Review Article J Cardiol & Cardiovasc Ther

Volume 12 Issue 5 - December 2018

Copyright © All rights are reserved by Stewart Rose
DOI: 10.19080/JOCCT.2018.12.555847

A Comprehensive Review of the Prevention and

Treatment of Heart Disease with a Plant-Based Diet
Stewart Rose* and Amanda Strombom
Plant-based diets in Medicine, USA
Submission: November 22, 2018; Published: December 14, 2018
*Corresponding author: Stewart Rose, Plant-Based Diets in Medicine, 12819 SE 38th St, #427, Bellevue, WA 98006, USA

Abstract
Epidemiological studies show that vegetarians have a much lower risk of myocardial infarction. Reductions of risk factors, and comorbidities
such as angina, hypercholesterolemia, hypertension, diabetes, metabolic syndrome and obesity, have also been shown.

A low-fat plant-based diet can reverse or prevent further progression of coronary atheroma, improve endothelial dysfunction and is effective
even in cases of severe stenosis. Studies show that in addition to regression, there is a remolding of the geometry of the stenosis with consequent
improvement in coronary flow reserve.

Those following a plant-based diet have much lower total cholesterol and LDL. They also have lower levels of cardio-reactive protein,
apolipoprotein (a) and apolipoprotein (b), plus levels of MPO, MMP-9, MMP-2 and MMP-9/TIMP-1 ratios. In addition, studies have determined
that vegans produce less TMAO than their omnivorous counterparts after dietary challenge.

Long term exposure to persistent organic pollutants can drastically affect the circulatory system. The consumption of animal products is the
greatest source of exposure to these toxins, due to bioaccumulation of these lipophilic toxins in animal tissues.

Interventional studies confirm that a plant-based diet is as effective in lowering cholesterol as statin drugs. Such studies also show that a
plant-based diet can help treat heart failure and is very efficacious in treating angina pectoris. Vegetarians also show better improvements in
cardiac rehab. Follow-up studies at one and four years confirm continued benefit to the patient, and patient compliance has been demonstrated
over several years. Treatment with a plant-based diet is devoid of side effects and contraindications.

Keywords: Plant-based diet; Vegetarian; Vegan; Hypercholesterolemia; Angina; Stenosis; Heart disease; CVD; CAD; Persistent organic pollutants

Abbreviations: AhR: Aryl-Hydrocarbon Receptor; CABG: Coronary Artery Bypass Graft; CAD: Coronary Artery Disease; CHD: Coronary Heart
Disease; CVD: Cardio-Vascular Disease; HD: Heart Disease; HDL: High Density Lipoprotein; LDL: Low Density Lipoprotein; MMP: Matrix
Metalloproteinases; MPO: Myeloperoxidase; PAH: Polycyclic Aromatic Hydrocarbons; PCBs: Polychlorinated Biphenyls; POPs: Persistent Organic
Pollutants; TCDD: Tetrachlorodibenzo-p-dioxin; TIMP: Tissue Inhibitors of Metalloproteinases; TMAO: Trimethylamine N-oxide; VLDL: Very Low
Density Lipoprotein

Introduction
This treatment can be used alone or in combination with
It has long been known from epidemiological studies that
standard treatment regimens, including medication, stenting
vegetarians have lower incidences of several common chronic
and CABG. Treatment with the plant-based diet has the distinct
diseases including ischemic heart disease. Epidemiological
advantages of having no adverse reactions or contraindications, is
studies have also shown that they have lower incidences of risk
affordable, effectively treats common comorbidities and has been
factors for ischemic heart disease such as hypercholestrolemia,
shown to have a high patient compliance.
type 2 diabetes and essential hypertension.
Reducing hypercholesterolemia
This prompted research on using a vegetarian diet as a
treatment for coronary artery disease. For over 45 years, evidence Hypercholesterolemia is a well-known risk factor for CAD.
from interventional studies has strongly indicated that a low-fat Dietary saturated fat and cholesterol intake are shown to be
plant-based diet is both safe and efficacious in the treatment of strongly correlated with serum cholesterol levels. Less well-
coronary artery disease (CAD). It’s particularly effective in the known is the fact that both apolipoproteins (a) and (b) are
treatment angina pectoris. Interventional studies have shown that significant risk factors for CAD. While statin drugs are effective
a low-fat plant-based diet is a safe and efficacious alternative to at lowering serum cholesterol levels, they are not effective at
other treatments. lowering Apolipoprotein (a).

J Cardiol & Cardiovasc Ther 12(5): JOCCT.MS.ID.555847 (2018) 001

 Journal of Cardiology & Cardiovascular Therapy

Epidemiology The main reason for this is that animal products are high in
both saturated fats and cholesterol. While saturated and trans-fat
Vegetarians, and most especially vegans, have a much lower
intake have the greatest effect on blood cholesterol concentrations,
risk of hypercholesterolemia (for both total cholesterol and LDL)
serum cholesterol concentrations also rise in response to dietary
and a less atherogenic profile. They have been found to have lower
cholesterol intake. This relationship is linear within the range
total and LDL cholesterol levels on average. The following chart
of cholesterol intakes in typical omnivorous diets, but at higher
shows the average cholesterol levels among three dietary groups.
cholesterol intakes, the relationship is curvilinear; changes in
[1,2] Vegans, or total vegetarians, have the lowest levels (Figure
dietary cholesterol have less impact on serum cholesterol [3].
1).

Figure 1: Cholesterol levels as affected by diet.

Another reason why low-fat vegetarian and vegan diets men had better arterial function as measured by arterial stiffness
result in lower serum cholesterol levels is that they improve determined by carotid-femoral pulse wave velocity, relative
insulin sensitivity, which in turn can reduce cholesterol synthesis. carotid distensibility and carotid intima-media thickness than
This may account for a portion of the lower prevalence of non-vegetarian men [12].
hypercholesterolemia among vegetarians and vegans and for the
Apolipoproteins
results obtained in interventional studies [4,5].
Apolipoprotein (a)
The fact that vegetarians and especially vegans have lower
Several large population studies have shown a strong
cholesterol levels, and better cholesterol ratios, leads to much
independent relationship between high apolipoprotein (a)
less atherosclerosis. One of the important mechanisms whereby
(Lp(a)) levels and heart disease. This has led to the consensus
LDL cholesterol results in atherosclerotic lesions involves the
agreement that it is a very important risk factor for cardiovascular
oxidation of LDL cholesterol [6,7]. There is evidence that the LDL
disease, even when cholesterol levels and other classical risk
cholesterol in vegetarians is much less oxidizable [8].
factors such as elevated cholesterol, hypertension and diabetes
Vegans have also been found to have better regulation of the have been taken into account. It is thought to increase the risk of
metabolism of triglyceride-rich lipoproteins than omnivores, cardiovascular disease by two different mechanisms:
because they are more efficient in removing remnants that are
1. It promotes atherosclerosis. Research studies have
potentially atherogenic. In addition, the diminished cholesteryl
shown that Lp(a) may accelerate atherosclerotic damage. It
ester transfer shown in the study, and the diminished LDL
is thought to increase the size of plaque atheroma in artery
cholesterol levels that have been previously documented in other
walls, causing inflammation, instability and growth of smooth
published studies, clearly suggest that a vegan diet offers some
muscle cells. It is retained in the artery wall more than LDL
protection against atherogenesis [9]. A vegetarian diet also results
cholesterol as it binds to the artery lining through its “sticky”
in lower levels of C-reactive protein [10,11].
apolipoprotein.
In a cross-sectional study of apparently healthy vegetarian
2. It can trigger blockage of arteries by formation of clots.
and non- vegetarian men, all over 35 years old, the vegetarian
Lp(a) is thought to increase risk of heart attacks by interfering
men had lower body mass index, systolic and diastolic blood
with clotting mechanisms and therefore promoting clot
pressures, fasting serum total cholesterol, LDL and non-HDL-
development on the inner surface of blood vessels. Lp(a)
cholesterol, apolipoprotein B, glucose and glycated hemoglobin
appears similar to proteins involved in clotting, such as
values in comparison with non- vegetarian men. The vegetarian

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
002 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

plasminogen. It is thought to form a link between lipids and Persistent Organic Pollutants
the coagulation system by preventing fibrinolysis.
Epidemiology
Existing data show that elevated Lp(a) levels are associated The increasing deterioration of the natural environment is
with increased risk of coronary heart disease (CHD), stroke, having serious consequences on human health. The circulation
peripheral arterial disease, and calcific aortic valve stenosis [13- system is the major organ exposed to xenobiotics and endobiotics
15]. In a recent individual-patient data meta-analysis of statin- during metabolic homeostasis [28-30] and exposure to persistent
treated patients, elevated baseline and on-statin Lp(a) showed an organic pollutants can drastically alter this system, resulting in
independent approximately linear relation with cardiovascular cardiovascular diseases such as hypertension, atherosclerosis,
disease risk. This study provides a rationale for lowering Lp(a) and ischemic heart disease [30-36].
even in statin-treated patients [16].
Exposure to persistent organic pollutants such as dioxins and
Not only does a plant-based diet reduce serum cholesterol, dioxin-like polychlorinated biphenyls (PCBs) is associated with
but a recent study showed that Lp(a) could also be reduced. increased risk of multiple pro-inflammatory human diseases
In a four-week study on patients following a plant-based diet, including diabetes, cancer, and cardiovascular disease [37-45].
significant reductions were observed for serum Lp(a) with an
average reduction of -32.0 nmol/L. Lp(a) had been considered High quality studies found consistent and significant dose-
resistant to change by lifestyle modification making this result related increases in ischemic heart disease with dioxin [46]. Given
very notable [17]. In contrast, initiation of statin therapy reduced the large worldwide burden of CAD, the potential role of dioxin
LDL cholesterol (mean change −39% [95% CI −43 to −35]) exposure as a preventable risk factor could be of substantial
without a significant change in Lp(a) [16]. public health and clinical interest [46].

Apolilipoprotein (b) Mechanism A - The Aryl-Hydrocarbon Receptor

It is also evident that an increased serum apolipoprotein The aryl-hydrocarbon receptor (AhR) is a well-known
(b) (Lp(b)) concentration is an important CHD risk factor [18]. environmental sensor. Because many environmental pollutants
Lp(b) is the primary apolipoprotein of chylomicrons, VLDL, contain exogenous AhR ligands, increasing attention is being
intermediate-density lipoprotein, and LDL particles. Prospective given to the relationship between AhR and cardiovascular
studies suggest that concentrations of Lp(b) are indicators of diseases. Recent evidence from gene knock-out studies and
vascular heart disease and CVD risk [19,20]. clinical trials suggests that not only does AhR have a major impact
on general physiological functions, including immune responses,
Studies have also shown that vegetarians and vegans have reproduction, oxidative stress, tumor promotion, the cell cycle,
lower Lp(b) than meat eaters [21]. Several studies show that a and proliferation, but also influences cardiovascular physiological
low-fat vegetarian diet reduces Lp(b) concentrations [22,23]. functions [31-36].
When a low-fat vegetarian diet is introduced, Lp(b) levels are
reduced more than by other diets such the Atkins and South Beach AhR is a ligand activated transcription factor that mediates
diets [24]. the cellular response to environmental contaminants, including
dioxin and Polycyclic Aromatic Hydrocarbons (PAH) (from meat
Hypercholesterolemia Intervention or cigarette smoke), and has recently been associated with CAD
Vegetarian and vegan diets can be very efficacious in reducing [47,48]. Exposure to pollutants containing ligands of AhR, such as
serum cholesterol. Patients in a 4-week plant-based diet program dioxins, Tetrachlorodibenzo-p-dioxin (TCDD), PAH, and benzo(α)
had significant reductions in total cholesterol (34mg/dl), LDL-C pyrene, is thought to promote the development and progression
(25 mg/dl), triglycerides (20mg/dl), hs‐CRP (2.5 mg/dl), systolic of atherosclerosis, indicating that AhR may play a role in the
BP (16 mmHg), and diastolic BP (9 mmHg) [25]. regulation of atherosclerosis [37]. These environmental toxins, as
well as endogenous activators such as ox-LDL, activate the AhR
One study showed that a low-fat vegetarian diet was as effective pathway, leading to increased inflammatory burden in the plaque
at lowering serum cholesterol as the Standard Heart Association [47].
diet plus Lovostatin [26]. This study is notable because it contains
nuts in the treatment regimen. (See Clinical Considerations for Studies have shown that dioxin-like PCBs may also increase
more information about the benefit of including nuts in the diet.). oxidative stress and subsequent chronic inflammatory states
which can lead to glucose intolerance, alterations of lipid and
Another study examining children and their adult parents cholesterol homeostasis, and other risk factors for multiple
found that a plant-based, or vegan, diet reduced total cholesterol, metabolic diseases [37,49].
LDL cholesterol and C-reactive protein more than the American
Heart Association diet. This study is especially important given Mechanism B - TMAO
the recent increase in the incidence of hypercholesterolemia in Dioxin-like PCBs can lead to increased levels of the known pro-
children and the fact that atherosclerosis seems to start early in atherogenic nutrient biomarker Trimethylamine N-oxide (TMAO)
life [27]. [50]. A strong link between plasma levels of nutrient-derived

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
003 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

TMAO and coronary artery disease has been identified. Dietary It is known that the arterial wall consists of collagen types
precursors of TMAO include carnitine and phosphatidylcholine, I and III, macrophages and smooth muscle cells. The evolution
which are abundant in animal-derived foods [50]. of the atherosclerotic plaque from the fatty streak to advanced
plaque is associated with an increase in its content of collagen
TMAO levels are strongly linked to human diseases, and
[68], in the number of smooth muscle cells [69], and in MMP-9
plasma concentrations are correlated to dietary choices [51,52].
levels [69]. Increased levels of MMP-9 are found more often in
For example, diets high in red meat, and specifically L-carnitine,
patients with unstable angina compared with those with stable
produce TMAO and accelerate atherosclerosis [53,54]. However,
angina [70]. Human coronary plaques that are less likely to rupture
human studies have determined that vegans and vegetarians
demonstrate lower MMP-9 expression [69]. In patients with
produce less TMAO than their omnivorous counterparts after
coronary artery disease, higher MMP-9 levels are an independent
dietary challenge [53].
risk factor of cardiovascular mortality [71]. Increased TIMP-1
The Diet Connection levels have been reported consistently in human atherosclerotic
plaques, mainly in relation to areas of calcification [72]. Increased
Significant exposure of human populations to persistent
circulating TIMP-1 levels have also been related to stable coronary
organic pollutants (POPs) such as PCBs and dioxin occurs through
[73], carotid [74], and peripheral artery atherosclerosis [74].
consumption of fat-containing food such as fish, dairy products,
and meat [55-57], with the highest POP concentrations being One study of circulating cardiovascular biomarker profiles
commonly found in fatty fish [55,56,58-62]. compared the plasma concentrations of myeloperoxidase
(MPO), matrix metalloproteinases MMP-9 and MMP-2, and
Humans bioaccumulate these lipophilic pollutants in their
tissue inhibitors of MMP TIMP-1 and TIMP-2, between healthy
adipose tissues for many years because POPs are highly resistant
vegetarians and healthy omnivores. The study found significantly
to metabolic degradation [57,63]. This is likely to be one of the
lower concentrations of MPO, MMP-9, MMP-2 and MMP-9/TIMP-
factors reducing the risk of CAD for vegans.
1 ratio in vegetarians compared to omnivores. Moreover, MMP-9
Coronary Artery Disease concentrations were correlated positively with leukocyte and
Epidemiology neutrophil counts in both groups. Therefore, a vegetarian diet is
associated with a healthier profile of cardiovascular biomarkers
Epidemiological studies show a 40% risk reduction of
compared to omnivores [75].
ischemic heart disease [64] and a 50% risk reduction of coronary
heart disease mortality [65] for vegetarians. E-selectin (cE-Selectin) is a cell adhesion molecule expressed
only on endothelial cells activated by cytokines. Like other
Pathophysiology
selectins, it plays an important role in inflammation [76].
Myeloperoxidase (MPO) is a leukocyte-derived pro-oxidant
The intercellular adhesion molecule-1 (cICAM-1) is an Ig-like
enzyme that is released from granules of neutrophils and
cell adhesion molecule expressed by several cell types, including
monocytes [66]. MPO and its oxidant products, nitrotyrosine and
leukocytes and endothelial cells. It can be induced in a cell-specific
chlorotyrosine, have been identified in atherosclerotic plaque
manner by several cytokines, for example, tumor necrosis factor
and at the site of plaque rupture, and play an important role in
alpha, interleukin 1, and interferon gamma, and inhibited by
the genesis of atherosclerosis [66]. MPO promotes a number of
glucocorticoids [77].
pathological events involved in plaque formation and rupture,
including uptake of oxidized lipid by macrophages and impaired Upregulation of leukocyte adhesion molecules under
nitric oxide bioavailability. MPO levels independently predict atherogenic conditions is accompanied by the release of soluble
outcomes in patients presenting with acute coronary syndromes forms of adhesion molecules into the bloodstream [78]. One study
or for evaluation of chest pain of suspected cardiac etiology and assessed the levels of circulating E-selectin (cE-selectin) and
endothelial dysfunction [66]. circulating intercellular adhesion molecule-1 (cICAM-1), in both
vegetarians and subjects from the general population [78]. In
Matrix Metalloproteinases (MMPs) are extracellular
this study vegetarians were characterized by a significantly lower
enzymes that are important in many physiologic and pathologic
cE-selectin levels. Vegetarians also showed a tendency towards
processes. Their activity is regulated mainly by tissue inhibitors of
lower cICAM-1 levels in comparison with control subjects [78].
metalloproteinases (TIMPs). Their expression is associated with
Low cE-selectin levels of vegetarians may reflect the favorable
classical cardiovascular risk factors as well as with inflammation.
cardiovascular risk profile of this group.
They play a central role in atherosclerosis, plaque formation,
platelet aggregation, acute coronary syndrome, restenosis, aortic The lower levels of myeloperoxidase, matrix
aneurysms and peripheral vascular disease. Many studies have metalloproteinases and cE-selectin combine to give vegetarians
shown that commonly prescribed antihypertensive medications, a less atherogenic profile and helps explain their lower levels of
glitazones and statins, may influence MMPs activity [67]. atherosclerotic plaque.

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
004 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

General Intervention percent diameter stenosis in the control group increased by 2.3
percentage points after 1 year (a 5.4% relative worsening) and by
For over 45 years, evidence from interventional studies has
11.8 percentage points after 4 years (a 27.7% relative worsening).
strongly indicated that a low-fat plant-based diet is both safe and
efficacious in the treatment of coronary artery disease (CAD). Patients in the experimental group lost 10.9 kg (23.9 lbs) at
Researchers have investigated using a very low-fat vegan or nearly 1 year and sustained a weight loss of 5.8 kg (12.8 lbs) at 4 years,
vegan diet to treat CAD of varying severity, and have achieved very whereas weight in the control group changed little from baseline.
positive results. In the experimental group, LDL cholesterol levels decreased
by 40% at 1 year and remained 20% below baseline at 4 years.
A moderately low-fat vegetarian diet was studied as an
Experimental group patients also had a 91% reduction in reported
intervention for CAD as early as 1960. Morrison placed 50
frequency of angina after 1 year, and a 72% reduction after 4 years
patients with confirmed CAD on a moderately low-fat (25 g/day)
[80]. It is important to note that the results obtained above were
vegetarian diet and followed them, and the 50 patients with CAD
dose dependent – the more closely patients adhered to the dietary
in the control group, for 12 years. While none of the patients in the
regimen the better their results.
control group survived for that length of time, 38% of the patients
in the treatment group did [79]. It should be noted that since in A smaller study also showed good results. 17 patients with
1960 neither stent, nor CABG surgery, nor cholesterol-reducing CAD treated with a low-fat vegan diet, were followed for 5 years.
drugs, were available this was a very notable finding. Lesion analysis by percent stenosis showed that of 25 lesions,
11 regressed and 14 remained stable. Mean arterial stenosis
More recently in 1990, a prospective, randomized, controlled
decreased from an average of 53.4% to 46.2% [81].
trial was done to determine whether comprehensive lifestyle
changes affect coronary atherosclerosis after one year. Twenty- A larger study, though with only a 3.7 year follow up, also
eight patients were assigned to an experimental group (very- showed positive results. 198 patients were placed on a low-
low-fat vegetarian diet, healthy lifestyle and stress management) fat vegan, or total vegetarian diet. 93% of patients experienced
and 20 to a standard care control group. 195 coronary artery improvement or resolution of angina symptoms during the follow
lesions were analyzed by quantitative coronary angiography. The up period. Radiographic or stress testing results documented
average percentage diameter stenosis regressed from an average disease reversal in 22% of patients. 99.4% of adherent patients
40.0% to 37.8% in the experimental group yet progressed from avoided major cardiac events. 89% patients were adherent to the
an average of 42.7% to 46.1% in the control group. When only treatment regimen. However, this was not a controlled study and
lesions greater than 50% stenosed were analyzed, the average the self-selected patients were very motivated [82].
percentage diameter stenosis regressed from an average of
An Indian study examined 360 coronary lesions in 123 such
61.1% to 55.8% in the experimental group and progressed from
patients. Results were dose dependent. In CAD patients with the
an average of 61.7% to 64.4% in the control group. Overall, 82%
greatest adherence to a low-fat vegetarian diet, percent diameter
of experimental-group patients had an average change towards
stenosis regressed by an average of 18.23 absolute percentage
regression [23]. In evaluating the regression, it is very important
points. 91% of all patients showed a trend towards regression,
to keep in mind that blood flow increases by the radius raised to
and 51.4% lesions regressed by more than 10 absolute percentage
the 4th power according to Poiseuille’s Law, so small changes make
points [83].
a big difference.
A Dutch interventional study took patients who had at least one
This landmark study provided compelling evidence that a
50% obstruction and placed them on a vegetarian diet, although
low-fat vegetarian diet can not only halt the progression of CAD,
not as low in fat and cholesterol as other studies. After 2 years,
but even result in modest regressions in arterial stenosis. Given
46% of patients showed no progression of the stenosis. Dietary
that CAD culminating in myocardial infarction is the leading cause
changes were associated with a significant increase in linoleic acid
of death in the developed world, and a tremendous burden on
content of cholesteryl esters, and a significant lowering of body
the health care system as well as on the patients themselves, the
weight, systolic blood pressure, serum total cholesterol, and the
importance of this finding can hardly be overstated.
ratio of total to high-density lipoprotein (total/HDL) cholesterol
Following up on these results, researchers then looked to see [84].
if the treatment effects were sustained for longer periods of time,
Coronary Perfusion Study
and if even further improvements could be obtained. The answer
to both questions seems to be yes. As might be expected, patients on a low-fat vegetarian
diet experience improvement in coronary perfusion as well.
In a group of patients who participated in a 4-year follow
In one study after 4 years, the size and severity of perfusion
up, the average percent diameter stenosis at baseline decreased
abnormalities on dipyridamole PET images decreased after risk
1.75 absolute percentage points after 1 year (a 4.5% relative
factor modification in the experimental group, compared with an
improvement) and by 3.1 absolute percentage points after 4
increase of size and severity in controls. The percentage of left
years (a 7.9% relative improvement). In contrast, the average

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
005 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

ventricle perfusion abnormalities, on the dipyridamole PET image hypertension, coronary artery disease, diabetes, obesity, valvular
of normalized counts outside 2.5 SDs of those of normal persons, heart disease, and the metabolic syndrome [90].
worsened in controls by an average of 10.3% and improved in
Coronary artery disease, which can lead to heart failure, may
the experimental group by an average of 5.1%. The percentage of
be the underlying cause in most cases of heart failure patients with
left ventricle with activity less than 60% of the maximum activity
low ejection fraction. Coronary artery disease may also play a role
worsened in controls by an average 13.5% and improved in the
in the progression of heart failure through mechanisms such as
experimental group 4.2%. The myocardial quadrant on the PET
endothelial dysfunction, ischemia, and infarction, among others.
image with the lowest average activity, expressed as a percentage
of maximum activity, worsened in controls by an average of 8.8% Since those following a plant-based diet are at lower risk of
and improved in the experimental group by an average of 4.9%. coronary artery disease, diabetes and obesity, they can be expected
The size and severity of perfusion abnormalities on resting PET to be at lower of heart failure as well. Several population-based
images were also significantly improved in the experimental group cohort studies that have demonstrated an inverse relationship
as compared with controls. The relative magnitude of changes in between increased consumption of plant-based foods and
size and severity of PET perfusion abnormalities was comparable incidence of heart failure [91-95].
to, or greater than, the magnitude of changes in percent diameter
Five prospective studies examined the association between
stenosis, absolute stenosis lumen area, or stenosis flow reserve
meat consumption and HF incidence in separate medium to large,
documented by quantitative coronary arteriography [85].
middle-aged cohorts. All of these studies found increased HF risk
Stenotic Morphology Study with meat consumption [96-100].

In 1992, an interesting study looked at the change of the In a prospective cohort study of 21,275 participants from
geometric shape of the stenosis, in addition to the degree of the Physicians’ Health Study I, consumption of one egg a day
stenosis, and their combined effect on flow reserve. Percent increased the risk of heart failure by 28% and consuming two
stenosis is an incomplete measure of stenosis because length, eggs a day increased the risk of heart failure by 64% [101]. In
absolute lumen area and shape effects are not accounted for, another prospective study of over 15,000 participants, those who
and correlate poorly with the functional measure of coronary ate a plant-based diet most of the time had a 42% reduced risk of
stenosis, coronary reserve flow [86]. Patients treated with a low- heart failure [102].
fat vegetarian diet show complex stenosis shape change, with
The beneficial effects of a low-fat vegetarian diet are indicated
profound effects on fluid dynamic severity, not accounted for
for patients at risk of heart failure and who also have CAD. One
by simple percent narrowing in a dose dependent manner. This
study showed significant improvements in such patients with
effect is most pronounced with patients with severe pretreatment
documented CHD, regardless of ejection fraction, in lifestyle
stenosis, with stenosis flow reserve less than 3. In this study, the
behaviors, body weight, body fat, blood pressure, resting heart
minimal diameter increased by 18%. Patients with a pretreatment
rate, total and LDL-cholesterol, exercise capacity, and quality of
average of 67% stenosis showed a 14% improvement in diameter
life by 3 months. Most improvements were maintained over 12
[87]. As mentioned earlier, coronary blood flow effects are a
months [103].
function of arterial radius raised to the 4th power, so small changes
in the radius have proportionately much larger effects on flow A recent case report demonstrated the effects of a plant-based
capacity and functional severity of stenosis, thus contributing to diet in a 79-year-old male with documented triple vessel disease
the greater significance of stenosis flow reserve as a measure of (80–95 % stenosis) and left ventricular systolic dysfunction
change in severity. (ejection fraction 35%) in the context of progressive dyspnea.
Two months on a plant-based diet led to clinically significant
Angina pectoris
reductions in body weight and lipids, with improved exercise
An all-too-common comorbidity, angina, can also be treated tolerance and ejection fraction (+15 %) [95].
with a low-fat plant-based diet. One study examined over 100
Post Op Cardiac Rehabilitation Studies
patients with CAD at 22 different clinics throughout the U.S. After
12 weeks, 74% of these patients placed on a plant-based diet were Researchers have also studied the effects of a low-fat
angina free, and an additional 9% moved from limiting to mild vegetarian diet on patients who had already had standard
angina [88]. Another study of patients placed on a vegetarian diet treatments and were ready for post op cardiac rehabilitation.
found that 91% of patients had a reduction in the frequency of
One study compared patients in cardiac rehabilitation
angina episodes [80]. Using a purely vegan diet, one small study
programs using either the standard treatment or a low-fat
found complete remission of symptoms in all patients by the 6th
vegetarian diet (combined with stress reduction). Low-fat
month [89].
vegetarian program participants had significantly greater
Heart failure reductions in anginal frequency, body weight, body mass index,
systolic blood pressure, total cholesterol, low-density lipoprotein
Several epidemiological investigations have identified the
cholesterol, glucose and dietary fat [104].
following key risk factors for heart failure (HF): increasing age,

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
006 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

Another study looked at psychosocial risk factors and quality of Fish Oil Supplementation
life variables for patients in cardiac rehabilitation programs, using
There has been an unfortunate tendency amongst some
either the standard treatment or a low-fat vegetarian program. At
physicians to recommend fish oils to their patients. However, this
3 and 6 months, vegetarian participants demonstrated significant
has not been borne out by the evidence. One metastudy conducted
improvements in all 12 outcome measures, while the standard
on the supposed benefits of fish oil reported, “All of the studies
rehabilitation group improved in only 7 of the 12 [105].
included were the gold-standard kind of clinical trial -- with people
Clinical Considerations assigned at random to either take fish oil or a placebo. The studies
ranged in length from one to nearly five years. The authors detected
Substantial evidence indicates that plant-based diets can
no reduction in any cardiovascular events, such as heart attacks,
play an important role in preventing and treating CVD and its
sudden death, angina, heart failures, strokes or death, no matter
risk factors [106]. This suggests that a plant-based diet should be
what dose of fish oil used [115].”
recommended as a prophylaxis to all patients, given that CAD is
such a frequent cause of disability and death. A recent meta-analysis of 10 randomized clinical trials also
demonstrated that randomization to trial showed that fish oil had
Dietary intervention is an extremely cost-effective treatment
no significant effect on either of fatal CHD, nonfatal MI, stroke,
and may be the only viable treatment for those patients struggling
revascularization events, or any major vascular events. Likewise,
with the affordability of other options. Some patients are either
the study showed no significant association of omega-3 FA
unwilling, fearful of or not good candidates for surgery. This
supplementation with all-cause mortality or cancer [116].
treatment also offers them a nonsurgical option of proven efficacy.
In patients with established cardiovascular disease or an
One of the key advantages of the treatment of coronary heart
increased risk of cardiovascular disease, omega-3 fatty acid
disease with a low-fat vegetarian diet is the very low restenosis
supplementation also had no effect on major adverse cardiac
rate. One study reports the following average restenosis rates:
events, all-cause mortality, sudden cardiac death, coronary artery
balloon angioplasty 30-60%, bare metal stents, 16-44%, drug
revascularization, or hypertension [117]. In addition, a large,
eluting stents <10% [107]. Compare this with the low-fat vegan
long-term randomised trial showed that fish oil supplements
diet, which resulted in a zero-percentage restenosis rate in a study
do not reduce the risk of cardiovascular events in patients with
by Dean Ornish [108].
diabetes [118].
A low-fat vegetarian treatment regimen has also been shown
There has also been a mistaken notion that the Eskimo had a
suitable for diabetics with CAD. In a one-year study, diabetic
lower incidence of coronary heart disease, by virtue of their high
patients with comorbid CAD showed good adherence to the
fish oil consumption. This also turns out to not be the case. One
treatment, and improvements in both cardiovascular and diabetic
report state, “Greenland Eskimos and the Canadian and Alaskan
parameters, as demonstrated by significant improvements in
Inuit have CAD as often as the non-Eskimo populations [119].”
weight, body fat, LDL cholesterol, and exercise capacity. About
Another study states, “Eskimos have CHD despite high consumption
20% of these patients were able to reduce or discontinue diabetic
of omega-3 fatty acids.” [120].
medications such as insulin or oral anti-hyperglycemics [109].

The problem of depression is a common concomitant of Discussion

heart disease. A study using a low-fat plant-based diet in cardiac Treatment Advantages
rehab patients, found that 80% saw very significant reductions in Interventional studies have shown that a low-fat (<10% of
depression by 12 weeks, and the improvement was maintained calories) plant-based diet is a viable and highly advantageous
for at least one year [110]. Another study of patients at high risk alternative to other interventional strategies. The low-fat
also showed an improvement in depressive symptoms [111]. vegetarian diet also has no surgical risk of mortality, morbidity,
While the interventional studies stressed a low-fat dietary no post op complications, and no adverse reactions or contra-
regimen, there is good evidence that the inclusion of tree nuts, indications. The cost to the patient is minimal, and also both
despite their fat content, reduces cardiac risk [112,113]. The treats and lowers the risk of common comorbidities such as
research has been accumulating on the value of nuts in the hypertension, diabetes and certain forms of cancer. It can serve as
prevention and treatment of a variety of diseases, including a monotherapy or as an adjunct to standard treatment regimens,
cardiovascular, indicating that the low-fat regimen now more including medication, stenting and CABG.
commonly employed may be enhanced by moderate amounts Cost-Effective Treatment
of tree nuts. In one study, nut consumption was associated with
The treatment of CAD with a plant-based diet has been shown
reduced prevalence of high cholesterol and high blood pressure;
to be very cost effective. Highmark’s Blue Cross estimated cost
having a history of heart attack, diabetes and gallstones; and
savings per participant in the Ornish low-fat vegetarian cardiac
markers of diet quality. In this cross-sectional analysis, higher nut
program is $16,186 measured in 1999 dollars [121]. Estimated
consumption was also associated with lower body mass index and
savings would likely be much higher today. A Mutual of Omaha
waist circumference [114].
Insurance study, also conducted in the 1990s, determined that

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
007 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

for every dollar spent on the Ornish program there was a savings diabetes mellitus, obesity, myocardial infarction and mortality,
of $5.55 in health care costs that would have otherwise accrued as well as many non-cardiac issues that affect our patients in
[122]. cardiology, ranging from cancer to a variety of inflammatory
conditions. Challenges with the science are, however, less daunting
According to a Kaiser Family Foundation/New York Times
to overcome than inertia, culture, habit and widespread marketing
survey, among people with health insurance, one in five (20%)
of unhealthy foods. Our goal must be to get data out to the medical
working age Americans report having had problems paying
community and the public where it can actually change lives—
medical bills in the past year, often causing serious financial
creating healthier and longer ones [129].”
challenges and changes in employment. The situation is even
worse among people who are uninsured or underinsured: half Conflict of Interest
(53%) face problems with medical bills, bringing the overall total
The authors state no conflicts of interest.
to 26 percent [123]. Many people struggle with copayments and
have high deductibles. References
Coronary artery disease takes a tremendous toll in both lives 1. Thorogood M, Carter R, Benfield L, McPherson K, Mann JI (1987)
Plasma and lipoprotein cholesterol concentrations in people with
and money. Heart disease remains the leading cause of death different diets in Britain. Brit Med J (Clin Res Ed) 295(6594): 351–353.
for both men and women [124]. CAD costs the United States
2. Haddad E, Berk LS, Kettering JD, Hubbard RW, Peters WR (1999)
$108.9 billion each year [125,126]. Clearly, a more cost-effective Dietary intake and biochemical, hematologic, and immune status of
treatment to Percutaneous Coronary Intervention and CABG vegans compared with nonvegetarians. Am J Clin Nutr 70(3 Suppl):
is needed. As we have seen, treatment of CAD with a low-fat 586S-593S.
vegetarian diet would save a very considerable amount of money. 3. Hopkins PN (1992) Effects of dietary cholesterol on serum cholesterol:
a meta-analysis and review. Am J Clin Nutr 55(6): 1060-1070.
A Needed Treatment Option
4. Barnard ND, Cohen J, Jenkins DJ, Turner-McGrievy G, Gloede L,
As most physicians know, many patients these days attempt et.al. (2006) A low-fat vegan diet improves glycemic control and
to gain health-related information and to treat themselves cardiovascular risk factors in a randomized clinical trial in individuals
with type 2 diabetes. Diabetes Care 29(8): 1777-1783.
based upon what they read on the internet. Such information is
often highly unreliable [127]. In our experience, most patients 5. Tobin KA, Ulven SM, Schuster GU, Steineger HH, Andresen SM, et al.
(2002) Liver X Receptors as Insulin-mediating Factors in Fatty Acid
would rather get their health information and advice from their
and Cholesterol Biosynthesis. J Biol Chem 277(12): 10691-10697.
physicians, but turn to the internet when they can’t. Therefore,
to serve the best interests and needs of their patients, physicians 6. Berliner JA, Navab M, Fogelman AM, Frank JS, Demer LL, et.al. (1995)
Atherosclerosis: basic mechanisms. Oxidation, inflammation, and
should familiarize themselves with this treatment. genetics. Circulation 91(9): 2488-2496.
Research has documented the high rate of compliance with 7. Li D, Mehta JL (2005) Oxidized LDL, a critical factor in atherogenesis.
this treatment, especially when physicians explain the rationale Cardiovas Res 68(3): 353-354.
behind the treatment and specifically prescribes it to their 8. Lu SC, Wu WH, Lee CA, Chou HF, Lee HR, et al. (2000) LDL of Taiwanese
patients. vegetarians are less oxidizable than those of omnivores. J Nutr 130(6):
1591-1596.
We live in an age of advanced medical technology. These 9. Vinagre JC, Vinagre CG, Pozzi FS, Slywitch E, Maranhão RC (2013)
advances have alleviated much suffering and saved countless Metabolism of triglyceride-rich lipoproteins and transfer of lipids to
lives. They have an unquestioned place in modern medicine. high-density lipoproteins (HDL) in vegan and omnivore subjects. Nutr
Metab Cardiovas Dis 23(1): 61-67.
However, this can sometimes lead towards a kind of technological
fundamentalism. Little notice is taken of treatments that, while 10. Krajcovicova-Kudlackova M, Blazicek P (2005) C-reactive protein and
nutrition. Bratisl Lek Listy 106(11): 345-347.
lacking in technological sophistication, are nevertheless quite
efficacious. This indeed seems to be the case with treating CAD 11. Chen CW, Lin YL, Lin TK, Lin CT, Chen BC, et al. (2008) Total
cardiovascular risk profile of Taiwanese vegetarians. Eur J Clin Nutr
with a low-fat vegetarian diet.
62(1): 138-144.
Fortunately, many doctors have already started to integrate 12. Acosta-Navarro J, Antoniazzi L, Oki AM, Bonfim MC, Hong V, et al. (2017)
therapeutic plant-based diets into their patients’ prevention and Reduced subclinical carotid vascular disease and arterial stiffness in
treatment of CAD. The former president of the American College vegetarian men: The CARVOS Study. Int J Cardiol 230: 562-566.

of Cardiology, Dr. Kim Williams, uses this modality of treatment 13. Tsimikas S (2017) A test in context: lipoprotein(a): diagnosis,
for his patients [128]. prognosis, controversies, and emerging therapies. J Am Coll Cardiol
69(6): 692-711.
In a recent article, he states: 14. Tsimikas S, Fazio S, Ferdinand KC, Ginsberg HN, Koschinsky ML,
et al. (2018) NHLBI Working Group recommendations to reduce
“Unlike many of our cardiovascular prevention and treatment lipoprotein(a)-mediated risk of cardiovascular disease and aortic
strategies, including antioxidants, vitamin E, folic acid and niacin stenosis. J Am Coll Cardiol 71(2):177-192.
to name a few, that have disintegrated over time, the “truth” (i.e., 15. Yu B, Hafiane A, Thanassoulis G, Ott L, Filwood N, et al. (2017)
evidence) for the benefits of plant-based nutrition continues to Lipoprotein(a) induces human aortic valve interstitial cell calcification.
mount. This now includes lower rates of stroke, hypertension, JACC Basic Transi Sci 2(4): 358-371.

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
008 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

16. Willeit P, Ridker PM, Nestel PJ, Simes J, Tonkin AM, et al. (2018) 33. Oesterling E, Toborek M, Hennig B (2008) Benzo[a]pyrene induces
Baseline and on-statin treatment lipoprotein(a) levels for prediction of intercellular adhesion molecule-1 through a caveolae and aryl
cardiovascular events: individual patient-data meta-analysis of statin hydrocarbon receptor mediated pathway. Toxicol Appl Pharmacol
outcome trials. Lancet 392(10155): 1311-1320. 232(2): 309-316.
17. Najjar RS, Moore CE, Montgomery BD (2018) Consumption of a 34. Kopf PG, Huwe JK, Walker MK (2008) Hypertension, cardiac
defined, plant-based diet reduces lipoprotein(a), inflammation, and hypertrophy, and impaired vascular relaxation induced by
other atherogenic lipoproteins and particles within 4 weeks. Clin 2,3,7,8-Tetrachlorodibenzo-p-Dioxin are associated with increased
Cardiol 41(8): 1062-1068. superoxide. Cardiovasc Toxicol 8(4): 181-193.
18. Contois JH, McConnell JP, Sethi AA, Csako G, Devaraj S, et al. (2009) 35. Savouret JF, Berdeaux A, Casper RF (2003) The aryl hydrocarbon
Apolipoprotein B and Cardiovascular Disease Risk: Position Statement receptor and its xenobiotic ligands: A fundamental trigger for
from the AACC Lipoproteins and Vascular Diseases Division Working cardiovascular diseases. Nutr Metab Cardiovasc Dis 13(2): 104-113.
Group on Best Practices. Clin Chem 55(3): 407-419.
36. Dalton TP, Kerzee JK, Wang B, Miller M, Dieter MZ, et al. (2001) Dioxin
19. Sandhu PK, Musaad SM, Remaley AT, Buehler SS, Strider S, et al. exposure is an environmental risk factor for ischemic heart disease.
(2016) Lipoprotein Biomarkers and Risk of Cardiovascular Disease: A Cardiovasc Toxicol 1(4): 285-298.
Laboratory Medicine Best Practices (LMBP) Systematic Review. J Appl
Lab Med 1(2): 214-229. 37. Perkins JT, Petriello MC, Newsome BJ, Hennig B (2016) Polychlorinated
biphenyls and links to cardiovascular disease. Environ Sci Pollut Res
20. Davidson MH, Ballantyne CM, Jacobson TA, Bittner VA, Braun LT, et Int 23(3): 2160-2172.
al. (2011) Clinical utility of inflammatory markers and advanced
lipoprotein testing: advice from an expert panel of lipid specialists. J 38. Kim SA, Kim KS, Lee YM, Jacobs DR, Lee DH (2015) Associations of
Clin Lipidol 5(5): 338-367. organochlorine pesticides and polychlorinated biphenyls with total,
cardiovascular, and cancer mortality in elders with differing fat mass.
21. Bradbury KE, Crowe FL, Appleby PN, Schmidt JA, Travis RC, et al. Environ Res 138: 1-7.
(2014) Serum concentrations of cholesterol, apolipoprotein A-I,
and apolipoprotein B in a total of 1694 meat-eaters, fish-eaters, 39. Pavuk M, Olson JR, Wattigney WA, Dutton ND, Sjödin A, et al. (2014)
vegetarians, and vegans. Eur J Clin Nutr 68(2): 178-183. Predictors of serum polychlorinated biphenyl concentrations in
Anniston residents. Sci Total Environ 496: 624-634.
22. Cooper RS, Goldberg RB, Trevisan M, Tsong Y, Liu K, et al. (1982)
The selective lipid-lowering effect of vegetarianism on low density 40. Pavuk M, Olson JR, Sjödin A, Wolff P, Turner WE, et al. (2014) Serum
lipoproteins in a cross-over experiment. Atherosclerosis. 44(3): 293- concentrations of polychlorinated biphenyls (PCBs) in participants of
305. the Anniston Community Health Survey. Sci Total Environ 473-474:
286-297.
23. Ornish D, Brown SE, Scherwitz LW, Billings JH, Armstrong WT, et.al.
(1990) Can lifestyle changes reverse coronary heart disease? The 41. Aminov Z, Haase RF, Pavuk M, Carpenter DO, Consortium AEHR (2013)
Lifestyle Heart Trial. Lancet 336(8708): 129-133. Analysis of the effects of exposure to polychlorinated biphenyls and
chlorinated pesticides on serum lipid levels in residents of Anniston,
24. Miller M, Beach V, Sorkin J, Mangano C, Dobmeier C, et al. (2009) Alabama. Environ Health 12: 108.
Comparative effects of three popular diets on lipids, endothelial
function, and C-reactive protein during weight maintenance. J Am Diet 42. Silverstone AE, Rosenbaum PF, Weinstock RS, Bartell SM, Foushee HR,
Assoc 109(4): 713-717. et al. (2012) Polychlorinated biphenyl (PCB) exposure and diabetes:
results from the Anniston Community Health Survey. Environ Health
25. Najjar RS, Moore CE, Montgomery BD (2018) A defined, plant‐based Perspect 120(5): 727-732.
diet utilized in an outpatient cardiovascular clinic effectively treats
hypercholesterolemia and hypertension and reduces medications. Clin 43. Goncharov A, Bloom M, Pavuk M, Birman I, Carpenter DO (2010)
Cardiol 41(3): 307-313. Blood pressure and hypertension in relation to levels of serum
polychlorinated biphenyls in residents of Anniston, Alabama. J
26. Jenkins DJ, Kendall CW, Marchie A, Faulkner DA, Wong JM, et al. (2005) Hypertens 28(10): 2053-2060.
Direct comparison of a dietary portfolio of cholesterol-lowering foods
with a statin in hypercholesterolemic participants. Am J Clin Nutr 44. Langer P, Kocan A, Tajtáková M, Susienková K, Rádiková Z, et al. (2009)
81(2): 380-387. Multiple adverse thyroid and metabolic health signs in the population
from the area heavily polluted by organochlorine cocktail (PCB, DDE,
27. Macknin M, Kong T, Weier A, Worley S, Tang AS, et al. (2015) Plant- HCB, dioxin). Thyroid Res 2(1): 3.
based, no-added-fat or American Heart Association diets: Impact on
Cardiovascular Risk in Obese Children with Hypercholesterolemia and 45. Lind PM, Orberg J, Edlund UB, Sjöblom L, Lind L (2004) The dioxin-
Their Parents. J Pediatr 166(4): 953-959. like pollutant PCB 126 (3,3′,4,4′,5-pentachlorobiphenyl) affects risk
factors for cardiovascular disease in female rats. Toxicol Lett 150(3):
28. Hanieh H (2014) Toward understanding the role of aryl hydrocarbon 293-299.
receptor in the immune system: current progress and future trends.
BioMed Res Int p. 14. 46. Humblet O, Birnbaum L, Rimm E, Mittleman M, Hauser R (2008)
Dioxins and Cardiovascular Disease Mortality. Environ Health Perspect
29. Hernández-Ochoa I, Karman BN, Flaws JA (2009) The role of the aryl 116(11): 1443-1448.
hydrocarbon receptor in the female reproductive system. Niochem
Pharmacol 77(4): 547-559. 47. Kim JB, Pjanic M, Nguyen T, Miller CL, Iyer D, et al. (2017) TCF21 and
the environmental sensor aryl-hydrocarbon receptor cooperate to
30. Yi T, Wang J, Zhu K, Tang Y, Huang S, et al. (2018) Aryl Hydrocarbon activate a pro-inflammatory gene expression program in coronary
Receptor: A New Player of Pathogenesis and Therapy in Cardiovascular artery smooth muscle cells. PLoS Genet 13(5): e1006750.
Diseases. Biomed Res Int. 2018: 6058784.
48. Kim J, Pjanic M, Sazanova O, Wang T, Miller C, et al. (2018) TCF21
31. Xiao L, Zhang Z, Luo X (2014) Roles of xenobiotic receptors in vascular Regulates Coronary Artery Disease Causing Aryl-hydrocarbon
pathophysiology. Circ J 78(7): 1520-1530. Receptor Gene Expression and its Downstream Pathway Activation by
Environmental Ligands. Circulation 132(Suppl 3).
32. Chuang KJ, Yan YH, Chiu SY, Cheng TJ (2011) Long-term air pollution
exposure and risk factors for cardiovascular diseases among the 49. Murphy M, Petriello M, Han S, Sunkara M, Morris A, et al. (2016)
elderly in Taiwan. Occup Environ Med 68(1): 64-68. Exercise protects against PCB-induced inflammation and associated

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
009 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

cardiovascular risk factors. Environ Sci Pollut Res Int. 23(3): 2201- 67. Liu P, Sun M, Sader S (2009) Matrix metalloproteinases in
2211. cardiovascular diseases. Can J Cardiol 22 Suppl B:25B-30B.
50. Petriello M, Hoffman J, Sunkara M, Wahlang B, Perkins J, et al. 68. Stary H, Chandler A, Dinsmore R, Fuster V, Glalov S, et al. (1995) A
(2016) Dioxin-like pollutants increase hepatic flavin containing definition of advanced types of atherosclerotic lesions and a histological
monooxygenase (FMO3) expression to promote synthesis of the pro- classification of atherosclerosis. A report from the Committee on
atherogenic nutrient biomarker Trimethylamine N-oxide from dietary Vascular Lesions of the Council on Arteriosclerosis, American Heart
precursors. J Nutr Biochem 33: 145-153. Association. Circulation 92(5): 1355-1374.
51. Wang Z, Klipfell E, Bennett B, Koeth R, Levison B, et al. (2011) Gut flora 69. Brown D, Hibbs M, Kearney M, Isner J (1997) Differential expression
metabolism of phosphatidylcholine promotes cardiovascular disease. of 92-kDa gelatinase in primary atherosclerotic versus restenotic
Nature 472(7341): 57-63. coronary lesions. Am J Cardiol 79(7): 878-882.
52. Fogelman A. (2015) TMAO is both a biomarker and a renal toxin. Circ 70. Brown D, Hibbs M, Kearney M, Loushin C, Isner JM (1995)
Res 116(3): 396-397. Identification of 92-kD gelatinase in human coronary atherosclerotic
lesions: association of active enzyme synthesis with unstable angina.
53. Koeth R, Wang Z, Levison B, Buffa J, Org E, et al. (2013) Intestinal Circulation 91(8): 2125-2131.
microbiota metabolism of L-carnitine, a nutrient in red meat, promotes
atherosclerosis. Nat Med 19(5): 576-585. 71. Blankenberg S, Rupprecht H, Poirier O, Bickel C, Smieja M, et al.
(2003) Plasma concentrations and genetic variation of matrix
54. Ufnal M, Jazwiec R, Dadlez M, Drapala A, Sikora M, et al. (2014) metalloproteinase 9 and prognosis of patients with cardiovascular
Trimethylamine-N-oxide: a carnitine-derived metabolite that prolongs disease. Circulation 107(12): 1579-1585.
the hypertensive effect of angiotensin II in rats. Can J Cardiol 30(12):
1700-1705. 72. Orbe J, Fernandez L, Rodríguez J, Rábago G, Belzunce M, et al. (2003)
Different expression of MMPs/TIMP-1 in human atherosclerotic
55. Walker P, Rhubart-Berga P, McKenzie S, Kelling K, Lawrence R (2005) lesions. Relation to plaque features and vascular bed. Atherosclerosis
Public health implications of meat production and consumption. Pub 170(2): 269-276.
Health Nutr 8(4): 348-356.
73. Noji Y, Kajinami K, Kawashiri M, Todo Y, Horita T, et al. (2001) Circulating
56. Sasamoto T, Ushio F, Kikutani N, Saitoh Y, Yamaki Y, et al. (2006) matrix metalloproteinases and their inhibitors in premature coronary
Estimation of 1999-2004 dietary daily intake of PCDDs, PCDFs and atherosclerosis. Clin Chem Lab Med 39(5): 380-384.
dioxin-like PCBs by a total diet study in metropolitan Tokyo, Japan.
Chemosphere 64(4):634-641. 74. Beaudeux J, Giral P, Bruckert E, Bernard M, Foglietti M, et al.
(2003) Serum matrix metalloproteinase-3 and tissue inhibitor of
57. Fisher B. (1999) Most Unwanted. Environ Health Perspect 107(1): metalloproteinases-1 as potential markers of carotid atherosclerosis
A18-23. in infraclinical hyperlipidemia. Atherosclerosis 169(1): 139-146.
58. Bocio A, Domingo J (2005) Daily intake of polychlorinated dibenzo-p- 75. Navarro J, de Gouveia L, Rocha Penha L, Cinegaglia N, Belo V, et
dioxins/polychlorinated dibenzofurans (PCDD/PCDFs) in foodstuffs al. (2016) Reduced levels of potential circulating biomarkers of
consumed in Tarragona, Spain: a review of recent studies (2001-2003) cardiovascular diseases in apparently healthy vegetarian men. Clin
on human PCDD/PCDF exposure through the diet. Environ Res 97(1): Chim Acta 461: 110-113.
1-9.
76. Leeuwenberg J, Smeets E, Neefjes J, Shaffer M, Cinek T, et al. (1992)
59. Schecter A, Colacino J, Haffner D, Patel K, Opel M, et al. (2010) E-selectin and intercellular adhesion molecule-1 are released by
Perfluorinated compounds, polychlorinated biphenyls, and activated human endothelial cells in vitro. Immunology 77(4): 543-
organochlorine pesticide contamination in composite food samples 549.
from Dallas, Texas, USA. Environ Health Perspect 118(6): 796-802.
77. van de Stolpe A, van der Saag P (1996) Intercellular adhesion
60. Darnerud P, Atuma S, Aune M, Bierselius R, Glynn A, et.al. (2006) molecule-1. J Mol Med (Berl) 74(1): 13-33.
Dietary intake estimations of organohalogen contaminants (dioxins,
PCB, PBDE and chlorinated pesticides, e.g. DDT) based on Swedish 78. Purschwitz K, Rassoul F, Reuter W, Purschwitz R, Jahn N, et al. (2001)
market basket data. Food Chem Toxicol 44(9): 1597-1606. Soluble leukocyte adhesion molecules in vegetarians of various ages. Z
Gerontol Geriatr 34(6): 476-479.
61. Bergkvist C, Oberg M, Appelgren M, Becker W, Aune M, et al. (2008)
Exposure to dioxin-like pollutants via different food commodities in 79. Morrison LM (1960) Diet in Coronary Atherosclerosis. J Am Med Assoc
Swedish children and young adults. Food Chem Toxicol 46(11): 3360- 173: 884-888.
3367.
80. Ornish D, Scherwitz L, Billings J, Brown S, Gould K, et al. (1998)
62. Dougherty C, Henricks Holtz S, Reinert J, Panyacosit L, Axelrad D, et Intensive Lifestyle Changes for Reversal of Coronary Heart Disease.
al. (2000) Dietary exposures to food contaminants across the United JAMA 280(23): 2001-2007.
States. Environ Res 84(2): 170-185.
81. Esselstyn CJ, Ellis S, Medendorp S, Crowe T (1995) A strategy to arrest
63. Kiviranta H, Tuomisto JT, Tuomisto J, Tukiainen E, Vartiainen T (2005) and reverse coronary artery disease: a 5-year longitudinal study of a
Polychlorinated dibenzo-p-dioxins, dibenzofurans, and biphenyls in single physician’s practice. J Fam Pract 41(6): 560-568.
the general population in Finland. Chemosphere 60(7): 854-869.
82. Esselstyn CJ, Gendy G, Doyle J, Golubic M, Roisen M (2014) A way to
64. Kwok C, Umar S, Myint P, Mamas M, Loke Y (2014) Vegetarian diet, reverse CAD? J Fam Pract 63(7): 356-364b.
Seventh Day Adventists and risk of cardiovascular mortality: a
systematic review and meta-analysis. Int J Cardiol 176(3): 680-686. 83. Gupta S, Sawhney R, Rai L, Chavan V, Dani S, et al. (2011) Regression of
coronary atherosclerosis through healthy lifestyle in coronary artery
65. Phillips R, Lemon F, Beeson W, Kuzma J (1978) Coronary heart disease disease patients--Mount Abu Open Heart Trial. Indian Heart J 63(5):
mortality among Seventh-Day Adventists with differing dietary habits: 461-469.
a preliminary report. Am J Clin Nutr 31(10 Suppl): S191-S198.
84. Arntzenius A, Kromhout D, Barth J, Reiber J, Bruschke A, et al. (1985)
66. Upadhyay R (2015) Emerging Risk Biomarkers in Cardiovascular Diet, Lipoproteins, and the Progression of Coronary Atherosclerosis-
Diseases and Disorders. J Lipids 2015: 971453. The Leiden Intervention Trial. N Engl J Med 312: 805-811.

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
0010 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

85. Gould K, Ornish D, Scherwitz L, Brown S, Edens R, et al. (1995) ejection fraction of 40% in the Multicenter Lifestyle Demonstration
Changes in myocardial perfusion abnormalities by positron emission Project.. Eur J Heart Fail 9(9): 928-934.
tomography after long-term, intense risk factor modification. JAMA
274(11): 894-901. 104. Aldana S, Whitmer W, Greenlaw R, Avins A, Slberg A, et al. (2003)
Cardiovascular risk reductions associated with aggressive lifestyle
86. Gould K (1990) Coronary arterial stenosis: a textbook of Coronary modification and cardiac rehabilitation. Heart Lung 32(6): 374-382.
Pathophysiology, Quantitative Arteriography, Cardiac PET and reversal
of Coronary Artery Disease. Elsevier, USA. 105. Aldana S, Whitmer W, Greenlaw R, Avins A, Thomas D, et al. (2006)
Effect of intense lifestyle modification and cardiac rehabilitation on
87. Gould K, Ornish D, Kirkeeide R, Brown S, Stuart Y, et al. (1992) psychosocial cardiovascular disease risk factors and quality of life.
Improved stenosis geometry by quantitative coronary arteriography Behav Modif 30(4): 507-525.
after vigorous risk factor modification. Am J Cardiol 69(9): 845-853.
106. Patel H, Chandra S, Alexander S, Soble J, Williams KS (2017) Plant-
88. Frattaroli J, Weidner G, Merritt Worden T, Frenda S, Ornish D (2008) Based Nutrition: An Essential Component of Cardiovascular Disease
Angina pectoris and atherosclerotic risk factors in the multisite cardiac Prevention and Management. Curr Cardiol Rep. 19(10):104.
lifestyle intervention program. Am J Cardiol 101(7): 911-918.
107. Buccheri D, Piraino D, Andolina G, Cortese B (2016) Understanding
89. Ellis F, Sanders T (1977) Angina and the Vegan Diet. American Heart and managing in-stent restenosis: a review of clinical data, from
Journal 93(6): 803-805. pathogenesis to treatment. J Thorac Dis 8(10): E1150-E1162.
90. Velagaleti R, Vasan R (2007) Heart Failure in the 21st Century: Is it a 108. Ornish D (1998) Avoiding revascularization with lifestyle changes:
Coronary Artery Disease Problem or Hypertension Problem? Cardiol The Multicenter Lifestyle Demonstration Project. Am J Cardiol
Clin 25(4): 487-495. 82(10B): 72T-76T.
91. Djoussé L, Driver J, Gaziano J (2009) Relation between modifiable 109. Pischke C, Weidner G, Elliott-Eller M, Scherwitz L, Merritt-Worden
lifestyle factors and lifetime risk of heart failure. JAMA 302(4): 394- T, et al. (2006) Comparison of coronary risk factors and quality of
400. life in coronary artery disease patients with versus without diabetes
mellitus. Am J Cardiol 97(9): 1267-1273.
92. Wang Y, Tuomilehto J, Jousilahti P, Antikainen R, Mähönen M, et al.
(2011) Lifestyle factors in relation to heart failure among Finnish men 110. Silberman A, Banthia R, Estay I, Kemp C, Studley J, et al. (2010)
and women. Circ Heart Fail 4(5): 607-612. The effectiveness and efficacy of an intensive cardiac rehabilitation
program in 24 sites. Am J Health Promot 24(4): 260-262.
93. Pfister R, Sharp S, Luben R, Wareham N, Khaw K (2011) Plasma
vitamin C predicts incident heart failure in men and women in 111. Pischke C, Frenda S, Ornish D, Weidner G (2010) Lifestyle changes
European Prospective Investigation into Cancer and Nutrition-Norfolk are related to reductions in depression in persons with elevated
prospective study. Am Heart J 162(2): 246-253. coronary risk factors. Psychol Health 25(9): 1077-1100.
94. Rautiainen S, Levitan E, Mittleman M, Wolk A (2015) Fruit and vegetable 112. Gopinath B, Flood V, Burlutksya G, Mitchell P (2015) Consumption of
intake and rate of heart failure: a population-based prospective cohort nuts and risk of total and cause-specific mortality over 15 years. Nutr
of women. Eur J Heart Fail 17(1): 20-26. Metab Cardiov Dis 25(12): 1125-1131.
95. Choi E, Allen K, McDonnough M, Massera D, Ostfeld R (2017) A plant- 113. Kris Etherton P (2014) Walnuts decrease risk of cardiovascular
based diet and heart failure: case report and literature review. J Geriatr disease: a summary of efficacy and biologic mechanisms. J Nutr:
Cardiol 14(5): 375-378. 547S-554S.
96. Wirth J, di Giuseppe R, Boeing H, Weikert C (2016) A Mediterranean 114. Brown R, Gray A, Tey S, Chisholm A, Burley V, et al. (2017) Associations
style diet, its components and the risk of heart failure: a prospective between Nut Consumption and Health Vary between Omnivores,
population-based study in a non-Mediterranean country. Eur J Clin Vegetarians, and Vegans. Nutrients 9(11): E1219.
Nutr 70(9): 1015-1021.
115. Kwak S, Myung S, Lee Y, Seo H, Korean Meta-analysis Study Group
97. Nettleton J, Steffen L, Loehr L, Rosamond W, Folsom A (2008) (2012) Efficacy of Omega-3 Fatty Acid Supplements in the Secondary
Incident heart failure is associated with lower whole-grain intake and Prevention of Cardiovascular Disease. Arch Intern Med 172(9): 686-
greater high-fat dairy and egg intake in the Atherosclerosis Risk in 694.
Communities (ARIC) study. J Am Diet Assoc 108(11): 1881-1887.
116. Aung T, Halsey J, Kromhout D, Gerstein H, Marchioli R, et al.
98. Ashaye A, Gaziano J, Djoussé L (2011) Red meat consumption and (2018) Associations of Omega-3 Fatty Acid Supplement Use With
risk of heart failure in male physicians. Nutr Metab Cardiovasc Dis Cardiovascular Disease Risks: Meta-analysis of 10 Trials Involving
21(12):941-946. 77 917 Individuals. JAMA Cardiol 3(3): 225-234.
99. Kaluza J, Åkesson A, Wolk A (2015) Long-term processed and 117. Rogers T, Seehusen D (2018) Omega-3 Fatty Acids and Cardiovascular
unprocessed red meat consumption and risk of heart failure: a Disease. Am Fam Physician 97(9): 562-564.
prospective cohort study of women. Int J Cardiol 193: 42-46.
118. The ASCEND Study Collaborative Group (2018) Effects of n−3 Fatty
100. Kerley C (2018) A Review of Plant-based Diets to Prevent and Treat Acid Supplements in Diabetes Mellitus. New Eng J Med 379: 1540-
Heart Failure. Card Fail Rev 4(1): 54-61. 1550.
101. Djoussé L, Gaziano J (2008) Egg consumption and risk of heart failure 119. Fodor J, Helis E, Yazdekhasti N, Vohnout B (2014) Fishing for the
in the Physicians’ Health Study. Circulation 117(4): 512-516. origins of the “Eskimos and heart disease” story: facts or wishful
thinking? Can J Cardiol 30(8): 864-868.
102. Lara K, Levitan E, Guitterrez O, Shikany J, Safford MJS, et al. (2017)
Dietary patterns and incident heart failure in adults with no known 120. Ebbesson S, Risica P, Ebbesson L, Kennish J (2005) Eskimos have
coronary disease or heart failure: The REGARDS Cohort. Circulation CHD despite high consumption of omega-3 fatty acids: the Alaska
136(Suppl 1). Siberia project. Int J Circumpolar Health 64(4): 387-395.
103. Pischke C, Weidner G, Elliott-Eller M, Ornish D (2007) Lifestyle 121. Highmark Blue Cross Blue Shield (1999) Two-Year Results of
changes and clinical profile in coronary heart disease patients with an Highmark Blue Cross Blue Shield’s Dr. Dean Ornish Program for

How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
0011 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.
 Journal of Cardiology & Cardiovascular Therapy

Reversing Heart Disease Demonstrates Outstanding Lifestyle 125. Centers for Disease Control and Prevention, National Center for
Improvements By The Men and Women Who Took Bold Step in Quest Health Statistics (2015) Underlying Cause of Death 1999-2013:
For Longer, Better, Happier Lives. PR Newswire, Pittsburgh, USA. Wonder.CDC.gov/ucd-icd10.html.
122. Ornish D (2010) Dr Dean Ornish’s Program for Reversing Heart 126. Heidenreich P, Trogdon J, Khavjou O, Butler J, Dracup K, et al. (2011)
Disease. Random House. New York Forecasting the future of cardiovascular disease in the United States:
a policy statement from the American Heart Association. Circulation
123. Kaiser Family Foundation (2016) New Kaiser/New York Times 123(8): 933-944.
Survey Finds One in Five Working-Age Americans With Health
Insurance Report Problems Paying Medical Bills: https://www.kff. 127. Schwartz K, Roe T, Northrup J, Meza J, Seifeldin R, et al (2006) Family
org/health-costs/press-release/new-kaisernew-york-times-survey- Medicine Patients’ Use of the Internet for Health Information: A
finds-one-in-five-working-age-americans-with-health-insurance- MetroNet Study. J Am Board Fam Med 19(1): 39-45.
report-problems-paying-medical-bills/
128. Tuso P (2013) Nutritional Update for Physicians: Plant-Based Diets.
124. Hasty RT, Garbalosa RC, Barbato VA, Valdes PJ Jr, Powers DW, Permanente J 17(2): 61-66.
et al. (2014) Wikipedia vs peer-reviewed medical literature for
information about the 10 most costly medical conditions. J Am 129. Williams K (2017) Introduction to the “A plant-based diet and
Osteop Assoc 114(5): 368-373. cardiovascular disease” special issue. J Geriatr Cardiol 14(5): 316.

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How to cite this article: Rose S, Strombom A. A Comprehensive Review of the Prevention and Treatment of Heart Disease with a Plant-Based Diet. J Cardiol &
0012 Cardiovasc Ther. 2018; 12(5): 555847. DOI: 10.19080/JOCCT.2018.12.555847.