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Nutritional Supplement Program Halts Progression of
Early Coronary Atherosclerosis Documented by Ultrafast
Computed Tomography
Aleksandra Niedzwiecki Ph.D. and Matthias Rath M.D.
Published in Journal of Applied Nutrition, 1996. Vol. 48 (pp 68-78)
Introduction
According to the World-Health Organization, over 12 million people die every year from heart attacks, strokes
and other forms of cardiovascular disease.1
Current concepts of the pathogenesis of cardiovascular
disease focus on elevated plasma risk factors damaging the vascular wall and thereby initiating
atherogenesis and cardiovascular disease.2-4 Accordingly, drugs lowering cholesterol and modulating
other plasma risk factors have become a predominant therapeutic approach in the prevention of
cardiovascular disease.
A new scientific rationale about the initiation of atherosclerosis and cardiovascular disease was
proposed by one of us5,6. It can be summarized as follows: cardiovascular disease is primarily caused
by chronic deficiencies of vitamins and other essential nutrients with defined biochemical properties,
such as coenzymes, cellular energy carriers, and antioxidants.7,8 Chronic depletion of these essential
nutrients in endothelial and vascular smooth muscle cells impairs their physiological function. For
example, chronic ascorbate deficiency, similar to early scurvy, leads to morphological impairment of
the vascular wall and endothelial microlesions, histological hallmarks of early atherosclerosis. 9-11
Consequently, atherosclerotic plaques develop as the result of an overcompensating repair mechanism
comprising deposition of systemic plasma factors as well local cellular responses in the vascular
wall.5,6 This repair mechanism is primarily exacerbated at sites of hemodynamic stress, explaining
the predominantly local development of atherosclerotic plaques in coronary arteries and myocardial
infarction as the most frequent clinical manifestation of cardiovascular disease.
Animal studies have confirmed this scientific rationale for the combination of ascorbate with other
essential nutrients in the prevention and treatment of cardiovascular disease.12
Subjects and Methods
Patients
A total of 55 patients, 50 men and 5 women, with documented coronary artery disease assessed by
Ultrafast CT, were recruited for the study. The inclusion criterion was the availability of a high quality
Ultrafast CT scan from a previous visit to the Heart Scan facility in South San Francisco. At the
beginning of the study each patient completed a comprehensive questionnaire, which was updated
after six months and after 12 months. This questionnaire included medical history, previous cardiac
events, and cardiovascular risk factors, as well as individual life style data. Specific questions related
to the patientsÕ regular diet, such as strictly vegetarian diet, predominantly fruits and vegetables,
predominantly meat, fish or poultry; the daily intake of different vitamins and other essential
nutrients; and the frequency of physical exercise by the patient. The laboratory tests available
documented a heterogeneous population with respect to plasma cholesterol and triglycerides. About
half of the patients were taking different types of prescription medication, including calcium
antagonists, nitrates, betablockers, and cholesterol-lowering drugs. Before entering the study, the
patients were instructed not to change their diet or lifestyle other than adding the nutritional
supplement program tested. Any changes were to be documented in their questionnaires. Compliance
with the nutritional supplement program was monitored in the questionnaires, through telephone calls
and during the control visits.
Composition and Administration of Nutritional Supplement Program
The following daily dosages of nutritional supplements were taken for a period of one year: Vitamins:
Vitamin C 2700 mg, Vitamin E(d-Alpha-Tocopherol) 600 IU, Vitamin A (as Beta-Carotene) 7,500
IU, Vitamin B-1 (Thiamine) 30 mg, Vitamin B-2 (Riboflavin) 30 mg, Vitamin B-3 (as Niacin and
Niacinamide) 195 mg, Vitamin B-5 (Pantothenate) 180 mg, Vitamin B-6 (Pyridoxine) 45 mg, Vitamin
B-12 (Cyanocobalamin) 90 mcg, Vitamin D (Cholecalciferol) 600 IU. Minerals: Calcium 150 mg,
Magnesium 180 mg, Potassium 90 mg, Phosphate 60 mg, Zinc 30 mg, Manganese 6 mg, Copper 1500
mcg, Selenium 90 mcg, Chromium 45 mcg, Molybdenum 18 mcg. Amino acids: L-Proline 450 mg, L-
Lysine 450 mg, L-Carnitine 150 mg, L-Arginine 150 mg, L-Cysteine 150 mg. Coenzymes and other
nutrients: Folic Acid 390 mcg, Biotin 300 mcg, Inositol 150 mg, Coenzyme Q-10 30 mg, Pycnogenol
30 mg, and Citrus Bioflavonoids 450 mg.
Monitoring of Coronary Artery Disease
The extent of coronary calcification was measured non-invasively with an Imatron C-100 Ultrafast CT
scanner in the high-resolution volume mode, using a 100- millisecond exposure time. ECG triggering
was used so that each image was obtained at the same point in the diastole, corresponding to 80% of
the RR interval. In each scan, 30 consecutive images were obtained at 3-mm intervals beginning 1 cm
below the carina and progressing caudally to include the entire length of the coronary arteries. The
scans at study entry and after 6 and 12 months of the study included a second scan sequence of 30
images at 3 mm intervals across the entire heart. The 30 images of the second scan were taken
between the 3 mm intervals of the first scan resulting in a scanning of the heart at an interval of 1.5
mm. Total radiation exposure using this technique was <1rad per patient (<.01Gy).
The scan threshold was set at 130 Hounsfield units (Hu) for identification of calcified lesions. The
minimum area to differentiate calcified lesions from CT artifact was 0.68 mm2. The lesion score, also
designated Coronary Artery Scanning (CAS) score, was calculated by multiplying the lesion area by a
density factor derived from the maximal Hounsfield unit within this area.13 The density factor was
assigned in the following way: 1 for lesions with a maximal density with 130-199 Hu, 2 for lesions
with 200-299 Hu, 3 for lesions with 300-399 Hu and 4 for lesions > 400 Hu. The total calcium areas
and CAS scores of each Ultrafast CT scan were determined by summing individual lesion areas or
scores from the left main, left anterior descending, circumflex, and right coronary artery.
Several studies have confirmed an excellent correlation of the extent of coronary artery disease as
assessed by Ultrafast CT scanning when compared to angiographic and histomorphometric
methods.13-15 Considering the accuracy and the non-invasive approach, Ultrafast CT was the method
of choice for an intervention study that included early, asymptomatic stages of coronary artery
disease.
Statistical Analysis
The growth rate of coronary calcifications was calculated as the quotient of the differences in the
calcification areas or CAS scores between two scans divided by the months between these scans
according to the formula (Area2-Area1):(Date2-Date1), or (CAS score2-CAS score1):(Date2-Date1)
respectively. The data were analyzed using standard formulas for means, medians, and standard error
of the means (SEM). PearsonÕs correlation coefficient was used to determine the association between
continuous variables. One tailed Student t-test was used to analyze differences between mean values,
with a significance defined at <0.5. Progression of calcification was predicted by linear extrapolation.
The distribution of the growth rate of CAS scores was described by a smooth curve resulting from a
third order polynominal fit (y=a + bx3, where a = 0.9352959, b = 8.8235 x 10-5).
Results
The aim of this study was to determine the effect of a defined nutritional supplement program on the
natural progression of coronary artery calcification particularly in its initial stages as measured by
Ultrafast CT. We therefore evaluated the results of the entire study group (n=55) and of a subgroup of
21 patients with early coronary artery calcification, as defined by a CAS score of <100.
Table 2 separately lists the characteristics of the study population assessed by the questionnaire for all
patients and for a subgroup with early coronary artery disease.
Table 1.
Figure 1.
This is the first intervention study using Imatron's Ultrafast CT technology. One of the first aims of
this study was to determine the rate of natural progression of coronary calcium deposits in situ ,
without the intervention of the nutritional supplement program. Figure 1 shows the distribution of the
monthly progression of calcifications in the coronary arteries of all 55 patients in relation to their CAS
score at study entry.
We found that the higher the CAS score was initially, without intervention, the faster the coronary
calcification progressed. Accordingly, the average monthly growth rate of coronary calcifications
ranged from 1 CAS score per month in patients with early coronary heart disease to more than 15
CAS score per month in patients with advanced stages of coronary calcifications. The growth pattern
of coronary calcifications can be described as a third order polynomial fit curve. The exponential
shape of this curve signifies a first quantification of the aggressive nature of coronary atherosclerosis
and emphasizes the importance of early intervention.
The changes in the natural progression rate of coronary artery calcification before the nutritional
supplement program (-NS) and after one year on this program (+NS) are shown in Figure 2. The
results are presented separately for the calcified area and the CAS score.
As presented in Figure 2.a. the average monthly growth of calcified areas for all 55 patients decreased
from 1.24 mm2/month (SEM +/- 0.3) before the nutritional supplement program (-NS) to 1.05
mm2/month (+/- 0.2) after one year on this program (+NS).For patients with early coronary artery
disease (Figure 2b), the average monthly growth of the calcified area decreased from 0.49 mm2/month
(+/- 0.16) before taking the nutritional supplements (-NS) to 0.28 mm2/month (+/- 0.09) after one year
on this program (+NS).
Figure 2.
As shown in Figure 2.c the average monthly changes in the total CAS score (calcified area X density
of calcium deposits) for all 55 patients had decreased after one year on the nutritional supplement
program by 11%, from 4.8 CAS score/month (SEM +/-0.97) before the program (-NS) to 4.27 CAS
score /month(+/- 0.87) (+NS). In patients with early coronary artery disease (Figure 2.d) the average
monthly growth of the total CAS score decreased during the same time by as much as 65%, from 1.85
CAS score /month (+/-0.49) before the nutritional supplement program (-NS) to 0.65 CAS score
/month (+/- 0.36) on this program (+NS). The slow-down of the progression of coronary calcification
during this nutritional supplement intervention for CAS scores of patients with early coronary artery
disease was statistically significant (p<0.05)(Figure 2.d). For the other three sets of data the decrease
of coronary calcifications with the nutritional supplement program was evident; however, largely due
to the wide range of calcification values at study entry reflecting the different stages of coronary artery
disease, it did not reach statistical significance.
It is noteworthy that the decrease in the CAS scores during intervention with nutritional supplements
were more pronounced than for the calcified areas. This indicates a decrease in the density of calcium
in addition to a reduction in the area of coronary calcium deposits during nutritional supplement
intervention.
Ultrafast CT scans at the beginning of the study and after 12 months on the nutritional supplement
program, were complemented by a control scan after 6 month, allowing for additional insight into the
time required for the nutritional supplements to exert their therapeutic effect. This additional
evaluation was particularly important for early forms of coronary artery disease, because any
therapeutic approach that can halt progression of early coronary calcification would ultimately prevent
myocardial infarctions.
Figure 3 shows the average coronary calcification areas (Figure 3.a) and total CAS scores (Figure 3.b)
for patients with early coronary artery disease measured during different scanning dates before and
during the course of the study. The actual coronary calcification values for areas and total CAS scores
during nutritional supplement intervention are compared to the predicted values obtained from linear
extrapolation of the growth rate without intervention. The letters A to D mark the different time points
at which Ultrafast CT scans were performed. AB represents the changes in coronary calcification
before intervention with nutritional supplement for the areas (Figure 3.a) and CAS scores (Figure 3.b).
Accordingly, BC represents calcification changes during the first six months on the nutritional
supplement program and CD changes during the second six months on the program. The calculated
progression rate for coronary calcifications without therapeutic intervention by the nutritional
supplement program is marked by a dotted line (B through F).
As seen in Figure 3.a without the nutritional supplement program, the average area of coronary
calcifications in patients with early coronary artery disease increased from 17.62 mm2 (+/- 1.0) at
time point A to 23.05 mm2 (+/- 1.8) at time point B. Thus, the annual extension of calcified areas
without intervention was assessed with 31 %. At this progression rate, the average calcified area
would reach 26.3 mm2 after six months (point E) and 29.8 mm2 after twelve months (point F). The
nutritional supplement intervention, resulted in an average calcified area of 25.2 mm2 (+/-2.2) after
six months and of 27.0 mm2 (+/-1.7) after 12 months, reflecting a 10% decrease compared to the
predicted value.
Figure 3.
Analogous observations were made for the total CAS before and during the nutritional supplement
program. Figure 3.b shows that the CAS score before the nutritional supplement program increased by
44% per year, from 45.8 (+/- 3.2) (point A) to 65.9 mm2 (+/- 5.2) (point B). At this progression rate
the total CAS score, without the nutritional supplement program, would reach an average of 77.9 after
six months (point E) and of 91 (point F) after twelve months. In contrast to this trend the actual CAS
score values measured with the nutritional supplement program were 75.8 (+/-6.2) after 6 months
(point C) and 78.1 (+/-5.1) after 12 months (point D). Thus, the progression of coronary calcification
as determined by the total CAS scores decreased significantly during the second six months of
nutritional supplement intervention (CD). The total score after twelve months on the nutritional
supplement program was only 3% higher than after six months (CD), as compared to the projected
increase of 17% (EF), indicating that during the second six months on the nutritional supplement
program the process of coronary calcification has practically stopped.
Figure 4 shows the actual Ultrafast CT scans of a 51 year old patient with early, asymptomatic,
coronary artery disease. The patientsÕ first Ultrafast CT scan was performed in 1993 as part of an
annual routine check-up. The scan film revealed small calcifications in the left anterior descendent
coronary artery as well as in the right coronary artery. The second CT scan was performed one year
later at which time the initial calcium deposits had further increased. Figure 4.a shows two Ultrafast
CT scan images taken before the nutritional supplement program. Subsequently, the patient started on
the nutritional supplement program. About one year later the patient received a control scan. At this
time point, coronary calcifications were not found (Figure 4b), indicating the natural reversal of
coronary artery disease.
Figure 4.
Discussion
This is the first study that provides quantifiable data from in situ measurements about the natural
progression rate of coronary artery disease. Although atherosclerotic plaques have a complex
histomorphological composition, calcium dispersion within these plaques has been shown to be an
excellent marker for their advancement.11,13 Our study determined that the calcified vascular areas
expand at a rate between 5 mm2 (early atherosclerotic lesions) and 40 mm2 (advanced atherosclerotic
lesions). Before the nutritional supplement program the average annual increase of total coronary
calcification was 44% (Figure 1). Considering the exponential increase of coronary calcification, it is
evident that the control of cardiovascular disease has to focus on early diagnosis and early
intervention.
Today, the diagnostic assessment of individual cardiovascular risk is largely confined to the
measurement of plasma cholesterol and other risk factors with little correlation to the extent of
atherosclerotic plaques. More accurate methods, such as coronary angiography, are confined to
advanced, symptomatic, stages of coronary artery disease. Ultrafast CT provides the diagnostic option
to quantify coronary artery disease non-invasively in its early stages.14,15
The most important finding of this study is that coronary artery disease can be effectively prevented
and treated by natural means. This nutritional supplement program was able to decrease the
progression of coronary artery disease within the relatively short time of one year, irrespective of the
stage of this disease. Most significantly, in patients with early coronary calcifications this nutritional
supplement program was able to essentially stop its further progression. In individual cases with small
calcified deposits, nutritional supplement intervention led to their complete disappearance (Figure 4).
We postulate that the nutritional supplement program tested in this study initiates the reconstitution of
the vascular wall. Restructuring of the vascular matrix is facilitated by several nutrients tested, such as
ascorbate (vitamin C), pyridoxine (vitamin B-6), L-lysine, and L-proline, as well as the trace element
copper. Ascorbate is essential for the synthesis and hydroxylation of collagen and other matrix
components,16-18 and can be directly and indirectly involved in a variety of regulatory mechanisms
in the vascular wall from cell differentiation to distribution of growth factors.19,20 Pyridoxine and
copper are essential for the proper cross-linking of matrix components.8 L-lysine and L-proline are
important substrates for the biosynthesis of matrix proteins; they also competitively inhibit the binding
of lipoprotein(a) to the vascular matrix, facilitating the release of lipoprotein(a) and other lipoproteins
from the vascular wall.5,12,21 Ascorbate and -tocopherol have been shown to inhibit the proliferation
of vascular smooth muscle cells.22-24 Moreover, tocopherols, beta-carotene, ascorbate, selenium and
other antioxidants scavenge free radicals and protect plasma constituents, as well as vascular tissue,
from oxidative damage.25,26 In addition, nicotinate, riboflavin, pantothenate, carnitine, coenzyme Q-
10, as well as many minerals and trace elements, function as cellular cofactors in form of NADH,
NADPH, FADH, Coenzyme A and other cellular energy carriers.8 The results of this study confirm
that maintaining the integrity and physiological function of the vascular wall is the key therapeutic
target in controlling cardiovascular disease. This also corroborates early angiographic findings that
supplemental vitamin C may halt the progression of atherosclerosis in femoral arteries.27
These conclusions are even more relevant since deficiencies of essential nutrients are common.28,29
Moreover, many epidemiological and clinical studies have already documented the benefits of
individual nutrients in the prevention of cardiovascular disease.30-35 Compared to the high dosages
of vitamins used in some of these studies the amounts of nutrients used in this study are moderate,
indicating the synergistic effect of this program.
In this context, it seems appropriate to critically review some of the approaches currently used in the
primary and secondary prevention of cardiovascular disease, including the extensive use of
cholesterol-lowering drugs. An intervention study including lovastatin was performed with a highly
selected group of hyperlipidemic patients, representing only an extremely narrow fraction of a normal
population.36 More recently, the reduction of myocardial infarctions and other cardiac events in
patients taking simvastatin, led to recommendations for its long-term use even by normolipidemic
patients.37 However, because of their potential side-effects, the recommended use of these drugs has
now been restricted to patients at high short term risk for coronary heart disease.38
Similarly, certain natural approaches to prevention of cardiovascular disease deserve a critical review.
A program of rigorous diet and exercise program claims to be able to reverse coronary heart
disease.39 However, the published study does not provide compelling evidence documenting the
regression of coronary atherosclerosis. Thus, the improved myocardial perfusion shown in that study,
was likely the result of the physical training program, leading to an increased ventricular ejection
fraction and an increased coronary perfusion pressure.
Considering the urgent need for effective and safe public health measures towards the control of
cardiovascular disease, the validity of this study is of particular importance. In light of this, the
following study elements are noteworthy.
1 The patients in this study served as their own controls before and during nutritional supplement
intervention, thereby minimizing undesired co-variables such as age, gender, genetic predisposition,
diet or medication.
2 Ultrafast CT has been extensively validated to assess the degree of coronary atherosclerosis, and it
allowed quantification of coronary atherosclerotic plaques in situ.13-15 This diagnostic technique also
minimizes errors as they occur in angiography studies in which vasospasms, formation or lysis of
thrombi, and other events cannot be differentiated from progression or regression of atherosclerotic
plaques. Moreover, Ultrafast CT provides valuable information about the morphological changes
during progression and regression of atherosclerotic plaques, by quantifying not only the area of
coronary calcifications but also their density. Furthermore, the automatic CT measurements of
coronary calcifications eliminates human error in the evaluation of the data.
In summary, the results of this study imply that coronary heart disease is a preventable and essentially
reversible condition. This study documents that coronary artery disease could be halted in its early
stages by following this nutritional supplement program. These results were achieved within one year,
suggesting that additional therapeutic benefits in patients with advanced coronary artery disease can
be obtained by an extended use of this program. The continuation of this study is currently under way
to document these effects. This nutritional supplement program signifies an effective and safe
approach for the prevention and adjunct therapy of cardiovascular disease.
Acknowledgements
We are grateful to Jeffrey Kamradt for his help in coordinating this study. Douglas Boyd Ph.D., Lew
Meyer Ph.D. from Imatron/HeartScan., South San Francisco, for helping to plan the study and
providing the HeartScan facility; Lauranne Cox, Susan Brody, and Tom Caruso for their collaboration
in conducting the heart scans. Dr. Roger Barth and Bernard Murphy for their assistance in planning
the study, as well as to Martha Best for her secretarial assistance.
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