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      Angina rapidly improved with a plant-based diet and returned after resuming a Western diet

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          Abstract

          Atherosclerosis and its related cardiovascular disease is the most common cause of morbidity and mortality in the Western world.[1] The roots of this disease may lie, in part, in dietary and lifestyle behaviors, indicating that modification of these behaviors may lead to profound improvements. A 77-year-old woman presented with unstable angina. Her past medical history included hypertension, hyperlipidemia and remote tobacco use for which she had been treated with atenolol 50 mg daily and simvastatin 20 mg daily. At her baseline, she could walk more than half a mile without complaints. Over the two to three months prior to presenting, she developed gradually worsening chest pressure and shortness of breath to the point where she was unable to walk more than half of a city block or up one flight of stairs. Her symptoms resolved with rest. Coronary angiography revealed severe three-vessel disease, and a referral for coronary artery bypass graft surgery (CABG) was made. Her left ventricular size and function were normal on echocardiography. Daily aspirin 81 mg and sublingual nitroglycerin as needed were added to her medication regimen. The patient chose, however, to not proceed with surgery and rather she chose to adopt a whole-food plant-based diet, which included all vegetables, fruits, whole grains, potatoes, beans, legumes and nuts. She eliminated all animal derived products, such as eggs, cow's milk, yoghurt, chicken and beef, and she presented to our cardiac wellness program. She described her previous diet as a ‘healthy’ Western one. Clopidogrel 75 mg daily was added to her medical regimen, simvastatin was replaced by a high-potency statin (atorvastatin 80 mg daily) and atenolol was replaced by carvedilol. Within one month of lifestyle change her symptoms had nearly resolved, and she was able to walk on a treadmill for up to 50 min without chest discomfort or dyspnea. Her total cholesterol decreased from 5.7 mmol/L to 3.2 mmol/L, and her LDL cholesterol decreased from 3.7 mmol/L to 1.5 mmol/L over three months. Four to five months after the initial lifestyle change, her adherence to a whole-food plant-based diet ended. She returned to her prior eating habits, which included chicken, fish, low fat dairy and other animal products multiple times per day. Although her medical regimen had not changed, her anginal symptoms returned within four to six weeks. She had chest discomfort with minimal exertion at a gym and she was admitted to an outside hospital. Shortly thereafter, she underwent CABG surgery. She moved out of state and continued her prior eating habits. A coronary stent was placed one year later for another episode of unstable angina. We present the case of a 77-year-old woman with unstable angina, whose symptoms resolved without mechanical intervention while consuming a whole-food plant-based diet. This case highlights the potential of this lifestyle to help rapidly improve anginal symptoms and to contribute to improving the atherosclerotic disease process. This potential is reinforced by our patient's rapid deterioration despite no change in her medications when she returned to her baseline ‘healthy’ Western diet. A growing body of evidence suggests that animal-based foods may be harmful for health, while plant-based diets can halt and even improve both coronary atherosclerotic disease and survival. Large population-based studies found consumption of animal products to be associated with both increased mortality and incidence of atherosclerotic cardiovascular disease.[2]–[5] Multiple mechanisms for these observational findings have been proposed, such as saturated fat consumption,[6] salt intake,[7] increased inflammation,[8] obesity,[9] hyperlipidemia,[10] hypertension,[11] diabetes mellitus,[4] and the role of trimethylamine-N-oxide (TMAO). Intestinal microbiota dependent metabolic pathways involving dietary phosphatidylcholine (derived mainly from eggs, beef and pork) and L-carnitine (mainly from beef) have been implicated, in part, in the pathogenesis of atherosclerotic cardiovascular disease via TMAO, which is associated with accelerated atherosclerosis, increased risk of death, myocardial infarction and stroke.[12] Furthermore, endothelial dysfunction has been invoked as an effect of a lipid-laden meal. Vogel, et al.[13] described that a single high-fat meal (mainly from animal sources) rapidly induced endothelial dysfunction as measured by brachial artery flow-mediated dilation independently of serum lipid levels. In contrast, consuming plant-based foods may be more optimal for health. Studies evaluating a plant-based diet have found a beneficial effect in regards to cardiovascular disease outcomes. Investigators in the Adventist Health Study 2 reported vegetarian and vegan diets to be associated with decreased rates of all-cause and cardiovascular mortality compared to nonvegetarians.[14] Authors of the EPIC-Elderly study (European Prospective Investigation into Cancer and Nutrition) reported that increased adherence to a plant-based diet was associated with substantially reduced all-cause mortality.[15] In a recent analysis of the PREDMIED trial (a randomized controlled trial of a Mediterranean diet vs. a low-fat control diet), Martínez-González, et al.[16] reported that the risk of all-cause mortality was lower among study participants consuming a mainly plant-based diet compared to omnivores. The benefits of a whole-food plant-based diet, which our patient followed for a limited time, are manifold. A review by Ferdowsian and Barnard describes the beneficial effects of plant-based diets on plasma lipids, reporting an up to 35% decrease in plasma low-density lipoprotein (LDL) cholesterol with a whole-food plant-based diet combined with nuts, soy and fiber.[17] The beneficial effect of plant-based diets on weight, plasma lipids and glycemic control has been investigated in a randomized controlled trial by Mishra, et al.[18] with favorable results. In addition to published case reports,[19],[20] several larger studies are applicable to the case we present. The Lifestyle Heart Study randomized patients with coronary atherosclerotic heart disease to a low-fat vegetarian diet (among other interventions, such as exercise, smoking cessation and stress reduction) vs. a standard diet, and followed them for one year. Patients in the experimental group were found to have regression of angiographically detected coronary atherosclerosis and a 91% reduction of frequency of angina, while patients on the standard diet were found to have a 186% increase in the frequency of angina.[21],[22] Esselstyn, et al.[23] reported a similar regression of coronary atherosclerotic heart disease by angiography in patients who adhered to a whole-food plant-based diet. In a study by Dod, et al.,[24] endothelial function was measured by flow-mediated dilation in patients undergoing an intensive lifestyle modification program including a whole-food plant-based diet, and was improved in the experimental group. Lin, et al.[25] found decreased endothelial function in omnivores compared to vegetarians. Future interventions should focus on ways to help patients successfully adopt and maintain a whole-food plant-based diet, as increased adherence to a healthy lifestyle is associated with greater health benefits.[26] In summary, a whole-food plant-based diet was associated with reversing angina symptoms in our patient with severe coronary atherosclerotic disease Her angina returned when she resumed consuming a ‘healthy’ Western diet.

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          Most cited references15

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          Meat intake and mortality: a prospective study of over half a million people.

          High intakes of red or processed meat may increase the risk of mortality. Our objective was to determine the relations of red, white, and processed meat intakes to risk for total and cause-specific mortality. The study population included the National Institutes of Health-AARP (formerly known as the American Association of Retired Persons) Diet and Health Study cohort of half a million people aged 50 to 71 years at baseline. Meat intake was estimated from a food frequency questionnaire administered at baseline. Cox proportional hazards regression models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) within quintiles of meat intake. The covariates included in the models were age, education, marital status, family history of cancer (yes/no) (cancer mortality only), race, body mass index, 31-level smoking history, physical activity, energy intake, alcohol intake, vitamin supplement use, fruit consumption, vegetable consumption, and menopausal hormone therapy among women. Main outcome measures included total mortality and deaths due to cancer, cardiovascular disease, injuries and sudden deaths, and all other causes. There were 47 976 male deaths and 23 276 female deaths during 10 years of follow-up. Men and women in the highest vs lowest quintile of red (HR, 1.31 [95% CI, 1.27-1.35], and HR, 1.36 [95% CI, 1.30-1.43], respectively) and processed meat (HR, 1.16 [95% CI, 1.12-1.20], and HR, 1.25 [95% CI, 1.20-1.31], respectively) intakes had elevated risks for overall mortality. Regarding cause-specific mortality, men and women had elevated risks for cancer mortality for red (HR, 1.22 [95% CI, 1.16-1.29], and HR, 1.20 [95% CI, 1.12-1.30], respectively) and processed meat (HR, 1.12 [95% CI, 1.06-1.19], and HR, 1.11 [95% CI 1.04-1.19], respectively) intakes. Furthermore, cardiovascular disease risk was elevated for men and women in the highest quintile of red (HR, 1.27 [95% CI, 1.20-1.35], and HR, 1.50 [95% CI, 1.37-1.65], respectively) and processed meat (HR, 1.09 [95% CI, 1.03-1.15], and HR, 1.38 [95% CI, 1.26-1.51], respectively) intakes. When comparing the highest with the lowest quintile of white meat intake, there was an inverse association for total mortality and cancer mortality, as well as all other deaths for both men and women. Red and processed meat intakes were associated with modest increases in total mortality, cancer mortality, and cardiovascular disease mortality.
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            Dietary patterns are associated with biochemical markers of inflammation and endothelial activation in the Multi-Ethnic Study of Atherosclerosis (MESA).

            Dietary patterns may influence cardiovascular disease risk through effects on inflammation and endothelial activation. We examined relations between dietary patterns and markers of inflammation and endothelial activation. At baseline, diet (food-frequency questionnaire) and concentrations of C-reactive protein (CRP), interleukin 6 (IL-6), homocysteine, soluble intercellular adhesion molecule-1 (sICAM-1), and soluble E selectin were assessed in 5089 nondiabetic participants in the Multi-Ethnic Study of Atherosclerosis. Four dietary patterns were derived by using factor analysis. The fats and processed meats pattern (fats, oils, processed meats, fried potatoes, salty snacks, and desserts) was positively associated with CRP (P for trend < 0.001), IL-6 (P for trend < 0.001), and homocysteine (P for trend = 0.002). The beans, tomatoes, and refined grains pattern (beans, tomatoes, refined grains, and high-fat dairy products) was positively related to sICAM-1 (P for trend = 0.007). In contrast, the whole grains and fruit pattern (whole grains, fruit, nuts, and green leafy vegetables) was inversely associated with CRP, IL-6, homocysteine (P for trend < or = 0.001), and sICAM-1 (P for trend = 0.034), and the vegetables and fish pattern (fish and dark-yellow, cruciferous, and other vegetables) was inversely related to IL-6 (P for trend = 0.009). CRP, IL-6, and homocysteine relations across the fats and processed meats and whole grains and fruit patterns were independent of demographics and lifestyle factors and were not modified by race-ethnicity. CRP and homocysteine relations were independent of waist circumference. These results corroborate previous findings that empirically derived dietary patterns are associated with inflammation and show that these relations in an ethnically diverse population with unique dietary habits are similar to findings in more homogeneous populations.
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              A provegetarian food pattern and reduction in total mortality in the Prevención con Dieta Mediterránea (PREDIMED) study.

              Vegetarian diets have been associated with reduced mortality. Because a pure vegetarian diet might not easily be embraced by many individuals, consuming preferentially plant-derived foods would be a more easily understood message. A provegetarian food pattern (FP) emphasizing preference for plant-derived foods might reduce all-cause mortality. The objective was to identify the association between an a priori-defined provegetarian FP and all-cause mortality. We followed 7216 participants (57% women; mean age: 67 y) at high cardiovascular risk for a median of 4.8 y. A validated 137-item semiquantitative food-frequency questionnaire was administered at baseline and yearly thereafter. Fruit, vegetables, nuts, cereals, legumes, olive oil, and potatoes were positively weighted. Added animal fats, eggs, fish, dairy products, and meats or meat products were negatively weighted. Energy-adjusted quintiles were used to assign points to build the provegetarian FP (range: 12-60 points). Deaths were confirmed by review of medical records and the National Death Index. There were 323 deaths during the follow-up period (76 from cardiovascular causes, 130 from cancer, 117 for noncancer, noncardiovascular causes). Higher baseline conformity with the provegetarian FP was associated with lower mortality (multivariable-adjusted HR for ≥ 40 compared with <30 points: 0.59; 95% CI: 0.40, 0.88). Similar results were found with the use of updated information on diet (RR: 0.59; 95% CI: 0.39, 0.89). Among omnivorous subjects at high cardiovascular risk, better conformity with an FP that emphasized plant-derived foods was associated with a reduced risk of all-cause mortality. This trial was registered at www.controlled-trials.com as ISRCTN35739639. © 2014 American Society for Nutrition.
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                Author and article information

                Journal
                J Geriatr Cardiol
                J Geriatr Cardiol
                JGC
                Journal of Geriatric Cardiology : JGC
                Science Press
                1671-5411
                May 2016
                : 13
                : 4
                : 364-366
                Affiliations
                [1 ]Department of Medicine, Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
                [2 ]Stevens Institute of Technology, Hoboken, NJ, USA
                Author notes
                Article
                jgc-13-04-364
                10.11909/j.issn.1671-5411.2016.04.005
                4921549
                27403146
                737b96f8-7adc-4e45-b249-1a52fc5d9e9c
                Institute of Geriatric Cardiology

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License, which allows readers to alter, transform, or build upon the article and then distribute the resulting work under the same or similar license to this one. The work must be attributed back to the original author and commercial use is not permitted without specific permission.

                History
                Categories
                Letter to the Editor

                Cardiovascular Medicine
                cardiovascular disease,lifestyle therapy,nutrition,plant-based diet
                Cardiovascular Medicine
                cardiovascular disease, lifestyle therapy, nutrition, plant-based diet

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