Myocardial infarction is the technical name for a heart attack. A heart attack occurs when an artery leading to the heart becomes blocked and the heart does not get enough blood or oxygen. Without oxygen, cells in that area of the heart die (called an infarct).
A heart attack is a medical emergency. If you, or someone you know, has any of the symptoms below, call 9-1-1 immediately. If you get prompt medical treatment, you can limit damage to your heart. Waiting even 10 minutes can be fatal. Although heart attack is the leading cause of death in the United States, up to 95% of people who are hospitalized with a heart attack survive.
Most heart attacks are caused by blood clots, which are caused by atherosclerosis (stiffening and narrowing of the arteries). High blood fats (triglycerides) and LDL (bad) cholesterol contribute to the formation of plaque inside arteries, narrowing the passageway and reducing the amount of blood that can flow through. Your lifestyle plays a crucial role in preventing a heart attack or recovering from one. Eating a heart-healthy diet and getting at least 30 minutes of exercise 5 days a week (or more) can greatly reduce your risk of heart attack.
Signs and Symptoms
- Squeezing pain, heaviness, tightness, pressure in center of chest
- Pain that spreads to your back, left arm, jaw, neck
- Shortness of breath
- Dizziness, weakness
- Nausea, vomiting
- Irregular heartbeat
- Feeling of doom
Women may experience different symptoms than men. In women, along with chest pain, symptoms can include:
- Heartburn or pain in the abdomen
- Unusual fatigue
- Clammy skin
Heart attacks happen when an artery supplying your heart with blood becomes blocked. Without blood, the heart does not get enough oxygen and cells in the heart start to die.
The most common cause of blocked arteries is atherosclerosis. No one knows the exact cause of atherosclerosis. But most researchers believe it begins with an injury to the innermost layer of the artery, known as the endothelium. The following factors are thought to contribute to the damage:
- High blood pressure
- Elevated LDL (bad) cholesterol
- An accumulation of homocysteine (an amino acid produced by the human body, thought to be a risk factor for heart disease, stroke, osteoporosis, diabetes, and dementia)
Once the artery is damaged, blood cells called platelets build up at the site to repair the injury. Over time, fats, cholesterol, and other substances also accumulate, which thickens and hardens the artery wall. The amount of blood that flows through the artery dwindles, and oxygen supply to organs also decreases. Blood clots may also form, blocking the artery.
Rarely, a spasm in a coronary artery (one that supplies blood to the heart) stops blood flow and can cause a heart attack.
The following risk factors increase your chances of developing atherosclerosis:
- Gender (men are at higher risk than women)
- High-fat diet
- High LDL (bad) cholesterol and triglycerides (fats in the blood)
- Lack of exercise
- Being overweight or obese
- Family history of heart attack
- High blood pressure
- History of mental illness
Also, people who have elevated homocysteine, C-reactive protein (CRP), and fibrinogen levels seem to have an increased risk of heart attack. These are markers of inflammation. But researchers are not sure whether they contribute to heart disease or occur when you have heart disease. High homocysteine can be treated with folic acid. More research in these areas is underway.
If you think you are having a heart attack, call 911 immediately. Treating a heart attack quickly can save your life, while delay can be fatal. In the emergency room, a doctor will ask you about your symptoms and perform a physical examination. The doctor will immediately run tests to determine your heart function. They may include:
- Electrocardiogram (ECG). The first test done to check for a heart attack. You may be hooked up to a monitor even as the doctor is asking you questions. An ECG measures electrical activity of your heart.
- Blood tests. Your doctor may look for certain enzymes that are released into your blood when you have a heart attack.
Other tests include:
- Chest x-ray
- Echocardiogram (uses sound waves to take a picture of your heart)
- Coronary catheterization or angiogram (uses a liquid dye inserted through a catheter to see whether your arteries are blocked)
- Stress test (involves walking on a treadmill while hooked up to an ECG machine to see how your heart responds to exercise)
You can reduce your risk of heart attack by:
- Stopping smoking.
- Exercising (such as walking, biking, or swimming) for at least 30 minutes 5 days per week. If you haven't exercised much in the past, walking is a great way to start. If you have any heart risk factors, you should get an okay from your health care provider before starting an exercise program.
- Reducing stress and learning stress-reduction techniques such as deep breathing and meditation. Practicing yoga and tai chi, two forms of exercise that emphasize stretching, breathing, and meditating, can also help you reduce your stress level.
- Eating a diet low in saturated fat and rich in fruits, vegetables, and whole grains.
- Losing weight or maintaining a proper weight.
If you have high cholesterol, diabetes, or high blood pressure, follow your doctor's instructions to keep these risk factors under control. You may need medications in addition to lifestyle changes. If you do not have heart disease, or have not had a heart attack despite these risk factors, aggressive control can help prevent a heart attack. And, if you already have heart disease, aggressive control of these risk factors can prevent further heart attacks or other heart-related problems.
The goal when treating a heart attack is to restore blood flow to the affected area of the heart immediately, to preserve as much heart muscle and heart function as possible. If your doctor has prescribed nitroglycerin, take it while you are waiting for emergency medical personnel to arrive. Once at the hospital, your doctor may use drug therapy, angioplasty (using one of several methods to clear the blocked blood vessel, such as inflating a balloon inside it or holding it open with a device called a stent), and surgery.
Once you have been treated for a heart attack, making changes in your lifestyle (especially in your diet and exercise habits), and taking medications as prescribed are very important for avoiding recurrent heart attacks and even death. Although certain herbal remedies, as well as relaxation techniques may also be used, they should never be used alone to treat a heart attack. A heart attack always requires emergency medical attention.
Making lifestyle changes can improve many risk factors for heart disease, including high cholesterol, high blood pressure, extra weight, high homocysteine, and elevated C-reactive protein. Cardiac rehabilitation programs generally involve teaching you about diet, physical activity, and relaxation techniques. To keep your risk factors low, you will need to follow the healthy habits taught in cardiac rehab, such as exercise and eating properly, for the rest of your life.
When you arrive at the hospital, you will likely be given medication to help your body cope with, or ward off, damage from the heart attack, including:
- Aspirin. Helps stop blood from clotting. You may be given aspirin in the ambulance or as soon as you get to the hospital. Aspirin should be continued indefinitely at a dose of 81 mg per day, or as directed by your physician.
- Nitroglycerin. Helps dilate (widen) blood vessels. You may be given nitroglycerin in the ambulance or as soon as you get to the hospital.
- Pain reliever. Helps relieve pain and is often given intravenously (IV).
- Thrombolytics. Work to break up clots. They are most effective when taken within 2 hours of the heart attack, and are not given after 12 hours have elapsed. These drugs may be given with other anticoagulants (blood thinners).
- Anticoagulants (blood thinners). Make your blood less likely to form clots. Heparin is often given by injection while you are in the hospital.
After you recover, other drugs are used to lower your risk of having another heart attack. They include:
ACE inhibitors. Widen blood vessels and make it easier for your heart to pump blood. Side effects can include chronic cough. ACE inhibitors include:
- Benazepril (Lotensin)
- Captopril (Capoten)
- Fosinopril (Monopril)
- Lisinopril (Zestril)
- Enlapril (Vasotec)
Beta-blockers. Slows heart rate, thus lowering blood pressure. These drugs include:
- Acebutolol (Sectral)
- Atenolol (Tenormin)
- Bisoprolol (Zebeta)
- Carteolol (Cartrol)
- Metoprolol (Toprol XL)
- Nadolol (Corgard)
- Propranolol (Inderal)
Statins. Help lower cholesterol. People who are pregnant or have liver disease should not take statins. They include:
- Lovastatin (Mevacor)
- Simvastatin (Zocor)
- Pravastatin (Pravachol)
- Atorvastatin (Lipitor)
- Fluvastatin (Lescol)
- Rosuvastatin (Crestor)
Niacin (nicotinic acid). In prescription form, is sometimes used to lower cholesterol. Dietary supplements of niacin should not be used instead of prescription niacin, as it can cause side effects. Take niacin for high cholesterol only with your doctor's supervision.
Bile acid sequestrants. Lowers cholesterol; people who have high levels of triglycerides (fats in the blood) should not take bile acid sequestrants. These drugs include:
- Cholestyramine (Questran)
- Colestipol (Colestid)
- Colesevelam (Welchol)
Fibric acid derivatives. Lower triglycerides and moderately lower LDL cholesterol. They include Gemfibrozil (Lopid).
Anticoagulants (blood thinners). Help keep clots from forming. Your doctor may prescribe aspirin, warfarin (Coumadin), or Clopidogrel (Plavix).
Percutaneous coronary intervention (PCI). In primary PCI, the doctor performs a coronary angiogram (injecting dye into the arteries) to see where the artery is blocked. The doctor then performs balloon angioplasty (widening an artery with a balloon), often with stent placement, to keep the artery open.
Coronary artery bypass graft (CABG). This surgery bypasses the blocked arteries by using a graft of another blood vessel (usually from your arm or leg) to restore blood flow to the heart.
Nutrition and Dietary Supplements
Healthy eating habits can help reduce high cholesterol, high blood pressure, and excess weight, three of the major risk factors for heart disease. The American Heart Association (AHA) has developed dietary guidelines that help lower fat and cholesterol intake and reduce the risk of heart disease and heart attack. The AHA does not recommend very low fat diets, because new research shows that "good" fats, such as those found in olive oil and avocadoes, are good for your heart.
Fad diets are popular, but they may not help you lose weight and keep it off. In some cases, they may not even be healthy. Any healthy diet will include a variety of foods. If a diet bans an entire food group (such as carbohydrates), it is probably not healthy.
The AHA recommends the following for healthy eating:
- Grains: 6 to 8 servings per day (half of those servings should be whole grains)
- Vegetables: 3 to 5 servings per day
- Fruits: 4 to 5 servings per day
- Fat-free or low-fat dairy: 2 to 3 servings per day
- Lean meat, poultry, and seafood: 3 to 6 oz. per day (about the size of a deck of cards)
- Fats and oils: 2 to 3 tbsp. per day (use unsaturated fats such as olive oil or canola oil)
- Nuts, seeds, legumes: 3 to 5 servings per week
- Sweets, sugars: 5 or fewer servings per week (the fewer, the better)
In addition, the AHA also recommends eating 2 servings of fatty fish (such as salmon or lake trout) per week; holding sodium (salt, including salt already added to food) to 2,400 mg per day or less; and limiting alcohol intake to one drink a day for women and two for men.
Diets for People with High Blood Pressure
People with high blood pressure especially need to lower the amount of sodium in their diet. The DASH diet (Dietary Approaches to Stop Hypertension) emphasizes a diet rich in fruits, vegetables, and low-fat or nonfat dairy products that provide high intake of potassium, magnesium, and calcium sources. Sodium intake should be between 1,500 to 2,400 mg per day (the lower, the better). Weight loss, regular exercise, and limiting alcohol are also very important factors for lowering blood pressure.
The Mediterranean Style Diet concentrates on whole grains, fresh fruits and vegetables, fish, olive oil, and moderate wine consumption. The Mediterranean Style Diet is not low fat; it is low in saturated fat, but high in monounsaturated fat. It appears to be heart healthy: In a long-term study of 423 people who had a heart attack, those who followed a Mediterranean Style Diet had a 50 to 70% lower risk of recurrent heart disease compared with people who received no special dietary counseling.
Vitamins and Supplements
Some supplements may help lower your risk factors for heart attacks, such as high blood pressure or high cholesterol. Most do not work as well as prescription medications. But some can be used along with prescription medications in your treatment. If you have had a heart attack, or are at high risk of having one, ask your doctor before taking any supplements. Your physician should manage your heart disease, and you should not take supplements without your physician's approval. Many supplements can have negative interactions with medications used to treat heart disease.
- B vitamins. Folic acid, vitamin B6, and vitamin B12 help the body break down homocysteine, an amino acid that has been linked to increased risk of heart disease and stroke. Researchers believe that homocysteine may also contribute to atherosclerosis by damaging artery walls, making it easier for blood clots to form, but so far they haven't found a definite link. Researchers also do not yet know whether taking B vitamins reduces the risk of atherosclerosis or heart attack, nor do they know how much might have an effect. Talk to your doctor about checking your homocysteine levels and whether you should take a B complex vitamin supplement. In the meantime, be sure to get enough B vitamins through your diet by eating fruits and leafy green vegetables every day.
- Vitamin D. Studies show that lower levels of vitamin D are associated with higher risk of myocardial infarction and premature death. Dose recommendations for vitamin D vary greatly between physicians. Your physician may do blood work to monitor your vitamin D levels and determine the appropriate dose for your needs.
- Omega-3 fatty acids. There is good evidence that omega-3 fatty acids (known as EPA and DHA) found in fish oil can help treat atherosclerosis by preventing the development of plaque and blood clots. Omega-3s can also help prevent heart disease, lower blood pressure, and reduce the level of triglycerides (fats) in the blood. The AHA recommends that people eat at least 2 servings of fatty fish (such as salmon) per week. For people who have had a heart attack, several studies show that eating fish or taking fish oil reduces the risk of both fatal and nonfatal heart attacks, as well as lowers your risk of death from any cause. Because fish oil at high doses can increase the risk of bleeding, talk to your doctor before taking a high dose (more than 1 g per day), especially if you already take blood-thinning medication.
- Beta-sitosterol. A plant sterol, a chemical found in plants that can stop cholesterol from being absorbed by the intestines. A number of well-designed scientific studies have shown that beta-sitosterol does lower LDL (bad) cholesterol levels in the body. Beta-sitosterol may lower the amount of vitamin E and beta-carotene absorbed by the body, so you may want to ask your doctor if you need to take extra E or carotene.
- Policosanol. A mix of waxy alcohols usually derived from sugar cane and yams. Several studies have indicated it may lower LDL (bad) cholesterol and possibly even raise HDL (good) cholesterol. One study found that policosanol was equivalent to fluvastatin (Lescol) and simvastatin (Zocor) in lowering cholesterol levels. It may also help stop blood clots from forming. However, almost all the studies have been conducted in Cuba by a research group that uses a proprietary form of policosanol, and is funded by the manufacturer. So it is hard to evaluate the evidence. Policosanol may increase the risk of bleeding, and it should not be taken by people who also take blood-thinning medications.
- Coenzyme Q10 (CoQ10). Researchers believe that CoQ10 may help stop blood clots from forming and boost levels of antioxidants. One study found that people who received daily CoQ10 supplements within 3 days of a heart attack were much less likely to experience another heart attack and chest pain. They were also less likely to die from heart disease than those who did not receive the supplements. Statins, drugs that lower cholesterol, can actually interfere with the body's natural ability to make CoQ10, so your doctor may recommend taking a CoQ10 supplement. Still, more research is needed to say whether CoQ10 has any role in preventing or treating atherosclerosis. CoQ10 may interact with blood-thinning medications, such as warfarin (Coumadin), and others since CoQ10 helps blood clot it may make these medications less effective.
- Psyllium. This fiber helps lower cholesterol levels and blood sugar levels. If you take medicine for diabetes or have digestive problems, talk to your health care provider before taking psyllium. Always take your medications at least a few hours away fro when you take psyllium.
- L-carnitine. Studies suggest that people who take L-carnitine (an amino acid) soon after a heart attack may be less likely to have a subsequent heart attack, die of heart disease, experience chest pain and abnormal heart rhythms, or develop heart failure. (Heart failure occurs when the heart can't pump blood properly and blood backs up into the lungs and legs.) Studies also suggest that people with heart disease who take carnitine may be better able to exercise. Most studies used a special form of carnitine called propionyl-L-carnitine. L-carnitine can interact with certain medications, including thyroid and blood-thinning medications such as warfarin (Coumadin). Talk to your provider about whether L-carnitine is right for you.
Herbs should not be used in place of emergency medical attention for a heart attack, nor should they be used by themselves to lower your risk of heart attack after you have had one. However, certain herbs can be used along with prescription medications in your treatment, although many can interact with a variety of medications. The herbs below have the potential to interact with several different medications. It is critical that you consult your physician before adding any herbs to your regimen. If you have had a heart attack, or are at high risk of having one, ask your doctor before taking any herbs.
- Hawthorn (Crataegus monogyna). Hawthorn contains the polyphenols rutin and quercetin, and was used traditionally to treat cardiovascular diseases. Animal and laboratory studies show that hawthorn has antioxidant properties that help protect against the formation of plaques and may help lower high cholesterol and high blood pressure. Talk to your doctor before taking hawthorn, as it can interact with other drugs taken for heart disease and high blood pressure.
- Garlic (Allium sativum). Studies show that fresh garlic and garlic supplements may lower cholesterol levels, prevent blood clots, and destroy plaque. However, other studies show mixed evidence. In one study, people who had a previous heart attack and then took a garlic oil extract for 3 years had fewer second heart attacks and a 50% reduction in death rate than those who did not take garlic. Garlic can increase the risk of bleeding. Garlic can interact with a number of medications, including some of those used to treat HIV/AIDS. You should not take garlic if you are also taking blood-thinning medication.
- Bilberry (Vaccinium myrtillus) and other flavonoids. A close relative of the cranberry, bilberry fruits contain flavonoid compounds called anthocyanidins. Flavonoids are plant pigments that have antioxidant properties. Researchers think they may help prevent several illnesses, including heart disease and diabetes. Bilberry has been used traditionally to treat heart disease. But only animal and test tube studies have been done. Animal studies have found that anthocyanidins and other flavonoids may strengthen blood vessels, improve circulation, and prevent LDL (bad) cholesterol from being damaged (which may cause blood clots to form in arteries). Bilberry may have a blood-thinning effect and therefore can increase the risk of bleeding in people taking blood-thinning medications such as warfarin (Coumadin) and others. Talk to your health care provider.
- Green tea (Camellia sinensis). Population studies suggest that regularly drinking green tea may reduce the risk of heart attack from atherosclerosis. It also may help you lower lose weight and your cholesterol levels. More research is needed to know for sure. Avoid caffeinated varieties.
- Kudzu (Pueraria lobata). Kudzu has been used traditionally to treat heart disease, including heart attack and congestive heart failure. A few studies suggest it may help relieve angina, but the studies were of poor quality. More research is needed to know whether kudzu has any benefit for heart disease. Kudzu might slow blood clotting, so people with bleeding disorders or who take blood-thinning medications, such as warfarin (Coumadin), should use caution. Talk to your doctor.
Homeopathy should not be used instead of immediate medical attention for a heart attack. However, homeopathy may be used to help reduce the risk of heart disease. Although few studies have examined the effectiveness of specific homeopathic remedies, professional homeopaths would recommend appropriate therapy to lower high blood pressure and cholesterol. Before prescribing a remedy, homeopaths take into account your constitutional type. In homeopathic terms, a person's constitution is their physical, emotional, and intellectual makeup. An experienced homeopath assesses all of these factors when determining the most appropriate remedy for you as an individual.
Acupuncture may be helpful in reducing some risk factors for heart disease. Some studies show that it can help people who want to stop smoking, and it may help some people lose weight and lower their blood pressure.
Massage and Physical Therapy
Although few studies have examined the effectiveness of massage therapy for heart disease, massage has a relaxing effect and can reduce stress-related hormone levels. Lowering stress hormone levels can lower cholesterol and blood pressure, reducing your risk of heart disease. In addition, relaxation techniques may help you make lifestyle changes such as eating healthy, quitting smoking, and exercising. At least one study found that massage can lower blood pressure.
Other ConsiderationsPrognosis and Complications
After a heart attack, a person's prognosis depends on how damaged the heart is. If the person is alive 2 hours after an attack, he or she has a good chance for survival, but may experience complications such as:
- Irregular heart rhythm, called an arrhythmia
- Heart failure
- Infarct extension (extension of the amount of affected heart tissue) or recurrent heart attack(s)
- Pericarditis (infection around the lining of the heart)
- Pulmonary embolism (blood clot in the lungs)
- Complications from treatment (for example, thrombolytic agents increases the risk of bleeding)
However, the good news is that heart attacks are not always disabling, especially when there are no complications. In fact, a full recovery is possible that allows you to do all the things you used to do, including sexual activity. Going through cardiac rehabilitation and committing to positive lifestyle changes can improve your chances of recovery.
Abbott RD, Ando F, Masaki KH, et al. Dietary magnesium intake and the future risk of coronary heart disease (the Honolulu Heart Program). Am J Cardiol. 2003;92(6):665-9.
Abrams J. C-reactive protein, inflammation, and coronary risk: an update. Cardiol Clin. 2003;21(3):327-31.
Ackermann RT, Mulrow CD, Ramirez G, Gardner CD, Morbidoni L, Lawrence VA. Garlic shows promise for improving some cardiovascular risk factors. Arch Intern Med. 2001;161:813-24.
Alissa EM, Bahijri SM, Ferns GA. The controversy surrounding selenium and cardiovascular disease: a review of the evidence. Med Sci Monit. 2003;9(1):RA9-18.
Anderson TJ. Nitric oxide, atherosclerosis and the clinical relevance of endothelial dysfunction. Heart Fail Rev. 2003;8(1):71-86.
Angerer P, von Schacky C. n-3 polyunsaturated fatty acids and the cardiovascular system. Curr Opin Lipidol. 2000;11(1):57-63.
Antoniades C, Tousoulis D, Tentolouris C, Toutouzas P, Stefanadis. Oxidative stress, antioxidant vitamins, and atherosclerosis. From basic research to clinical practice. Herz. 2003;28(7):628-38.
Arnow WS. C-reactive protein. Should it be considered a coronary risk factor? Geriatrics. 2003;58(5):19-22,25.
Atar S, Barbagelata A, Birnbaum Y. Electrocardiographic Diagnosis of ST-elevation Myocardial Infarction. Cardiology Clinics. 2006;24(3).
Bahrke MS, Morgan WR. Evaluation of the ergogenic properties of ginseng: an update. Sports Med. 2000;29(2):113-33.
Berman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infacrction: the Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA. 2003;289(23):3106-16.
Bjork Petersen C, Bauman A, Gronbaek M, Wulff Helge J, Thysgesen LC, Tolstrup JS. Total sitting time and risk of myocardial infarction, coronary heart disease and all-cause mortality in a prospective cohort of Danish adults. Int J Behav Nutr Phys Act. 2014; 11:13.
Blake GJ. Inflammatory biomarkers of the patient with myocardial insufficiency. Curr Opin Crit Care. 2003;9(5):369-74.
Boateng S, Sanborn T. Acute myocardial infarction. Disease-a-month. Philadelphia, PA: Elsevier; 2013;59(3).
Boden R, Molin E, Jernberg T, Kieler H, Lindahl B, Sundstrom J. Higher mortality after myocardial infarction in patients with severe mental illness: a nationwide cohort study. J Intern Med. 2015;277(6):727-36.
Brondum-Jacobsen P, Benn M, Jensen GB, Nordestgaard BG. 25-hydroxyvitamin d levels and risk of ischemic heart disease, myocardial infarction, and early death: populationbased study and meta-analyses of 18 and 17 studies. Arterioscler Thromb Vasc Biol. 2012;32(11):2794-802.
Bucher HC, Hengstler P, Schindler C, et al. N-3 polyunsaturated fatty acids in coronary heart disease: a meta-analysis of randomized controlled trials. Am J Med. 2002;112:298-304.
Buckley MS, Goff AD, Knapp, WE. Fish oil interaction with warfarin. Ann Pharmacother. 2004;38(1):50-52.
Carney RM, Blumenthal JA, Catellier D, et al. Depression as a risk factor for mortality after acute myocardial infarction. Am J Cardiol. 2003;92(11):1277-81.
Chan MM, Mattiacci JA, Hwang HS, Shah A, Fong D. Synergy between ethanol and grape polyphenols, quercetin, and resveratrol, in the inhibition of the inducible nitric oxide synthase pathway. Bio Pharm. 2000;60(10):1539-48.
Cheung MC, Zhao XQ, Chait A, Albers JJ, Brown BG. Antioxidant supplements block the response of HDL to simvastatin-niacin therapy in patients with coronary heart disease and low HDL. Arterioscler Thromb Vasc Biol. 2001;21(8):1320-6.
Elgharib N, Chi DS, Younis W, Wehbe S, Krishnaswamy G. C-reactive protein as a novel biomarker. Reactant can flag atherosclerosis and help predict cardiac events. Postgrad Med. 2003;114(6):39-44; quiz 16.
Erbs S, Gielen S, Linke A, et al. Improvement of peripheral endothelial dysfunction by acute vitamin C application: different effects in patients with coronary artery disease, ischemic, and dilated cardiomyopathy. Am Heart J. 2003;146(2):280-5.
Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults. Executive summary of the third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). JAMA. 2001;285(19):2486-97.
Fatty fish consumption and ischemic heart disease mortality in older adults: The cardiovascular heart study. Presented at the American Heart Association's 41st annual conference on cardiovascular disease epidemiology and prevention. AHA. 2001.
Fedacko J, Pella D, Mechírová V, Horvath P, Rybár R, Varjassyová P, Vargová V. n-3 PUFAs-From dietary supplements to medicines. Pathophysiology. 2007 Oct;14(2):127-32.
Ferri: Ferri's Clinical Advisor 2016. 1st ed. Philadelphia, PA: Elsevier Mosby; 2016.
Frasure-Smith N, Lesperance F. Depression - a cardiac risk factor in search of a treatment. JAMA. 2003;289(23):3171-3.
Fugh-Berman A. Herbs and dietary supplements in the prevention and treatment of cardiovascular disease. Prev Cardiology. 2000;3:24-32.
Fung TT, Hu FB. Plant-based diets: what should be on the plate? Am J Clin Nutr. 2003;78(3):357-8.
Galan P, Kesse-Guyot E, Czernichow S, Briancon S, Blacher J, Hercberg S; SU.FOL.OM3 Collaborative Group. Effects of B vitamins and omega 3 fatty acids on cardiovascular diseases: a randomised placebo controlled trial. BMJ. 2010;341:c6273. doi: 10.1136/bmj.c6273.
Geelen A, Brouwer IA, Schouten EG et al. Effects of n-3 fatty acids from fish on premature ventricular complexes and heart rate in humans. Am J Clin Nutr. 2005;81:416-20.
Geleijnse JM, de Goede J, Brouwer IA. Alpha-linolenic acid: is it essential to cardiovascular health? Curr Atheroscler Rep. 2010;12(6):359-67.
Geleijnse JM, Giltay EJ, Schouten EG, de Goede J, Oude Griep LM, Teitsma-Jansen AM, Katan MB, Kromhout D; Alpha Omega Trial Group. Effect of low doses of n-3 fatty acids on cardiovascular diseases in 4,837 post-myocardial infarction patients: design and baseline characteristics of the Alpha Omega Trial. Am Heart J. 2010;159(4):539-46.e2.
Geleijnse JM, Launer LJ, Van der Kuip DA, Hofman A, Witteman JC. Inverse association of tea and flavonoid intakes with incident myocardial infarction: the Rotterdam Study. Am J Clin Nutr. 2002;75(5):880-6.
Gotto AM. Antioxidants, statins, and atherosclerosis. J Am Coll Cardiol. 2003;41(7);1205-10.
Grant PJ. The genetics of atherothrombotic disorders: a clinician's view. J Thromb Haemost. 2003;1(7):1381-90.
Gulliksson M, Burell G, Vessby B, Lundin L, Toss H, Svärdsudd K. Randomized controlled trial of cognitive behavioral therapy vs standard treatment to prevent recurrent cardiovascular events in patients with coronary heart disease: Secondary Prevention in Uppsala Primary Health Care project (SUPRIM). Arch Intern Med. 2011;171(2):134-40.
Guo H, Lee JD, Ueda T, Cheng J, Shan J, Wang J. Hyperhomocysteinaemia and folic acid supplementation in patients with high risk of coronary artery disease. Indian J Med Res. 2004;119:33-37.
Guo H, Lee JD, Ueda T, Shan J, Wang J. Plasma homocysteine levels in patients with early coronary artery stenosis and high risk factors. Jpn Heart J. 2003;44(6):865-71.
Hak AE, Stampfer MJ, Campos H, Sesso HD, Gaziano JM, Willett W, Manson J. Plasma carotenoids and tocopherols and risk of myocardial infarction in a low-risk population of US male physicians. Circulation. 2003;108(7):802-7.
Hamilton KL. Antioxidants and cardioprotection. Med Sci Sports Exerc. 2007 Sep;39(9):1544-53. Review.
Harper CR, Jacobson TA. The fats of life: the role of omega-3 fatty acids in the prevention of coronary heart disease. Arch Intern Med. 2001;161(18):2185-92.
Heart Protection Study Collaborative Group. MRC/BHF Heart Protection Study of antioxidant vitamin supplementation in 20,536 high-risk individuals: a randomised placebo-controlled trial. Lancet. 2002;360(9326):23-33.
Heck AM, DeWitt BA, Lukes AL. Potential interactions between alternative therapies and warfarin. Am J Health Syst Pharm. 2000;57(13):1221-7.
Heinecke JW. Clinical trials of vitamin E in coronary artery disease: is it time to reconsider the low-density lipoprotein oxidation hypothesis? Curr Atheroscler Rep. 2003;5(2):83-87.
Hernandez-Reif M, Field T, Krasnegor J, Theakston H, Hossain Z, Burman I. High blood pressure and associated symptoms were reduced by massage therapy. J Bodywork Movement Ther. 2000;4:31-38
Higgins JP. Chlamydia pneumoniae and coronary artery disease: the antibiotic trials. Mayo Clin Proc. 2003;78(3):321-32.
Houston MC. Treatment of hypertension with nutraceuticals, vitamins, antioxidants and minerals. Expert Rev Cardiovasc Ther. 2007 Jul;5(4):681-91.
Hu J, Zhang W, Xie Y, Wang LX, Nie XL, Zhang YL. Meta-analysis of Shenmai injection treatment for acute myocardial infarction. Zhongguo Zhong Yao Za Zhi. 2012;37(18):2760-7.
Klevay LM, Milne DB. Low dietary magnesium increases supraventricular ectopy. Am J Clin Nutr. 2002;75(3):550-4.
Koenig W. Inflammation and coronary heart disease: an overview. Cardiol Rev. 2001;9(1):31-35.
Krauss RM, Eckel RH, Howard B, Appel LJ, Daniels SR, Deckelbaum RJ, et al. AHA Scientific Statement: AHA dietary guidelines revision 2000: A statement for healthcare professionals from the nutrition committee of the American Heart Association. Circulation. 2000;102(18):2284-99.
Kris-Etherton P, Eckel RH, Howard BV, St. Jeor S, Bazzare TL. AHA science advisory: Lyon diet heart study. Benefits of a Mediterranean-style, National Cholesterol Education Program/American Heart Association Step I dietary pattern on cardiovascular disease. Circulation. 2001;103:1823-5.
Kromhout D, Giltay EJ, Geleijnse JM; Alpha Omega Trail Group. n-3 fatty acids and cardiovascular events after myocardial infarction. N Engl J Med. 2010;363(21):2015-26.
Kurono Y, Egawa M, Yano T, Shimoo K. The effect of acupuncture on the coronary arteries as evaluated by coronary angiography: a preliminary report. Am J Chin Med. 2002;30(2-3):387-96.
Lee BJ, Lin PT< Liaw YP, Chang SJ, Cheng CH, Huang YC. Homocysteine and risk of coronary arter disease: Folate is the important determinant of plasma homocysteine concentration. Nutrition. 2003;19(7-8):577-83.
Lefevre M, Kris-Etherton PM, Zhao G, Tracy RP. Dietary fatty acids, hemostasis, and cardiovascular disease risk. J Am Diet Assoc. 2004;104(3):410-9, quiz 492.
Liem A, Reynierse-Buitenwerf GH, Zwinderman AH, Jukema JW, van Veldhuisen DJ. Secondary prevention with folic acid: effects on clinical outcomes. J Am Coll Cardiol. 2003;41(12):2105-13.
Linton MF, Fazio S; National Cholesterol Education Program (NCEP)-the third Adult Treatment Panel (ATP III). Am J Cardiol. 2003;92(1A):19i-26i.
Little D. An intervention to treat depression and increase social support did not prolong event-free survival in coronary heart disease. ACP J Club. 2004;140(1):8.
Lonn E, Yusuf S, Hoogwerf B, et al. Effects of vitamin E on cardiovascular and microvascular outcomes in high-risk patienst with diabetes: results of the HOPE study and MICRO-HOPE substudy. Diabetes Care. 2002;25(11):1919-27.
Loy MH, Rivlin RS. Garlic and cardiovascular disease. Nutr Clin Care. 2000;3(3):146-51.
Marcovina SM, Koschinsky ML, Albers JJ, Skarlatos S. Report of the National Heart, Lung, and Blood Institute Workshop on Lipoprotein (a) and Cardiovascular Disease: recent advances and future directions. Clin Chem. 2003;49(11):1785-96.
Matetzky S, Freimark DD, Ben-Ami S, et al. Association of elevated homocysteine levels with a higher risk of recurrent coronary events and mortality in patients with acute myocardial infarction. Arch Intern Med. 2003;163(16):1933-7.
McKenna DJ, Hughes K, Jones K. Green tea monograph. Alt Ther. 2000;6(3):61-84.
Mendes de Leon CF, Dilillo V, Czajkowski S, et al. Enhancing Recovery in Coronary Heart Disease (ENRICHD) Pilot Study. Psychosocial characteristics after acute myocardial infarction: the ENRICHD pilot study. Enhancing Recovery in Coronary Heart Disease. J Cardiopulm Rehabil. 2001;21(6):353-62.
Merry AH, Boer JM, Schouten LJ, Feskens EJ, Verschuren WM, Gorgels AP, van den Brandt PA. Smoking, alcohol consumption, physical activity, and family history and the risks of acute myocardial infarction and unstable angina pectoris: a prospective cohort study. BMC Cardiovasc Disord. 2011;11:13.
Meydani M. Omega-3 fatty acids alter soluble markers of endothelial function in coronary heart disease patients. Nutr Rev. 2000;58(2 pt 1):56-59.
Milani RV, Lavie CJ, Mehra MR. Reduction in C-reactive protein through cardiac rehabilitation and exercise training. J Am Coll Cardiol. 2004;43(6):1056-61.
Miura Y, Chiba T, Tomita I, et al. Tea catechins prevent the development of atherosclerosis in apoprotein E-deficient mice. J Nutr. 2001;131(1):27-32.
Meagher EA. Treatment of atherosclerosis in the new millennium: is there a role for vitamin E? Prev Cardiol. 2003;6(2):85-90.
Muhlestein JB, Anderson JL. Chronic infection and coronary artery disease. Cardiol Clin. 2003;21(3):333-62.
Naghavi M, Libby P, Falk E, et al. From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part II. Circulation. 2003;108(15):1772-8.
Negri E, La Vecchia C, Pelucchi C, Bertuzzi M, Tavani A. Fiber intake and risk of nonfatal acute myocardial infarction. Eur J Clin Nutr. 2003;57(3):464-70.
Osganian SK, Stampfer MJ, Rimm E, Spiegelman D, Manson JE, Willet WC. Dietary carotenoids and risk of coronary artery disease in women. Am J Clin Nutr. 2003;77(6):1390-9.
Possel P, Mitchell AM, Ronkainen K, Kaplan GA, Kauhanen J, Valtonen M. Do depressive symptoms predict the incidence of myocardial infarction independent of hopelessness? J Health Psychol. 2015;20(1):60-8.
Price JR. Treating low perceived social support and depression after myocardial infarction does not increase event-free survival. Evid Based Ment Health. 2004;7(1):22.
Rahman K. Historical perspective on garlic and cardiovascular disease. J Nutr. 2001;131(3s):977S-9S.
Rakel & Bope: Conn's Current Therapy 2009. 1st ed. Phliladelphia, PA: Elsevier Saunders; 2008.
Rauch B, Schiele R, Schneider S, Diller F, Victor N, Gohlke H, Gottwik M, Steinbeck G, Del Castillo U, Sack R, Worth H, Katus H, Spitzer W, Sabin G, Senges J; OMEGA Study Group. OMEGA, a randomized, placebo-controlled trial to test the effect of highly purified omega-3 fatty acids on top of modern guideline-adjusted therapy after myocardial infarction. Circulation. 2010;122(21):2152-9.
Reed J. Cranberry flavonoids, atherosclerosis and cardiovascular health. Crit Rev Food Sci Nutr. 2002;42(3 Suppl):301-16.
Research update: the benefits of folate. Johns Hopkins Med Lett Health After 50. 2007 Aug;19(6):6.
Rigelsky JM, Sweet BV. Hawthorn: pharmacology and therapeutic uses. Am J Health Syst Pharm. 2002;59(5):417-22.
Rodriguez-Porcel M, Lerman LO, Herrmann J, Sawamura T, Napoli C, Lerman A. Hypercholesterolemia and hypertension have synergistic deleterious effects on coronary endothelial function. Arterioscler Thromb Vasc Biol. 2003;23(5):885-91.
Roe E, Nunez I, Perez-Heras A, et al. A walnut diet improves endothelial function in hypercholesterolemic subjects.Circulation. 2004;109(13):1609-14.
Rosenson RS, Koenig W. Utility of inflammatory markers in the management of coronary artery disease. Am J Cardiol. 2003;92(1A):10i-18i.
Rotblatt M, Ziment I. Evidence-Based Herbal Medicine. Philadelphia, PA: Hanley & Belfus, Inc; 2002:231-5.
Ruburg FL, Leooplold JA, Loscalzo J. Atheothrombosis: plaque instability and thrombogenesis. Prog Cardiovasc Dis. 2002;44(5):381-94.
Sasazuki S, Kodama H, Yoshimasu K et al. Relation between green tea consumption and the severity of coronary atherosclerosis among Japanese men and women. Ann Epidemiol. 2000;10:401-8.
Scanu AM. Lipoprotein(a) and the atherothrombotic process: mechanistic insights and clinical implications. Curr Atheroscler Rep. 2003;5(2):106-13.
Schulman SP, Becker LC, Kass DA, et al. L-Arginine therapy in acute myocardial infarction. The Vascular Interaction With Age in Myocardial Infarction (VINTAGE MI) randomized clinical trial. JAMA. 2006;295(1):58-64.
Shah SH, Newby LK. C-reactive protein: a novel marker of cardiovascular risk. Cardiol Rev. 2003;11(4):169-79.
Shechter M. Does magnesium have a role in the treatment of patients with coronary artery disease? Am J Cardiovasc Drugs. 2003;3(4):231-9.
Sheps DS, Freedland KE, Golden RN, et al. ENRICHD and SADHART: implications for future biobehavioral intervention efforts. Psychosom Med. 2003;65(1):1-2.
Simon JA, Murtaugh MA, Gross MD, Loria CM, Hulley SB, Jacobs DR Jr. Relation of ascorbic acid to coronary artery calcium: the Coronary Artery Risk Development in Young Adults Study. Am J Epidemiol. 2004;159(6):581-8.
Singh RB, Neki NS, Kartikey K, et al. Effect of coenzyme Q10 on risk of atherosclerosis in patients with recent myocardial infarction. Mol Cell Biochem. 2003;246(1-2):75-82.
Sobczak AJ. The effects of tobacco smoke on the homocysteine level – a risk factor of therosclerosis. Addict Biol. 2003;8(2):147-58.
Soltero-Perez IF. Thinking intelligently about therapy of atherosclerosis. Am J Ther. 2003;10(6):429-37.
Spigelski D, Jones PJ. Efficacy of garlic supplementation in lowering serum cholesterol levels. Nutr Rev. 2001;59(7):236-41.
Stampfer MJ, Hu FB, Manson JE, Rimm EB, Willett WC. Primary prevention of coronary heart disease in women through diet and lifestyle. NEJM. 2000;343(1):16-22.
Stevinson C, Pittler MH, Ernst E. Garlic for treating hypercholesterolemia. Ann Intern Med. 2000;133(6):420-9.
Strike PC, Steptoe A. Psychosocial factors in the development of coronary artery disease. Prog Cardiovasc Dis. 2004;46(4):337-47.
Study of the Effectiveness of Additional Reductions in Cholesterol and Homocysteine (SEARCH) Collaborative Group, Armitage JM, Bowman L, Clarke RJ, Wallendszus K, Bulbulia R, Rahimi K, Haynes R, Parish S, Sleight P, Peto R, Collins R. Effects of homocysteine-lowering with folic acid plus vitamin B12 vs placebo on mortality and major morbidity in myocardial infarction survivors: a randomized trial. JAMA. 2010;303(24):2486-94.
Sung J, Han KH, Zo JH, Park HJ, Kim CH, Oh B-H. Effects of red ginseng upon vascular endothelial function in patients with essential hypertension. Am J Chin Med. 2000;28(2):205-16.
Superko HR, Krauss RM. Garlic powder, effect on plasma lipids, postprandial lipemia, low-density lipoprotein particle size, high-density lipoprotein subclass distribution and lipoprotein(a). J Am Coll Cardiol. 2000;35(2):321-6.
Tarantini G, Scrutinio D, Bruzzi P et al. Metabolic Treatment with L-Carnitine in Acute Anterior ST Segment Elevation Myocardial Infarction. A Randomized Controlled Trial. Cardiology. 2006 May 9 [Epub ahead of print].
Tokmakidis SP, Volaklis KA. Training and detraining effects of a combined-strength and aerobic exercise program on blood lipids in patients with coronary artery disease. J Cardiopulm Rehabil. 2003;23(3):193-200.
Tousoulis D, Davies G, Stefanadis C, Toutouzas P, Ambrose JA. Inflammatory and thrombotic mechanisms in coronary atherosclerosis. Heart. 2003;89(9):993-7.
Trichopoulou A, Bamia C, Norat T, Overvad K, Schmidt EB, Tjønneland A, et al. Modified Mediterranean diet and survival after myocardial infarction: the EPIC-Elderly study. Eur J Epidemiol. 2007 Oct 10; [Epub ahead of print]
Vaes LP, Chyka PA. Interactions of warfarin with garlic, ginger, ginkgo, or ginseng: nature of the evidence. Ann Pharmacother. 2000;34(12):1478-82.
Valgimigli M, Merli E, Malagutti P, et al. Endothelial dysfunction in acute and chronic coronary syndromes: evidence for a pathogenetic role of oxidative stress. Arch Biochem Biophys. 2003;420(2):255-61.
Vermeulen EGJ, Stehouwer CDA, Twisk JWR, et al. Effect of homocysteine-lowering treatment with folic acid plus vitamin B6 on progression of subclinical atherosclerosis: a randomised, placebo-controlled trial. Lancet. 2000;355:517-22.
Watkins LL, Schneiderman N, Blumenthal JA, et al. Cognitive and somatic symptoms of depression are associated with medical comorbidity in patients after acute myocardial infarction. Am Heart J. 2003;146(1):48-54.
Yeh ET, Palusinski RP. C-reactive protein: the pawn has been promoted to queen. Curr Atheroscler Rep. 2003;5(2):101-5.
Yokoyama M, Origasa H, Matsuzaki M, et al. Effects of eicosapentaenoic acid on major coronary events in hypercholesterolaemic patients (JELIS): a randomised open-label, blinded endpoint analysis. Lancet. 2007;369:1090-8.
Yologlu S, Sezgin AT, Ozdemir R, et al. Identifying risk factors in a mostly overweight patient population with coronary artery disease. Angiology. 2003;54(2):181-6.
Zambón D, Sabate J, Munoz S, et al. Substituting walnuts for monounsaturated fat improves the serum lipid profile of hypercholesterolemic men and women. Ann Intern Med. 2000;132:538-46.
Review Date: 2/4/2016
Reviewed By: Steven D. Ehrlich, NMD, Solutions Acupuncture, a private practice specializing in complementary and alternative medicine, Phoenix, AZ. Review provided by VeriMed Healthcare Network. Also reviewed by the A.D.A.M. Editorial team.