women may cause neurologic harm in their offspring. A genetic defect that causes vitamin B12 deficiencies is responsible for pernicious anemia, a serious disorder that causes rapid heart rate, shortness of breath, dizziness, weakness, and fatigue. It must be treated with injections of vitamin B12 or else neurologic damage may occur.
People at risk for deficiencies	Alcoholics and any malnourished person. In rare cases, infants are born unable to metabolize pyridoxine; in such cases, seizures or convulsions can occur and vitamin B6 must be administered.	Alcoholics and any malnourished persons. Evidence suggests deficiencies may be caused by Helicobacter pylori (H. pylori) bacteria (a cause of ulcers). Nearly 30% of patients with inflammatory bowel disease have vitamin B6 deficiency, as well as low levels of iron and vitamin D. People who take the antibiotic isoniazid, high blood pressure medication hydralazine, and the drug penicillimine are at risk for vitamin B6 deficiency. The elderly and people with Crohn’s disease and those who have undergone ileal and ileocolonic resection may have trouble absorbing natural vitamin B12 and require supplements. Some evidence shows that patients with Parkinson’s disease treated with levodopa plus dopa decarboxylase inhibitor (DDC-i) and catechol-O-methyltransferase inhibitor (COMT-i) have low levels of both vitamin B12 and folate. As a result, they need to take supplements of these vitamins. Other studies have found that patients with diabetes treated with metformin, but not roziglitazone, are at risk for low levels of vitamin B12. Vitamin B12 deficiency is also common in patients with polyneuropathy. In up to one-third of patients, vitamin B12 deficiency is the sole or major contributing cause of their neuropathy. Treatment with vitamin B12 has a high success rate in improving the symptoms. Vegetarians are at higher risk for deficiencies.
Toxicities	Very high doses can cause nerve damage with symptoms of instability and numbness in the feet and hands, which may be permanent in some cases. Of specific concern are possible adverse effects on nerve development in the offspring of pregnant women who take large doses, such as for morning sickness.	There is no evidence of toxicity with this vitamin.


	Biotin (a B vitamin)	Choline (a B vitamin)	Folate, or Folic Acid, its synthetic form (a B vitamin)
Benefits	Involved in the production of amino acid proteins and fatty acids.	Essential for fetal brain development and for learning and memory.	Important for many metabolic processes in the body. It is used in the manufacturing of neurotransmitters (chemical messengers in the brain), in protecting the heart, and for synthesizing genetic materials (DNA) in the cells. It may improve blood flow.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)	There is no DRI for biotin; some experts suggest 30-100 mcg.	RDA 425 mg for nonpregnant women, 450 mg for pregnant women, and 550 mg for nursing women.	Supplements may be folate (natural) or folic acid (synthetic). Folic acid is nearly twice as potent as folate. DRI is 400 mcg (.4 mg) of folate for the general population, 600 mcg during pregnancy and 500 mcg while nursing. Women who are planning to be pregnant should certainly take 400 mcg of folic acid before conception, during pregnancy, and while nursing.
Foods containing the vitamin	Dietary sources are eggs, milk, liver, mushrooms, bananas, tomatoes, whole grains, nuts, and brewer's yeast. Also produced by bacteria in the intestines.	Peanuts, eggs, cauliflower, and meats, especially liver.	Avocado, bananas, orange juice, cold cereal, asparagus, green leafy vegetables, dried beans and peas, and yeast. Folic acid supplements are now added to commercial breads and cereals.
Effects of deficiencies	Deficiencies are almost unheard of.	Low levels during pregnancy increase risk of birth defects in newborns.	As with vitamins B6 and B12, deficiencies of folate elevate levels of homocysteine, an amino acid in the body that may increase the risk for heart disease, and possibly Alzheimer's disease. Folic acid supplements lower homocysteine levels, but with little or no impact on risk of atherosclerotic disease in the heart or in the peripheral arteries and veins. This suggests that homocysteine may be a marker of cardiovascular disease, rather than a cause. This being said, one 2007 study found that folic acid supplementation in patients with low folic acids levels substantially reduced the risk of a first stroke. Low levels during pregnancy increase risk of birth defects in newborns, and folic acid supplementation plays a key role in preventing birth defects. Folic acid deficiencies Deficiencies can also cause depression and megaloblastic anemia and impair concentration, memory, and hearing.
People at risk for deficiencies			Alcoholics, malnourished persons, people with conditions that disturb the small intestine, people taking certain drugs, particularly methotrexate. Other risk factors for deficiency: high-dose aspirin, smoking, treatment for seizures, taking oral contraceptives.
Toxicities		Excessive doses can cause intestinal problems, and there is also some concern that high doses can be carcinogenic.	Possible connection between high consumption of folate/folic acid and colorectal cancer now under exploration. Some link between high doses and central nervous system disorders, zinc deficiency, and seizures in epileptics. This risk appears to be low, but results indicate that megadoses should be avoided. High amounts in the elderly may mask symptoms of vitamin B12 deficiencies.


Benefits	Vitamin C is a water-soluble vitamin. Acts as an antioxidant (reduces harm from damaging chemical processes in the body). Essential for the production of collagen, the basic protein in bones, cartilage, tendons, and ligaments. A 2007 study found that vitamin C supplements can help prevent the development of complex regional pain syndrome following wrist fracture. Another study found that prostate cancer risk dropped as consumption of vegetables high in vitamin C, such as broccoli and bell peppers, rose. It may also protect against brochoconstriction during exercise in people with asthma. May help boost the immune system.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)	DRI is 75 mg (women) and 90 mg (men). (Smokers need an additional 35 mg.)
Foods containing the vitamin	Citrus fruits and juices, papayas, hot chili peppers, bell peppers, broccoli, potatoes, dark leafy greens, kale, red cabbage, cauliflower, cantaloupe, sweet potatoes, and Brussels sprouts. Orange juice is the most important source of vitamin C in the U.S., with frozen juice being the best source of the vitamin.
Effects of deficiencies	Scurvy is the primary deficiency disease. Affects most body tissues, particularly bones, teeth, and blood vessels. Early symptoms include tiredness, weakness, irritability, weight loss, and vague muscle aches. Later symptoms are bleeding gums, wounds that won't heal, rough skin, and wasting away of the muscles. Deficiencies may contribute to periodontal disease and gallstones. Low dietary intake of vitamin C has been associated with impaired lung function in children. Low intake may also increase lead levels in the blood.
People at risk for deficiencies	Deficiency has been uncommon in the U.S., usually occurring in the elderly, alcoholics, cancer patients, and some people on severely limited diets low in fresh fruits and vegetables. Surprisingly, however, studies now suggest that as many as 16% of middle-aged Americans, with the highest risk in smokers and middle aged men, are deficient in vitamin C. High doses of aspirin taken over a long period of time can interfere with vitamin C.
Toxicities	Tolerable upper limit is 2000 mg/day. High doses may cause headaches and diarrhea. Long-term high doses may increase risk for kidney stones. Ascorbic acid increases iron absorption so people with blood disorders, such as hemochromatosis, thalassemia, or sideroblastic anemia, should avoid high doses. Large doses may also thin blood and interfere with anticoagulant medications, blood tests used in diabetes, and stool tests. Rebound scurvy can occur after abrupt withdrawal from long-term large doses. This may affect infants or pregnant women who withdraw suddenly from high doses.


Benefits	Vitamin D is actually a single term for several hormones that are stored mainly in the liver and also in fat and muscle tissue. It is essential for the absorption of calcium into the bone and for normal bone growth.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)	RDA is 200 IU (5 mcg) per day for children and most adults to age 50, 400 IU (10 mcg) for people between ages 50 and 60, and 600 IU over age 70. and 1000 IU (15 mcg) for those over 70. People who are housebound, do not have sufficient exposure to sunlight, or are dark-skinned individuals, as well as breast-fed infants, should take need vitamin D supplements. The maximum tolerated dose after the age of 12 months is 2,000 IU/day
How the body gets the vitamin	There are two forms of vitamin D. Vitamin D3 is made in the body from a chemical reaction to the ultraviolet radiation in sunlight. Vitamin D2 is found in a few food sources, including vitamin D fortified milk, fatty fish, egg yolk, and liver.
Effects of deficiencies	Softening of the bones caused by low levels of calcium and phosphorous (called rickets in children and osteomalacia in adults). Also increases the risk for bone-related knee problems, and hip fractures in postmenopausal women. Associated with a higher risk for prostate cancer and breast cancer risk. Evidence suggests that vitamin D deficiency may be responsible for poor muscle strength after bone fracture. The deficiency is associated with high blood pressure and diabetes, but it is unknown whether supplementation with vitamin D impacts these diseases. Studies now suggest vitamin D plays a role in age-related macular degeneration (AMD), and that drinking milk with added vitamin D can help protect against AMD.
People at risk for deficiencies	Older people, particularly if they live in the North, who are underexposed to sunlight. Obesity may also increase risk. There is some concern, in fact, that vitamin D deficiency may be a growing problem in the US among younger adults as sunscreen use becomes widespread. Individuals at highest risk for vitamin D deficiency are those who assiduously avoid the midday sun, wear protective clothing, regularly use sunscreen, and have dark skin. Exposure to sunlight for about 15 - 20 minutes at mid-morning or mid-afternoon three times a week is recommended for most people who live in temperate climates.
Toxicities	Vitamin D is very toxic in high doses. In infants, daily amounts higher than 1,000 IU can cause mental and growth retardation, kidney failure, and death. In children and adults, daily amounts over 50,000 IU can cause weakness, anorexia, vomiting, diarrhea, and mental changes. Prolonged use of megadoses can cause calcification of soft tissue and life-threatening kidney failure. Low-calcium diets and withdrawal from the vitamin can usually reverse the side effects except for kidney failure.


	Vitamin E (Tocopherol or Tocotrienol)	Vitamin K
Benefits	A fat-soluble antioxidant vitamin that helps prevent cell membrane damage and may inhibit oxidation of LDL cholesterol (a process that increases its harmful effects on arteries). Researchers once thought that vitamin E might protect against cardiovascular disease. This theory has been debunked. However, a 2007 study found that vitamin E supplementation reduced the risk of deep vein thrombosis (DVT) in women at risk for, or with a history of, DVT. Vitamin E supplements have also been shown to produce a statistically significant decrease in menopausal hot flashes. There is also early evidence that vitamin E may protect against ovarian cancer.	The most important function of vitamin K is its role in blood clotting and prevention of bleeding. As a result, the vitamin may be able to help treat hepatoma, leukemia, and hepatocellular carcinoma, a form of liver cancer. The vitamin also contributes to maintaining healthy bones and healing fractures. Vitamin K is widely used in Japan to treat osteoporosis, and studies suggest it may be effective in treating rheumatoid arthritis.
Recommended daily allowance (RDA) or dietary reference intake (DRI) (mcg = micrograms, mg = milligrams, IU = international units)	RDA is 15 mg (22 IU) for all adults, including pregnancy women. Nursing mothers need 19 mg (28 IU). (Supplements should be taken along with some oil or fat to be absorbed.) Vitamin E is composed of 8 compounds (four tocopherols and four tocotrienols). Vitamin E is most often available as supplements of dl alpha tocopherol (a synthetic form). Other vitamin E compounds may prove to be more active than the standard synthetic supplement. They include natural vitamin E, called d-alpha- or RRR-alpha-tocopherol succinate (VES). Other vitamin E compounds of interest are tocotrienol and beta and gamma tocopherol. Supplements that contain a combination of some of these forms may be most beneficial.	RDA is 60 - 65 micrograms (women) and 70 - 80 micrograms (men).
Foods containing the vitamin	Vegetable oils (particularly wheat germ oil), sweet potatoes, turnip greens, mangos, avocados, nuts, sunflower seeds, and soybeans. Tocotrienol (a possibly beneficial form) is found in natural tropical oils. Palm oil sold in the US is refined and does not contain tocotrienol.	Best dietary sources are canola oil, cruciferous vegetables, and soybean oil. Good sources are beef liver, bran, and olive oil. Also produced by bacteria in the intestines.
Effects of deficiencies	Deficiencies have not been established.	Easy bruising, bleeding. May increase the risk of hip fractures in women.
People at risk for deficiencies	Low-birth weight infants. People who eat a low-fat diet. People with medical problems that impair fat absorption, such as Crohn's disease, cystic fibrosis, steatorrhea, liver diseases (such as cirrhosis). People with abetalipoproteinemia, a rare genetic disorder that impairs fat metabolism.	Deficiency may occur in patients who have problems absorbing fats, such as those with cirrhosis, people who are on long-term antibiotic therapy, or who are taking other medications, including cholestyramine, Dilantin, and phenobarbital. Some evidence suggests that more young people may be deficient than previously believed.
Toxicities	Upper level recommended is 1,500 IU of alpha tocopherol. Large doses may cause bleeding problems, particularly in people taking anti-clotting medications. Some research now indicates that vitamin E, like other antioxidants, may have pro-oxidant and damaging effects. Although vitamin E is one of the best studied vitamins, research has yielded conflicting results, and definitive conclusions about the benefits and toxicity of vitamin E have not yet been determined. In a major 2005 study, there was no significant difference in cancer rates between people who took 400 IU of vitamin E daily and those who did not, although those who took the supplement had a higher risk of heart failure. Additional studies also link high levels of vitamin E with a slightly increased risk of heart failure and death. On the other hand, studies show that vitamin E may reduce heart problems in high-risk patients such as certain people with diabetes.	Allergic-type responses, including rash and itching, to high doses have been reported. Those who are taking Coumadin, an anticoagulant, should not take vitamin K without consulting a physician. Vitamin K deficiency can cause anorexia, lethargy, growth retardation, bone loss, soft tissue calcification, and death.

Carotenoids

Carotenoids are a group of more than 700 fat soluble nutrients that produce the colors in foods such as carrots, pumpkins, sweet potatoes, tomatoes, and other deep green, yellow, orange, and red fruits and vegetables. Many are proving to be very important for health. Beta carotene is the most widely studied carotenoid, but others are proving to be of great interest. As with some, but not all, carotenoids, beta carotene is known as a provitamin A because it converts to the vitamin in the body.

They are categorized as either xanthophylls or carotenes according to their chemical composition.

Carotenes are hydrocarbons and most are found in yellow, orange, and red vegetables. They include beta and alpha carotene and lycopene.

Beta Carotene and other Provitamin A Carotenoids. Beta carotene, alpha-carotene, and beta-cryptoxanthin are carotenes that are converted into vitamin A or retinol (the active form of vitamin A) in the body. They are found in many yellow fruits and vegetables. Beta carotene is the most widely studied carotenoid. Evidence now strongly suggests that when taken as a separate supplement it can have harmful effects.
Lycopene. Lycopene is responsible for the red color in fruits and vegetables, including tomatoes, red grapes, watermelon, and pink grapefruit. It is also found in papayas and apricots. It does not convert to vitamin A but may have important cancer fighting properties and other health benefits.
The beneficial actions of most carotenes such as those tomatoes, corn, and carrots, appear to be enhanced by cooking them, especially in oil (preferably olive, canola, or another monounsaturated oil). (Note: Cooking can also destroy certain nutrients, such as vitamin C, in these vegetables.)

Xanthophylls contain oxygen and most are found in green vegetables, such as broccoli, cabbage, and kale. They are also in yellow fruits and vegetables. Xanthophylls include lutein and zeaxanthin, which are both stored in the retina of the eye. Neither converts to vitamin A. Both are powerful antioxidants and may be very important for healthy eyes. Unlike carotenes, cooking may reduce the antioxidant activity of some xanthophylls in foods, although probably not to any significant degree.

Phytochemicals

The word phytochemicals means plant chemicals. Hundreds of phytochemicals are being studied. Many are believed to have a major positive impact on human health. Some contribute to the bright and vivid colors found in fruits and vegetables. The results of studies on specific phytochemicals are not necessarily applicable to the vegetables or fruits that harbor small concentrations of these chemicals.

Nevertheless, it is obvious that vegetables and fruits are healthful, which is probably due to some balance of phytochemicals, carotenoids, vitamins, fibers, and minerals rather than any single substance.

The benefits of individual phytochemical supplements are largely unproven. Furthermore, they are not regulated and high concentrations of some may behave like drugs and can be toxic and possibly even contribute to cancer cell growth.

Polyphenols are important phytochemicals, and flavonoids (or catechins) are members of the polyphenol family that may have significant health benefits. Laboratory studies have shown that specific flavonoids suppress tumor growth, interfere with sexual hormones, prevent blood clots, and have anti-inflammatory properties. In general, flavonoids are found in celery, cranberries, onions, kale, dark chocolate, broccoli, apples, cherries, berries, tea, red wine or purple grape juice, parsley, soybeans, tomatoes, eggplant, and thyme. Most common berries contain flavonoids and are particularly rich in potent antioxidants.

Among the important flavonoids are resveratrol, quercetin, and catechin. Evidence suggests that resveratrol (found in red wine, grapes, olive oil) may be extremely potent. In laboratory studies, it increases cell survival and has been shown to increase the life span of worms and fruit flies. Catechins are the primary flavonoids in tea and may be responsible for its possible beneficial effects. Flavonoids in dark chocolate may also be health protective.

Isoflavones, commonly known as phytoestrogens, have actions that are similar to the female hormone estrogen. A high consumption of soy, which is primarily composed of isoflavones, may reduce symptoms resulting from estrogen depletion during menopause. In a recent study, supplementation with isoflavones decreased hot flashes by 57% and night sweats by 43%, but other research is less favorable.

Lignan is another phytoestrogen and is found in the fiber layers of whole-grains, berries, some seeds, some vegetables, and a few fruits.

Isothiocyanates and related substances, indoles, are also known as mustard oils and are responsible for the sharp taste in cruciferous (also called brassica) vegetables. Such vegetables include broccoli, cabbage, Brussels sprouts, cauliflower, collards, kale, kohlrabi, mustard greens, rutabaga, turnips, and bok choy. Isothiocyanates also stimulate enzymes that convert estrogen to a more benign form and may block steroid hormones that promote breast and prostate cancers. (Cruciferous vegetables are also high in fiber, vitamin C, and selenium.)

Monoterpenes have two important phytochemicals, perillyl alcohol and limonene. They block proteins that stimulate cell growth and reproduction and are being tested for actions against cancer. Limonene is found in the peels of citrus fruits.

Organosulfurs are part of the allium family of phytochemicals. Compounds, such as allicin, may have benefits on the immune system, assist the liver in rendering carcinogens harmless, and reduce production of cholesterol in the liver. These compounds are found in garlic, leeks, onions, chives, scallions, and shallots.

Capsaicin seems to reduce levels of substance P, a compound that contributes to inflammation and the delivery of pain impulses from the central nervous system. Research suggests that it may inhibit cancer-generating substances. It is found in hot red peppers.

Sterols, which include sitosterol, stigmasterol, campesterol, and squalene, are found in vegetable oils. Sitosterol is the most studied and appears to have cholesterol-lowering effects.

Beta-sitosterols may help improve urine flow and urinary symptoms in men with enlarged prostate glands (benign prostatic hyperplasia, or BPH). A recent review study of five randomized trials (519 men) found that urinary flow and other urinary symptoms improved in men who took the herbal remedy from 4 - 26 weeks. The study’s authors cautioned that while beta-sitosterols show effectiveness in the short term, their long-term effectiveness, ability to prevent complications from BPH, and safety are not known. More research is necessary. Beta-sitosterols come from South African star grass, Hypoxis rooperi, or species of Pinus and Picea.

Healthy Foods

Evidence increasingly suggests that a varied diet, not individual food chemicals, is essential for basic health and a longer life. Such diets are rich in fresh fruits and vegetables and whole grains, and low in saturated fats.


Foods	Phytochemicals and Carotenoids	Vitamins and other valuable food components	Benefits
Apples	Flavonoids		May have activity against certain cancers (lung). Also may help maintain healthy cholesterol. May protect against asthma.
Beans	Flavonoids	Folate, iron, potassium, and zinc	Some experts believe beans are the perfect food.
Berries, all kinds of dark colored	Ellegic Acid	Vitamin C, minerals	The anthocyanins in berries such as bilberries, blueberries, cranberries, elderberries, and others, have numerous healthful properties including anti-cancer and antioxidant effects. Bilberry (Vaccinium myrtillis) is widely used to prevent macular degeneration. Blueberries may protect the aging brain. (In one study blueberries were most effective.)
Broccoli (also kale, Brussels sprouts, cauliflower)	Flavonoids, isothiocyanates, lutein, beta and alpha carotene. Note: Young sprouts of broccoli and cauliflower contain much higher levels of isothiocyanates than their mature forms.	Vitamin C, folate, fiber, and selenium	Anticancer properties. Protective against heart disease and stroke.
Carrots and other bright yellow vegetables	Lutein, beta carotene and other provitamin A carotenoids	Vitamin A (converted from carotenoids), vitamin C	Protects eyes, lungs. (Cooking carrots may increase the potency of food nutrients.)
Chocolate, dark. Note: Milk chocolate does not have benefits.	Flavonoids		Heart protective (may improve lipids and help prevent blood clotting. May have protective properties against lung cancer (not other cancers).
Eggs	Lutein	Many B vitamins, vitamin A, vitamin D	Although egg yolks are high in cholesterol, very little of it has a negative effect on people with normal levels. And the health benefits of eggs are now known to be very high. (People with diabetes or those with high cholesterol should restrict eggs, however.)
Fish, oily (mackerel, salmon, sardines)		Vitamin B3, B12. Essential fatty acids, selenium	Heart and brain protective.
Garlic	Allium (organosulfurs)		Possibly protective against certain cancers, heart diseases, and infection. Heating garlic can reduce benefits. Allowing crushed fresh garlic to stand 10 minutes before heating, however, may preserve beneficial chemicals while cooking.
Ginger	Zingiberaceae		Cancer fighting properties.
Grains (whole)	Lignans (phytoestrogens)	Vitamin B, Selenium (important antioxidant mineral), fiber, folate	May help reduce the ability of cancer cells to invade health tissue.
Grapes, including purple grape juice, and red wine	Flavonoids, (resveratrol, quercetin and catechin)		Fight heart disease and cancer. May help lower the risk for asthma.
Nuts		Vitamin E, vitamin B1, essential fatty acids, folate	Protects the heart and may help prevent stroke.
Onions	Flavonoids, allium (organosulfurs)		May have activity against certain cancers (lung).
Oranges	Monoterpenes	Vitamin C, folate, potassium.	Many health benefits. Increases HDL levels.
Potatoes (Sweet)		Vitamin C, vitamin E, vitamin A	Many health benefits.
Soy. The best products are tofu, soy milk, or whole soy protein.	Isoflavones (phytoestrogens), flavonoids, phytosterol, phytate, saponins.		May have effects similar to estrogen, including maintaining bone and benefiting the heart in women. May also be protective against prostate cancer and possibly other cancers. More studies are needed. Effects on breast cancer are uncertain. (Note: Soy may have different effects in men than in women. Of some concern is one study reporting more mental decline in men who consume greater amounts of tofu.)
Spinach and other dark green leafy vegetables	Zeaxanthin, Beta carotene	Vitamin C, folate, vitamin A (converted from carotenoids)	Protects lungs and brain.
Tea (Both black and green tea are beneficial. Best results associated with green tea.)	Flavonoids (primarily catechins)		Cancer fighting properties, particularly in green tea, which may be especially beneficial for smokers. Both black and green tea may protect against heart disease and stroke, although studies are mixed. Tea drinking also may help with weight control and help prevent osteoporosis.
Tomatoes	Lycopene, Flavonoids	Vitamin C, biotin, minerals	Studies link to reductions in prostate and other cancers. Infection fighters.
Note on Organic versus Inorganic Products. There is some evidence that organic produce has higher levels of antioxidants and that some agricultural chemicals may destroy flavonoids. Nevertheless, organic produce is expensive, and fruits and vegetables, no matter how they are grown, are still filled with healthful nutrients.

Dietary Health Benefits

The benefits of any dietary factors are very difficult to prove, and, to date, there is little evidence that most dietary supplements protect against major diseases in otherwise healthy people with normal eating habits. An exception is lutein, which is known to reduce the risk of macular degeneration. However, a diet naturally high in vitamins and minerals can be the best defense against many diseases. Fresh fruits and vegetables and whole grains are the primary sources of vitamins, carotenoids, and vitamins, as well as of fiber and important minerals.

Description of Oxygen-Free Radicals (Oxidants). Currently, the most important benefit claimed for vitamins A, C, E, and many of the carotenoids and phytochemicals is their role as antioxidants, which are scavengers of particles known as oxygen-free radicals (also sometimes called oxidants). These chemically active particles are by-products of many of the body's normal chemical processes. Their numbers are increased by environmental assaults, such as smoking, chemicals, toxins, and stress. In higher levels, oxidants can be very harmful in the following way:

They can damage cell membranes and interact with genetic material, possibly contributing to the development of a number of disorders including cancer, heart disease, cataracts, and even the aging process itself.
Oxygen-free radicals can also enhance the dangerous properties of low-density lipoprotein (LDL) cholesterol, a major player in the development of atherosclerosis.

Description of Antioxidants and Warnings on High-Dose Supplements. Antioxidant vitamins (A, C, and E), carotenoids, and many phytochemicals can neutralize free radicals. Unfortunately, although it is clear that vitamins are required to prevent deficiency diseases, high doses of vitamin C, vitamin E, and beta carotene supplements may also have pro-oxidant effects, which can be harmful in patients with cancer. In these people, high doses of antioxidant vitamins may actually protect cancer cells just as they do healthy cells.

The strongest evidence on negative effects to date comes from studies reporting an increase in lung cancer and overall mortality rates among smokers who took beta carotene supplements. In determining reasons for this disturbing effect, one animal study suggested that beta carotene increased enzymes in the lungs that actually promote cancerous changes. One study also reported a higher risk for cancer in male smokers who took multivitamins plus A, C, or E.

Some evidence also indicates that high doses of vitamin C may speed up atherosclerosis, or hardening of the arteries. In one study, women with heart disease who took antioxidant vitamins had a higher risk for heart attack or death than those who didn't take one.

Another study also reported a higher incidence and greater severity of respiratory infections in older adults who took 200 mg of vitamin E daily. Some researchers speculate that certain immune factors generate oxidants to fight bacteria. This antioxidant vitamin, then, may block that action. Research published in 2005 suggests that those who take large amounts of vitamin E (1,500 IU/day) may slightly increase their risk for heart failure and death, but this evidence is not considered conclusive. Further study is necessary.

Vitamins and Heart Protection.

Antioxidant Vitamins A, C, and E. Deficiencies in vitamins A, C, E, and beta carotene have been linked to heart disease. All of these nutrients have antioxidant effects and other properties that should benefit the heart. A study in patients with heart failure has shown that vitamin C can work with dobutamine, a powerful intravenous medication, to strengthen the heart’s ability to contract following a heart attack. In fact, a 2005 study has found that taking high doses of vitamin E is associated with an increased risk of heart failure. In 2007, the Women’s Antioxidant Cardiovascular Study failed to find that vitamins C, E, and beta carotene could reduce the risk of heart attack, stroke, need for revascularization, or cardiovascular death in women. According to the U.S. Preventive Service Task Force, evidence is insufficient to confirm or refute the benefits of supplements of any of these vitamins in protecting against heart disease.
Folate and B12 Vitamins. Deficiencies in the B vitamins folate (known also as folic acid) and B12 have been associated with elevated blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure. One study, reported lower failure rates after heart surgery in patients who took folic acid and vitamins B12 and B6. And a major 2002 study suggested that lowering homocysteine levels with folic acid would reduce the risk for heart disease by 16% and stroke by 24%. However, a 2007 trial in adults with stable coronary artery disease found that lowering homocysteine levels 33% with B vitamins and folic acid had no effect on arterial inflammation, meaning that lower levels were unlikely to offer protection against heart attack or stroke. More evidence is needed to determine whether homocysteine plays a causal role in cardiovascular disease and whether the B vitamins are protective. Folate improves blood flow through the arteries, which may be important for the heart, regardless of its effect on homocysteine. Although people with high levels of homocysteine are prone to damaging blood clots in their arteries and veins, a 2007 study found that lowering homocysteine with folic acid and other B vitamins does not reduce the incidence of blood clots in the peripheral veins (deep venous thrombosis).
Niacin. Niacin (vitamin B3) is used for lowering unhealthy cholesterol levels. Although vitamin B3 is available over the counter, it can have significant side effects. A physician should prescribe niacin in order to ensure its safety and effectiveness. [See In-Depth Report #23, Cholesterol.]

Carotenoids and Heart Protection. Studies have reported that a diet high in fruits and vegetables containing beta carotene, lycopene, and other carotenoids may reduce the risk of heart attack. A small Finish study found that a diet high in tomatoes reduced total cholesterol and LDL ("bad") cholesterol. Diets low in lycopene (particularly from tomatoes) were associated with a significantly higher risk of heart disease and stroke.

Atherosclerosis is a disease of the arteries in which fatty material is deposited in the vessel wall, resulting in narrowing and eventual impairment of blood flow. Severely restricted blood flow in the arteries to the heart muscle leads to symptoms such as chest pain. Atherosclerosis shows no symptoms until a complication occurs.

Phytochemicals and Heart Protection. Several phytochemicals are associated with heart protection.

Flavonoids. Certain flavonoids, found in both black and green tea, dark chocolate, onions, red wine or red grape juice, and apples, appear to be strongly heart protective. In one study, people who consumed the most flavonoids in foods had a 20% lower risk for heart disease than those with low consumption. Flavonoids may protect against damage done by cholesterol and help prevent blood clots. A number of studies have now reported heart protection from the flavonoid catechin, which is found in both black and green tea. The flavonoid resveratrol, which is found in grape skin, appears to be responsible for the well-known heart protective effects in red wine and purple grape juice.
Organosulfurs. Organosulfurs found in onions and garlic have been under investigation for possible beneficial effects on cholesterol levels. One study reported an association between taking garlic capsules and significantly lower cholesterol-build up in the arteries of older women but not in older men. In the study, daily garlic supplements dramatically reduced the build-up of newly formed plaque in the arteries, while having much less effect on older, harder plaque deposits. Garlic supplements for cardiovascular disease may be most beneficial when used during earlier years among men and later years among women.
Isoflavones. Soy protein is the most studied source of isoflavones (known as phytoestrogens, or plant estrogens). Not all studies are consistent, but the majority has shown an improvement in at least one of the cholesterol components in people who consumed at least 25 grams of soy protein. A 2007 meta-analysis of all soy protein studies performed from 1990 - 2006 found that soy protein significantly decreased total cholesterol and LDL cholesterol, but had no effect on HDL or triglycerides. The effect was particularly evident in people with hypercholesterolemia. A 2007 study found that 12 weeks of soy supplement lowered total cholesterol and LDL levels in both Caucasian and African-American postmenopausal women. Soy may also reduce other heart risk factors, at least in certain populations. For example, in one 2002 study, soy was beneficial for controlling blood sugar and lowering LDL in postmenopausal women with type 2 diabetes. In a 2007 study of overweight men and postmenopausal women, soy protein reduced blood pressure and arterial stiffness. In another study, soy protein was associated with lower systolic blood pressure in men. The best sources are soy products (tofu, soy milk) or whole soy protein. Powdered soy protein that contains at least 60 mg of isoflavones may provide similar benefits.
Sterols. The plant sterols, including sitosterol, are also proving to be potent cholesterol fighters by blocking the absorption of cholesterol in the intestine. Sitostanol, a derivative of sitosterol, is being used in new margarine products to lower cholesterol levels. Sterols and stanols are now found in breads, cereals, yogurt, and fruit juices.

A healthy diet rich in fruits and vegetables and low in salt and saturated fats may significantly lower the risk for a first stroke, perhaps by helping to protect against high blood pressure -- a major risk factor for stroke.

Vitamins and Stroke Protection. The effects of antioxidant vitamins and carotenoids on stroke, dementia, or both are being studied. Studies are conflicting, however. A 2007 study of 8,171 women with cardiovascular disease reported that vitamins C, E, and beta carotene offered no protection against heart attack and stroke.

The B vitamin folate (usually in the form of folic acid) may protect against stroke. However, exactly which people benefit from this therapy has yet to be determined. Studies have suggested that people who have higher blood levels of folate have a lower than average risk for stroke. Its primary benefit in this case appears to be to reduce levels of homocysteine, an amino acid that has been strongly linked to an increased risk of coronary artery disease, stroke, and Alzheimer's disease. A 2007 meta-analysis of 8 trials found that folate supplements decreased homocysteine 20% and lowered stroke risk 18%. Interestingly, lowering homocysteine with folic acid and B vitamins had no effect on heart attack, strokes, amputations, need for dialysis, or death in patients with chronic or end-stage kidney disease.

Carotenoids and Stroke Protection. Some, but not all, studies have reported a lower risk of stroke from carotenoids, including beta carotene and lycopene.

Many fresh fruits and vegetables contain chemicals that may fight many cancers, including lung, breast, colon, and prostate cancers. Examples of important cancer fighting foods include the following:

Cruciferous vegetables (such as cabbage, Brussels sprouts, and broccoli)
Tomatoes (which contain lycopene)
Carrots (which contain alpha carotene)

Some evidence suggests that antioxidants may enhance the anticancer effects of chemotherapy. In multiple studies, patients who maintained their antioxidant levels were better able to withstand the high stress caused by chemotherapy or radiation therapy compared to those with low antioxidant levels. Antioxidant nutrients that may help reduce the side effects of chemotherapy include vitamins E and C, beta carotene, genistein and daidzein (isoflavones found in soy), and quercetin (found in red wine an purple grape juice).

Any protective effects of vitamins or specific phytochemical against cancer, however, appear to depend on the cooperative effort among them. Individual supplements of any vitamin or food chemical have not as yet shown any benefits.

Additionally, certain supplements may actually encourage tumor growth, particularly when taken in large amounts. Two 2007 studies found a connection between folate supplements and colorectal cancer. In one study, which was designed to evaluate the benefits of folic acid in patients who had previous colorectal adenomas (precancerous polyps), the researchers instead found that folic acid was associated with a higher risk of having 3 or more adenomas and noncolorectal cancers. In another study, it was noted that the downward trend in colorectal cancer diagnoses abruptly started to rise in 1996 when mandatory folate enrichment of grains within the U.S. and Canada began. Rates continue to exceed pre-1996 levels. Additionally, a large 2007 National Cancer Institute/AARP study found an increased risk of advanced and fatal prostate cancer in men who took more than 7 multivitamins a week, but no association between multivitamin use and localized prostate cancer.

High consumption of cruciferous vegetables (at least once per week) was associated with lower risk of kidney cancer, and low consumption (less than once per month) of cruciferous vegetables was associated with higher risk of kidney cancer in a multinational 2007 European study. Cruciferous vegetables also appear to offer protection against head and neck cancer resulting from chemical toxins found in cigarettes and alcohol, for example.

Vitamins and Cancer Protection. Because many cancers are thought to be initiated by the effects of oxygen-free radicals on DNA, the antioxidants A, C, and E and beta carotene have been intensively studied. A major study found that men who took selenium for 6 or 7 years reduced their risk of prostate cancer by 52%. Nevertheless, most individual supplements have not been proven to protect against cancer, and high doses may be dangerous.

A 2007 review of the diets of men exposed to asbestos found a decreased risk of prostate cancer associated with increasing intakes of vitamin C-rich vegetables, but not fruits and vegetables high in vitamin A. The chemopreventive role of silymarin (Silybum marianum), found in milk thistle extract, has been extensively studied and has shown anticancer efficacy against various cancers, especially prostate and skin, by inhibiting UVB radiation.

A review of 13 cancer registries found 416,134 cases of skin cancer and 3,776,501 cases of non-skin cancer as a first cancer. Rates from cancer registries in sunny countries (such as Australia and Spain) and less sunny countries (such as Canada and Iceland) were compared. The researchers concluded that vitamin D production in the skin decreases the risk of several solid cancers, especially stomach, colorectal, liver and gallbladder, pancreas, lung, female breast, prostate, bladder, and kidney cancers. The apparently protective effect of sun exposure against second primary cancer is more pronounced after non-melanoma skin cancers than melanoma.

Consumption of aflatoxins, a common fungus-related toxin infecting cereal grains, oil seeds, spices, tree nuts, and the milk of animals fed contaminated feed, is known to cause hepatocellular carcinoma, a deadly form of liver cancer. Rodent studies have shown that phenolic antioxidants, dithiolethiones, isothiocyanates, and triterpenoids may act as chemopreventive agents, dispersing aflatoxins and protecting against hepatocellular carcinoma. Human trials are planned. A similar study found that several isothiocyanates, diallyl sulfide, and polyphenolic compounds can prevent esophageal dysplasia from progressing to squamous cell carcinoma.

A review of all articles on vitamins and cancer published through February 2007 found that multivitamin/mineral supplement use may prevent cancer in individuals with poor or suboptimal nutritional status. One trial on poorly nourished Chinese showed supplementation with combined Beta-carotene, vitamin E and selenium reduced gastric cancer incidence and mortality, and overall cancer mortality. In a French trial, combined vitamin C, vitamin E, beta-carotene, selenium, and zinc reduced cancer risk in men but not in women. With few exceptions, neither beta-carotene nor vitamin E had benefits for preventing cancer. Beta-carotene supplementation increased lung cancer risk in smokers and persons exposed to asbestos.

A 2007 study of nearly 82,000 men and women in Sweden found that high intake of methionine was associated with reduced risk of pancreatic cancer. The same relationship was not seen with vitamin B6 or folate.

Vitamin A, C, and E. Although some studies have reported an association between low blood levels of these antioxidant vitamins and a higher risk for cancer, supplements of vitamins A, C, and E appear to have few advantages in most cases. And there are some studies finding higher cancer risks with high intakes of antioxidants. For example, a 2003 study reported a higher risk in melanoma in people with vitamin-C rich diets. Another study also reported a higher risk for cancer in male smokers who took multivitamins plus A, C, or E. (Vitamin E may be protective against bladder cancer and ovarian cancer.)
Vitamin D. Some studies have suggested that certain vitamin D compounds may inhibit certain cancer cells, specifically prostate cancer, from proliferating. More research is needed. In 2007, the National Cancer Institute confirmed that ultraviolet (UV) radiation exposure may reduce the risk of developing non-Hodgkin lymphoma (NHL), but only in patients with certain variations in the D vitamin receptor gene. A second 2007 study found that variations in this gene increase the risk of diffuse large B-cell lymphoma. A 2007 prospective analysis of 31,500 women in the Women’s Health Study evaluated calcium and vitamin D intake. The researchers found a moderately lower risk of premenopausal, but not postmenopausal, breast cancer with higher intakes of total calcium and vitamin D. A 2007 review of breast cancer cases reported in Ontario, Canada, found reduced breast cancer risks were associated with increasing sun exposure in women ages 10 - 19, less evidence for associations in women ages 20 - 29, and no evidence for ages 45 - 54. Researchers concluded that sun exposure earlier in life, particularly during breast development, may be key in the connection between vitamin D exposure and breast cancer risk.
Folic acid and B12. These B vitamins convert the amino acid homocysteine to methionine, a substance that helps prevent cells from becoming malignant. Folic acid may provide some protection against cervical and colon cancer. One small study showed a reduction of lung cancer cells in smokers taking folic acid and vitamin B12, but the study was very small, of short duration, and other factors might have biased the results. Still another study reported that folic acid may reduce the risk for breast cancer among women who regularly drink alcohol. (In the study, folic acid had no other effect on breast cancer.)

In 2006, a study for the National Institutes of Health reviewed randomized trials evaluating the effectiveness and safety of multivitamin and mineral supplements in preventing cancer and chronic disease. The studies had mixed results, and some supplements reduced cancer rates in certain populations. However, the reviewers concluded that current evidence is not sufficient to determine whether multivitamin and mineral supplements may prevent cancer and chronic disease.

Carotenoids and Cancer Protection. A number of studies have reported that fruits and vegetables rich in carotenoids are associated with protection against many cancers. Lycopene, found in tomatoes, may have particular value in protection against prostate, colon, lung, and bladder cancer. A 2005 study found that in one out of four men with genetic variations that cause them to be more sensitive to oxidative stress, supplementation with selenium, vitamin E, and lycopene significantly reduces the risk of prostate cancer. Individual supplements, however, do not offer any advantage. In fact, evidence now strongly suggests that beta carotene supplements increase the risk for lung cancer in smokers and people exposed to asbestos

Phytochemicals and Cancer Protection. The following phytochemicals appear to have cancer-protecting properties.

Isothiocyanates. Isothiocyanates and sulforaphane, found in cruciferous vegetables, may block the effects of carcinogens and suppress tumor growth. In one study, for example, women with the highest consumption of cruciferous vegetables had a 24% lower risk of breast cancer than women with the lowest consumption.
Isoflavones. Isoflavones, found in soy beans and flax seed, behave like estrogen in some ways and not in others. Researchers are very interested, then, in their effects on hormone-related cancers, including breast and prostate cancers. Much research has focused on soy. In general, a number of Asian studies have reported an association between a higher intake of soy and a lower incidence of reproductive and breast cancers. The effects of phytoestrogens, however, in all women are far from settled. Some evidence suggests the genistein in soy may have properties that are protective against lung cancer. Nonfermented soy products (tofu, soy milk) also may protect against stomach cancer, while fermented soy products (miso, soy paste) appears to increase the risk.
Organosulfurs. The organosulfur compounds found in the onion and garlic family may have very potent properties in suppressing or blocking carcinogenic substances. A 2007 study found that synthetic organosulfur compounds act as selective inhibitors of growth in breast cancer cells. Studies indicate that people who regularly consume fresh or cooked garlic have about half the risk of developing stomach cancer and two thirds the risk of colorectal cancer as people who eat little or no garlic. One possible explanation for garlic's anti-cancer effect in the stomach is its antibacterial action against H. pylori, which can promote stomach cancer. Taking garlic supplements, however, did not offer these benefits.

It should be noted that studies on the health benefits of vitamins and minerals have some important limitations. Some are held to rigorous standards, while others are not. In most cases, the results of existing research are complex, as they can easily be complicated by factors such as diet, exercise, the presence of healthy or unhealthy lifestyle behaviors, environmental factors, and more.


Disease or Condition	Vitamins	Carotenoids, Phytochemicals, and Healthy Foods
Alzheimer's Disease	Vitamin E. Some reports, including a large 2002 population study, have suggested that vitamin E intake, from food or supplements, may protect against mental decline. (One study suggested that the vitamin protected only those who carried the apoE4 gene. No strong evidence to date has found any protection from antioxidant supplements.) Some studies performed since 2002 challenge this finding, while others agree with it. B Vitamins. Some studies suggest that deficiencies of the B vitamins B6, B12, and folate may be a risk factor for Alzheimer' diseases, possibly because deficiencies elevate homocysteine levels, which some research now associated with a higher risk for Alzheimer's disease. Of these, folates may offer the best protection. In 2007, researchers at Tufts-New England Medical Center reviewed all human studies on folate, vitamin B-6, vitamin B-12, and cognitive function in the elderly conducted between 1966 and November 2006. Six of 10 folate studies reported a significant association between low baseline blood folate concentrations and poor cognitive test performance; 4 of 9 folate studies found associations between low blood folate concentrations and increased prevalence of Alzheimer's disease. No association between vitamin B-6 and vitamin B-12 blood concentrations and cognitive-test performance or Alzheimer's disease was seen, and B-vitamin dietary intake was not associated with cognitive function. Although the majority of studies indicated that low blood folate concentrations predicted poorer cognitive function, data are not solid, due to variations in the way the studies were conducted and lack of agreement on what constitutes a low B-vitamin status.	According to several studies, eating plenty of darkly colored fruits and vegetables may slow brain aging. The estrogen-like properties in isoflavones are of interest in the study of Alzheimer's disease. Animal studies suggest that soy might be protective against AD, particularly in postmenopausal women. Of some concern, however, were one population and a few animal studies suggesting that soy intake may pose a risk for greater mental decline among older men. More research is needed to confirm the effects of soy on the aging brain and to determine if there are gender differences.
Infectious Disease	Studies are mixed whether vitamin supplements protect against upper respiratory infections. Large doses of vitamin C, for example, may help reduce the duration of a cold, but they do not appear to protect against one in the first place, even after exposure to a cold virus. Two studies in 2002 on multivitamins reported opposite results, with one finding fewer infections and one finding no difference. It is possible that vitamin C or multivitamin supplements may be helpful in specific people, such those who are vitamin deficient or have medical problems that impair their immune systems. A review of all studies on vitamin C and pneumonia prevention found only 1 placebo-controlled, randomized trial conducted in an English boarding school during World War II. The trial found a statistically significant (80% or greater) reduction in pneumonia incidence among boys consuming vitamin C. Two less-well-constructed trials arrived at the same conclusion. Therapeutic trials were even scarcer. Only one randomized, double-blind, placebo-controlled study of vitamin C for treatment of pneumonia was found. In this trial, elderly patients given vitamin C had lower mortality and respiratory symptom scores. However, the benefits were restricted to the sickest patients. One other trial of adults in the former Soviet Union found a dose-dependent reduction in the time to recover with two vitamin C doses. One 2007 study on vitamin D found that a single dose by mouth of this vitamin might prevent healthy individuals from activating the bacterium that causes tuberculosis in patients who harbor the infection. Studies on vitamin E specifically have been mixed. A 2002 study, in fact, reported a higher incidence and greater severity of respiratory infections in older adults who took 200 mg of vitamin E daily. However, a 2004 clinical trial conducted among elderly nursing home residents found that daily supplementation with 200 IU of vitamin E did provide protection from upper respiratory infections, especially the common cold. At present, there is not enough evidence to recommend vitamin E for infection prevention. Diarrhea is a worldwide problem, particularly in developing countries and those with poor sanitation. Taking supplements with B-complex vitamins, vitamin C, vitamin E, and selenium may reduce the risk of diarrhea, depending upon the organism that causes the disease. Meanwhile, iron supplements appear to increase the risk of infection from organisms that cause diarrhea. Vitamin A has not been shown to prevent diarrhea. Urinary tract infections (UTIs) may affect as many as 25% of pregnant women. A 2007 study found that women who took vitamin C (100 mg) for 3 months had significantly fewer UTIs than women who did not take vitamin C supplements. Rotavirus is a common cause of acute gastric pain in children under age 5. A 2007 study showed that the high amount of isoflavones found in soy-based infant formula can help prevent rotavirus infection.	Lycopene, found in tomatoes, appears to have properties that protect infection-fighting white blood cells. Saponins extracted from ginseng and allicin (found in garlic) have properties that boost the immune system. Both ginseng and garlic have long been traditionally used for their health benefits.
Asthma	Vitamin C from diet has been associated with lower risk for asthma. In one study, some people with exercise-induced asthma benefited from taking vitamin C one hour before strenuous physical activity. In a 2007 study, taking 1,500 mg supplements of vitamin C for 2 weeks helped prevent exercise-induced airway narrowing in patients with asthma.	Flavonoids found in apples and red wine may help lower the risk for asthma. Some evidence indicates that a low dietary intake of antioxidant nutrients could increase the risk for lung damage. Such nutrients should be obtained from fresh, deep green and yellow-orange fruits and vegetables. A 2007 study found low blood lycopene levels in people with asthma. Increasing lycopene- and vitamin A-rich foods may help raise lycopene levels.
Eye Disorder	Cataracts and Macular Degeneration. Oxygen-free radicals play a role in cataract formation and age related macular degeneration, the most common cause of irreversible blindness in the elderly. Bilberry (Vaccinium myrtillis), which contains powerful anthocyanins, is widely used to prevent macular degeneration. Low levels of vitamin C in the lens of the eye have been particularly strong predictors of cataracts. People with cataracts are frequently deficient in vitamin A, the carotenes, lutein, and zeaxanthin. Studies on protection against cataracts using antioxidant supplements have been mixed, including two identically conducted studies that reported opposite results. Vitamin C currently has the strongest evidence for protection, but even with this antioxidant studies are not consistent. A combination of zinc and antioxidants, including vitamin C and E, may slow the progression of macular degeneration. (Vitamin E alone does not appear to be protective.) Glaucoma. Although no evidence exists that antioxidants will prevent glaucoma, some studies reported an association between vitamin E and improved visual fields in patients with glaucoma.	Several studies report that the consumption of antioxidant-rich foods is associated with a decreased risk for cataracts. Carotenoids, especially lutein, lycopene, and zeaxanthin, are especially eye-protective and may help prevent cataracts and macular degeneration. The National Eye Institute in 2007 suggested that people with intermediate- or advanced macular degeneration in one eye may want to take a vitamin formula shown to reduce the risk of macular degeneration in the other eye by 25%. The formula contains vitamin C, vitamin E, beta-carotene, and zinc. They also suggest that a diet high in lutein and zeaxanthin may help reduce the risk of advanced age-related macular degeneration. Several studies report that the consumption of antioxidant-rich foods is associated with a decreased risk for cataracts. Carotenoids, especially lutein lycopene, and zeaxanthin are especially eye-protective and may help prevent cataracts and macular degeneration.
Skin Disorders and Wrinkles	Topical vitamin A (retinol) has been shown to improve fine wrinkles due to aging, by increasing glycosaminoglycan, which retains water, and increasing collagen production. One small study found that taking a combination of vitamins oral C and E supplements may help reduce sunburn reactions, although the protection is much less than from sunscreens. Taking the vitamins singly did not have any effect. In fact, a 2002 study reported that oral vitamin C had no effect on sunburn reaction. Of concern, in the same study some natural antioxidants in the body were reduced in people who took the vitamin. Also of concern are studies reporting no benefits and possibly harm from topical vitamin C in the form of ascorbyl palmitate, which is soluble in fat. One study reported that older adults had fewer wrinkles if they ate whole grains, fresh fruits and vegetables, and the use of healthy oils (such as olive oil). Diet played a role in improving skin regardless of whether the people in the study smoked or lived in sunny countries.	The following foods and phytochemicals may be especially skin protective: Both green tea and ginger appear to have properties that may provide some protection against skin cancer. Green tea skin care products are now available. The substance silymarin, found in the milk thistle family (which includes artichokes), may inhibit UVB-promoted cancers in animals. In one interesting study, eating garlic protected animals very effectively against UVB damage by interfering with urocanic acid in the skin. Whether these results may apply to humans (and what quantities of garlic might be beneficial) is still unknown.
Osteoporosis	Vitamin D. Vitamin D is the essential companion to calcium in maintaining strong bones. Supplements may be needed for people who have poor exposure to sunlight. It should be noted that diet supplies most people's need and high amounts of vitamin D can be toxic. Of interest: Taking vitamin D supplements does not prevent bone loss in post-menopausal African American women, according to research published in 2005. Further study will be needed to determine whether vitamin D prevents bone loss in women from other ethnic groups. Vitamin K. Studies suggest that vitamin K has properties that protect bone and prevent fracture. Vitamin K2 (menatetrenone), a form of vitamin K, is proving to prevent fractures in people with osteoporosis. Vitamin K affects blood clotting, and supplements are not recommended without specific physician instruction. Vitamin B12. One study reported that in people with osteoporosis and pernicious anemia, taking vitamin B12 (which is used to treat the anemia) also increased bone density. Vitamin C and E. There has been some indication of a positive association between vitamin C and E intake and bone density, although evidence proving actual benefits is weak. Note on Vitamin A. High amounts of dietary vitamin A reduces bone density and may even increase the risk for fracture in both postmenopausal women and men. (A form of vitamin A, retinoic acid, has been found to stimulate bone break down.) Beta carotene does not appear to increase risk. Studies suggest that diets rich in fresh fruits and vegetables (which include those high in potassium and magnesium) reduce elimination of calcium from the body and help preserve bones.	Studies suggest that diets rich in fresh fruits and vegetables (which include those high in potassium and magnesium) reduce elimination of calcium from the body and help preserve bones. Studies are suggesting that isoflavones-rich soy products may actually improve bone density in postmenopausal women. A 2007 study of postmenopausal women in Italy found that 24 months of treatment with genistein plus calcium and vitamin D increased bone density, while women who took calcium and D alone lost bone density. Flavonoids and other compounds in tea may protect the bones.
Menstrual Disorders	Vitamin B6. Limited clinical evidence suggests that vitamin B6 may be beneficial in reducing premenstrual symptoms, including depression. Typically, women take 100 mg per day, although one study suggested that a lower dose (50 mg) may have the same effect. Other preliminary research indicates that women who receive the equivalent of 1,200 mg of calcium and 400 IU of vitamin D per day (through food or supplements) have a significantly lower incidence of premenstrual symptoms than women who did not. Vitamin B1. One study reported relief from menstrual pain using vitamin B1 (thiamin). Vitamin E. Several randomized controlled trials have shown that vitamin E significantly improves both physical and emotional premenstrual symptoms. One study reported that high doses of vitamin E helped reduce menstrual cramps. The doses were much higher than those recommended and could possibly increase the risk for bleeding. Although anecdotal evidence reports that vitamin E helps reduce the frequency of hot flashes for menopausal women, there is no clinical evidence to support this claim.

Resources

http://fnic.nal.usda.gov -- The Food and Nutrition Information Center
http://dietary-supplements.info.nih.gov -- Office of Dietary Supplements, National Institutes of Health
www.ars.usda.gov/ba/bhnrc/ndl -- Nutrient Data Laboratory
www.fda.gov -- Food and Drug Administration
www.eatright.org -- The American Dietetic Association
www.acsh.org -- American Council on Science and Health
www.aicr.org -- American Institute for Cancer Research
www.nutritiondata.com -- Information on vitamins and nutrients in foods
www.consumerlab.com -- Independent testing of nutritional supplements' contents and quality
www.usp.org -- US Pharmacopeia
www.herbs.org -- Herb Research Foundation

References

Age-Related Eye Disease Study Research Group, SanGiovanni JP, Chew EY, Clemons TE, Ferris FL 3rd, Gensler G, Lindblad AS, Milton RC, Seddon JM, Sperduto RD. The relationship of dietary carotenoid and vitamin A, E, and C intake with age-related macular degeneration in a case-control study: AREDS Report No. 22. Arch Ophthalmol. 2007;125(9):1225-1232.

Ambrosini GL, de Klerk NH, Fritschi L, Mackerras D, Musk B. Fruit, vegetable, vitamin A intakes, and prostate cancer risk. Prostate Cancer Prostatic Dis. 2007 May 22; [Epub ahead of print]

Aubertin-Leheudre M, Lord C, Khalil A, Dionne IJ. Six months of isoflavone supplement increases fat-free mass in obese-sarcopenic postmenopausal women: a randomized double-blind controlled trial. Eur J Clin Nutr. 2007 Feb 21; [Epub ahead of print]

Bermudez Y, Ahmadi S, Lowell NE, Kruk PA. Vitamin E suppresses telomerase activity in ovarian cancer cells. Cancer Detect Prev. 2007;31(2):119-28. Epub 2007 Feb 28.

Bodnar LM, Catov JM, Simhan HN, Holick MF, Powers RW, Roberts JM. Maternal vitamin d deficiency increases the risk of preeclampsia. J Clin Endocrinol Metab. 2007 ;92(9):3517-22. Epub 2007 May 29.

Clements RH, Katasani VG, Palepu R, Leeth RR, Leath TD, Roy BP, Vickers SM. Incidence of vitamin deficiency after laparoscopic Roux-en-Y gastric bypass in a university hospital setting. Am Surg. 2006;72(12):1196-202.

Coull DB, Tait RC, Anderson JH, McKee RF, Finlay IG. Vitamin B12 deficiency following restorative proctocolectomy. Colorectal Dis. 2007;9(6):562-566.

Dietary Guidelines for Americans 2005. Dept of Health and Human Services, US Dept of Agriculture. Accessed 10/3/2007.

Fischer Walker CL, Black RE. Micronutrients and diarrheal disease. Clin Infect Dis. 2007;45 Suppl 1:S73-S77.

Glynn RJ, Ridker PM, Goldhaber SZ, Zee RY, Buring JE. Effects of random allocation to vitamin E supplementation on the occurrence of venous thromboembolism: report from the Women's Health Study. Circulation. 2007;116(13):1497-503.

Headstrom PD, Rulyak SJ, Lee SD. Prevalence of and risk factors for vitamin B(12) deficiency in patients with Crohn's disease. Inflamm Bowel Dis. 2007 Sep 20; [Epub ahead of print]

Inderjeeth CA, Glennon D, Petta A, Soderstrom J, Boyatzis I, Tapper J.Vitamin D and muscle strength in patients with previous fractures. N Z Med J. 2007;120(1262):U2730.

Ishihara J, Otani T, Inoue M, Iwasaki M, Sasazuki S, Tsugane S; Japan Public Health Center-based Prospective Study Group. Low intake of vitamin B-6 is associated with increased risk of colorectal cancer in Japanese men. J Nutr. 2007;137(7):1808-1814.

J.G. Ray, C. Kearon, Q. Yi, P. Sheridan, and E. Lonn, for the Heart Outcomes Prevention Evaluation 2 (HOPE-2) Investigators. Randomized Trial of Homocysteine-Lowering Therapy and Risk for Venous Thromboembolism. Ann Intern Med. 2007;146(11):761-767.

Kitchin B, Morgan SL. Not just calcium and vitamin D: other nutritional considerations in osteoporosis. Curr Rheumatol Rep. 2007;9(1):85-92.

Kune G, Watson L. Colorectal cancer protective effects and the dietary micronutrients folate, methionine, vitamins B6, B12, C, E, selenium, and lycopene. Nutr Cancer. 2006;56(1):11-21.

Lim MR, Huang RC, Wu A, Girardi FP, Cammisa FP Jr. Evaluation of the elderly patient with an abnormal gait. J Am Acad Orthop Surg. 2007;15(2):107-117.

Martin H, Lindblad B, Norman M. Endothelial function in newborn infants is related to folate levels and birth weight. Pediatrics. 2007;119(6):1152-1158.

Mason JB, Dickstein A, Jacques PF, Haggarty P, Selhub J, Dallal G, Rosenberg IH. A temporal association between folic acid fortification and an increase in colorectal cancer rates may be illuminating important biological principles: a hypothesis. Cancer Epidemiol Biomarkers Prev. 2007;16(7):1325-1329.

Nardin RA, Amick AN, Raynor EM. Vitamin B(12) and methylmalonic acid levels in patients presenting with polyneuropathy. Muscle Nerve. 2007;36(4):532-535.

Ochoa-Brust GJ, Fernández AR, Villanueva-Ruiz GJ, Velasco R, Trujillo-Hernández B, Vásquez. Daily intake of 100 mg ascorbic acid as urinary tract infection prophylactic agent during pregnancy. Acta Obstet Gynecol Scand. 2007;86(7):783-787.

Parekh N, Chappell RJ, Millen AE, Albert DM, Mares JA. Association between vitamin D and age-related macular degeneration in the Third National Health and Nutrition Examination Survey, 1988 through 1994. Arch Ophthalmol. 2007;125(5):661-669.

Pham DQ, Plakogiannis R. Vitamin E supplementation in Alzheimer’s disease, Parkinson’s disease, tardive dyskinsia, and cataract: Part 2. Ann Pharmacother. 2005;39(12): 2065-2072.

Riccioni G, Bucciarelli T, Mancini B, Di Ilio C, Della Vecchia R, D'Orazio N. Plasma lycopene and antioxidant vitamins in asthma: the PLAVA study. J Asthma. 2007;44(6):429-432.

Ronnenberg AG, Venners SA, Xu X, Chen C, Wang L, Guang W, Huang A, Wang X. Preconception B-vitamin and homocysteine status, conception, and early pregnancy loss. Am J Epidemiol. 2007;166(3):304-12. Epub 2007 May 2.

Sahin M, Tutuncu NB, Ertugrul D, Tanaci N, Guvener ND. Effects of metformin or rosiglitazone on serum concentrations of homocysteine, folate, and vitamin B12 in patients with type 2 diabetes mellitus. J Diabetes Complications. 2007;21(2):118-123.

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Tecklenburg SL, Mickleborough TD, Fly AD, Bai Y, Stager JMAscorbic acid supplementation attenuates exercise-induced bronchoconstriction in patients with asthma. Respir Med. 2007;101(:1770-1778.

Triantafyllou NI, Kararizou E, Angelopoulos E, Tsounis S, Boufidou F, Evangelopoulos ME, Nikolaou C, Vassilopoulos D. The influence of levodopa and the COMT inhibitor on serum vitamin B12 and folate levels in Parkinson's disease patients. Eur Neurol. 2007;58(2):96-99.

Vagianos K, Bector S, McConnell J, Bernstein CN. Nutrition assessment of patients with inflammatory bowel disease. J Parenter Enteral Nutr. 2007;31(4):311-319.

Velasquez MT, Bhathena SJ. Role of dietary soy protein in obesity. Int J Med Sci. 2007; 4(2):72-82.

Wang Y, Hodge AM, Wluka AE, English DR, Giles GG, O'sullivan R, Forbes A, Cicuttini FM. Effect of antioxidants on knee cartilage and bone in healthy, middle-aged subjects: a cross-sectional study. Arthritis Res Ther. 2007;9(4):R66 [Epub ahead of print]

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Weingärtner J, Lotz K, Fanghänel J, Gedrange T, Bienengräber V, Proff P. Induction and Prevention of Cleft Lip, Alveolus and Palate and Neural Tube Defects with Special Consideration of B Vitamins and the Methylation Cycle. J Orofac Orthop. 2007; 68(4):266-277.

Wierzbicki AS. Homocysteine and cardiovascular disease: a review of the evidence. Diab Vasc Dis Res. 2007;4(2):143-50.

Zeisel SH. The fetal origins of memory: the role of dietary choline in optimal brain development. J Pediatr. 2006;149(5 Suppl):S131-136.

Ziaei S, Kazemnejad A, Zareai M. The Effect of Vitamin E on Hot Flashes in Menopausal Women. Gynecol Obstet Invest. 2007;64(4):204-207 [Epub ahead of print]

Zollinger PE, Tuinebreijer WE, Breederveld RS, Kreis RW. Can vitamin C prevent complex regional pain syndrome in patients with wrist fractures? A randomized, controlled, multicenter dose-response study. J Bone Joint Surg Am. 2007;89(7):1424-1431.

Review Date:
10/29/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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adam.com

Heart attack and acute coronary syndrome

FitSugar — Wed, 08 Oct 2008 17:34:57 -0700

In This Report

Highlights
Introduction
Symptoms
Prognosis
Risk Factors
Diagnosis
Treatment
Medications
Surgery
Rehabilitation
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Approval

In 2006, the FDA approved the use of clopidogrel (Plavix) for patients who have had a STEMI heart attack and who will not be having angioplasty. A STEMI is a very severe type of heart attack caused by sudden and total artery blockage.

Angioplasty and Stents

Surgery with angioplasty and stents that is performed more than 3 days after a heart attack offers no advantage over standard drug therapy for clinically stable patients, indicates an important 2006 New England Journal of Medicine study. Experts recommend that this procedure be performed to open blocked arteries within 12 hours of a heart attack.

Drug-Coated Stents

Drug-coated stents may be better than bare metal stents for patients who have had a STEMI heart attack, suggest several New England Journal of Medicine studies. However, recent research has raised concern that these types of stents increase the risk for blood clots.
Patients who have a drug-coated stent must take aspirin and clopidogrel (Plavix) for at least 1 year after the stent is inserted, according to an important 2007 advisory from the American Heart Association (AHA). The combination of these drugs can help prevent blood clots.

Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs such as acetaminophen (Tylenol), ibuprofen (Advil) should be used with caution by patients who have had a heart attack:

In 2007, the AHA warned that NSAIDs (with the exception of aspirin) and COX-2 inhibitors increase the risk of heart attack and stroke. The AHA is recommending that doctors change the way they prescribe these pain relievers for patients who have or are at risk for heart disease.
A 2006 Journal of the American Medical Association study suggested that the prescription NSAID diclofenac (Cataflam) carries a higher risk for heart attack than other NSAIDs.

Introduction

The heart is the human body's hardest working organ. Throughout life it continuously pumps blood enriched with oxygen and vital nutrients through a network of arteries to all parts of the body's tissues. In order to perform the arduous task of pumping blood to the rest of the body, the heart muscle itself needs a plentiful supply of oxygen-rich blood, which is provided through a network of coronary arteries. These arteries carry oxygen-rich blood to the heart's muscular walls (the myocardium).

Coronary artery disease is the most common cause of heart attacks. Coronary artery disease is the end result of a complex process called atherosclerosis (commonly called "hardening of the arteries"). This causes blockage of arteries (ischemia) and prevents oxygen-rich blood from reaching the heart. A full-blown heart attack occurs when blood flow to the myocardium is blocked and tissue death occurs from loss of oxygen, severely damaging the heart. The medical term for heart attack is myocardial infarction. [See In-Depth Report #3: Coronary artery disease.]

Click the icon to see an image of atherosclerosis.

Heart attack (or myocardial infarction) is the most serious outcome of atherosclerosis. It can occur as a result of one or two effects of atherosclerosis:

(1) If the artery becomes completely blocked and ischemia becomes so extensive that oxygen-bearing tissues around the heart die.

(2) If the plaque itself develops fissures or tears. Blood platelets adhere to the site to seal off the plaque, and a blood clot (thrombus) forms. A heart attack can then occur if the formed blood clot completely blocks the passage of oxygen-rich blood to the heart.

Click the icon to see an image of an acute myocardial infarction.

Angina is the primary symptom of coronary artery disease and is typically experienced as chest pain. There are two kinds of angina:

Stable Angina is predictable chest pain that can usually be managed with lifestyle measures and medications, such as low-dose aspirin.
Unstable angina is a much more serious situation than stable angina that is often an intermediate stage between stable angina and a heart attack. Unstable angina is part of a condition called acute coronary syndrome.

Acute coronary syndrome (ACS) is a severe and sudden heart condition that requires aggressive treatment, but has not developed into a full blown heart attack. Acute coronary syndrome includes:

Unstable angina. Unstable angina is a much more serious situation than stable angina. It is often an intermediate stage between stable angina and a heart attack.
NSTEMI (non ST-segment elevation myocardial infarction). This condition, also called non Q-wave myocardial infarction, is diagnosed when blood tests and ECGs suggest a developing heart attack. The injury in the arteries is less severe than with a full-blown heart attack.

Symptoms

ANYONE WHO BELIEVES THEY ARE HAVING A HEART ATTACK SHOULD IMMEDIATELY CALL THE EMERGENCY MEDICAL SYSTEM (911 IN THE UNITED STATES).

In people with known heart disease, any unusual chest pain or other symptoms of heart attack that do not clear up with medications are signals to go to the hospital. The degree of pain and the specific symptoms before a heart attack vary greatly among individuals. Onset can be abrupt, gradual, or intermittent.

Chest Pain. People with heart disease or risk factors should be concerned about any chest pain, usually precipitated by exercise or stress, that interrupts normal activities and does not clear up after resting or taking angina medications. Chest symptoms might be experienced as follows:

Pain is typically felt as a crushing weight against the chest, accompanied by profuse sweating. The pain may radiate to the left shoulder and arm, the neck or jaw, and even infrequently to the right arm. The arm may be tingling or numb.
Some people may have only a tingling sensation or a sense of fullness, squeezing, or pressure in the chest.
In some patients with a history of heart disease, chest pain is mild. Such patients may have experienced unexplained fatigue, depression, and ill health within a month of a heart attack.

Although chest pain is the classic symptom, it occurs in only about half of patients with a heart attack.

Other Common Symptoms. Other common symptoms of a heart attack include:

Nausea, vomiting, and cold sweats
A feeling of indigestion or heartburn
Fainting
A great fear of impending death, a phenomena known as angor animi

Uncommon Symptoms. Some studies suggest that nearly half of patients with heart attack do not have chest pain as the primary symptom. Common atypical symptoms of a heart attack include:

Shortness of breath
Cardiac arrest
Dizziness, weakness, and fainting
Abdominal pain

Patients most likely to have atypical symptoms are women and the very elderly (although they can certainly have classic heart attack symptoms as well.)

In one study, 52% of elderly people with acute coronary syndrome had atypical symptoms that included shortness of breath, nausea, profuse sweating, pain in the arms, and fainting. Such symptoms were more likely to occur in people with personal or family history of heart disease.
Before a heart attack, women are more likely than men to be nauseous and experience pain high in the abdomen or chest. Their first symptom may be extreme fatigue after physical activity rather than chest pain. Chest pain in women is also more likely to be caused by non-heart problems than in men.

Symptoms That Are Less Likely to Indicate a Heart Attack. The following are symptoms that are more likely to be due to causes other than a heart event:

Sharp pain brought on by lung movements or coughing
Pain that is mainly or only in the middle or lower abdomen
Pain that can be pinpointed with the top of one finger
Pain that can be reproduced by moving or pressing on the chest wall or arms
Pain that is constant and lasts for hours (although no one should wait hours if they suspect they are having a heart attack)
Pain that is very brief and lasts for a few seconds
Pain that spreads to the legs

The presence of these symptoms, however, does not always rule out a serious heart event.

Chest pain is a very common symptom in the emergency room, but heart problems account for only 10% to a third of all episodes. High on the list of other causes of chest pain are the following:

The most common causes of chest pain are muscular and bone problems. Problems affecting the ribs and chest muscles include injured muscles, fractures, arthritis, spasms, and infections.
Anxiety attacks
Gastrointestinal disorders (gallstone attacks, peptic ulcer disease, hiatal hernia, heartburn)
Asthma
Spasm in the coronary artery
Abnormalities of the heart muscle itself
Rupture of the aorta, collapsed lung, acute inflammation of the heart, or a blood clot in the lung
Hyperthyroidism
Anemia
Vasculitis (a group of disorders that cause inflammation of the blood vessels)
Exposure to high altitudes (rare)

Immediately call 911 or the local emergency number.

If patients have been previously diagnosed with angina, they should take one nitroglycerin dose either as an under-the-tongue tablet or in spray form at the onset of symptoms. They should take another dose every 5 minutes up to three doses or when the pain is relieved, whichever comes first.

It should be noted, however, that only 20% of heart attacks occur in patients with long-standing angina.

Anyone who has heart disease or risk factors for it and experiences heart attack symptoms should immediately contact emergency services.

The patient should chew an aspirin (250 - 500 mg) and be sure that emergency health providers are informed of this so an additional dose is not given.

Patients who experience chest pain should go immediately to the nearest emergency room, preferably traveling by ambulance. They should not drive themselves.

Prognosis

Each year, an estimated 650,000 Americans will suffer a first heart attack, and 450,000 will have a recurrent episode. Currently, half of the men and 63% of the women who died of heart disease had no warning prior to their fatal attacks.

Heart attacks may be rapidly fatal, evolve into a chronic disabling condition, or lead to full recovery. The long-term prognosis for both length and quality of life after a heart attack depends on its severity and the preventive measures taken afterward.

About 88% of patients under age 65 who experience a heart attack can expect to return to work. About 12,600,000 Americans who have had heart attacks, angina, or both are alive today. However, within 6 years of a heart attack, 18% of men and 35% of women have a recurrent attack. And, about 22% of men and 46% of women develop heart failure.

Although no tests can absolutely predict whether another heart attack will occur, experts estimate that up to 30% of fatal attacks, and many follow-up surgeries, could be avoided with healthy lifestyle changes and adherence to medical treatments. Two-thirds of patients who have suffered a heart attack, however, do not take the necessary steps to prevent another.

Higher Risk Individuals. A heart attack is always more serious in certain people:

Elderly (particularly those who are thinner)
People with a history of heart disease or risk factors for heart disease
People with heart failure
People with diabetes
People on long-term dialysis

Women are more likely to die after a heart attack than men. The risk is highest in younger women (although in the younger population, the risk for having a first heart attack and then dying from it is very low). It is still unclear why heart attacks are more severe in this group.

Factors Occurring at the Time of a Heart Attack That Increase Severity. The presence of other conditions during a heart attack can contribute to a poorer outlook:

Arrhythmias (disturbed heart rhythms). A dangerous arrhythmia called ventricular fibrillation is a major cause of short-term death from heart attack. Such arrhythmias are more likely to occur within the first 4 hours and are associated with a high mortality rate. Patients who are successfully treated, however, have the same long-term prognosis as those who do not experience such arrhythmias.
Signs of severe physical damage to the heart may indicate a poorer outlook.
Shock. This very dangerous condition is associated with very low blood pressure, reduced urine levels, and cellular abnormalities. Shock occurs in about 7% of heart attacks. The incidence has not declined over recent years, although its survival rates have improved.
Heart block, also called atrioventricular (AV) block, is a condition in which the electric conduction of nerve impulses to specialized muscles in the heart is slowed or interrupted. Although heart block is dangerous, it can be treated effectively with a pacemaker, and it rarely causes any long-term complications in patients who survive it.

Heart attacks and acute coronary syndrome pose a high risk for stroke. According to a major 2002 study, the risk for stroke after heart attack is 2.5% in the first 6 months and 5% per year thereafter. In the study, patients with a higher risk (about 4%) for stroke within 6 months of a heart attack were older (over age 75), African-American, had a history of stroke, atrial fibrillation, hypertension, diabetes, or peripheral artery disease. Most people who fall into these categories have more than one of these risk factors.

Risk Factors

About 25% of all Americans have one or more risk factors for heart disease, increasing their risk for heart attack. Most risk factors for heart disease are related to lifestyle. Some risk factors, (such as age, gender, and ethnicity) cannot be changed. Nevertheless, overall risks can be reduced with healthy lifestyle changes. [See In-Depth Report #3: Coronary artery disease.]

The American Heart Association's guidelines for preventing heart disease recommend:

Improve Cholesterol. People with at least two risk factors and a 10-year risk for heart disease or stroke of more than 20% should aim for LDL levels of less than 100 mg/dl. Statins are now used in more cases.

Keep Blood Pressure Low. People in normal health should have a blood pressure reading of 120/80 mm Hg or less. According to new guidelines, blood pressure readings of 120/80 are considered normal, readings of 140/90 or higher indicate hypertension, and readings in between the two are called pre-hypertension. Patients with diabetes or chronic kidney disease should maintain blood pressure readings of 130/80 mm Hg or less, while others should be no higher than 140/90 mm Hg.

Exercise. Everyone in normal health should engage in at least moderate physical activity for a minimum of 30 minutes on most -- if not all -- days of the week.

Healthy Diet. Everyone should aim for a diet that contains a healthy balance of fruits, vegetables, grains, fish, nuts, legumes, poultry, lean meat, and low-fat dairy items. Avoid saturated fats and trans-fatty acids.

Quit Smoking. Also avoid exposure to second-hand smoke.

Maintain Weight. People should aim for a BMI index of 18.5 - 24.9.

Take Aspirin. People at high risk for heart disease should take a low-dose aspirin every day, unless they have medical reasons to avoid aspirin.

Control Diabetes. People with diabetes should aim for fast blood glucose levels of less than 110 mg/dl and hemoglobin A1C of less than 7%.

Control Atrial Fibrillation. People with atrial fibrillation should use anticoagulants to reduce the risk for blood clots.

The approach for managing acute coronary syndrome involves lifestyle changes and medications. Experts have come up with a mnemonic device (ABCDE) for remembering the factors that are fundamental for management of acute coronary syndrome:

A. Antiplatelets, anticoagulants, and ACE inhibitors

B. Blood pressure and beta-blockers

C. Cholesterol-lowering drugs (typically statins) and cigarettes (stopping)

D. Diet and diabetes control

E. Exercise and education

Age. About 85% of people who die from heart disease are over the age of 65.

Gender. Coronary artery disease and heart attacks are much more common in middle-aged men. Women have, on average, 10 - 15 more years of heart disease-free life than do men, but as women age, they catch up to men. Women are more likely to have angina than men are. Younger women with heart disease often do not have the same symptoms as their male counterparts and may be less likely to be diagnosed correctly. They are also more likely than men are to die after a heart attack. Evidence suggests that this is because women tend to be older and sicker than men at the time of a first attack. A 2002 study indicated, however, that with early aggressive treatment women with acute coronary syndrome do as well or better than men with the same condition and treatments.

Ethnicity. Of all major ethnic groups, African-American women face the highest risk for death from heart disease, and their rate of heart attacks is increasing. (Mortality rates in men do not differ much by race.) Native American men have a lower risk for heart disease than Caucasian men, and Hispanics have the lowest risk for heart disease of all major American population groups.

Timing of Heart Attack. A 2007 study suggested that patients who are admitted to a hospital on a weekend are less likely to receive aggressive heart attack treatment and less likely to survive than patients who are treated on a weekday. However, no one can predict when a heart attack will occur. The most important point is to get treatment quickly, regardless of the day of the week. And, if you think you having a heart attack, call an ambulance -- or have someone call for you -- to ensure prompt treatment. Do not drive yourself.

Cholesterol. Cholesterol is a white, powdery substance that is found in all animal cells and in animal-based foods (not in plants). In spite of its bad press, cholesterol is an essential nutrient necessary for many functions. However, when certain cholesterol levels rise in the blood, they can have dangerous consequences, depending on the type of cholesterol.

Low-density lipoprotein (LDL) cholesterol is the "bad" cholesterol responsible for many heart problems. Triglycerides are another type of lipid (fat molecule) that can be bad for the heart. High-density lipoprotein (HDL) cholesterol is the "good" cholesterol that helps protect against heart disease. Doctors test for a "total cholesterol" profile that includes measurements for LDL, HDL, and triglycerides. The ratio of these lipids can affect heart disease risk. [See In-Depth Report #23: Cholesterol.]

Cholesterol Goals. In 2004, the National Cholesterol Education Program updated its clinical practice guidelines. The new recommendations set lower treatment goals for LDL levels based on a patient's risk factors for heart disease.

These risk factors include:

Having a first-degree female relative diagnosed with heart disease before age 65 or a first-degree male relative diagnosed before age 55
Being male and over age 45 or female and over age 55
Cigarette smoking
Diabetes
High blood pressure
Metabolic syndrome (risk factors associated with obesity such as low HDL levels and high triglycerides)

Having two or more of these risk factors indicates a greater than 20% chance of having a heart attack within 10 years.


Risk Level	Goal (d/L)	OptimalGoal(d/L)
Very High Risk	70	70
High Risk	100	70
Moderate Risk	130	100
Low Risk	160	130

LDL cholesterol, together with other risk factors for heart disease, is the best determinant for whether cholesterol therapy is needed and whether it is working properly. In particular, the new guidelines emphasize lower LDL levels and earlier treatment for people with coronary artery disease, or other forms of atherosclerosis, and diabetes.


Total Cholesterol Goals	LDL Goals	HDL Goals	Triglyceride Goals
Less than 200 mg/dL is desirable. Between 200 and 239 is borderline. Over 240 is high.	70 mg/dL or less is the new goal for very high-risk patients (recent heart attack; current active or unstable cardiovascular or cerebrovascular disease; or two multiple risk factors as defined above.) Below 100 mg/dl is optimal for everyone. It should be the goal for high-risk people including those with existing heart disease, diabetes, or two or more risk factors for heart disease; 70 mg/dL is an optimal goal for these individuals. 130 mg/dl or below for people with two or more risk factors; 100 mg/dL is the optimal goal. 160 mg/dl or less for people at less risk (one or zero risk factors); 130 mg/dL is an optimal goal. Anything over 160 is high, with levels over 190 being very high. LDL levels over 190 require medication even with no other cardiac risk factors present.	Levels above 40 mg/dL are desirable; levels above 60 mg/dL are optimal.	Below 150 mg/dL is normal. 150-199 is borderline high. 200-499 is high. Over 500 is very high.
*Risk factors for heart disease include a family history of early heart problems before age 55 for men (before age 65 for women), smoking, high blood pressure, diabetes, being older (over 45 for men and 55 for women), and having HDL levels below 35 mg/dl. People with two or more of these risk factors may have a 10-year risk of heart attack that exceeds 20%, and may therefore need to aim for LDL levels of 100 mg/dL or below.

Other Lipids. Elevated levels of other fatty molecules (lipids) are also now thought to be important indicators of heart disease risk. Studies are finding an elevated risk for angina and first heart attacks in people with elevated levels of lipoprotein(a), or lp(a). This lipoprotein falls somewhere in density between HDL and LDL and may have some properties that increase the risk for blood clots. Some experts suggest, however, that high levels of lp(a) may merely be markers of late-stage atherosclerosis, not a cause.

High blood pressure, or hypertension, has long been a proven cause of coronary artery disease. Blood pressure is categorized as normal, prehypertensive, and hypertensive (which is further divided as Stage 1 or 2 according to severity). High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120 - 139 systolic or 80 - 89 diastolic) indicate an increased risk for developing hypertension. [See Blood Pressure Ranges table.]

A normal blood pressure reading is 120/80 mm Hg or lower. Most people with high blood pressure should aim for a goal of below 140/90 mm Hg. Patients with certain health problems should aim lower (blood pressure in patients with kidney disease, heart failure, or diabetes should be equal to or lower than 130/80 mm Hg.) [See In-Depth Report #14: High blood pressure.]


Blood Pressure Category	Ranges for Most Adults (systolic/diastolic)
Normal Blood Pressure (systolic/diastolic)	Systolic below 120 mm Hg Diastolic below 80 mm Hg
Prehypertension (Formerly Classified as Normal to High-Normal Blood Pressure)	Systolic 120 to 139 mm Hg Diastolic 80 to 89 mm Hg (NOTE: 139/89 or below should be the minimum goal for everyone. People with diabetes or chronic kidney disease should strive for 130/80 or less.)
Mild Hypertension (Stage 1)	Systolic 140 to 159 mm Hg Diastolic 90 to 99 mm Hg
Moderate-to-Severe Hypertension (Stage 2)	Systolic over 160 mm Hg and/or Diastolic over 100 mm Hg
Note: If one of the measurements is in a higher category than the other, the higher measurement is usually used to determine the stage. For example, if systolic pressure is 165 (Stage 2) and diastolic is 92 (Stage 1), the patient would still be diagnosed with Stage 2 hypertension. It should be strongly noted that a high systolic pressure should be a major focus of concern in most adults.

American obesity is at epidemic levels in all age groups. The effect of obesity on cholesterol levels is complex. Although obesity does not appear to be strongly associated with overall cholesterol levels, among obese individuals triglyceride levels are usually high while HDL (beneficial cholesterol) levels tend to be low, both risk factors for heart disease. Obesity, in any case, has other effects (hypertension, increase in inflammation) that pose major risks to the heart.

Obesity is particularly hazardous when it is one of the components of the metabolic syndrome. This syndrome is diagnosed when three of the following are present: abdominal obesity, low HDL cholesterol, high triglyceride levels, high blood pressure, and insulin resistance. Metabolic syndrome is a pre-diabetic condition that is significantly associated with heart disease and higher mortality rates from all causes. A 2002 study estimated that 24% of the population now has this condition. Obesity is highly linked with type 2 diabetes, in any case. And diabetes itself poses a significant risk for high cholesterol levels and heart disease. [See In-Depth Report #53: Weight control and diet.]

People who are sedentary are almost twice as likely to suffer heart attacks as are people who exercise regularly. Exercise has several effects that benefit the heart and circulation, including improving cholesterol and lipid levels, reducing inflammation in the arteries, assisting weight loss programs, and helping to keep blood vessels flexible and open. Studies continue to show that physical activity and avoiding high-fat foods are the two most successful means of reaching and maintaining heart healthy levels of fitness and weight.

Experts have been attempting to define how much exercise is needed to produce heart benefits. In 2002, a well-conducted study on overweight adults confirmed previous research that reported beneficial changes in cholesterol and lipid levels even when people performed low amounts of moderate or high intensity exercise (walking or jogging 12 miles a week). However, more intense exercise is required to significantly change cholesterol levels, notably by increasing HDL (the so-called good cholesterol). Overweight people who have trouble losing pounds can still achieve considerable heart benefits by exercising. Resistance (weight) training has also been associated with heart protection. Exercises that train and strengthen the chest muscles may prove to be very important for patients with angina.

Some studies suggest that people may gain the greatest heart protection benefit from the total daily amount of energy they expend, rather than from the length of a single exercise session. Therefore, the best way to exercise may be in multiple short bouts of intense exercise, which can be particularly helpful for older people.

Sudden strenuous exercise (such as snow shoveling and mowing lawns) can put people at risk for angina and heart attack. Activities that involve raising the arms above the head may also be risky. Patients with angina should never exercise shortly after eating. People with risk factors for heart disease should seek medical clearance and a detailed exercise prescription. And all people, including healthy individuals, should listen carefully to their bodies for signs of distress as they exercise. [See In-Depth Report #29: Exercise.]

Heart disease and stroke are the leading causes of death in people with diabetes. People with diabetes are at risk for the following heart-risk conditions, and the more of these conditions they have, the worse the outlook:

High blood pressure (hypertension) --up to 75% of cardiovascular problems in people with diabetes may be due to hypertension.
Very unhealthy cholesterol and lipid balances (high triglyceride levels and lower high density lipoprotein).
Blood clotting problems.
Impaired nerve function (neuropathy), which can also damage the heart. In fact, some experts estimate that the mortality rates from neuropathy-related heart conditions ranges from 15 - 53%.

Patients with both diabetes and heart disease may have a higher risk for silent ischemia, a condition in which people have blocked arteries but do not experience the angina, the chest pain that signals heart disease [See In-Depth Report #9: Diabetes - type 1 ; or In-Depth Report #60: Diabetes - type 2.]

Smokers in their 30s and 40s have a heart-attack rate that is five times higher than their nonsmoking peers. Cigarette smoking may be directly responsible for at least 20% of all deaths from heart disease, or about 120,000 deaths annually. Smoking cigars may increase the risk of early death from heart disease, although evidence is much stronger for cigarette smoking. Although heavy cigarette smokers are at greatest risk, a 2002 study suggested that people who smoke as few as three cigarettes a day are at higher risk for blood vessel abnormalities that endanger the heart. Regular exposure to passive smoke also increases the risk of heart disease in nonsmokers. [See In-Depth Report #41: Smoking.]

Eating habits can either protect or hurt the heart. Experts generally agree on the following heart-smart recommendations:

Choose fiber-rich food (whole grains, legumes, nuts) as the main source of carbohydrates, along with a high intake of fresh fruits and vegetables.
Avoid saturated fats (found mostly in animal products) and trans fatty acids (found in hydrogenated fats and many commercial products and fast foods). Choose unsaturated fats, particularly omega-3 fatty acids (found in vegetable and fish oils).
In selecting proteins, choose soy, legumes, poultry, and fish over meat. Fat free and low fat dairy products (skimmed milk, yogurt) are also healthy choices.
Controlling weight, quitting smoking, and exercising are essential companions of any diet program.

After starting any heart healthy diet, it generally takes an average of 3 - 6 months before any noticeable reduction in cholesterol occurs, although some people have reported better levels in as few as 4 weeks. An intensive program may be necessary to achieve significant improvements in cholesterol levels and to reduce other heart risk factors. [See In-Depth Report #43: Heart-healthy diet.]

Stress. The effects of mental stress on heart disease are controversial. Stress can affect the heart when it activates the sympathetic nervous system (the automatic part of the nervous system that affects many organs, including the heart). Some studies suggest an association between acute stress and a higher risk for serious cardiac events, such as heart rhythm abnormalities and heart attacks, in people with heart disease. However, not all studies report strong evidence that stress has any effect on the heart, particularly in people without any history of heart disease. [See In-Depth Report #31: Stress.]

Depression. Depression increases the severity of heart attack and may even impair a patient's response to medication for heart disease. Although people with heart disease may certainly become depressed, this does not explain entirely the link between the two problems. The data now suggest that depression itself may be a true risk factor for heart disease as well as its increased severity. Several studies have suggested that depression has biologic effects on the heart, including blood clotting and heart rate. A study in 2001, for example, reported an association between depression and a greater risk for death from heart problems even in people without a history of heart disease. A 2002 study reported a higher risk for heart failure in women -- although not in men -- with depression. The more severe the depression, the more dangerous to the health, although even mild depression, including feelings of hopelessness, experienced over many years, may harm the heart, even in people with no early signs of heart disease. [See In-Depth Report #8: Depression.]

Benefits of Moderate Drinking. Several studies have found heart protection from moderate intake of alcohol (one or two glasses a day). Moderate alcohol consumption can help boost HDL levels. Alcohol may also prevent blood clots and inflammation. Although red wine is most often cited for healthful properties, any type of alcoholic beverage appears to have similar benefit.

Adverse Effects of Heavy Drinking on the Heart. By contrast, heavy drinking harms the heart; heart disease is the leading cause of death in alcoholics. Evidence suggests that people who consume more than three drinks a day have abnormal blood clotting factors. Heavy alcohol consumption can raise blood pressure, and binge drinking may increase the risk for hemorrhagic stroke (caused by bleeding in the brain). Large doses of alcohol can trigger irregular heartbeats, which can be dangerous in people with existing heart disease.

Pregnant women and people who can't drink moderately should not drink at all.

In 2005, the FDA warned that all nonsteroidal anti-inflammatory drugs (NSAIDs) -- with the exception of aspirin -- carry heart risks. NSAIDs and COX-2 inhibitors may increase the risk for death in patients who have experienced a heart attack. The risk is greatest at higher dosages, but not necessarily for length of time. According to a 2006 Danish study of heart attack survivors, patients do not need to take NSAIDs for long periods of time to be at risk.

NSAIDs include nonprescription drugs like ibuprofen (Advil, Motrin) and prescription drugs like diclofenac (Cataflam, Voltaren). Celecoxib (Celebrex) is currently the only COX-2 inhibitor that is available in the U.S. It has been linked to cardiovascular risks such as heart attack and stroke. Patients who have had heart attacks should talk to their doctors before taking any of these drugs.

A 2006 comprehensive report from the U.S. Agency for Healthcare Quality and Research indicated that both NSAIDs and COX-2 inhibitors pose similar risks for heart attacks. The report found that one particular NSAID, naproxen (Aleve, Naprosyn), may present less risk of heart attack for some patients, but other studies have contradicted this finding. A 2006 Journal of the American Medical Association study suggested that diclofenac (Voltaren, Cataflam) poses a higher risk for heart attack than other NSAIDs.

In 2007, the American Heart Association issued a scientific statement encouraging doctors to change the way they prescribe pain relief medication for patients with or who are at risk for heart disease. The AHA recommends that patients first try non-drug methods of pain relief (physical therapy, exercise, weight loss to reduce stress on joints, and heat or cold therapy). If these methods don’t work, patients should take the lowest possible dose of acetaminophen (Tylenol) or aspirin. COX-2 inhibitors, such as celecoxib (Celebrex), should be the last resort.

Anemia. Anemia has adverse effects on the heart and increases the severity of cardiac conditions, including heart failure and heart attacks.

Iron Overload. An inherited disease called hemochromatosis, in which the intestinal tract absorbs too much iron from food, has been associated with atherosclerosis and heart attack. About 10% of Caucasians carry the gene. There is no strong evidence that excess iron levels in people without hemochromatosis can contribute to heart disease.

Sleep Apnea. Obstructive sleep apnea is a condition in which tissues in the upper throat collapse at intervals during sleep, thereby blocking the passage of air. It has been strongly associated with high blood pressure and obesity, but is also associated with heart disease and heart attacks, regardless of these risk factors. Some evidence suggests that obstructive apneas cause an increase in stiffness and inflammation in the arteries.

Pregnancy Complications. Although women of child-bearing age are generally at low risk of heart attack, pregnancy can increase the risk for women with certain health conditions. Pregnant women who have diabetes, high blood pressure, or coronary artery disease are at greater risk of having a heart attack than healthy pregnant women. Smoking can increase the risk of heart attack during pregnancy by eight times. Pregnant women who are over 40 years old are at much greater risk than younger women.

Diagnosis

When a patient comes to the hospital with chest pain, the following diagnostic steps are usually taken to determine any heart problems, and, if present, their severity.

The patient will report all symptoms so that a health professional can rule out either a non-heart problem or possible other serious accompany conditions.
An electrocardiogram (ECG) reading is taken, which records the waves made the heart. It is the key tool for determining if heart problems are causing chest pain and, if so, how severe they are.
Blood tests showing elevated levels of certain factors (troponins and CK-MB) indicate heart damage. (The doctor will not wait for results, however, before administering treatment if a heart attack is strongly suspected.)
Imaging tests, including echocardiogram and perfusion scintigraphy, help rule out a heart attack if there is any question.

An electrocardiogram (ECG or EKG) measures and records the electrical activity of the heart. The waves measured by the ECG correspond to the contraction and relaxation pattern of the different parts of the heart. Specific waves seen on an ECG are named with letters:

P. The P wave is associated with the contractions of the atria (the two chambers in the heart that receive blood from outside).
QRS. The QRS is a series of waves associated with ventricular contractions. (The ventricles are two major pumping chambers in the heart.)
T and U. These waves follow the ventricular contractions.

Click the icon to see an image of a normal sinus rhythm.

Doctors use a term called the P-Q or P-R interval, which is the time taken for an electrical impulse to travel from the atria to the ventricle.

The most important wave patterns in diagnosing and determining treatment for a heart attack are called ST elevations and Q waves.

Elevated ST Segments: Heart Attack. Elevated ST segments are strong indicators of a heart attack in patients with symptoms and other indicators. They suggest that an artery to the heart is blocked and that the full thickness of the heart muscle is damaged. When this finding coincides with a heart attack, the condition is sometimes referred to as either as a Q-wave myocardial infarction or a STEMI (ST-segment elevation myocardial infarction). STEMI heart attacks are very severe and usually have complete artery blockage. ST-elevations are strong indicators for aggressive treatments (thrombolytic drugs or angioplasty) to reopen blood vessels. (ST segment elevations do not always mean the patient has a heart attack. Also, some patients do not have elevated ST segments. Other factors are important in making a diagnosis.)

Non-Elevated ST Segments: Angina and Acute Coronary Syndrome. A depressed or horizontal ST wave suggests some blockage and the presence of a heart disease, even if there is no angina present. It occurs in about half of patients with other signs of a heart event. This finding, however, is not very accurate, particularly in women, and can occur without heart problems. In such cases, laboratory tests are needed to determine the extent, if any, of heart damage. In general, one of the following conditions may be present:

Stable Angina (blood test results or other tests show no serious problems and chest pain resolves). Most patients with angina can go home. (Between 25 - 50% of people who have angina or silent ischemia have normal ECG readings.)
Acute Coronary Syndrome (ACS). This includes severe and sudden heart conditions that require aggressive treatment but have not developed into a full-blown heart attack. ACS, refers to either unstable angina or NSTEMI (non ST-segment elevation myocardial infarction) -- also referred to as non Q-wave myocardial infarction. Unstable angina is potentially serious, and chest pain is persistent, but blood tests do not show markers for heart attack. With NSTEMI, the blood tests suggest a developing heart attack, but most likely, injury in the arteries is less serious than with a full-blown heart attack.

An echocardiogram is a noninvasive test that uses ultrasound images of the heart. This test is more expensive than an ECG, but it can be very valuable, particularly when used with an exercise stress test, to detect the location and extent of heart muscle damage.

Nuclear ventriculography (also known as a radionuclide test) uses radioactive materials called tracers to make heart chambers and blood vessels visible. The procedure is noninvasive. It is a reliable measure of severe heart events and can help identify if damage has occurred from a heart attack. A radioactive isotope such as thallium (or technetium) is injected into the patient's vein. The radioactive isotope attaches to red blood cells and passes through the heart in the circulating blood. The isotope can then be traced through the heart using special cameras or scanners. The images may be combined with an electrocardiogram. The patient is tested while resting, then tested again during an exercise stress test. If the scan detects damage, more images are taken 3 or 4 hours later. Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time.

Angiography is an invasive test. It is used for patients who show strong evidence for severe obstruction on stress and other tests and for patients with acute coronary syndrome.

A narrow tube is inserted into an artery, usually in the leg or arm, and then threaded up through the body to the coronary arteries.
A dye is injected into the tube, and an x-ray records the flow of dye through the arteries.
This process provides a map of the coronary circulation, revealing any blocked areas.

Click the icon to see an image of cardiac catheterization.

Click the icon to see an image of dye injected into the coronary arteries.

Major complications include stroke, heart attacks, and kidney damage. These risks are very low (about 0.1%), however, if the procedure is done in an experienced medical center (one that performs at least 300 of these operations every year). Allergic reactions can also occur. The procedure is expensive, and between 10 - 30% of patients who have this procedure have normal results.

Magnetic Resonance Angiography (MRA). MRA is a very promising noninvasive imaging technique that can provide three-dimensional images of the major arteries to the heart and identify disease with high accuracy. Experts believe this approach will eventually be a good alternative to angiography.

Tests that measure kidney function can help predict which patients are at greatest risk of heart attack, stroke, or death from heart disease. Kidney tests measure proteins in the blood that are filtered through the kidneys. These proteins include creatinine and blood urea nitrogen (BUN). A more recent type of kidney test measures the protein cystatin C. Recent research suggests that the cystatin C kidney test may be better at predicting cardiovascular risks in elderly patients.

When heart cells become damaged, they release different enzymes and other molecules into the blood stream. Elevated levels of such markers of heart damage in the blood or urine may help predict a heart attack in patients with severe chest pain and help determine treatment. Some markers include:

Troponins. The proteins cardiac troponin T and I are released when the heart muscle is damaged. Both are proving to be among the best diagnostic indications of heart attacks. They help to identify many individuals with ACS who might otherwise be misdiagnosed.
Creatine kinase myocardial band (CK-MB). CK-MB has been a standard marker, but the MB fraction is not as accurate as troponin levels, since elevated levels can appear in people without heart injury.
Myoglobin. Myoglobin is a protein found in heart muscles. It is released early in the injured heart and may be useful in combination with CK-MB and the troponins.
Newer biomarkers, including C-reactive protein (CRP), homocysteine, B-type natriuretic peptide (BNP), urinary albumin, and fibrinogen.

Several 2006 studies that evaluated how well biomarkers predict the risk of heart events concluded that they do not provide much more useful information than standard risk factors (high blood pressure, unhealthy cholesterol levels, diabetes). At this time, most experts feel that these standard disease risk factors provide the best predictors of the likelihood of developing coronary artery disease, heart attack, or stroke.

Treatment

Treatment options will depend on whether the patient has angina, acute coronary syndrome, or a full-blown heart attack.

Patients who are diagnosed with acute coronary syndrome (ACS) may be at risk for a heart attack. ACS refers to either unstable angina or NSTEMI (non ST-segment elevation myocardial infarction). Unstable angina is potentially serious and chest pain is persistent, but blood tests do not show markers for heart attack. With NSTEMI, the blood tests suggest a developing heart attack, but most likely, injury in the arteries is less serious than with a full-blown heart attack.

Doctors use a patient's medical history, various tests, and the presence of certain factors to help predict which ACS patients are most at risk for developing a more serious condition. The degree of chest pain itself is not necessarily useful for determining the actual damage in the heart.

Depending on how severe the condition is, the patient is then given either medical treatments or more invasive approaches, such as angioplasty. Some experts believe that even if patients with ACS are only given drug therapy, they should still be transferred to centers equipped for angioplasty.

Early supportive treatments are similar for patients who have ACS or those who have had a heart attack.

Oxygen. Oxygen is almost always administered right away, usually through a tube that enters through the nose. The patient is given aspirin if one was not taken at home.

Medications for Relieving Symptoms.

Nitroglycerin. Most patients will receive nitroglycerin after a heart attack, usually under the tongue. Nitroglycerin decreases blood pressure and dilates the blood vessels around the heart, increasing blood flow. Nitroglycerin may be given intravenously in certain cases (recurrent angina, congestive heart failure, or high blood pressure). Some evidence suggests that intravenous administration may help reduce long-term heart muscle changes that can occur after a heart attack. (Patients with very low blood pressure or severely slow heart rate will not receive nitroglycerin.)
Morphine. Morphine not only relieves pain and reduces anxiety but also dilates blood vessels, aiding the circulation of blood and oxygen to the heart. Morphine can decrease blood pressure and slow down the heart. In patients in which such effects may worsen their heart attacks, other drugs such as meperidine (Demerol) or nalbuphine (Nubain) may be used.

Anticlotting Medications. Appropriate anticlotting medications are started immediately in all patients.

Aspirin (antiplatelet drug) should be taken immediately after a heart attack. It can be either swallowed or chewed, but chewing provides more rapid benefit. If the patient has not taken an aspirin at home, it will be given at the hospital.
Clopidogrel (a stronger antiplatelet drug) is usually given along with other anticlotting drugs. It is sometimes used in place of aspirin.
Heparin (an anticoagulant) is usually given to moderate- to high-risk patients. Low-molecular weight heparin (LMWH), such as enoxaparin, is now recommended over standard heparin. Fondaparinux (Arixtra) is another type of blood thinner that is showing promise for treating patients with STEMI (ST-elevation myocardial infarction), a severe type of heart attack. Fondaparinux may also be better than enoxaparin for patients with acute coronary syndrome (ACS).
Glycoprotein IIb/IIIa inhibitors (antiplatelet drugs), most often tirofiban, are added for patients undergoing angioplasty. These drugs include tirofiban (Aggrastat) and abciximab (ReoPro). They are also beneficial for nonsurgical patients with ACS, notably NSTEMI (non ST-segment elevation myocardial infarction).

After a heart attack, clots form in the injured artery within 4 - 6 hours in 90% of patients. Opening a clotted artery as quickly as possible is the best approach to improving survival.

The standard medical and surgical solutions for opening arteries are:

Angioplasty, also called percutaneous coronary intervention (PCI), is standard procedure for opening the arteries. Coronary artery bypass graft (CABG) is sometimes used as an alternative to angioplasty. Angioplasty should be performed no later than 12 hours after a heart attack.
Thrombolytics are known as blood-clot-busting drugs and are the standard medications used to open the arteries. They are administered as soon as possible in centers where angioplasty is not available or in patients who are not good candidates for angioplasty.

The best candidates for either thrombolytic therapy or angioplasty are:

Adults younger than 75 years old with elevated ST segments or indications of bundle branch block (an ECG reading showing an interruption in the electrical pathway within the heart).
Patients whose symptoms occur within 12 hours of treatment.

Specific Candidates for Emergency Angioplasty. Most patients who meet the criteria for either thrombolytic drugs or angioplasty do better with angioplasty (although only in centers equipped to do this procedure).

Good candidates for angioplasty include:

Elderly patients (including those over age 75) who meet the criteria for both approaches tend to do better with angioplasty than thrombolytic therapy
Patients with diabetes who meet the criteria for both approaches
Patients under age 75 who go into shock, provided that angioplasty can be performed within 18 hours of shock (There is no advantage for patients over 75 who are in shock.)

As with thrombolytic treatments, angioplasty is most effective when performed within 12 hours of symptoms, and the sooner the better. Unfortunately not all communities have centers experienced in the procedure. The experience of the medical center's staff is critical for optimal benefits, and not all surgeons are experienced in angioplasty. However, the procedure is becoming increasingly available, and overall mortality rates are improving over time with angioplasty. Patients or their families should be sure their surgeon has performed at least 75 of these procedures and that the medical center has performed at least 200.

Specific Candidates or Non-Candidates for Thrombolytics. People who meet the criteria for either thrombolytics or angioplasty may benefit from thrombolytic drugs even if they have high-risk conditions such as diabetes, high systolic blood pressure less than 180 mm Hg, or a history of heart attack.

Several studies report that women do worse after thrombolytic therapy. Evidence indicates, however, that they are generally older and have more serious medical conditions when they seek treatment. One study also reported that women were given these drugs an average of 14 minutes later than men were. Women on thrombolytic therapy still do better than those not given these drugs. The bottom line is that thrombolytic therapy is life-saving, and appropriate candidates, regardless of age or gender, should not be denied this therapy.

Thrombolytics should be avoided or used with great caution in the following patients:

People older than age 75 -- a 2000 study suggested that their risk of death was 38% higher than patients in their age group who were not given therapy; a higher risk exists in such older patients even if they are otherwise healthy.
Patients with elevated ST segments whose symptoms have continued beyond 12 hours
Pregnant women
People who have experienced recent trauma (especially head injury) or invasive surgery
People with active peptic ulcers
Patients who have been given prolonged CPR
Current users of anticoagulants

Thrombolytics should not be used in the following patients:

Patients who have experienced any recent major bleeding
Patients with low ST segments
Patients with a history of stroke
Patients with uncontrolled high blood pressure

After a heart attack, the patient may need a number of different medications, depending on their risk factors for a future heart attack:

Beta-blockers reduce the oxygen demand of the heart by slowing the heart rate and lowering arterial pressure. They have been proven to help improve survival in patients who have had a heart attack.
Angiotensin converting enzyme (ACE) inhibitors should be given on the first day to all patients, unless there are medical reasons for not taking them.
Calcium channel blockers may provide relief in patients with unstable angina whose symptoms do not respond to nitrates and beta blockers. They are also useful for patients with Prinzmetal's angina.
Statins. Statins are important cholesterol lowering drugs that are beneficial for patients who have experienced a heart attack. They may also have heart-protective properties that go beyond lowering cholesterol.
Atropine. Atropine may be given for a very low heart rate (bradycardia) or signs of atrioventricular (AV) block, in which electric conduction of nerve impulses to specialized muscles in the heart is slowed or interrupted.

Severely ill patients, particularly those in cardiogenic shock (a dangerous condition that includes a drop in blood pressure and other abnormalities) or with heart failure, will be monitored closely and stabilized. Oxygen is administered, and fluids are given or replaced when it is appropriate to either increase or reduce blood pressure. Such patients may be given dopamine, dobutamine, or both. Other treatments depend on the specific condition.

Heart failure. Intravenous furosemide may be administered. Patients may also be given nitrates, and ACE inhibitors, unless they have a severe drop in blood pressure or other conditions that preclude them. Clot-busting drugs or angioplasty may be appropriate and life-saving in many of these patients, although heart failure patients are less likely to be given these treatments.

Cardiogenic Shock. A procedure called intra-aortic balloon counterpulsation (IABP) is proving to help these patients when used in combination with thrombolytic therapy. IABP involves inserting a catheter containing a balloon, which is inflated and deflated within the artery to boost blood pressure. Left ventricular assist devices and early angioplasty might be considered.

An important study published in 2006 in the Journal of the American Medical Association indicated that early surgical intervention is important for patients who have cardiogenic shock. The study found that patients who had angioplasty or bypass surgery within 6 hours of a heart attack complicated by shock had greatly improved odds for long-term survival compared to patients who received intensive medical therapy with clot-busting drugs.

An arrhythmia is a deviation from the heart's normal beating pattern caused when the heart muscle is deprived of oxygen and is a dangerous side effect of a heart attack. A very fast or slow rhythmic heart rate often occurs in patients who have had a heart attack, and is not usually a dangerous sign.

Premature beats or very fast arrhythmias called tachycardia, however, may be predictors of ventricular fibrillation. This is a lethal rhythm abnormality, in which the ventricles of the heart beat so rapidly that they do not actually contract but quiver ineffectually. The pumping action necessary to keep blood circulating is lost.

Preventing Ventricular Fibrillation. People who develop ventricular fibrillation do not always experience warning arrhythmias, and to date, there are no effective drugs for preventing arrhythmias during a heart attack.

Potassium and magnesium levels should be monitored and maintained.
Intravenous beta-blockers followed by oral administration of the drugs may help prevent arrhythmias in certain patients.

Treating Ventricular Fibrillation.

Defibrillators. Patients who develop ventricular arrhythmias are given electrical shocks with defibrillators to restore normal rhythms. Some studies suggest that implantable cardioverter-defibrillators (ICDs) may prevent further arrhythmias in heart attack survivors of these events who are at risk for further arrhythmias. Patients with ICDs should not take fish oil supplements, as they may increase the risk of ventricular fibrillation.
Antiarrhythmic Drugs. Antiarrhythmic drugs include lidocaine, procainamide, or amiodarone. Amiodarone or another antiarrhythmic drug may be used afterward to prevent future events.

Managing Other Arrhythmias. People with an arrhythmia called atrial fibrillation have a higher risk for stroke after a heart attack and should be treated with anticoagulants such as warfarin (Coumadin). Other rhythm disturbances called bradyarrhythmias (very slow rhythm disturbances) frequently develop in association with a heart attack and may be treated with atropine or pacemakers.

[For more information on atrial fibrillation, ICDs, and pacemakers see In-Depth Report #45: Stroke.]

Medications

Thrombolytic, also called clot-busting or fibrinolytic, drugs are now mainstays in the early treatment of many patients with heart attacks. These drugs dissolve the clot, or thrombus, responsible for causing artery blockage and heart-muscle tissue death.

The standard thrombolytic drugs are recombinant tissue plasminogen activators or rt-PAs. They include alteplase (Activase) and reteplase (Retavase). Both are similar in effectiveness, although reteplase is easier to administer. Tenecteplase (TNKase), a newer drug, can be delivered more rapidly than alteplase, and to date, survival rates are similar. Streptokinase (Kabikinase, Streptase) is sometimes used but is somewhat less effective that the others.

The sooner that thrombolytic drugs are given after a heart attack, the better. The benefits of thrombolytics are highest within the first 3 hours. They can still help if given within 12 hours of a heart attack.

A thrombolytic drug, such as alteplase or tenecteplase, is typically given by IV along with heparin, an anticoagulant drug. (Heparin, like aspirin, cannot destroy existing blood clots but can prevent clots from reforming after they are broken up.) Enoproxin, a form of heparin called low-molecular weight heparin, may be more beneficial than standard heparin.

Other anticlotting drugs are being tested in combination with thrombolytic drugs for emergency treatment following a severe heart attack. Several 2005 studies have indicated that the antiplatelet drug clopidogrel (Plavix) can help prevent arteries from reclosing, and a second heart attack, when given along with aspirin and thrombolytic drugs. The studies evaluated patients who received thrombolytic drugs for treatment of STEMI (severe heart attacks with complete artery blockage).

Hemorrhagic stroke, usually occurring during the first day, is the most serious complication of thrombolytic therapy, but fortunately it is rare. Streptokinase given without heparin poses the lowest risk (although it is also less effective than other regimens in restoring blood flow). In general, the mortality rate from bleeding is only 3 in 1,000 patients treated with thrombolytics, whereas 39 patients in 1,000 would die without these clot-busting drugs. Recent evidence suggests that the survival benefits of thrombolytic therapy, particularly in combination with aspirin, last for years.

Anti-clotting drugs that inhibit or break up blood clots are used at every stage of heart disease. They are generally classified as either antiplatelets or anticoagulants. All anti-clotting therapies carry the risk of bleeding, which can lead to dangerous situations, including stroke.

Anti-platelet Drugs. These drugs prevent formation of blood platelets. Platelets are very small disc-shaped blood cells that are important for blood-clotting.

Aspirin. Aspirin is an antiplatelet drug. It is the most common anti-clotting drug and nearly anyone with heart disease is advised to take it daily in low dose.
Thienopyridines. Clopidogrel (Plavix) and ticlopidine (Ticlid) are thienopyridines, another type of anti-platelet drug.
Glycoprotein IIb/IIIa Inhibitors. These powerful blood-thinning drugs include abciximab (ReoPro), eptifibatide (Integrilin), tirofiban (Aggrastat), and lamifiban. They are administered intravenously in the hospital and are used with angioplasty and stent placement. They are proving to be helpful for ACS patients with NSTEMI (non ST-segment elevation myocardial infarction).

Anticoagulants. Anticoagulants thin blood. They include:

Heparin
Fondaparinux (Arixtra)
Warfarin (Coumadin)
Direct thrombin inhibitors such as argatroban (Novastan), danaparoid (Orgaran), and lepirudin (Refludan)

How Anti-Clotting Drugs Are Used For Heart Attacks. Unlike the thrombolytic (clot-busting) drugs, which are used to break up blood clots during a heart attack, anti-clotting drugs are used to prevent blood clots from forming in the first place. Such drugs are sometimes used along with thrombolytics, immediately after a heart attack, and also as on-going maintenance to prevent a heart attack.

Aspirin is given immediately, and heparin is usually started during or at the end of the thrombolytic infusion.
Clopidogrel (Plavix) is given along with aspirin, heparin, and thrombolytic (“clot busting”) drugs as emergency treatment following a heart attack and to prepare for angioplasty surgery. In 2006, the FDA approved clopidogrel for patients who have had a STEMI heart attack and who are not going to have angioplasty. Clopidogrel is also helpful for patients with acute coronary syndrome. A 2006 study suggested that clopidogrel plus aspirin may not work better than aspirin alone in preventing a first heart attack. However, many studies show that clopidogrel is an important treatment for patients who have already had a heart attack. Clopidogrel and aspirin may reduce the risk of a second heart attack by 30%. The combination of clopidogrel (or ticlopidine) and aspirin is essential for patients who have a drug-eluting stent. In 2007, the American Heart Association recommended that patients with drug-eluting stents take this drug combination for at least 1 year after the stent is inserted to reduce the risks of blood clots.

All of these drugs pose a risk for bleeding. [See In-Depth Report #03: Coronary artery disease.]

Beta-blockers reduce the oxygen demand of the heart by slowing the heart rate and lowering pressure in the arteries. They are effective for reducing deaths from heart disease. These drugs include propranolol (Inderal), carvedilol (Coreg), bisoprolol (Zebeta), acebutolol (Sectral), atenolol (Tenormin), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol-XL), and esmolol (Brevibloc).

Administration During a Heart Attack. The beta-blocker metoprolol is given through an IV within the first few hours of a heart attack to reduce the destruction of heart tissue. However, a study suggests that emergency intravenous use of metoprolol may increase the risk of cardiac shock.

Prevention After a Heart Attack. Beta-blockers taken by mouth are also used on a long-term basis (“maintenance therapy”) after a first heart attack to help prevent future heart attacks.

Side Effects. Beta-blocker side effects include fatigue, lethargy, vivid dreams and nightmares, depression, memory loss, and dizziness. They can lower HDL (“good”) cholesterol. Beta-blockers are categorized as non-selective or selective. Non-selective beta-blockers such as carvedilol and propranolol can narrow bronchial airways. These beta-blockers should not be used by patients with asthma, emphysema, or chronic bronchitis.

Patients should not abruptly stop taking these drugs. The sudden withdrawal of beta-blockers can rapidly increase heart rate and blood pressure. The doctor may want the patient to slowly decrease the dose before stopping completely.

In 2004, the National Cholesterol Education Program issued updated recommendations on how to control cholesterol levels. These guidelines emphasize that patients should lower their LDL (“bad”) cholesterol and recommend that more people take LDL-lowering medication. Lowering LDL cholesterol and raising HDL (“good”) cholesterol can significantly reduce the risk of heart disease. Several different types of drugs (statins, bile-acid binding resins, niacin, and fibrates) are used to treat cholesterol. [See In-Depth Report #23: Cholesterol.]

Statins are the most important of these drugs. Brands include lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor). A major analysis of over 200 studies found that statins reduced the risk for heart problems by 60% and stroke by 17%. A 2005 review found that the more that statins lower LDL, the more they reduce CAD and other heart disease risks.

An important 2006 study found that aggressive treatment with statins may have the potential to reverse coronary artery disease. In the study, rosuvastatin reduced fatty plaque in the arteries in addition to improving LDL and HDL cholesterol levels. However, a follow-up 2007 study of rosuvastatin indicated that while the drug slowed the rate of atherosclerotic progression, it did not reverse heart disease. Future studies will continue to investigate this issue.

A 2006 review of studies indicated that early, intensive therapy with statins can help reduce the risk of death, unstable angina, and revascularization (surgery to restore blood flow) for patients with acute coronary syndrome. The review indicated that statins work best when they are prescribed within 14 days of hospitalization for acute coronary syndrome. The researchers found that the effect of statins began about 4 months after starting drug therapy and that benefits lasted up to 2 years.

Side effects of statins may include stomach upset, headaches, skin rashes, muscle aches, sexual dysfunction, drowsiness, dizziness, nausea, constipation, and peripheral neuropathy (numbness or tingling in the hands and feet).

The main safety concern with statins is an uncommon condition called myopathy, which can cause muscle and joint pain and possible muscle damage. Doctors will immediately stop statin therapy if myopathy occurs. Patients should talk to their doctor about any unusual muscle discomfort or weakness or if their urine becomes brown-colored. Statins can also affect the liver, particularly at higher doses, so patients taking these drugs should receive regular liver function tests.

Angiotensin converting enzyme (ACE) inhibitors are important drugs for treating patients who have had a heart attack, particularly for patients at risk for heart failure. These drugs are commonly used to treat hypertension and are recommended as first-line treatment for people with diabetes and kidney damage.

ACE inhibitors include captopril (Capoten), ramipril (Altace), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Side Effects. Side effects of ACE inhibitors are uncommon but may include an irritating cough, excessive drops in blood pressure, and allergic reactions. In the past, doctors sometimes avoided giving aspirin to patients who were taking ACE inhibitors because the combination was believed to cause kidney problems. But, a 2005 study of patients with both coronary artery disease and heart failure found that taking aspirin and ACE inhibitor together is safe.

Magnesium has blood-thinning properties and may help open blood vessels. It is important to correct any magnesium deficiencies in patients (such as those who are taking diuretics).

Flu Shots. Influenza vaccinations may help protect patients against another heart attack during flu season.

Antibiotics. Researchers have investigated antibiotics for treating patients with heart disease and past infection of the bacteria Chlamydia pneumoniae. Results from several large-scale clinical trials, published in 2003 in the Journal of the American Medical Association (JAMA) and presented in 2004 at the European Society of Cardiology annual meeting, suggest that antibiotic treatment provides no benefit in preventing heart attack or other cardiac events in patients with coronary artery disease. While it is still possible that C. pneumoniae may play a role in triggering inflammatory responses associated with ACS, antibiotic therapy is no longer considered appropriate for treatment or prevention of heart disease.

Stem Cell Therapy. Researchers are investigating whether infusions of adult stem cells can help improve outcomes in patients who have a heart attack. Results from three small trials, published in 2006 in the New England Journal of Medicine, suggested that stem cell therapy may have some benefits in improving heart function. None of the studies reported treatment complications. Research presented at the 2007 American College of Cardiology annual meeting discussed intravenous stem cell therapy with Provacel (a commercial stem cell preparation). In the small study, patients who received Provacel had fewer adverse events (such as arrhythmia) and improved heart, lung, and overall function compared to patients who received placebo. Patients in the study received a Provacel infusion within 10 days of having a heart attack.

Surgery

Percutaneous coronary intervention (PCI), also called angioplasty, and coronary artery bypass graft surgery are the standard operations for opening narrowed or blocked arteries. They are known as revascularization procedures.

Emergency angioplasty is the standard procedure for heart attacks. It should be performed within 12 hours of a heart attack. Clot-buster drugs can help prevent damage, but must be given with 1 hour of a heart attack.
Coronary bypass surgery is typically used as elective surgery for patients with blocked arteries. It may be used after a heart attack if angioplasty or thrombolytics fail or are not appropriate. It is usually not performed for a few days to allow recovery of the heart muscles.

Click the icon to see an illustrated series detailing a heart bypass surgery.

Percutaneous coronary intervention (PCI), also called angioplasty, involves procedures such as percutaneous transluminal coronary angioplasty (PTCA) that help open the blocked artery. A typical angioplasty procedure involves the following steps:

Click the icon to see an image of an angioplasty.

The cardiologist threads a narrow catheter (a tube) containing a fiber into the blocked vessel.
The cardiologist opens the blocked vessel using balloon angioplasty, in which a tiny deflated balloon is passed through the catheter to the vessel.
The balloon is inflated to compress the plaque against the walls of the artery, flattening it out so that blood can once again flow through the blood vessel freely.
The balloon is inflated to compress the plaque against the walls of the artery, flattening it out so that blood can once again flow through the blood vessel freely.
To keep the artery open afterwards, doctors use a device called a coronary stent, an expandable metal mesh tube that is implanted during angioplasty at the site of the blockage.
Once in place, the stent pushes against the wall of the artery to keep it open. Stenting is improving results in patients with heart attack who have emergency angioplasty. It also significantly prevents reclosure and reduces heart attack rates in patients with ACS.

Experts recommend that appropriate patients receive angioplasty and stenting within 90 minutes after having a heart attack and no later than 12 hours following an attack. Although some hospitals have been performing angioplasty and stenting for up to a month following a heart attack, a landmark 2006 study found that delayed surgical intervention is not helpful for most patients. The Occluded Artery Trial (OAT), published in the New England Journal of Medicine, reported that balloon angioplasty and stenting failed to prevent heart complications in patients who received the procedure 3 – 28 days after a heart attack. The trial compared angioplasty to medications (aspirin, ACE inhibitors, beta-blockers, statins, clopidogrel).

Experts are now recommending delayed angioplasty and stenting only for patients who are unstable or who continue to have chest pain following a heart attack. This procedure may also be appropriate for patients who cannot tolerate beta-blocker drugs, which are commonly prescribed to help improve survival after a heart attack.

Complications occur in about 10% of patients (about 80% within the first day). Serious side effects include heart attack and the need for additional surgery. Best results occur in hospital settings with experienced teams and backup. Women who have angioplasty after a heart attack have a higher risk of death than men.

Reclosure and Blockage During or Shortly after Angioplasty. Reclosure of the artery often occurs during or shortly after angioplasty. A number of anticlotting drugs are used to reduce this risk. Clopidogrel (Plavix) is often given along with aspirin and thrombolytic drugs (such as abciximab) in the days before angioplasty surgery, to help prevent heart attack or stroke following surgery. Research suggests that abciximab (ReoPro) is especially helpful for patients with acute coronary syndrome.

Prevention of Restenosis. Narrowing or reclosing of the artery (restenosis) occurs within a year of angioplasty in many angioplasty patients, often requiring a repeat operation. In restenosis, the narrowing of the artery is usually due to scarring, not blood clots. Drug-eluting stents, which are coated with sirolimus (Rapamune) or paclitaxel (Taxol), can help prevent restenosis. Several 2006 studies indicated that this type of stent may be better than a bare metal stent for patients who have experienced a STEMI heart attack. However, because drug-eluting stents reduce arterial tissue growth, they can increase the risks of blood clots.

In February 2007, the American Heart Association and other professional organization issued an extremely important joint advisory statement. The statement advises that all patients who have drug-eluting stents must continue to take aspirin and clopidogrel (or, rarely,) ticlopidine for at least 1 year after the stent is inserted to reduce the risk of blood clots. Clopidogrel and ticlopidine are thienopyridine drugs that, like aspirin, help prevent blood platelets from clumping together. It is very important that patients who have drug-eluting stents take both aspirin and a thienopyridine drug. If for some reason patients cannot take a thienopyridine drug, they should receive a bare metal stent instead of a drug-eluting stent. [See In-Depth Report #03: Coronary artery disease.]

Click the icon to see an illustrated series detailing balloon angioplasty.

Coronary artery bypass graft surgery (CABG) is the alternative elective procedure to angioplasty for opening blocked arteries in patients with severe angina, particularly those who have two or more blocked arteries. It is a very invasive procedure, however:

The chest is opened, and the blood is rerouted through a lung-heart machine.
The heart is stopped during the procedure.
Segments of veins or arteries taken from elsewhere in the patient's body are fashioned into grafts, which are used to reroute the blood. The blood vessel grafts are placed in front of and beyond the blocked arteries, so the blood flows through the new vessels around the blockage.

Mortality rates with this procedure after a heart attack are much higher (6%) than when it is used electively (1 - 2%). How or when it should be used after a heart attack, then, is controversial. A 2002 study attempted to determine which patients are at highest risk for poor results from CABG after a heart attack. The study found higher risks for women, patients over age 75, and those with heart failure or other severe heart problems.

Rehabilitation

Lifestyle measures, particularly dietary factors, are equally important in preventing heart attacks and must be strenuously adhered to.

Physical rehabilitation is extremely important after a heart attack. It has been associated with a 25% reduction in mortality rates at 3 years. Rehabilitation may include:

Leg exercises may start as early as the first day. The patient usually sits in a chair on the second day, and begins to walk on the second or third day.
Most patients undergo low-level exercise tolerance tests early in their recovery. One study suggests that exercise testing within 3 days after a relatively minor attack may allow patients to go home earlier.
After 8 - 12 weeks, many patients, even those with heart failure, benefit from supervised exercise programs. Health professionals should provide the patient with schedules for low-level aerobic home-activity. Strength (resistance) training is also important. Tai Chi, a Chinese martial art, appears to be very beneficial and safe for people after a heart attack. It should be noted that the risk for serious heart events during rehabilitation is very low.

Patients generally return to work in about 2 months, although timing can vary depending on the severity of the condition.

Sexual activity after a heart attack carries a very low risk and is believed to be safe, particularly in people who had exercised regularly before the attack. In any case, the feelings of intimacy and love that accompany healthy sex can help offset depression, a far greater risk for a future attack.

Major depression affects between 15 - 23% of patients with ACS or heart attacks. Many studies suggest that depression is a major predictor for increased mortality in both women and men. (One reason may be that depressed patients are less likely to comply with their heart medications.)

Psychotherapeutic techniques, especially cognitive behavioral therapies, are very helpful. Doctors have been reluctant to prescribe antidepressant drugs after ACS or a heart attack because older antidepressants tended to have adverse effects on the heart. Newer antidepressants may be safer. Studies on sertraline (Zoloft), one of the selective serotonin reuptake inhibitor (SSRI) antidepressants, have not reported harmful effects for patients who have had a heart attack. It is not yet clear if other SSRIs are equally safe and effective.

Resources

www.nhlbi.nih.gov -- National Heart, Lung, and Blood Institute
www.acc.org -- American College of Cardiology
www.americanheart.org -- American Heart Association

References

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Review Date:
4/16/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

High blood pressure

FitSugar — Wed, 08 Oct 2008 17:35:08 -0700

In This Report

Highlights
Introduction
Diagnosis
Causes
Risk Factors
Complications
Symptoms
Treatment
Lifestyle Changes
Medications
Classes of Medications
Resources
References

HEALTH GUIDE REFERENCE FROM A.D.A.M

Highlights

Drug Approval

In 2007, the FDA approved a new type of high blood pressure drug. Aliskiren (Tekturna) blocks renin, a kidney enzyme that is associated with blood pressure regulation. Aliskiren can be taken alone or in combination with other blood pressure drugs, but it should not be used during pregnancy.

Drug Concerns

ACE inhibitors should never be taken during the second or third trimesters of pregnancy. An important 2006 New England Journal of Medicine study extended these concerns by reporting that ACE inhibitors may cause major heart birth defects during the first trimester. Although this research is still preliminary, the FDA and the American Heart Association now recommend that women who are pregnant or considering becoming pregnant switch to another type of blood pressure drug.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the risk of developing high blood pressure in men, suggests a 2007 Archives of Internal Medicine study. Previous research indicated that these non-prescription painkillers increase high blood pressure risk in women.

Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT)

The ALLHAT trial has been the most important long-running clinical study for evaluating the effects of high blood pressure medications. One of its most critical findings established the importance of thiazide-type diuretics as first-line treatment for high blood pressure. Recent trial results indicate:

Diuretics are very helpful for preventing heart failure in patients with high blood pressure. In a 2006 Circulation study, diuretics outperformed ACE inhibitors and calcium channel blockers in reducing heart failure risk.
Thiazide-type diuretics may slightly increase the risk of developing diabetes more than other drug classes but their blood pressure-lowering benefits outweigh the risks, according to a 2006 Archives of Internal Medicine study. The study found that all types of blood pressure medications increase blood sugar levels and diabetes risk.

Introduction

High blood pressure, also called hypertension, is elevated pressure of the blood in the arteries. Hypertension results from two major factors, which can be present independently or together:

The heart pumps blood with excessive force
The body's smaller blood vessels (known as the arterioles) narrow, so that blood flow exerts more pressure against the vessels' walls

Blood pressure is the force applied against the walls of the arteries as the heart pumps blood through the body. The pressure is determined by the force and amount of blood pumped and the size and flexibility of the arteries.

Although the body can tolerate increased blood pressure for months and even years, eventually the heart may enlarge (a condition called hypertrophy), which is a major factor in heart failure.

Click the icon to see an image of hypertrophic cardiomyopathy.

Such pressure can also injure blood vessels in the heart, kidneys, the brain, and the eyes.

Two numbers are used to describe blood pressure: the systolic pressure (the higher and first number) and the diastolic pressure (the lower and second number). Health dangers from blood pressure may vary among different age groups and depending on whether systolic or diastolic pressure (or both) is elevated. A third measurement, pulse pressure, may also be important as an indicator of severity.

Blood pressure is measured in millimeters of mercury (mm Hg). According to current adult guidelines, blood pressure is categorized as normal, prehypertensive, and hypertensive (which is further divided into Stage 1 and 2, according to severity). People in normal health should have a blood pressure reading of 120/80 mm Hg or less. High blood pressure is generally considered to be a blood pressure reading greater than or equal to 140 mm Hg (systolic) or greater than or equal to 90 mm Hg (diastolic). Blood pressure readings in the prehypertension category (120-139 systolic or 80-89 diastolic) indicate an increased risk for developing hypertension.

Current guidelines for children are based on percentile ranges for a child’s body size. Hypertension is defined as average systolic and diastolic readings that are greater than the 95th percentile for gender, age, and height on at least three occasions. Prehypertension in children is diagnosed when average systolic or diastolic blood pressure levels are at least in the 90th percentile but less than the 95th percentile. For adolescents, as with adults, blood pressure readings greater than 120/80 are considered prehypertensive. Increasing rates of childhood obesity have lead to higher than average blood pressure levels in children.

American expert groups recommend treating any blood pressure above normal. Some experts are concerned, however, that such guidelines may unnecessarily increase the use of anti-hypertensive drugs. It is important that patients establish a relationship with a doctor whom they trust, to help them determine individual blood pressure goals and treatment regimens. For some patients, a decrease of a few points in blood pressure may not be worth the side effects caused by higher doses of anti-hypertensive drugs.

Systolic Blood Pressure. The systolic pressure (the first and higher number) is the force that blood exerts on the artery walls as the heart contracts to pump out the blood. High systolic pressure is now known to be a greater risk factor than diastolic pressure for heart, kidney, and circulatory complications and for death, particularly in middle-aged and elderly adults. The wider the spread between the systolic and diastolic measurements, the greater the danger.

Elevated systolic pressure may pose a significant danger for heart events and stroke events even when diastolic is normal -- a condition called isolated systolic hypertension. Isolated systolic hypertension is the most common form of hypertension in people older than age 50. In one study, it comprised 87% of hypertension cases in people between ages 50 and 59.

Diastolic Blood Pressure. The diastolic pressure (the second and lower number) is the measurement of force as the heart relaxes to allow the blood to flow into the heart. High diastolic pressure is a strong predictor of heart attack and stroke in young adults.

Pulse Pressure. Pulse pressure is the difference between the systolic and the diastolic readings. It appears to be an indicator of stiffness and inflammation in the blood-vessel walls. The greater the difference between systolic and diastolic numbers, the stiffer and more injured the vessels are thought to be. Although not yet used by doctors to determine treatment, evidence suggests that it may prove to be a strong predictor of heart problems, particularly in older adults. Some studies suggest that in people over 45 years old, every 10 mm Hg increase in pulse pressure increases the risk for stroke rises by 11%, cardiovascular disease by 10%, and overall mortality by 16%. (In younger adults the risks are even higher.)

Click the icon to see an animation about blood pressure.

Some experts categorize hypertension into the following types:

Essential Hypertension. Essential hypertension is also known as primary or idiopathic hypertension. About 90% of all high blood pressure cases are this type. The causes of essential hypertension are unknown but are based on complex processes in all major organs and systems, including the heart, blood vessels, nerves, hormones, and the kidneys.

Secondary Hypertension. Secondary hypertension comprises about 5% of high blood pressure cases. In this condition, the cause has been identified.

Isolated Systolic Hypertension. This occurs when systolic hypertension is over 140 mm Hg but diastolic pressure is normal. It is related to arteriosclerosis (hardening of the arteries).

Click the icon to see an image of atherosclerosis.

Pregnancy Induced Hypertension. This condition occurs during pregnancy if blood pressure increases by more than 15 mm Hg above normal.

White Coat Hypertension. This form of hypertension is elevated blood pressure that occurs only during a visit to the doctor's office, but not at home. It is a factor in about 20% of patients with mild hypertension. Although previously considered a relatively harmless condition, research now suggests that white-coat hypertension shares certain features with essential hypertension. Studies have even suggested that white-coat hypertension actually may pose a risk for future heart problems, although the increased danger appears to be small compared with the risk in those with steady mild hypertension.


Blood Pressure Category	Ranges for Most Adults (systolic/diastolic)
Normal Blood Pressure (systolic/diastolic)	Systolic below 120 mm Hg Diastolic below 80 mm Hg
Prehypertension (Formerly Normal to High-Normal Blood Pressure)	Systolic 120 - 139 mm Hg Diastolic 80 - 89 mm Hg (NOTE: 139/89 or below should be the minimum goal for everyone. People with diabetes or chronic kidney disease should strive for 130/80 or less.)
Mild Hypertension (Stage 1)	Systolic 140 - 159 mm Hg Diastolic 90 - 99 mm Hg
Moderate to Severe Hypertension (Stage 2)	Systolic over 160 mm Hg or Diastolic over 100 mm Hg
Note: If one of the measurements is in a higher category than the other, the higher measurement is usually used to determine the stage. For example, if systolic pressure is 165 (Stage 2) and diastolic is 92 (Stage 1), the patient would still be diagnosed with Stage 2 hypertension. It should be strongly noted that a high systolic pressure compared to a normal or low diastolic pressure should be a major focus of concern in most adults.

Diagnosis

Most physical exams include a blood pressure measurement. Patients should not smoke or drink caffeinated beverages within 30 minutes before their blood pressure measurement.

The standard instrument used to measure blood pressure is called a mercury sphygmomanometer. Measurements are given as units of mercury, which has filled the central column in standard sphygmomanometers for years. (Some people view the mercury sphygmomanometer as an environmental health hazard, but modern devices are designed to prevent mercury spillage.)
An inflatable cuff with a meter attached is placed around the patient's arm over the artery while the patient is seated. The inflated cuff briefly interrupts the flow of blood in the artery, which then resumes as the cuff is slowly deflated.
The person taking the blood pressure listens through a stethoscope for so-called Korotkoff sounds, which first appear as blood begins to flow through the artery and then change in tone and volume as the cuff is deflated.
If a first blood pressure reading is above normal, the health professional may take two or more measurements separated by 2 minutes with the patient sitting or lying down. Another measurement may be taken after the patient has been standing for 2 minutes.

To measure blood pressure, your doctor uses an instrument called a "sphygmomanometer," more often referred to as a blood pressure cuff. The cuff is wrapped around your upper arm and inflated to stop the flow of blood in your artery. As the cuff is slowly deflated, your doctor uses a stethoscope to listen to the blood pumping through the artery. These pumping sounds register on a gauge attached to the cuff. The first pumping sound your doctor hears is recorded as the systolic pressure, and the last sound is the diastolic pressure.

Although this test has been used for more than 90 years, it is not completely accurate or sensitive. The following factors can cause a falsely low pressure reading:

An arm cuff that is too wide
Recent exercise
Not smoking for a while after heavy, long-term smoking

Falsely high pressure can result from:

An arm cuff that is too small
Talking during the test
Recently consuming foods or beverages (such as coffee) that raise blood pressure

Office blood pressure readings taken by a doctor are more likely to be higher than readings measured at home. This so-called white-coat hypertension requires additional readings by a nurse or by the patient. Home monitoring improves the accuracy of a simple office measurement. An average of all the measurements will be considered in the diagnosis of hypertension. If high normal or high blood pressure persists, further tests should be performed to determine if the organs are affected.

Other Blood-Pressure Monitors. Alternative pressure-measuring aneroid and electronic devices are available. Aneroid instruments are round, compass-like devices that use a metal spring to measure blood pressure and are often used by doctors. Electronic devices are typically used for home monitoring.

Monitoring Equipment. A number of home tests are available for checking blood pressure between doctor visits. A doctor may loan a patient a portable unit that records blood pressure during a full day's activity. This test, known as ambulatory monitoring, is particularly useful for those who experience wide blood pressure swings, such as those who have white-coat hypertension or show resistance to drug therapy. According to one study, accurately measuring blood pressure at home over a full day was a significantly better predictor of cardiovascular risk than standard office-based measurements. To improve clinical outcomes, devices are now available that allow 24-hour ambulatory blood pressure monitoring and electronically store results for analysis by the doctor. It is not clear if their added benefits justify their expense, however.

Cuffs and Stethoscopes. Manual cuffs and stethoscopes are fairly accurate, but they require practice to use. The cuff must be the right size (one size does not fit all). Devices that use a digital readout and a cuff that can be electronically inflated and deflated are proving to be as accurate as a stethoscope.

Blood Pressure Variations at Home. In general, everyone's blood pressure varies in the same way throughout a given day. In monitoring at home, it is important to note these changes:

Blood pressure is usually highest at work.
It drops slightly at home.
It then normally dips to its lowest level during sleep. There are important exceptions. Certain people have a condition called nondipper hypertension, in which blood pressure does not fall at night. Postmenopausal women appear to be at particular risk for this phenomenon, and it may pose a special danger for heart disease and stroke (particularly in older African-American women). It has also been linked to salt-sensitivity and insulin resistance.

Click the icon to see an image of stroke.

Upon waking, pressure in most people typically increases suddenly. In people with severe high blood pressure, this is the highest risk period for heart attack and stroke.

Click the icon to see an image of a heart attack.

Some studies have reported that when patients record and report their own blood pressure, they are unreliable and don't always tell the truth. Despite the difficulties and controversy surrounding this issue, home blood pressure monitoring has been shown to encourage patients to use measures that control their blood pressure and thereby reduce the risk of cardiovascular events.

Click the icon to see an image about monitoring blood pressure.

If blood pressure is elevated, the doctor will check the patient's pulse rate, examine the neck for distended veins or an enlarged thyroid gland, check the heart for enlargement and murmurs, and examine the abdomen and the eyes.

Click the icon to see an image of the thyroid gland.

If hypertension is suspected, the doctor should obtain the following information:

A family and personal medical history, especially incidence of high blood pressure, stroke, heart problems, kidney disease, or diabetes.
Risk factors for heart disease and stroke, including tobacco use, salt intake, obesity, physical inactivity, and unhealthy cholesterol levels.
Any medications being taken.
Any symptom that might indicate so-called secondary hypertension (that is, caused by another disorder). Such symptoms include headache, heart palpitations, excessive sweating, muscle cramps or weakness, or excessive urination.
Any emotional or environmental factors that could affect blood pressure.

If a physical examination indicates hypertension, additional tests may help determine whether it is secondary hypertension or essential hypertension (no other disorder is present) and whether organ damage is present. They include the following:

Blood tests and a urinalysis. (Performed to check for a number of factors, including potassium levels, cholesterol, blood sugar, infection, kidney function, and other possible problems. Measuring blood levels of the protein creatinine, for example, is important for all hypertensive patients in order to determine kidney damage. Higher concentrations may also be an indicator of heart disease.)

An electrocardiogram (ECG).

Click the icon to see an image of an electrocardiogram.

An exercise stress test. This could be important for those with borderline hypertension. Stress-induced blood pressure in such patients has been associated with a risk for left ventricular hypertrophy, a serious complication in which the muscles on the left side of the heart become enlarged. Studies also suggest that an excessive rise in systolic pressure during exercise indicates a risk for coronary artery disease, and stroke.

Click the icon to see an image of blood pressure tests.

Causes

Hypertension is referred to as essential (primary) when the doctor is unable to identify a specific cause. It is by far the most common type of high blood pressure. The causes of this type are unknown but are likely to be a complex combination of genetic, environmental, and other factors.

Genetic Factors. A number of genetic factors or interactions between genes play a major role in essential hypertension. Experts think that the chromosomes (13 and 18) house the genes responsible for blood pressure regulation, although pinning down the range of specific genes involved in hypertension is more difficult.

Abnormalities in the Angiotensin-Renin-Aldosterone System. Genes under intense study are those that regulate a group of hormones known collectively as the angiotensin-renin-aldosterone system. This system influences all aspects of blood pressure control, including blood vessel contraction, sodium and water balance, and cell development in the heart.

Experts believed that this system evolved millions of years ago to protect early humans during drought or stress by retaining salt and water and narrowing blood vessels to ensure adequate blood flow and repair injured tissue. With industrialization, however, this system wreaks havoc on modern humans by intensifying the effects of high-salt diets and sedentary lifestyle. Of particular importance in these harmful responses are the hormone aldosterone and a peptide (a component of proteins) called angiotensin II.

Inherited Abnormalities in the Sympathetic Nervous System. Studies suggest that some people with essential hypertension may inherit abnormalities of the sympathetic nervous system. This is the part of the autonomic nervous system that controls heart rate, blood pressure, and the diameter of the blood vessels.

Insulin Resistance and Type 2 Diabetes. Hypertension is strongly associated with diabetes, both type 1 and type 2. Kidney damage is generally the cause of high blood pressure in type 1 diabetes. Obesity and insulin resistance are the factors associated with hypertension in type 2 diabetes, the more common type. People with type 2 diabetes generally have normal or high levels of insulin, a critical hormone in the metabolism of sugar. However, they are unable to use the insulin, the condition called insulin resistance. Without insulin, blood glucose (sugar) levels rise, the hallmark of diabetes.

Some research indicates that obesity is the one common element linking insulin, type 2 diabetes, and high blood pressure. Obesity is common in both type 2 diabetes and hypertension. Oddly, however, studies have found a stronger association between hypertension and insulin resistance in thin patients as well as overweight people with type 2 diabetes. Some research indicates that insulin resistance may cause sodium retention, a contributor to high blood pressure.

In any case, regardless of the causal connections, people who have insulin resistance or full-blown diabetes plus hypertension have a significantly greater chance for heart attack, kidney disease, and stroke than people who have only high blood pressure.

Obesity. Obesity on its own has a number of possible effects that could lead to hypertension. It may blunt certain actions of insulin that open blood vessels, and it may cause structural changes in the kidney and abnormal handling of sodium. It is also associated with alterations in the systems that regulate blood flow.

Low Levels of Nitric Oxide. The gas nitric oxide can be produced in the body, where it affects the smooth muscle cells that line blood vessels; it helps keep them relaxed, flexible. It may also help prevent blood clotting. Low levels of nitric oxide have been observed in people with high blood pressure (particularly in African-Americans) and may be an important factor in essential hypertension.

Secondary hypertension has recognizable causes, which are usually treatable or reversible.

Medical Conditions. A number of medical conditions can cause secondary high blood pressure:

Kidney disease is the most common cause of secondary hypertension, particularly in older people.
Sleep apnea, a disorder in which breathing halts briefly but repeatedly during sleep, is now highly associated with hypertension. A weak but still higher than normal association with high blood pressure has even been observed in those who snore or have mild sleep apnea. The relationship between sleep apnea and hypertension has been thought to be largely due to obesity, but major studies are finding a higher rate of hypertension in people with sleep apnea regardless of their weight. Treating sleep apnea with a device known as nasal continuous positive airway pressure (CPAP) may have modest benefits blood pressure as well.

CPAP is an airway treatment using slight positive pressure during inhalation to increase the volume of inspired air and to decrease the work of breathing.

Other medical conditions that contribute to temporary hypertension are pregnancy, cirrhosis, and Cushing's disease.

Click the icon to see an image of cirrhosis of the liver.

Medications. Certain prescription and over-the-counter drugs can cause temporary high blood pressure. They include:

Corticosteroids
Acetaminophen (Tylenol)
Nonsteroidal anti-inflammatory drugs (NSAIDs) -- such as ibuprofen (Motrin), naproxen (Aleve), and aspirin -- may cause secondary hypertension as well as other complications. In one important study, women who used an NSAID for 5 or more days a month had a significantly higher risk for hypertension. The more often they used these drugs, the higher the risk. A 2007 study indicated that NSAIDs also increase the risk for hypertension in men. A 2005 study found that NSAIDs increase the risk for kidney failure, and that the risk is significantly greater for all patients with hypertension. Patients who took diuretics along with NSAIDs had 11.6 times the risk of developing acute kidney failure compared to non-NSAID users. The relative risk for calcium channel blockers and NSAIDs was 7.8. The researchers advised that NSAIDs should be used with caution in patients with hypertension or heart failure.
Cold medicines containing pseudoephedrine have also been found to increase blood pressure in hypertensive people, although they appear to pose no danger for those with normal blood pressure.
Oral contraceptives ("the pill") increase the risk for high blood pressure, particularly in women who are older, obese, smokers, or some combination. Stopping the pill nearly always reduces blood pressure, although a recent study suggested that oral contraceptives may produce a small but significant increase in diastolic pressure that persists in some older women who have been off the pill for years.

Alcohol, Cigarettes, and Coffee

An estimated 10% of hypertension cases are caused by alcohol abuse (three or more alcohol drinks a day), with heavier drinkers having higher pressure. Women may be more sensitive than men to the blood pressure effects of alcohol. Moderate drinking (one or two drinks a day) has benefits for the heart and may even protect against some types of stroke. In particular, red wine may have chemicals that help blood pressure.
Smoking. Smoking is a major risk factor. One study reported that smokers have blood pressures up to 10 points higher than nonsmokers.
Caffeine. In healthy people with normal blood pressure, drinking a couple of cups of coffee a day is unlikely to do any harm. A high intake of coffee may be harmful in people with hypertension and may even increase their risk for stroke.

Other Causes of Secondary High Blood Pressure

Stress
Intense workouts (snow shoveling, jogging, speed walking, tennis, heavy lifting, heavy gardening)

Risk Factors

During the last decade, the number of Americans with high blood pressure has increased by 30%. Over 65 million American adults now have high blood pressure, and this condition affects close to 1 billion people worldwide. Less than half of these people are on medication, however, and only about half of this group have their blood pressure under good control with such drugs. Older people are less likely to be treated adequately. The majority of people with high blood pressure have the mild type, but even this condition requires attention.

Age is the major risk factor of hypertension. Blood pressure increases with age in both men and women, and in fact, the lifetime risk for hypertension is nearly 90%. Two-thirds of Americans over age 60 have hypertension. Older women (60 years and above) currently have the highest rates of hypertension, and mortality rates from hypertension are higher in women than in men. Hypertension is also becoming more common in children and teenagers.

Compared to Caucasians, African Americans have 1.8 times the rate of fatal stroke, 1.5 times the risk for fatal heart disease, and 4.2 times the rates of end-stage kidney disease. In general, about 34% of African American men and women have hypertension; it may account for over 40% of all deaths in this group.

The prevalence of high blood pressure among African Americans is among the highest in the world. The rates of hypertension in Hispanic Americans, Caucasians, and Native Americans are about equivalent (ranging from 24 - 27%). The rate is much lower in Asian/ Pacific Islanders (9.7% in men and 8.4% in women). However, nearly 75% of older Japanese American men are hypertensive.

A number of theories have addressed the reasons for this difference:

African Americans may have lower levels of nitric oxide and higher levels of a peptide called endothelin-1 (ET-1) than Caucasians. Nitric oxide keeps blood vessels flexible and open and ET-1 narrows blood vessels.
African Americans have a higher risk for an impaired response to angiotensin (Ang II), which is a peptide important in regulating salt and water balances. African Americans are more likely to be salt-sensitive than other groups.
Social and income disparities and dietary issues may explain many of the differences in blood pressure rates observed between ethnic groups. For example, while African Americans have a disproportionately high rate of hypertension, one study in rural African villages, where diets are rich in fish, reported only a 3% rate of high blood pressure among inhabitants. Another study reported that Caucasian as well as African Americans in the Southeast have a higher incidence of hypertension and stroke than people in other U.S. regions. The Southeast also has a higher rate of obesity, stress, anxiety, and depression, and diets low in potassium and high in salt, all related to a lower socioeconomic level.
African Americans have a higher prevalence of risk factors (cardiovascular disease, obesity, diabetes and kidney disease) that are associated with hypertension.

In any case, hypertension appears to be dangerously undertreated in major minority groups. Inadequately controlled hypertension is the major factor for the higher mortality rate from heart disease among African Americans, and special treatment considerations need to be addressed in this population. A 2003 treatment consensus statement released by the International Society on Hypertension in Blacks (ISHIB) advises that many African Americans may need at least two medications to help lower their blood pressure. The ISHIB's "15 over 10" rule recommends combination therapy for any patient whose blood pressure exceeds their desired goal by 15 mm Hg systolic or 10 mm Hg diastolic.

Obesity. About one-third of patients with high blood pressure are overweight. Even moderately obese adults have double the risk of hypertension than people with normal weights. Moreover, the increase in blood pressure in aging Americans may be due primarily to weight gain. (In other cultures old age does not necessarily coincide with weight gain or high blood pressure.) Children and adolescents who are obese are at greater risk for high blood pressure when they reach adulthood.

Thinness. Interestingly, thin people with hypertension are at higher risk for heart attacks and stroke than obese people with high blood pressure. Experts think that thin people with hypertension are likely to have conditions such as an enlarged heart or stiff arteries that cause the blood pressure to rise and also pose greater dangers to health.

Low Birth Weight. Low birth weight, particularly in girls, has been associated with high blood pressure in both childhood and adulthood. One study suggested that breast-feeding these babies may help reduce this risk. Another study reported high levels of stress hormones in babies with low birth weight, which could increase the risk for high blood pressure later on. Low birth weight is also associated with subsequent obesity, a major contributor to hypertension.

Up to 75% of cardiovascular problems in people with diabetes may be due to hypertension. There are strong biologic links between insulin resistance (with or without diabetes) and hypertension. It is unclear which condition causes the other. Some experts believe angiotensin may be the common factor linking diabetes and high blood pressure. This natural chemical not only influences all aspects of blood pressure control but also interferes with insulin's normal metabolic signaling. People with diabetes or chronic kidney disease need to reduce their blood pressure to 130/80 mm Hg or lower to protect the heart and help prevent other complications common to both diseases. Lowering systolic pressure may be particularly important for people with diabetes.

Spouses. Studies suggest that spouses of people with high blood pressure are at a much higher risk as well. Such findings indicate that dietary and environmental factors play a role in this disease. Some evidence also indicates that higher risk in spouses may be due to people often choosing mates who are similar to them.

Family History and Genetics. Essential hypertension may be inherited in 30 - 60% of cases. According to one study, being a brother or sister of someone with premature coronary artery disease is a greater risk factor for hypertension than having a parent with the disease. A family history of heart disease is considered to be a major risk factor for high blood pressure in adults under age 65.

Atherosclerosis is a common disorder of the arteries. Fat, cholesterol, and other substances collect in the walls of arteries. Larger accumulations are called atheromas or plaque and can damage artery walls and block blood flow. Severely restricted blood flow in the heart muscle leads to symptoms such as chest pain.

People who are anxious or depressed may have over twice the risk for high blood pressure than those without these problems.

Mental Stress. Recent evidence confirms the association between stress and hypertension. In one 20-year study, men who periodically measured highest on the stress scale were twice as likely to have high blood pressure as those with normal stress. The effects of stress on blood pressure in women were less clear. Job stress and lack of career success have been specifically linked to high blood pressure in both men and women.

Anxiety. Studies suggest that anxiety is a risk factor for hypertension, particularly in women.

Depression. Mounting evidence suggests that depression has physiological effects that impair the heart and that it contributes to destructive behaviors, such as weight gain, smoking, or alcohol abuse. In one study, those who scored highest on a depression test had about twice the risk of high blood pressure as those with the lowest score. This link was particularly strong in African Americans. Depression was the strongest risk factor in this group.

Blood pressure levels tend to be lowest during the morning and midday hours and highest at the end of the day. Seasonal changes also affect blood pressure, with hypertension increasing during cold months and declining during the summer. Blood pressure readings can vary by as much as 40% depending on the time of day and season.

Complications

Hypertension places stress on several organs (called target organs), including the kidneys, eyes, and heart, causing them to deteriorate over time. High blood pressure contributes to 75% of all strokes and heart attacks. It is particularly deadly in African-Americans.

Research suggests that prehypertension is also a serious risk factor for heart complications. A 2005 study found that people with prehypertension are three times more likely to have a heart attack, and nearly twice as likely to develop coronary artery disease as people with normal blood pressure.

Hypertension is a disorder characterized by chronically high blood pressure. It must be monitored, treated and controlled by medication, lifestyle changes, or a combination of both.

Malignant hypertension, an emergency condition resulting from untreated primary hypertension, can be lethal.

About two-thirds of people who suffer a first stroke have moderate elevated blood pressure (160/95 mm Hg) or above. Hypertensive people have up to 10 times the normal risk of stroke, depending on the severity of the blood pressure. Hypertension is also an important cause of so-called silent cerebral infarcts, blockages in the blood vessels in the brain that may predict major stroke or progression to dementia over time.

Uncontrolled chronic high blood pressure is also associated with reduced short-term memory and mental abilities. Isolated systolic hypertension may pose a particular risk for complications in the brain. Fortunately, controlling blood pressure with medications can reduce or even prevent memory loss and mental decline due to hypertension. A 2006 study of older men indicated that anti-hypertensive treatment for at least 5 years may help prevent the development of dementia. Other studies suggest that anti-hypertensive drugs may help protect against Alzheimer's disease in people with genetic susceptibility to this disease.

High blood pressure is a major risk factor for heart disease.

Heart Attack. About half of people who suffer their first heart attack have moderate hypertension (160/95 mm Hg) or greater. High blood pressure increases the risk for a heart attack by up to five times, depending on the severity of the hypertension.

Heart Failure. Hypertension precedes heart failure in 75 - 90% of heart failure cases. High blood pressure has various effects that cause the heart to fail, including:

To compensate for increased blood pressure, the heart must work harder to pump blood, and so its muscles thicken (hypertrophy), usually on the left side (left-ventricle dysfunction). These thickened muscles pump inefficiently, and, over time, the force of their contractions weakens. The heart muscles then have difficulty relaxing and filling the heart with blood. The heart begins to fail.

Click the icon to see an image of a hypertensive heart.

The failing heart then triggers a number of hormonal and neurochemical mechanisms to correct imbalances in blood pressure and flow. This response, called remodeling, is helpful in the short run but very destructive and irreversible over time.
As part of the remodeling process, the heart muscle cells elongate. The muscular walls of the heart dilate and become thinner and inefficient. The cells themselves undergo molecular changes that result in calcium loss, a mineral crucial for healthy heart contractions.
The end-result of remodeling is a falling volume of blood pumped to the kidneys; the kidneys retain water and salt in response, increasing fluid buildup in the body.
To make matters worse, the body's arteries narrow in response to a lower blood volume. This constriction forces the heart to work even harder to pump blood through these narrowed vessels, increasing blood pressure and continuing the cycle.

A 2006 analysis of ALLHAT trial data indicated that diuretics are the best first-line high blood pressure medication for preventing heart failure.

Diabetes. High blood pressure, and the medications used to treat it, can increase the risk for developing diabetes. Studies have reported that thiazide diuretics and beta blockers carry a higher risk for causing diabetes than other anti-hypertensive drugs. However, an important 2006 ALLHAT study compared the effects of various drug classes on blood sugar levels and diabetes development. The results suggested that while diuretics may slightly increase diabetes risk more than other types of anti-hypertensive drugs, this effect does not cause worse heart problems. Most experts believe that thiazide diuretics should remain the first choice for high blood pressure treatment, and that the benefit of blood pressure reduction outweighs the risk of diabetes development.

Diabetes-Related Kidney Disease. High blood pressure is strongly associated with diabetic nephropathy (diabetes-related kidney disease). Most patients with type 2 diabetes who show early signs of nephropathy already have high blood pressure. When patients with type 1 diabetes are diagnosed with early nephropathy, on the other hand, they usually have normal blood pressure readings in the doctor's office. A 2002 study using home monitors, however, found that patients with type 1 diabetes often have high systolic blood pressure during sleep -- before development of nephropathy. Home blood pressure monitoring, then, may help identify patients who are at risk for kidney damage due to high systolic pressure.

End-Stage Kidney Disease. High blood pressure causes 30% of all cases of end-stage kidney disease (medically referred to as end-stage renal disease, or ESRD). Only diabetes leads to more cases of kidney failure.

Kidney Cancer. Men with high blood pressure may also have a higher risk of kidney cancer.

High blood pressure can injure the eyes, causing a condition called retinopathy.

Click the icon to see an image of hypertensive retinopathy.

Hypertension also increases the elimination of calcium in urine, potentially leading to loss of bone mineral density, a significant risk factor for fractures, particularly in elderly women. In one study, women with the highest levels of blood pressure lost bone density at nearly twice the rate of those in the lowest range. It is not clear whether this effect occurs in men or in non-Caucasian women.

Sexual dysfunction is more common and more severe in men with hypertension and in smokers than it is in the general population. Many of the drugs that treat hypertension are thought to cause impotence as a side effect. In these cases, it is reversible when the drugs are stopped. More recent evidence suggests, however, that the disease process that causes hypertension is itself the major cause of erectile dysfunction in these men.

Newer anti-hypertensive drugs, including angiotensin-converting enzyme (ACE) inhibitors and angiotensin-receptor blockers (ARBs), are less associated with erectile dysfunction. ARBs, such as losartan (Cozaar), may be particularly effective in restoring erectile function in men with high blood pressure. Sildenafil (Viagra) is successful in achieving erections in almost two-thirds of patients with controlled high blood pressure. Because sildenafil has a shorter half-life and is eliminated more quickly from the body than newer erectile dysfunction drugs, it may be a safer option for men with hypertension. In a 2003 review of safety data, sildenafil did not appear to pose a risk for men who had both high blood pressure and erectile dysfunction.

Severe, sudden high blood pressure in pregnant women is one component of a condition called preeclampsia (commonly called toxemia) that can be very serious for both mother and child. Preeclampsia occurs in up to 10% of all pregnancies, usually in the third trimester of a first pregnancy, and resolves immediately after delivery. Other symptoms and signs of preeclampsia include protein in the urine, severe headaches, and swollen ankles.

This condition may be caused by a failure of the placenta to embed properly in the uterus, which causes it to misconnect with the mother's blood vessels. As a result, the fetus does not receive a sufficient blood supply, and the mother's own blood pressure increases to replace it. The risk for preeclampsia is higher for first births, multiple births, and for very young women (teenagers) and those over age 35. Pre-existing high blood pressure, diabetes, and kidney disease also increase the risk for preeclampsia. There appears to be a genetic component for this condition, so women whose mothers experienced preeclampsia are also at higher risk.

The reduced supply of blood to the placenta can cause low birth weight and eye or brain damage in the fetus. Severe cases of preeclampsia can cause kidney damage, convulsion, and coma in the mother and can be lethal to both mother and child. Evidence also suggests that preeclampsia can lead to increased risks later in life for coronary heart disease and other heart problems.

Women at risk for preeclampsia (particularly those with existing hypertension) may benefit from having an ultrasound of uterine arteries at 20 - 24 weeks of pregnancy, followed (if abnormal) by 24-hour blood pressure monitoring. Blood pressure medications may be required. Delivery is the main cure for preeclampsia. In severe cases, the obstetrician will need to induce pre-term birth.

High blood pressure may increase the risk of developing fibroids, according to data from the Nurses’ Health Study. Tracking women for 10 years, the prospective epidemiologic study found that for every 10 mm/Hg increase in diastolic blood pressure, the risk for developing fibroids increased by 8 - 10%.

Children with high blood pressure should first be treated with lifestyle changes, including weight reduction, increased physical activity, and diet modification. If blood pressure is not controlled with lifestyle changes, drug treatment may be required. Although there are few clinical trials conducted in children, a 2005 study found that the angiotensin receptor blocker losartan was safe and effective in children. Results of studies evaluating outcomes of children with hypertension suggest that early abnormalities, including enlarged heart and abnormalities in the kidney and eyes, may occur even in children with mild hypertension. Children and adolescents with hypertension should be monitored and evaluated for any early organ damage. Secondary hypertension (high blood pressure due to another disease or drug) is more common in children than adults.

Symptoms

Hypertension has aptly been called the "silent killer" because it usually produces no symptoms. Untreated hypertension increases slowly over the years. It is important for anyone with risk factors to have their blood pressure checked regularly and to make appropriate lifestyle changes. Such recommendations are especially important for individuals who have prehypertension or hypertension, a family history of hypertension, are overweight, or are over age 40.

In rare cases (fewer than 1% of all patients with hypertension), the blood pressure rises quickly (with diastolic pressure usually rising to 130 mm Hg or higher), resulting in malignant or accelerated hypertension. This is a life-threatening condition and must be treated immediately. People with uncontrolled hypertension or a history of heart failure are at increased risk for this crisis.

People should call a doctor immediately if these symptoms occur:

Drowsiness
Confusion
Headache
Nausea
Loss of vision

Treatment

Patients with hypertension should work with their doctors to set blood pressure goals based on individual risk factors. Lifestyle and medication programs need to be planned on an individual basis.

Healthy lifestyle changes are imperative for anyone, and are critical for people with even normal blood pressure (120/80 mm Hg) and above. In appropriate patients, aggressive drug treatment of long-term high blood pressure can significantly reduce the incidence of mental decline and death from heart disease and other serious physical effects of hypertension. In people with diabetes, controlling both blood pressure and blood glucose levels prevents serious complications of that disease. Anti-hypertensive drugs may even prevent mental decline, including in people genetically susceptible to Alzheimer's disease. Nevertheless, only slightly over half of patients with hypertension are treated at all, and only a quarter have adequately controlled pressure.

It is not clear when drugs should be started, particularly for people with prehypertension or mild high blood pressure. To help make treatment choices, the U.S. National Heart, Lung, and Blood Institute has created categories (denoted as groups A, B, and C) according to a patient's risk factors for heart disease. Applying these categories to the severity of hypertension helps determine whether lifestyle changes alone or medications are needed.


Risk Groups	Blood Pressure Stages (Systolic/Diastolic)
	Prehypertension (120 - 139/80 - 89)	Mild (Stage 1) Blood Pressure (140 - 159/90 - 99)	Moderate-to-Severe (Stage 2) Blood Pressure (Systolic pressure over 160 or diastolic pressure over 100)
Risk Group A Have no risk factors for heart disease.	Lifestyle changes only. (Exercise and dietary program with regular monitoring.)	Year trial of lifestyle changes only. If blood pressure is not lower at 1 year, add drug treatments.	Lifestyle changes and medications.
Risk Group B Have at least one risk factor for heart disease* (excluding diabetes) but have no target organ damage (such as in the kidneys, eyes, or heart, or existing heart disease).	Lifestyle changes only.	6-month trial of lifestyle changes only. If blood pressure is not lower at 6 months, add drug treatments. Medications considered for patients with multiple risk factors.	Lifestyle changes and medications.
Risk Group C Have diabetes with or without target organ damage and existing heart disease (with or without risk factors for heart disease).	Lifestyle changes and medications.	Lifestyle changes and medications.	Lifestyle changes and medications.

* Risk factors for heart disease include the following: family history of heart disease, smoking, unhealthy cholesterol and lipid levels, diabetes, being over 60 years old.

Lifestyle Changes

Healthy lifestyle changes are an important first step for lowering blood pressure. Current guidelines recommend that people should:

Exercise at least 30 minutes a day
Maintain normal weight
Reduce salt intake
Increase potassium intake
Limit alcohol consumption; however, moderate alcohol consumption (1 – 2 glasses a day) may actually lower the risk for heart attack among men with high blood pressure
Consume a diet rich in fruits, vegetables, and low-fat dairy products while reducing total and saturated fat intake. (The DASH diet is one way of achieving such a dietary plan.)

The DASH diet (Dietary Approaches to Stop Hypertension) is proven to help lower blood pressure. Results are sometimes seen within a few weeks. Restricting sodium improves results. The diet appears to have antioxidant effects and may help lower LDL cholesterol levels, although beneficial HDL levels also decline. This diet is not only rich in important nutrients and fiber but also includes foods that contain far more electrolytes, potassium (4,700 mg/day), calcium (1,250 mg/day), and magnesium (500 mg/day) than are found in the average American diet.

A diet that is effective in lowering blood pressure is called Dietary Approaches to Stop Hypertension (DASH).

DASH diet recommendations:

Limit salt intake to no more than 2,300 mg a day (a maximum intake of 1,500 mg a day is an even better goal).
Reduce saturated fat to no more than 6% of daily calories and total fat to 27% of daily calories. (But, include dairy products that are non- or low-fat. Low-fat dairy products appear to be especially beneficial for lowering systolic blood pressure).
When choosing fats, select monounsaturated oils, such as olive or canola oils.
Choose whole grains over white flour or pasta products.
Choose fresh fruits and vegetables every day. In one study, people who increased their intake of fruits and vegetables experienced a drop in blood pressure after 6 months. Many of these foods are rich in potassium, fiber, or both, possibly helping lower blood pressure.
Include nuts, seeds, or legumes (dried beans or peas) daily.
Choose modest amounts of protein (no more than 18% of total daily calories). Fish, skinless poultry, and soy products are the best protein sources.
Other daily nutrient goals in the DASH diet include limiting carbohydrates to 55% of daily calories and dietary cholesterol to 150 mg. Patients should try to get at least 30 g of daily fiber.

Slight changes to the DASH diet might help further lower blood pressure, as well as improve cholesterol and lipid levels. Researchers reporting in the Journal of the American Medical Association and at the 2005 American Heart Association meeting said that replacing some carbohydrates in the DASH diet with more protein (from plant sources) or monounsaturated fats may help further reduce heart disease risk factors.

A combination of the DASH diet and salt restriction is extremely effective in reducing blood pressure. Reducing sodium may also help protect against heart failure. People with normal blood pressure should consume no more than 2,400 milligrams (about one teaspoon) of sodium each day. People with blood pressure should consume much less. (Patients should consult their doctor on individual recommendations for salt intake.) The following higher-risk groups should take particular measures to restrict salt:

People at Risk for Salt-Sensitivity. About half of people with hypertension have blood pressure that reacts significantly to salt. Such people are known to be salt-sensitive. Groups at particularly high risk for salt-sensitivity include African-Americans, the elderly, and people with diabetes. Even people with normal blood pressure can be salt-sensitive. High-salt diets in anyone who is salt-sensitive may harm the heart, kidneys, and brain and increase the risk for death, regardless of blood pressure. Because testing for salt-sensitivity is not easy, experts recommend that everyone proactively restrict their daily salt-intake.
Overweight People. Overweight individuals may absorb and retain sodium differently from people with normal weights. Reducing sodium can also help lower the risk of heart disease and stroke in people who are overweight. Unfortunately, because overweight people generally consume more calories, they are also likely take in more sodium.
People on Anti-Hypertensive Drugs. Restricting salt also enhances the benefits of many standard anti-hypertensive drugs by reducing potassium loss, and may help protect against kidney disease in patients who are also taking calcium-blocker drugs. A low-salt diet can also increase the chances for being able to stop such medications.

Simply eliminating table and cooking salt can be beneficial. Salt substitutes, such as Cardia, (containing mixtures of potassium, sodium, and magnesium) are available, but they are expensive. In any case, about 75% of the salt in the typical American diet comes from processed or commercial foods, not from food cooked at home, so the benefits of table-salt substitutes are likely to be very modest. Some sodium is essential to protect the heart, but most experts agree that the amount is significantly less than that found in the average American diet. If people cannot significantly reduce the amount of salt in their diets, adding potassium-rich foods might help to restore a healthy balance.

Evidence strongly indicates that a potassium-rich diet can help achieve healthy blood pressure levels, and that potassium supplements can lower systolic blood pressure by 1.8 m Hg and diastolic blood pressure by 1 mm Hg. Some evidence suggests that a potassium-rich diet can reduce the risk of stroke by 22 - 40%. Current expert guidelines support the use of potassium supplements or enough dietary potassium to achieve 3,500 mg per day for people with normal or high blood pressure (who have no risk factors for excess potassium levels). This goal is particularly important in people who have high sodium intake.

The best source of potassium is the fruits and vegetables that contain them. Some potassium-rich foods include bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas and beans, nuts, potatoes, and avocados.

Excess potassium can cause abdominal distress, muscle weakness, and, in rare cases, dangerous heart events. Some people should be particularly cautious about excess potassium, including those with conditions, such as diabetes or kidney disease, that increase potassium levels. People who take medications, such as ACE inhibitors or potassium-sparing diuretics that limit the kidney's ability to excrete potassium, should not take potassium supplements.

Smoking. Everyone should quit smoking.

Alcohol. People who drink alcohol should do so in moderation. Men with hypertension should limit their intake to no more than one or two drinks a day, and women and lighter people should drink less.

Caffeine Drinks. Coffee drinking is associated with small increases in blood pressure, but the risk is very small in people with normal blood pressure. People with existing hypertension should avoid caffeine altogether.

Fiber. Fiber supplementation can help reduce blood pressure levels. It may take up to 8 weeks to achieve the maximum benefit.

Folate. Increasing folate (a B vitamin) intake to more than 800 mcg/day can help reduce blood pressure, particularly for younger women (under age 46). Dietary sources of folate include citrus fruits, leafy green vegetables, beans, and grain products. Folate helps to reduce homocysteine levels.

Fish Oil and Omega 3 Fatty Acids. Omega 3 fatty acids (docosahexaenoic and eicosapentaneoic acids) are found in oily fish. Studies indicate that they may have specific benefits for many medical conditions, including hypertension. They appear to help keep blood vessels flexible and may help protect the nervous system. Fatty acids are also available in supplements, but their long-term effects on blood pressure are unknown.

Click the icon to see an image of omega-3 fatty acids

Calcium. Calcium regulates the tone of the smooth muscles lining blood vessels. Studies have found that people who have sufficient dietary calcium have lower blood pressure than those who do not. Hypertension itself increases calcium loss from the body. The effects of extra calcium on blood pressure, however, are mixed, with some even showing higher pressure.

Click the icon to see an image of the sources of calcium.

Magnesium. Some studies reported that magnesium supplements may induce small but significant reductions in blood pressure. No major studies, however, have been done on long-term benefits or risks of magnesium supplements. A major 2001 study on diet found no effect on blood pressure from magnesium intake from foods.

Antioxidant Supplements. Antioxidants are substances that help the body eliminate oxidants, (also called oxygen-free radicals), which are damaging particles produced as part of the body's chemical processes. Some antioxidant supplements, including vitamins C and E and alpha-lipoic acid, are being studied for possible benefits in protecting against hypertension by preventing injury in the blood vessels. Vitamin C may have specific benefits for hypertension by preventing dangerous effects on nitric acid, the substance that keeps arteries flexible.

Click the icon to see an image of vitamin C sources.

Click the icon to see an image of vitamin E sources.

In people who are overweight, even modest reductions in weight, particularly in the abdominal area, can immediately reduce blood pressure. Weight loss, particularly accompanied by salt restriction, may allow patients with mild hypertension, even older people, to safely reduce or go off medications. The benefits of weight loss on blood pressure are long-lasting.

Positive Effects on Blood Pressure. Regular exercise helps keep arteries elastic, even in older people, which in turn ensures blood flow and normal blood pressure. Sedentary people have a 35% greater risk of developing hypertension than athletes.

Experts recommend at least 30 minutes of exercise on most -- if not all-days. In one study, moderate exercise (jogging two miles per day) controlled hypertension so well that more than half the patients who had been taking drugs for high blood pressure were able to discontinue their medication.

Studies have also indicated that yoga and Tai Chi, an ancient Chinese exercise involving slow, relaxing movements, may lower blood pressure almost as well as moderate-intensity aerobic exercises.

High-intensity exercise may not lower blood pressure as effectively as moderate intensity exercise and may be dangerous in people with hypertension.

Negative Effects. Each year an estimated 75,000 heart attacks (5% of all heart attacks) occur after heavy exertion, leading to 25,000 deaths. Older people and those with uncontrolled hypertension or other serious medical conditions should be cautious when exercising. Studies report that older people who begin vigorous exercise are at a slightly higher than average risk for a heart attack during the first year, but over time, regular exercise is likely to be protective.

The following activities may pose particular dangers for high-risk individuals:

Intense workouts (snow shoveling, slow jogging, speed walking, tennis, heavy lifting, heavy gardening). They tend to stress the heart, raise blood pressure for a brief period, and may cause spasms in the arteries leading to the heart.
Competitive sports, which couple intense activity with aggressive emotions.

Effects of Anti-Hypertensive Drugs on Exercise. Certain anti-hypertensive medications, including diuretics and beta-blockers, can interfere with exercise capacity. ACE inhibitors or calcium-channel blockers are the best drugs for active individuals. However, patients who take drugs that interfere somewhat with exercise capability should still adhere to an exercise program and consult a doctor on how best to balance medications with exercise.

Click the icon to see an image about lifestyle changes for hypertension.

Certain sleep disorders, especially sleep apnea, are associated with hypertension. Even chronic, insufficient sleep may raise blood pressure in patients with hypertension, placing them at increased risk of heart disease and death. Stress hormone levels increase with sleeplessness, which can activate the sympathetic nervous system, a strong player in hypertension. Patients who have chronic insomnia or other severe sleep disturbances, (particularly sleep apnea), may want to consult a sleep expert. Patients with hypertension who are habitually poor sleepers should consider long-acting blood pressure medications to help counteract the increase in blood pressure that occurs in the early morning hours.

Improving mood or relieving stress may be helpful. The following studies suggested possible benefits:

Stress reduction programs that use cognitive-behavioral therapy may reduce blood pressure.
Active religious faith was associated with healthy blood pressure levels, possibly indicating the combined benefits of a strong social network and reduced stress from spiritual activities.
A simple relaxation technique called transcendental meditation (TM), which involves silent repetition of a single sound, was associated with lower blood pressure.

Treating stress cannot cure medical problems. Stress management programs are not a substitute for standard medical treatments, but can be a very important component of a lifestyle plan.

Medications

Dozens of anti-hypertensive drugs are available. Most fall into the following categories:

Diuretics rid the body of extra water and salt. Diuretics are usually the first-line treatment for high blood pressure.
Beta-blockers block the effects of adrenaline and ease the heart's pumping action.
Angiotensin converting enzyme (ACE) inhibitorsreduce the production of angiotensin, a chemical that causes arteries to narrow.
Calcium-channel blockers (CCBs) decrease the contractions of the heart and widen blood vessels.
Angiotensin-receptor blockers (ARBs) block angiotensin, another chemical that constricts the arteries.
Vasodilators expand blood vessels.

In about half of patients a single-drug regimen can control mild to moderate hypertension. More severe hypertension often requires a combination of two or more drugs. Each drug has specific benefits, but their effects may vary depending on the individual patient.

One of the most difficult issues that patients face, particularly those with primary hypertension, is that the treatment may make them feel worse than the disease, which usually has no symptoms. Whatever the difficulties, compliance with a drug and lifestyle program is worth the effort. It is very important that patients discuss medication concerns with their doctors. If current blood pressure drugs are causing uncomfortable side effects, the doctor may adjust dosages or combinations.

Patients whose blood pressure has been well-controlled and who are able to maintain a healthy life style may choose to withdraw from medications. They should do so in a step-down manner (gradual reduction) and be monitored regularly. Stopping too quickly can have adverse effects, including serious effects on the heart. The highest success rates are more likely in those who lose weight and reduce sodium intake, in patients who have been treated with a single drug, and in those who have maintained lower systolic blood pressure during treatment. People over 75 years old may have more trouble than younger adults in maintaining normal blood pressure after withdrawal.

Classes of Medications

There are several classes of drugs used to treat hypertension.

Diuretics help the kidneys get rid of excess salt and water. They are the mainstays of anti-hypertensive therapy and are the first drug of choice for most people with hypertension. They are especially helpful for treating the elderly and African-American patients. (African-Americans are more likely to be salt-sensitive, so they respond well to these drugs.) They also work well for patients with diabetes.

Results from the long-term Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), published in the Journal of the American Medical Association in 2005, confirm that thiazide-type diuretics should be the first treatment option for most patients with hypertension. The landmark trial included over 33,000 patients (35% black) with hypertension and at least one other cardiovascular risk factor. Patients were randomized to receive a calcium channel blocker, an ACE inhibitor, or a thiazide-type diuretic.

Results suggested that the diuretic worked just as well as the newer drugs in lowering blood pressure and was more effective in preventing heart failure, heart attack, and stroke. The benefits for the diuretic were even more significant for African-American patients. Other trial results indicated that patients taking the calcium channel blocker had the greatest risk for heart failure, and that the ACE inhibitor was much less effective than the diuretic in lowering blood pressure and preventing stroke in African-American patients.

Diuretic Types and Brands. There are many brands of diuretics. They are generally inexpensive. Some need to be taken once a day, some twice a day. Low doses are usually as effective for lowering blood pressure as higher doses. Diuretics are usually used in combination with other drugs, especially ACE inhibitors and beta blockers.

There are three main types of diuretics:

Potassium-sparing diuretics. These include amiloride (Midamor), spironolactone (Aldactone), and triamterene (Dyrenium).
Thiazide diuretics. These include chlorothiazide (Diuril), chlorthalidone (Hygroton), indapamide (Lozol), hydrochlorothiazide (Esidrix, HydroDiuril), and metolazone (Mykrox, Zaroxolyn).
Loop diuretics. Because loop diuretics act faster than other diuretics it is important to avoid dehydration and potassium loss. Loop diuretics include bumetanide (Bumex), furosemide (Lasix), and torsemide (Demadex).

Benefits of Diuretics. Diuretics can:

Reduce the risk for stroke
Reduce the risk for heart attack and heart failure
Protect against blood clots.

Problems with Diuretics. Loop and thiazide diuretics reduce the body's supply of potassium, which, if left untreated, increases the risk for arrhythmias. Arrhythmias are heart rhythm disturbances that can, in rare instances, lead to cardiac arrest. In such cases, doctors will prescribe lower doses of the current diuretic, recommend potassium supplements, or use potassium-sparing diuretics either alone or in combination with a thiazide. Potassium-sparing drugs have their own risks, which include dangerously high levels of potassium in people with existing elevated levels of potassium or in those with damaged kidneys. However, all diuretics are generally more beneficial than harmful.

Common Diuretic Side Effects:

Fatigue
Depression and irritability
Urinary incontinence
Reduced sexual drive

Beta-blockers help slow heart rate and lower blood pressure. They are usually used in combination with other drugs such as ACE inhibitors and diuretics.

Brands. Propranolol (Inderal), acebutolol (Sectral), atenolol (Tenormin), betaxolol (Kerlone), carteolol (Cartrol), metoprolol (Lopressor), nadolol (Corgard), penbutolol (Levatol), pindolol (Visken), carvedilol (Coreg), and timolol (Blocadren). The drugs may differ in their effects and benefits.

Problems with Beta-Blockers. Evidence presented at the 2005 meeting of the American College of Cardiology suggested that an ACE-inhibitor combined with a calcium channel blocker works just as well as a beta-blocker-diuretic combination in treating hypertension, and poses less risk of diabetes. Other recent studies suggest that beta-blockers may increase the risk of stroke, and should not be a first-line choice for high blood pressure treatment.

Do not abruptly stop taking these drugs. The sudden withdrawal of beta blockers can rapidly increase heart rate and blood pressure. The doctor may want the patient to slowly decrease the dose before stopping completely.
Beta blockers are categorized as non-selective or selective. Non-selective beta blockers such as carvedilol and propranolol may sometimes narrow bronchial airways. These beta blockers should not be used by patients with asthma, emphysema, or chronic bronchitis.
Beta blockers can lower HDL (“good”) cholesterol.
These drugs can hide warning signs of low blood sugar (hypoglycemia) in patients with diabetes. When combined with a diuretic, the risk of diabetes may be increased.

Common Side Effects

Fatigue and lethargy
Vivid dreams and nightmares
Depression
Memory loss
Dizziness and lightheadedness
Reduced ability to exercise
Coldness in extremities (legs, toes, arms, hands)

Check with your doctor about any side effects. Do not stop taking these drugs on your own..

Angiotensin-converting enzyme (ACE) inhibitors open blood vessels and decrease the workload of the heart. They are used to treat high blood pressure but can also help improve heart and lung muscle function.

These drugs are particularly important for patients with diabetes. A large study reported that patients with diabetes who took these drugs had fewer heart attacks and lower overall mortality rates than patients who took other types of high blood pressure medications. ACE inhibitors may also help slow progression of kidney disease, in addition to controlling blood pressure. They may also be better at preventing the development of diabetes in patients with kidney disease than other types of blood pressure medication. In a 2006 study of African-American patients with high blood pressure and kidney disease, patients who took an ACE inhibitor had a lower risk of developing diabetes than those who took a calcium channel blocker or beta-blocker drug.

Doctors sometimes avoid giving aspirin to patients who are taking ACE inhibitors due to concerns that this drug combination can cause kidney problems. A 2005 study of patients with both coronary artery disease and heart failure indicated that an aspirin and ACE inhibitor combination is not harmful, and that aspirin can significantly reduce mortality risk for these patients.

Brands. ACE inhibitors include captopril (Capoten), enalapril (Vasotec), quinapril (Accupril), benazepril (Lotensin), ramipril (Altace), perindopril (Aceon), and lisinopril (Prinivil, Zestril).

Common Side Effects of ACE Inhibitors:

Low blood pressure is the main side effect of ACE inhibitors. This can be severe in some patients, especially at the start of therapy.
Irritating cough is a common side effect, which some people find intolerable. Although all ACE inhibitors can have this side effect, sometimes switching to another brand will reduce this symptom.
ACE inhibitors can harm a developing fetus and should not be used during pregnancy. While it has long been known that these drugs can cause problems in the second and third trimester, an important 2006 study indicated that ACE inhibitors can also cause major heart birth defects when taken during the first trimester. The FDA and the American Heart Association recommend that women who become pregnant should change from ACE inhibitors to another type of blood pressure drug as soon as possible. Women of child-bearing age who are considering becoming pregnant should also discuss alternative drugs with their doctors.

Uncommon Side Effects of ACE Inhibitors:

ACE inhibitors protect against kidney disease, but they may also increase potassium retention by the kidneys. If potassium levels become extremely high, they can cause the heart to stop beating (cardiac arrest). This side effect is rare, except in patients with significant kidney disease. Because of this risk, ACE inhibitors are not usually used in combination with potassium-sparing diuretics or potassium supplements.
A rare but severe side effect is granulocytopenia, an extreme reduction in infection-fighting white blood cells.
In very rare cases, patients suffer a sudden and severe allergic reaction, called angioedema that causes swelling in the eyes and mouth and may close off the throat.

Patients who have difficulty tolerating ACE inhibitor side effects are usually switched to an angiotensin-receptor blocker (ARB).

ARBs, also known as angiotensin II receptor antagonists, are similar to ACE inhibitors in their ability to open blood vessels and lower blood pressure. They may have fewer or less-severe side effects than ACE inhibitors, especially coughing, and are sometimes prescribed as an alternative to ACE inhibitors. ARBs are particularly important drugs for patients with diabetes. They may help protect against kidney disease and kidney failure.

A 2006 study in the New England Journal of Medicine suggested that some patients with prehypertension may benefit from treatment with an ARB drug. Patients in the study received candesartan (Atacand).

Brands. Losartan (Cozaar, Hyzaar), olmesartan (Benicar) candesartan (Atacand), telmisartan (Micardis), eprosartan (Teveten), irbesartan (Avapro), and valsartan (Diovan). A combination medication containing candesartan and the diuretic hydrochlorothiazide (Diovan HCT, Atacand HCT) is also available.

Side Effects:

Low blood pressure
Dizziness and lightheadedness
Raised potassium levels
Drowsiness
Nasal congestion
Should not be used during pregnancy

Calcium-channel blockers (CCBs), or calcium antagonists, help relax blood vessels. Along with diuretics, CCBs may work better than other drug classes for lowering blood pressure in African-Americans. Recent research indicates that newer types of drugs (CCBs, ACE inhibitors) may be a better treatment option for some patients than older drugs (especially beta blockers).

Brands. Diltiazem (Cardizem, Dilacor), amlodipine (Norvasc), felodipine (Plendil), isradipine (DynaCirc), verapamil (Calan, Isoptin, Verelan), nisoldipine (Sular), nicardipine (Cardene), nifedipine (Adalat, Procardia), lercanidipine (Zanidip), lacidipine (Motens), and nitrendipine (Nitrepin). In 2004, a dual-therapy calcium channel blocker-statin combination drug (Caduet) was approved to treat high blood pressure and high cholesterol. Caduet is a fixed-dose combination of amlodipine and atorvastatin.

Side Effects:

Swelling in the feet
Constipation
Fatigue
Erectile dysfunction
Gingivitis
Rash
Food interactions (do not take CCBs with grapefruit or Seville orange products)

Alpha blockers such as doxazosin (Cardura), prazosin (Minipress), and terazosin (Hytrin) help widen small blood vessels. They are generally not used as first-line drugs for high blood pressure, but are prescribed if other drugs do not work or as add-on medication.

Vasodilators, which help open blood vessels by relaxing muscles in the blood vessel walls. These drugs are usually used in combination with a diuretic or a beta-blocker. They are rarely used by themselves. Vasodilators include hydralazine (Apresoline), clonidine (Catapres), available in tablets or as a skin patch), and Minoxidil (Loniten). Some of these drugs should be used with caution or not at all in people who have angina or who have had a heart attack.

Aliskiren (Tekturna). In 2007, the FDA approved aliskiren for treatment of high blood pressure. Aliskiren can be taken either alone or in combination with other blood pressure medication. It should not be used during pregnancy as it can cause injury or death to the fetus. Aliskiren is the first hypertension drug that inhibits renin, a kidney enzyme that is associated with the regulation of blood pressure.

Statins. Statins, common drugs used to lower cholesterol, are proving to have many other health benefits. They include lovastatin (Mevacor), pravastatin (Pravachol), simvastatin (Zocor), fluvastatin (Lescol), atorvastatin (Lipitor), and rosuvastatin (Crestor). In an important 2002 study, patients with high blood pressure but normal or slightly high cholesterol levels had fewer heart attacks and strokes when they took the a statin drug. In 2004, a calcium channel blocker-statin combination drug (Caduet) was approved to treat simultaneously high blood pressure and high cholesterol. Caduet is a fixed-dose combination of amlodipine and atorvastatin.

Resources

www.acc.org -- American College of Cardiology
www.americanheart.org -- American Heart Association
www.ash-us.org -- American Society of Hypertension
www.nhlbi.nih.gov/hbp -- National Heart, Lung, and Blood Institute
www.nhlbi.nih.gov/health/public/heart/hbp/dash -- DASH diet
www.ishib.org -- International Society on Hypertension in Blacks
www.eatright.org -- American Dietetic Association

References

Barzilay JI, Davis BR, Cutler JA, Pressel SL, Whelton PK, Basile J, et al. Fasting glucose levels and incident diabetes mellitus in older nondiabetic adults randomized to receive 3 different classes of antihypertensive treatment: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Arch Intern Med. 2006 Nov 13;166(20):2191-201.

Beulens JW, Rimm EB, Ascherio A, Spiegelman D, Hendriks HF, Mukamal KJ. Alcohol consumption and risk for coronary heart disease among men with hypertension. Ann Intern Med. 2007 Jan 2;146(1):10-9.

Cooper WO, Hernandez-Diaz S, Arbogast PG, Dudley JA, Dyer S, Gideon PS, et al. Major congenital malformations after first-trimester exposure to ACE inhibitors. N Engl J Med. 2006 Jun 8;354(23):2443-51.

Davis BR, Piller LB, Cutler JA, Furberg C, Dunn K, Franklin S, et al. Role of diuretics in the prevention of heart failure: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial. Circulation. 2006 May 9;113(18):2201-10.

Djousse L, Pankow JS, Hunt SC, Heiss G, Province MA, Kabagambe EK, et al. Influence of saturated fat and linolenic acid on the association between intake of dairy products and blood pressure. Hypertension. 2006 Aug;48(2):335-41.

Forman JP, Rimm EB, Curhan GC. Frequency of analgesic use and risk of hypertension among men. Arch Intern Med. 2007 Feb 26;167(4):394-9.

Peila R, White LR, Masaki K, Petrovitch H, Launer LJ. Reducing the risk of dementia: efficacy of long-term treatment of hypertension. Stroke. 2006 May;37(5):1165-70.

Taylor EN, Hu FB, Curhan GC. Antihypertensive medications and the risk of incident type 2 diabetes. Diabetes Care. 2006 May;29(5):1065-70.

Thornley-Brown D, Wang X, Wright JT Jr, Randall OS, Miller ER, Lash JP, et al. Differing effects of antihypertensive drugs on the incidence of diabetes mellitus among patients with hypertensive kidney disease. Arch Intern Med. 2006 Apr 10;166(7):797-805.

Review Date:
4/12/2007
Reviewed By:
Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

A.D.A.M. Copyright

adam.com

Stroke

FitSugar — Wed, 08 Oct 2008 17:35:11 -0700

Overview

Signs and Symptoms
Causes
Risk Factors
Diagnosis
Preventive Care
Treatment
Supporting Research

HEALTH GUIDE REFERENCE FROM A.D.A.M

A stroke occurs when the blood supply to part of the brain is suddenly interrupted due to the presence of a blood clot (ischemic stroke) or when a blood vessel in the brain bursts, spilling blood into the spaces surrounding brain cells (hemorrhagic stroke). Brain cells die when they no longer receive oxygen and nutrients from the blood or when they are damaged by sudden bleeding into or around the brain. This results in temporary or permanent neurologic impairment. Ischemic stroke, also known as cerebral infarction, accounts for 80 - 85% of all strokes, while hemorrhagic stroke accounts for the other 15 - 20%. Prior to a stroke, some people suffer transient ischemic attacks (TIAs), mini-strokes that generally last only 5 - 20 minutes but can linger for up to 24 hours before the symptoms go away completely. Many times, a TIA is a warning of an impending stroke. An estimated 700,000 people in the United States suffer a stroke each year, making this one of the most serious of all health problems. Half of stroke sufferers are left disabled, with many undergoing years of rehabilitation.

Signs and Symptoms

Symptoms of a stroke depend on which area of the brain is affected and, in turn, what functions in the body that area controls. Many of the warning signs of a possible stroke (like a TIA) and symptoms of an actual stroke are the same. If any of these symptoms occur, therefore, medical attention should be sought right away and appropriate treatment started as quickly as possible. The faster that treatment is started, the more likely it is that brain function will be preserved.

Symptoms and warning signs include:

Sudden weakness or numbness of the face, arm, and leg on one side of the body
Sudden loss of vision or dimmed vision, particularly in one eye
Loss of speech, or trouble talking or understanding speech
Sudden, severe headaches with no apparent cause
Unexplained dizziness, unsteadiness, or sudden falls, especially if accompanied by any of the previous symptoms

Causes

Ischemic stroke results from the following causes:

A clot (embolus) forms in a part of the body other than the brain, travels through blood vessels, and becomes wedged in a brain artery.
A blood clot (thrombus) forms in a brain artery and stays attached to the artery wall until it grows large enough to block blood flow.

Hemorrhagic stroke results from the following causes:

A bleeding aneurysm -- a weak or thin spot on an artery wall that, over time, has stretched or ballooned out under pressure from blood flow. The wall ruptures and blood spills into the space surrounding brain cells.
Artery walls lose their elasticity and become brittle and thin, prone to cracking.
Arteriovenous malformation (AVM) -- a tangle of defective blood vessels and capillaries within the brain that have thin walls that can rupture.

Free radical damage may make someone susceptible to stroke and other brain disorders. Free radicals are waste products created when the body turns food into energy (metabolism). Even though they are created naturally by normal metabolic processes (called oxidation), free radicals cause harmful chemical reactions that can damage cells in the body. There are also many environmental sources of free radicals like ultraviolet rays, radiation, and toxic chemicals in cigarette smoke, car exhaust, and pesticides.

Ways to help protect yourself include:

Avoid extra exposure to oxidative stress and its subsequent free radicals by staying away from environmental sources.
Take antioxidants (see Nutrition and Dietary Supplements).

Risk Factors

Anybody can have a stroke, but certain factors place you at higher risk. Some factors that increase the risk of stroke cannot be changed, while others are linked to lifestyle and are, therefore, under your control.

Risk factors that cannot be changed:

Age -- The older a person gets, the greater the risk of stroke.
Sex -- Men are more likely to have a stroke than women. But after menopause, a woman's risk of stroke rises significantly.
Family history -- Having a parent, grandparent, or sibling who has had a stroke, puts you at greater risk yourself.
Race -- African-Americans have a greater risk of stroke than Caucasians. This is related to an increased risk of high blood pressure, obesity, and diabetes in African-Americans.
Heart attack – If you have had a heart attack in the past, you are more likely to have a stroke than someone who has not had a heart attack.
A history of migraine headaches -- Recent studies indicate that people who experience migraines may be at higher risk for ischemic stroke.
A prior stroke -- If you have had a stroke, you are at increased risk for another.
Sickle cell anemia -- people with this condition are at risk for stroke at a younger age.
Berry aneurysms -- These are small, sac-like areas within the wall of an artery in the brain with which some people are born. They occur most often at the junctures of vessels at the base of the brain. Berry aneurysms may rupture without warning, causing bleeding within the brain.

Risk factors that can be changed with medical treatment:

High blood pressure -- High blood pressure has no symptoms, so regular blood pressure checks are important. The condition can be easily and successfully controlled with medication.
High blood cholesterol levels -- Studies have shown that lowering cholesterol levels by changing your lifestyle and taking medication can reduce the risk of stroke by as much as 30%. Keeping cholesterol low can reduce the risk of blood clots and plaque buildup within the walls of arteries in the brain.
TIAs, or "mini-strokes" -- A surprising number of people ignore the symptoms of TIAs, which are warning signs that a stroke may be about to happen. In fact, 50% of people who have had a TIA suffer a stroke within one year. It is very important to seek medical attention for these symptoms because if you have had a TIA, there are definite steps you can take to help prevent a major stroke. Doctors prescribe blood thinners such as aspirin, warfarin (Coumadin), or other drugs to prevent blood clots if you have had a TIA.
Cardiovascular disease -- Certain disorders of the heart or blood vessels, such as atherosclerosis (plaque build up in artery walls) and atrial fibrillation (an abnormal heart rhythm), can produce blood clots that may break loose and travel to the brain. These conditions are also treated with blood thinners to reduce risk of stroke.
Diabetes -- People with diabetes mellitus are more at risk. It is important to note that type 2 diabetes (often called adult onset) is highly influenced by certain lifestyle factors, particularly diet and excess weight.
Blood clotting disorders -- people who form blood clots more easily, called hypercoagulable conditions, are at greater risk for stroke. Hypercoagulable states are also treated with blood thinners such as warfarin (Coumadin) in order to try to prevent stroke and other complications.
Sleep apnea -- people with sleep apnea have three to six times the risk of stroke compared to people who do not have this disorder. This condition, defined as cessation of breathing many times throughout the night, is generally treatable by losing weight and/or using a special device called a CPAP machine.

Risk factors that can be changed by lifestyle modifications:

Cigarette smoking -- Cigarette smoking has been linked to heart attacks, strokes, artery disease in the legs, and lung cancer. Nicotine raises blood pressure, carbon monoxide reduces the amount of oxygen the blood can carry to the brain, and cigarette smoke makes the blood thicker and more likely to clot. It is never too late to give up smoking.
Smoking and birth control pills -- Research has proven that smoking and taking birth control pills significantly increases a woman's risk for stroke. Together, they can cause blood clots to form. Women who take birth control pills should not smoke.
Drinking large amounts of alcohol -- Frequent intoxication can make a person more likely to experience bleeding in the brain. Also, alcohol in large amounts can raise blood pressure.
Obesity -- Being overweight increases your risk of having a stroke, along with other health problems.
Lack of exercise -- Moderate exercise can help keep blood pressure and cholesterol levels within normal ranges.
Poor diet -- A diet high in fat can cause conditions within the body, such as obesity, type 2 diabetes, and high cholesterol, that contribute to a greater risk of stroke.
Stress -- Ongoing stress can raise blood pressure. Plus, not dealing well with stress can contribute to unhealthy habits such as smoking and overeating. Finding healthy ways to handle stress is important.

Other factors that may put you at increased risk for stroke include pregnancy, infection or inflammation, gum disease, and high homocysteine levels. Homocysteine is an amino acid that rises in the body if you have low levels of vitamins B6, B12, B9 (folic acid), and betaine.

Diagnosis

If you or someone you know experiences symptoms associated with stroke, call 911 or your local emergency number immediately. There are now effective therapies for stroke that must be administered at a hospital within the first 3 hours after stroke symptoms appear. At the hospital, a health care provider will make a diagnosis and guide you in determining which treatment or combination of therapies will work best for you. The health care provider will do a complete neurological exam and run a battery of tests, such as blood tests, an electrocardiogram, and a test to measure the severity of the stroke. Imaging techniques, such as CT scans, magnetic resonance imaging (MRI), and magnetic resonance angiography (MRA), may be used to reveal the cause of the stroke and pinpoint blockages or reveal malformations.

Preventive Care

The best way to prevent stroke is to reduce your risk factors and take control of your own health:

If you smoke, stop smoking -- many excellent smoking cessation programs are available today; your doctor can advise you about tools to use, such as the nicotine patch as well as exercise and other behavioral modifications.
Keep your weight within normal limits.
Get a moderate amount of exercise, preferably 5 days a week.
Eat a healthy diet that is rich in fruits and vegetables. Green leafy vegetables may be particularly important as well as whole grains, nuts (especially walnuts), and fish.
If you have heart disease or an abnormal heart rhythm, work with your doctor to treat it. Certain types of problems with the heart and blood vessels, such as atherosclerosis and atrial fibrillation can cause blood clots to form. These clots can travel through the bloodstream and block an artery in the brain, causing a stroke (or can block a blood vessel in the heart and cause a heart attack).
If you have high blood pressure, take your medication regularly.
Lower your cholesterol level if it is elevated -- some people can do this by modifying diet; others need to take medication. Lowering cholesterol levels has been proven to reduce the risk of stroke.
If you have diabetes, keep it under good control.
Know the warning signs of TIAs and strokes, and get help right away if you experience them.

Medications for prevention

Certain medications have been shown to reduce the risk of stroke. These drugs, which aim to prevent the formation of dangerous blood clots, fall under two major categories:

Antiplatelet agents -- These include aspirin and stronger prescription drugs like ticlopidine (Ticlid) and clopidogrel (Plavix). These drugs help keep tiny blood cells called "platelets" from clumping together in the bloodstream. When a blood vessel is damaged or injured, platelets will migrate to the area to begin a healing process. However, large numbers of platelets can clump together and form a clot that plugs up an artery. Antiplatelet agents help prevent this clumping.
Anticoagulants -- These drugs also prevent clots, but are much stronger than antiplatelet agents. Common anticoagulants are warfarin (Coumadin)and heparin (generally given at the hospital through injection into a vein).

Treatment

A stroke is a medical emergency, regardless of whether it is a major stroke or a short-lasting TIA.

A person suffering symptoms consistent with a stroke should be taken immediately to a hospital emergency department.

The ability to quickly pinpoint the type of stroke is critically important in treatment decisions. A stroke caused by a blocked artery is treated in an entirely different way than a stroke caused by bleeding within the brain.

The key to survival and recovery is prompt medical treatment.

Lifestyle

Rehabilitation -- learning certain skills that you might have lost is crucial following a stroke and can consist of one or more of the following:

Physical therapy -- Teaches walking, sitting, and lying down, switching from one type of movement to another.
Occupational therapy -- To relearn eating, drinking, swallowing, dressing, bathing, cooking, reading, writing, toileting.
Speech therapy -- To relearn language and communication skills. Often, non-verbal alternatives are encouraged until speech returns.
Psychological/psychiatric therapy -- To help relieve some mental and emotional stresses (such as depression) that often accompany a stroke. These feelings may be due to the location of the brain damage itself or may be a reaction to the stroke.

In addition, learning yoga may help you recover function after a stroke, even months later. If you have had a stroke and are considering yoga, first talk to your doctor. Then, find a qualified teacher in your area who has worked a lot with stroke victims; this is very important because there are certain yoga postures that you should NOT do if you have high blood pressure, narrowed carotid arteries (the main arteries in your neck supplying blood to the brain), or history of stroke. Check with your physical therapist for a referral.

Medications

If the stroke is caused by a blockage in an artery, medications called thrombolytics can be used. The only drug in this class approved by the Food and Drug Administration for treatment of stroke is tissue plasminogen activator (tPA). Popularly referred to as clot-busting, this medication has been used for years to treat heart attacks and only more recently has been used as part of the treatment of stroke.

Not all hospitals have the ability to give tPA to people having a stroke. Before this drug can be given, doctors must be certain that the stroke is the result of a blockage in the artery and not due to bleeding from an artery. This is determined through imaging procedures such as a computed tomography (CT) scan or magnetic resonance imaging (MRI). But not all hospitals have around-the-clock imaging services. If the stroke is due to bleeding, this powerful blood thinner can worsen the hemorrhage.

If tPA cannot be used (for example, too much time has passed since the stroke symptoms began), another less potent blood thinner called heparin may be considered for use instead.

Once the acute phase of the stroke has resolved, other less potent blood thinners called antiplatelet agents (such as aspirin and ticlopidine) or anticoagulants (such as warfarin) may be used to prevent future strokes due to blood clots (See "Preventing Future Strokes").

If a stroke is caused by bleeding, medication (such as mannitol) can be given to reduce swelling of brain tissue.

Following the acute treatment of a stroke, while in recovery, medications to control risk factors for stroke like high blood pressure and high cholesterol will be started or adjusted if you are already taking. Daily aspirin is also recommended for those who have had a stroke or a TIA.

Surgery and Other Procedures

If the stroke or TIA is caused by a blockage, a procedure called carotid endarterectomy can be used to remove the buildup of plaque from inside the effected carotid artery, one of the major vessels supplying blood to the head and neck.

This surgical procedure is best for those who have had symptoms and have a blockage of 70% or more of one of their carotid arteries. If the narrowing of the vessel is less than 50%, medication (not surgery) is the most appropriate treatment to prevent future strokes.

Unfortunately, carotid endarterectomy may actually cause a stroke. Therefore, the risks and benefits of this procedure must be carefully weighed with your doctor.

If the stroke is caused by bleeding, an artery within the brain can sometimes be "clipped" to prevent further bleeding. Emergency surgery for a bleeding stroke may involve locating and surgically evacuating (removing) blood that has pooled in the brain tissue (called a hematoma). A brain specialist, called a neurosurgeon, will determine if this procedure is appropriate or not.

Interventional radiologists, if this specialized service is available at your hospital, may be trained to perform carotid angioplasty. This procedure begins with carotid angiography, as described earlier, to locate the blockage in this main artery supplying blood to the brain. Once located, a tiny balloon is threaded up to the blocked area and then inflated to break up the clot or plaque responsible for the narrowing in the vessel. The specialist may leave a wire mesh (stent) inside the vessel to keep it open. This procedure is quite risky, however, and may even cause a stroke.

If an aneurysm is present but has not bled, your doctor will discuss the possibility of removing it surgically. The decision is based primarily on the size of the aneurysm.

Nutrition and Dietary Supplements

Potentially beneficial nutritional supplements include the following:

Alpha-lipoic acid. Alpha-lipoic acid works together with other antioxidants, such as vitamins C and E. It is important for growth, helps to prevent cell damage, and helps the body rid itself of harmful substances. Because alpha-lipoic acid can pass easily into the brain, it has protective effects on brain and nerve tissue and shows promise as a treatment for stroke and other brain disorders involving free radical damage. Animals treated with alpha-lipoic acid, for example, suffered less brain damage and had a four times greater survival rate after a stroke than the animals who did not receive this supplement, especially when alpha-lipoic acid is combined with vitamin E. While animal studies are encouraging, more research is needed to understand whether this benefit applies to people as well.

Calcium. In a population based study (one in which large groups of people are followed over time), women who take in more calcium, both through the diet and with added supplements, were less likely to have a stroke over a 14 year time course. More research is needed to fully assess the strength of the connection between calcium and risk of stroke.

Folic Acid, Vitamin B6, Vitamin B12, Betaine. Many clinical studies indicate that patients with elevated levels of the amino acid homocysteine are as much as 2.5 times more likely to suffer from a stroke than those with normal levels. Homocysteine levels are strongly influenced by dietary factors, particularly vitamin B9 (folic acid), vitamin B6, vitamin B12, and betaine. These substances help break down homocysteine in the body. Some studies have even shown that healthy individuals who consume higher amounts of folic acid and vitamin B6 are less likely to develop atherosclerosis than those who consume lower amounts of these substances. Despite these findings, the American Heart Association (AHA) reports that there is insufficient evidence to suggest that supplementation with betaine and B vitamins reduce the risk of atherosclerosis or that taking these supplements prevents the development or recurrence of heart disease. The AHA does not currently recommend population-wide homocysteine screening, and suggests that folic acid, as well as vitamin B6, B12, and betaine requirements be met through diet alone. Individuals at high risk for developing atherosclerosis, however, should be screened for blood levels of homocysteine. If elevated levels are detected, a health care provider may recommend supplementation.

Magnesium. Population based information suggests that people with low magnesium in their diet may be at greater risk for stroke. Some preliminary scientific evidence suggests that magnesium sulfate may be helpful in the treatment of a stroke or transient ischemic attack. More research is needed to know for certain if use of this mineral following a stroke or TIA is helpful.

Omega-3 Fatty Acids. Strong evidence from population-based studies suggests that omega-3 fatty acid intake (primarily from fish), helps protect against stroke caused by plaque buildup and blood clots in the arteries that lead to the brain. In fact, eating at least two servings of fish per week can reduce the risk of stroke by as much as 50%. However, people who eat more than 3 grams of omega-3 fatty acids per day (equivalent to 3 servings of fish per day) may be at an increased risk for hemorrhagic stroke, a potentially fatal type of stroke in which an artery in the brain leaks or ruptures. Omega-3 fatty acids may increase the chances of bleeding, especially in those taking anticoagulant medications such as warfarin (Coumadin) or even aspirin.

Pregnant women and women of childbearing age, who may become pregnant, however, are advised by the U.S. Food and Drug Administration (FDA), to limit their consumption of shark, tuna, and swordfish to no more than once a month. These fish have much higher levels of methyl mercury than other commonly consumed fish. Since the fetus may be more susceptible than the mother to the adverse effects of methyl mercury, FDA experts say that it is prudent to minimize the consumption of fish that have higher levels of methyl mercury, like shark, tuna, and swordfish.

Potassium. Although low levels of potassium in the blood may be associated with stroke, taking potassium supplements does not seem to reduce the risk of having a stroke.

Vitamin C. Having low levels of vitamin C contributes to the development of atherosclerosis and other damage to blood vessels and the consequences such as stroke. Vitamin C supplements may also improve cognitive function if you have suffered from multiple strokes.

Vitamin E. Eating plenty of foods rich in vitamin E, along with other antioxidants like vitamin C, selenium, and carotenoids, reduces your risk for stroke. In addition, low levels of vitamin E in the blood may be associated with risk of dementia (memory impairment) following stroke. Animal studies also suggest that vitamin E supplements, possibly in combination with alpha-lipoic acid, may reduce the amount of brain damaged if taken prior to the actual stroke. Researchers suggest testing this theory in people who are at high risk for stroke. Thus far, however, some large and well-designed studies of people suggest that it is safest and best to obtain this antioxidant via food sources and that supplements do not bring about any added benefit.

Others. Additional supplements that require further research but may be useful as part of the treatment or prevention of stroke include:

Coenzyme Q10 -- works as an antioxidant and may reduce damage following a stroke.
Selenium -- low levels can worsen atherosclerosis and its consequences. However, it is not known if taking selenium supplements will help.

Herbs

The use of herbs is a time-honored approach to strengthening the body and treating disease. Herbs, however, contain active substances that can trigger side effects and interact with other herbs, supplements, or medications. For these reasons, herbs should be taken with care and only under the supervision of a practitioner knowledgeable in the field.

Bilberry (Vaccinium myrtillus). A close relative of the cranberry, bilberry fruits contain flavonoid compounds called anthocyanidins. Flavonoids are plant pigments that have excellent antioxidant properties. This means that they scavenge damaging particles in the body known as free radicals and may help prevent a number of long-term illnesses, such as heart disease.

Garlic (Allium sativum). Clinical studies suggest that fresh garlic and garlic supplements may prevent blood clots and destroy plaque. Blood clots and plaque block blood flow and contribute to the development of heart attack and stroke. Garlic may also be beneficial for reducing risk factors for heart disease and stroke like high blood pressure, high cholesterol, and diabetes. Homocysteine, similar to cholesterol, may contribute to increasing amounts of blood clots and plaque in blood vessels. If you take aspirin or other blood thinners [like warfarin (Coumadin)}, ACE inhibitors (a class of blood pressure medications), sulfonylureas for diabetes, or statins for high cholesterol, talk to your doctor before using garlic supplements.

Ginkgo (Ginkgo biloba). Gingko may reduce the likelihood of dementia following multiple strokes (often called multi-infarct dementia). The protection from ginkgo may be related to the prevention of platelet adhesion which can help prevent blood clot formation. Ginkgo may also decrease the amount of brain damage following a stroke. While animal studies support these possible benefits of ginkgo, more research in people is needed. Also, ginkgo should not be used with the blood thinner warfarin (Coumadin) unless specifically instructed by your health care provider.

Ginseng (Panax ginseng). Asian ginseng may decrease endothelial cell dysfunction. Endothelial cells line the inside of blood vessels. When these cells are disturbed, referred to as dysfunction, it may lead to a heart attack or stroke. The potential for ginseng to quiet down the blood vessels may prove to be protective against these conditions. Much more research is needed before this use can be recommended. Ginseng may also thin your blood and, therefore, should be used only under the supervision of a doctor if you are taking blood-thinning medication warfarin (Coumadin).

Turmeric (Curcuma longa). Early studies suggest that turmeric may prove helpful in preventing heart attack or stroke in one of two ways. First, in animal studies an extract of turmeric lowered cholesterol levels and inhibited the oxidation of LDL ("bad") cholesterol. Oxidized LDL deposits in the walls of blood vessels and contributes to the formation of atherosclerotic plaque and other damage to the vessels. Turmeric may also prevent platelet build up along the walls of an injured blood vessel. Platelets collecting at the site of a damaged blood vessel cause blood clots to form and blockage of the artery as well. Clinical studies of the use of turmeric to prevent or treat stroke in people would be interesting in terms of determining if these mechanisms discovered in animals apply to people at risk for this condition.

Homeopathy

Although an experienced homeopath might prescribe a regimen for treating stroke that includes one of the remedies listed below, the scientific evidence to date does not confirm the value of homeopathy for this purpose.

Acontitum napellus for numbness or paralysis after a cerebral accident
Belladonna for stroke that leaves person very sensitive to any motion, with vertigo and trembling
Kali bromatum for stroke resulting in restlessness, wringing of the hands or other repeated gestures, insomnia, and night terrors
Nux vomica for cerebral accident with paresis (muscular weakness caused by disease of the nervous system), expressive aphasia (language disorder), convulsions, and great irritability

Acupuncture

Many studies have been conducted on the effects of acupuncture during stroke rehabilitation. These studies have found that acupuncture reduces hospital stays and improves recovery speed. Acupuncture has been shown to help stroke patients regain motor and cognitive skills and to improve their ability to manage daily functioning. Based on the available data, the National Institutes of Health recommended acupuncture as an alternative or supplemental therapy for stroke rehabilitation. In general, the evidence indicates that acupuncture is most effective when initiated as soon as possible after a stroke occurs, but good results have been found for acupuncture started as late as 6 months following a stroke.

People who have suffered a stroke often have a deficiency of qi in the liver meridian and a relative excess in the gallbladder meridian. In addition to a primary needling treatment on the liver meridian and the supporting kidney meridians, moxibustion (a technique in which the herb mugwort is burned over specific acupuncture points) may be used to enhance therapy. Treatment may also include performing acupuncture on affected limbs. Certain scalp acupuncture techniques that have been developed by Chinese, Korean, and Japanese practitioners also show promise.

Chiropractic

Chiropractors DO NOT treat stroke, and high velocity manipulation of the upper spine is considered inappropriate in individuals who are taking blood-thinning medications or other medications used to reduce the risk of stroke. It should also be noted that chiropractic spinal manipulation of the neck is associated with an exceedingly small risk of causing stroke (reports range from 1 per 400,000 to 1 per 2,000,000).

Traditional Chinese Medicine

In Traditional Chinese Medicine, there are reports of over 100 substances that have been used to treat stroke. In fact, pharmacologic research of these substances is focused on understanding the ingredients and their mechanisms of action in order to develop new drugs.

Prognosis and Complications

There are many possible complications associated with stroke.

Seizures
Paralysis
Cognitive (thinking) deficits
Speech problems
Emotional difficulties
Daily living problems
Pain

Many people begin to recover from a stroke almost immediately after it has occurred.

The recovery process is most rapid in the first three months after a stroke, but improvement will continue for six months or a year. Many stroke survivors even report that they slowly continue to regain function for years after their stroke. It is very important not to lose hope.

Supporting Research

Amarenco P, Labreuche J, Touboul PJ. High-density lipoprotein-cholesterol and risk of stroke and carotid atherosclerosis: A systematic review. Atherosclerosis. 2007; [Epub ahead of print].

Blanco M, Nombela F, Castellanos M, et al. Statin treatment withdrawal in ischemic stroke: a controlled randomized study. Neurology. 2007;69(9):904-10.

Broderick J, Connolly S, Feldmann E, et al; American Heart Association/American Stroke Association Stroke Council; American Heart Association/American Stroke Association High Blood Pressure Research Council; Quality of Care and Outcomes in Research Interdisciplinary Working Group. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Circulation. 2007;116(16):e391-413.

Desrosiers J, Noreau L, Rochette A, et al. Effect of a home leisure education program after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2007;88(9):1095-100.

Dorhout Mees S, van den Bergh W, Algra A, Rinkel G. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2007;(4):CD006184.

Egan M, Kessler D, Laporte L, Metcalfe V, Carter M. A pilot randomized controlled trial of community-based occupational therapy in late stroke rehabilitation. Top Stroke Rehabil. 2007;14(5):37-45.

Ford I, Murray H, Packard CJ, Shepherd J, Macfarlane PW, Cobbe SM; West of Scotland Coronary Prevention Study Group. Long-term follow-up of the West of Scotland Coronary Prevention Study. N Engl J Med. 2007;357(15):1477-86.

Hassan AE, Zacharatos H, Suri MF, Qureshi AI. Drug evaluation of clopidogrel in patients with ischemic stroke. Expert Opin Pharmacother. 2007;8(16):2825-38.

Hinkle JL, Guanci MM. Acute ischemic stroke review. J Neurosci Nurs. 2007;39(5):285-93, 310.

Jang SH. A review of motor recovery mechanisms in patients with stroke. NeuroRehabilitation. 2007;22(4):253-9.

Kruger E, Teasell R, Salter K, Foley N, Hellings C. The rehabilitation of patients recovering from brainstem strokes: case studies and clinical considerations. Top Stroke Rehabil. 2007;14(5):56-64.

Lynch EA, Hillier SL, Stiller K, Campanella RR, Fisher PH. Sensory retraining of the lower limb after acute stroke: a randomized controlled pilot trial. Arch Phys Med Rehabil. 2007;88(9):1101-7.

McColl BW, Allan SM, Rothwell NJ. Systemic inflammation and stroke: aetiology, pathology and targets for therapy. Biochem Soc Trans. 2007;35(Pt 5):1163-5.

O'Keefe JH, Bybee KA, Lavie CJ. Alcohol and cardiovascular health: the razor-sharp double-edged sword. J Am Coll Cardiol. 2007;50(11):1009-14.

Pan W, Kastin AJ. Tumor necrosis factor and stroke: Role of the blood-brain barrier. ProgNeurobiol. 2007; [Epub ahead of print].

Richards LG, Stewart KC, Woodbury ML, Senesac C, Cauraugh JH. Movement-dependent stroke recovery: A systematic review and meta-analysis of TMS and fMRI evidence. Neuropsychologia. 2007; [Epub ahead of print].

Smith WS, Johnston SC, Skalabrin EJ, et al. Spinal manipulative therapy is an independent risk factor for vertebral artery dissection. Neurology. 2003;60(9):1424-1428.

Spence JD. Review: Perspective on the efficacy analysis of the Vitamin Intervention for Stroke Prevention trial. Clin Chem Lab Med. 2007; [Epub ahead of print].

Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. CochraneDatabase Syst Rev. 2007;(4):CD000197.

Review Date:
12/7/2007
Reviewed By:
Ernest B. Hawkins, MS, BSPharm, RPh, Health Education Resources; and Steven D. Ehrlich, NMD, private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network.

A.D.A.M. Copyright

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MSG: Not Just for Chinese Food

FitSugar — Thu, 06 Mar 2008 02:30:00 -0800

Do you cringe when someone mentions MSG (monosodium glutamate)? While it gets a bad rap as causing Chinese Restaurant Syndrome, most scientific studies prove that moderate amounts of this flavor enhancer have no adverse effects on healthy people. The studies don't seem to really matter though, since MSG has the reputation of causing headaches, nausea, dizziness, numbing of the lips (weird), and heart palpitations, so most people try to avoid it.

It's hard though, since MSG can be found in many food products, and the list of ingredients won't necessarily say "monosodium glutamate." Other food additives contain MSG too such as hydrolyzed soy protein, glutamic acid, calcium caseinate, sodium caseinate, and autolyzed yeast. That means many common products have hidden MSG in them. Want to know which ones? Then read more

Hidden MSG can be found in: Doritos, Chex Mix, Stove Top Stuffing, Bologna, and even some salad dressings contain monosodium glutamate or other ingredients that also contain MSG. Honestly though, many of these products contain a lot of other unhealthy ingredients and not much actual food, so you're probably not eating these too often anyway. It's definitely good to be aware though, especially if you found that your body is sensitive to MSG.

Have you come across any other foods that surprisingly contain MSG? Share the details in the comment section below.

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