Cardiovascular disease (CVD) continues to be the leading cause of death among men and women in the United States and worldwide, accounting for an estimated 655,000 deaths annually in the United States.1,2

The most recent statistics from the American Heart Association indicate that in 2017, an estimated 17.8 million deaths were attributed to CVD globally, a surge of 21.1% from 2007.1,2 Annually, 805,000 individuals have a myocardial infarction, and 18.2 million adults 20 years and older have some degree of coronary artery disease.1 Among deaths attributable to CVD, coronary heart disease is the main contributor to mortality, accounting for 43.8% of deaths, followed by stroke, hypertension, and heart failure.3 Many of the classic risk factors for CVD, such as cigarette smoking, obesity, poor nutrition, and a sedentary lifestyle, are thought to increase inflammation and oxidative stress, thus influencing the development of atherogenesis.3

Research has shown that micronutrients, including many vitamins and minerals, such as selenium and zinc, are involved in pathways that can modulate inflammation and oxidative damage and therefore are thought to play a role in diminishing the risk of CVD.3

Pharmacists are in a pivotal position to expand awareness regarding the critical nature of being proactive about cardiovascular health. They can educate patients about both modifiable risk factors, such as diabetes, hyperlipidemia, hypertension, obesity, and smoking, and nonmodifiable cardiovascular risk factors, such as age, ethnicity, gender, and genetics/ familial history of CVD. Pharmacists can also encourage patients to discuss these risk factors with their primary health care providers.4 Results from a study show that an estimated 50% of deaths related to CVD are because of key modifiable CVD risk factors.4 Health experts indicate that implementing early-life interventions for cardiovascular health, before the occurrence of clinical manifestations, could assist in lessening the global burden of CVD.5

As some of the most accessible health care providers, pharmacists are likely to encounter patients seeking advice on the various nutritional supplements marketed for cardiovascular health and can guide them on the proper selection and use.

Studies show that men are more likely than women to use supplements for heart health or to lower cholesterol.6

There is a host of nutritional supplements marketed for the promotion of cardiovascular health and protective effects against CVD, which are available as combination or single-entity products in several dosage forms. Some foods are even fortified with omega-3 fatty acids and plant sterols for cardiovascular health. Manufacturers of some specialty mineral/multivitamin supplements are also marketing formulations specifically targeting a blend of essential nutrients for cardiovascular health. The most common supplements marketed for promotion of cardiovascular health include coenzyme Q10 (CoQ10), garlic, omega-3 fatty acids, and plant sterols.

RECENT CLINICAL STUDIES
There are many studies exploring the use of nutritional supplements in cases of CVD, and there is still debate about the issue.

For instance, in a 2019 publication, researchers indicated that low vitamin D levels have been associated with atrial fibrillation, heart failure, and coronary artery disease, and deficiency of CoQ10 has been linked with myocardial dysfunction and to statin myopathies.7

They also indicated that multivitamin supplementation has been shown to diminish cardiovascular events, and the use of probiotics has been proposed to lower both blood pressure and circulating lipids.7

Another study explored how multivitamin use is associated with the risk of CVD in initially healthy men at baseline. Researchers concluded that in initially healthy men, multivitamin use for 20 years or fewer years was correlated with a lesser risk of major CVD events.8

In a 2019 publication, researchers examined evidence about the effects of dietary interventions and nutritional supplements on cardiovascular events and mortality in adults. They concluded that the use of omega-3 long-chain polyunsaturated fatty acids and folate supplementation could lessen risk for some cardiovascular outcomes in adults.9

Ingles et al10 aimed to explore the literature supporting the use of minerals/multivitamins and oral multivitamins for treatment and prevention of CVD. They concluded that despite the popular use of supplements by patients, there is no evidence to support the routine supplementation of minerals/multivitamins and oral multivitamins for CVD prevention or treatment.

A recent study published noted that the pesco-Mediterranean diet, which consists of moderate amounts of dairy, extra virgin olive oil, plants, and fish and seafood as the principle sources of animal protein, with daily time-restricted eating within a window of 8 to 12 hours, is proposed as an ideal cardioprotective diet.11

Poor diet quality has surpassed all other risk factors for death, accounting for 11 million deaths and about 50% of cardiovascular deaths globally, according to the 2017 Global Burden of Disease Study, a comprehensive report on the health impact of diet in 195 countries around the world.

In August 2020, the American Heart Association (AHA) issued a new scientific statement recommending the implementation of a rapid diet screening tool that can be incorporated into electronic health record platforms across all health care settings.12

CONCLUSION
Before recommending any supplement marketed for cardiovascular health, it is imperative that pharmacists ascertain the appropriateness of use and screen for potential contraindications and drug interactions. Patients with preexisting medical conditions and those taking other medications should always consult their primary health care providers before using supplements. During counseling, advise patients that the use of supplements is not intended to be a replacement for a healthy diet or for any prescription antihyperlipidemia agents or other prescription drugs for CVD. The AHA indicates that an estimated 80% of CVD is preventable via controlling diabetes, hyperlipidemia, and hypertension, along with implementing healthy lifestyle behaviors, such as smoking cessation.
 
YVETTE C. TERRIE, BSPHARM, RPH, is a consulting pharmacist and a medical writer in Haymarket, Virginia.


REFERENCES
  1. CDC. Heart disease facts. Updated September 8, 2020. Accessed November 20, 2020. https://www.cdc.gov/heartdisease/facts.htm
  2. Virani SS, Alonso A, Benjamin EJ, et al;American Heart Association Council on Epidemiology and Prevention Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020;141(9):e139-e596. doi:10.1161/CIR.0000000000000757
  3. Sunkara A, Raizner A. Supplemental vitamins and minerals for cardiovascular disease prevention and treatment. Methodist Debakey Cardiovasc J. 2019;15(3):179-184. doi:10.14797/mdcj-15-3-179
  4. Patel SA, Winkel M, Ali MK, Narayan KV, Mehta NK. Cardiovascular mortality associated with 5 leading risk factors: national and state preventable fractions estimated from survey data. Ann Intern Med. 2015;163(4):245-253. doi:10.7326/M14-1753
  5. Magnussen CG, Smith KJ, Juonala M. When to prevent cardiovascular disease? As early as possible: lessons from prospective cohorts beginning in childhood. Curr Opin Cardiol. 2013;28:561-568. doi:10.1097/HCO.0b013e32836428f4
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  7.  Bronzato S, Durante A. Dietary supplements and cardiovascular diseases. Int J Prev Med. 2018;9:80. doi:10.4103/ijpvm.IJPVM_179_17
  8. Rautiainen S, Rist PM, Glynn RJ, Buring JE, Gaziano JM, Sesso HD. Multivitamin use and the risk of cardiovascular disease in men. J Nutr. 2016;146(6):1235-1240. doi:10.3945/jn.115.227884
  9. Khan SU, Khan MU, Riaz H, et al. Effects of nutritional supplements and dietary interventions on cardiovascular outcomes: an umbrella review and evidence map. Ann Intern Med. 2019;171(3):190-198. doi:10.7326/M19-0341
  10. Ingles DP, Cruz Rodriguez JB, Garcia H. Supplemental vitamins and minerals for cardiovascular disease prevention and treatment. Curr Cardiol Rep. 2020.
  11. O'Keefe JH, Torres-Acosta N, O'Keefe EL, et al. A pesco-Mediterranean diet with intermittent fasting: JACC review topic of the week. J Am Coll Cardiol. 2020;76(12):1484-1493. doi:10.1016/j.jacc.2020.07.049
  12. Vadiveloo M, Lichtenstein AH, Anderson C, et al. Rapid diet assessment screening tools for cardiovascular disease risk reduction across healthcare settings: a scientific statement from the American Heart Association. Circ Cardiovasc Qual Outcomes. 2020;13(9):e000094. doi:10.1161/HCQ.0000000000000094