Heart attacks occur when blood flow to a portion of the heart is severely reduced or cut off. The result is death of heart muscle cells (called an infarct). Hardening and narrowing of the coronary arteries (atherosclerosis) that feed the heart is usually the underlying problem. In some cases, a blood clot blocks blood flow; other times, the narrowing is caused by atherosclerosis alone. Spasm of the coronary arteries may also cause a heart attack.

The only items covered here are those that specifically relate to heart attacks. Elevated cholesterol, triglycerides, and homocysteine, and angina pectoris and diabetes increase the risk of suffering a heart attack; congestive heart failure can occur in some people from severe damage to the heart resulting from a heart attack.

Routine, moderate exercise is preferred over excessive exertion for people at risk for heart attacks. Research indicates that heart attack risk rises six fold for one hour immediately following heavy physical activity (compared to moderate or no activity), particularly among people who are sedentary.⁶ This risk is more than five times less in people who exercise four or more times per week.⁷ Regular, moderate exercise reduces overall risk for a heart attack in most studies. Therefore, researchers and doctors recommend that susceptible individuals engage in an exercise program.⁸ Exercise recommendations for people at risk or with a history of a heart attack need to be custom tailored to the individual. Therefore, anyone with a heart condition or anyone over the age of 40 should consult a healthcare professional before beginning an exercise plan.

Although sexual activity can trigger a heart attack, the risk is very low.⁹ This risk is no greater for people with a history of angina or heart disease. Doctors recommend regular, moderate exercise to reduce this risk.

Obesity is associated with increased risk for heart attack, particularly among younger people.¹⁰ One study found this relationship increased in women who also had a history of diabetes or high cholesterol.¹¹ Doctors encourage people who are at risk for heart attack and are overweight to lose the extra weight.

Type A behavior is typically defined as time-conscious, impatient, and aggressive feelings and the behavior that arises from those feelings. Type A behavior has been linked to increased heart attack risk in some¹² but not all studies.¹³ Instead, some researchers suggest that negative emotional states, such as hostility, distrust, anger,¹⁴ worry,¹⁵ and stress,¹⁶ promote heart attacks. Of these emotions, hostility may be the key component, but the link between personality and heart attacks remains unclear.¹⁷ In the study with the most hopeful outcome, psychological intervention aimed at modifying type A behavior was reported to successfully change not only emotional states but also to significantly lower the risk of subsequent heart attacks.¹⁸ Some healthcare professionals recommend that people at high risk for heart attacks who also have frequent feelings of impatience, lack of time, and hostility, seek counseling as a way to feel better and potentially reduce their risk of heart disease.

Research consistently shows that people who frequently eat nuts have a dramatically reduced risk of heart disease;^{22 23} this could be because nut consumption lowers cholesterol levels.^{24 25} Of nuts commonly consumed, almonds and walnuts may be most effective at lowering cholesterol, and macadamia nuts may be least beneficial.²⁶ Hazelnuts²⁷ and pistachio nuts²⁸ may also help lower cholesterol.

Nuts contain many nutrients that could be responsible for protection against heart disease, including fiber, vitamin E, alpha-linolenic acid (found primarily in walnuts), oleic acid, magnesium, potassium, and arginine. Therefore, exactly how nuts lower cholesterol or lower the risk of heart disease remains somewhat unclear. Some doctors even believe that nuts may not be directly protective; rather, people busy eating nuts will not simultaneously be eating eggs, dairy, or trans fatty acids from margarine and processed food, the avoidance of which would reduce both cholesterol levels and the risk of heart disease.^{29 30} Nonetheless, the remarkable consistency of research outcomes strongly suggests that nuts directly protect against heart disease. Although nuts are loaded with calories, a recent preliminary study reported that adding hundreds of calories per day from nuts for six months did not increase body weight in humans³¹ — outcome supported by several other reports.³² Even when increasing nut consumption has led to weight gain, the amount of added weight has been remarkably less than would be expected given the number of calories added to the diet.³³

Eating eggs may increase heart attack risk. People who consume eggs have been reported to be more likely to die from all types of heart disease, including heart attack in some,³⁹ although not all research.⁴⁰ Increased oxidation, a state associated with heart attack risk, may be the key. Cooking or exposure to air oxidizes the cholesterol in eggs.⁴¹ Eating eggs enhances LDL ("bad") cholesterol oxidation,⁴² which may in turn contribute to heart attack risk.

A high-fiber diet, particularly water-soluble fiber (high in oats, psyllium seeds, fruit, vegetables, and legumes), is associated with decreased risk of both fatal and nonfatal heart attacks,⁴³ probably because these fibers are known to lower cholesterol.⁴⁴ However, large trials separately studying men and women who were followed for years, have linked the greatest protection to water-insoluble fiber (from cereals),^{45 46} though scientists have yet to understand why. Until the details are better understood, doctors often recommend increasing intake of fruit, vegetables, beans, oats, and whole grains.

Making positive dietary changes immediately following a heart attack is likely to decrease one’s chance of having a second heart attack. In one study, individuals began eating more vegetables and fruits, and substituted fish, nuts, and legumes for meat and eggs 24–48 hours after a heart attack. Six weeks later, the diet group had significantly fewer fatal and nonfatal heart attacks than a similar group who did not make these dietary changes.⁴⁷ This trend continued for an additional six weeks.⁴⁸

Many doctors tell people trying to reduce their risk of heart disease to avoid all meat, margarine, and other processed foods containing hydrogenated oils and dairy fat. Fish are often suggested instead of meat, nuts instead of snack foods containing hydrogenated oils, olive oil instead of butter, non-fat yogurt, milk, and even cheese instead of full or reduced fat versions of the same foods, and oatmeal instead of eggs for breakfast.

Most studies confirm that light to moderate alcohol consumption (one to three drinks per day) significantly reduces both fatal and nonfatal heart attack risk^{49 50 51 52} compared to heavy or no drinking,^{53 54} though a few reports find the link to protection both weak and statistically insignificant.⁵⁵ In France, abundant red wine drinking was assumed to be responsible for the country’s remarkably low incidence of heart disease. However, a lower intake of animal fats in the French diet now appears to be the primary reason for what has been called the French paradox.⁵⁶ But as animal fat intake continues to increase, a trend that began in the 1970s, researchers now speculate that heart disease and heart attacks will also increase in France.

Although red wine has been branded best for heart disease in a few reports, all types of alcoholic beverages appear to be beneficial;⁵⁷ whether red wine has a clear advantage over other forms of alcohol remains unclear. Alcohol reduces the risk for heart attacks because it increases HDL ("good") cholesterol⁵⁸ and acts as a blood thinner.⁵⁹ High levels of another risk factor for heart attacks, lipoprotein (a), have also been reported to be lowered by drinking alcohol.⁶⁰

Despite this healthful effect, alcohol consumption can cause liver disease, cancer, high blood pressure, alcoholism, and, at high intake, even an increased risk of heart attacks. As a result, some doctors never recommend alcohol, even for people at risk for heart attack. Nevertheless, because limited intake of alcohol lowers heart attack risk, some people at high risk for heart attack who are not alcoholics, have healthy livers and normal blood pressure, and are not at an especially high risk for cancer, may benefit from light drinking. In fact, probably because heart disease is the leading cause of death in the United States, and alcohol reduces that risk, most studies report that light drinkers live slightly longer on average than teetotalers. In an analysis of 16 trials, men who drank less than two drinks per day and women who averaged less than one drink per day were likely to slightly outlive those who didn’t drink at all.⁶¹ In the same report, however, people who drank beyond these moderate levels in men and low levels in women were more likely to die sooner than non-drinkers. In deciding whether light drinking might do more good than harm, people at high risk for heart attack should consult a doctor.

Heavy coffee drinking should probably be avoided. Drinking five cups of coffee or more per day has been shown to increase the risk of nonfatal heart attack in both men⁶² and women.⁶³ Though many studies find such links,⁶⁴ many others do not.⁶⁵ This disparity may result in part from the fact that paper-filtered coffee does not raise cholesterol but percolated, boiled, or French press coffees do. Several recent studies have linked coffee drinking to increased blood levels of homocysteine, another risk factor for heart disease.^{66 67} In this regard, research has yet to absolve paper-filtered coffee because these studies have not examined separate effects for coffee prepared by different methods.

Recent preliminary evidence has implicated salt consumption as a risk factor for heart disease and death from heart disease in overweight people.⁶⁸ Among overweight persons, an increase in salt consumption of 2.3 grams per day was associated with a 44% increase in coronary heart disease mortality, a 61% increase in cardiovascular disease mortality and a 39% increase in mortality from all causes. Blinded, intervention trials are needed to confirm these preliminary observations.

Preliminary research conducted several decades ago suggested that high sugar consumption increased heart attack risk.⁶⁹ Some researchers at that time disagreed⁷⁰ and others have subsequently been unable to find a link. Nevertheless, sugar has been associated with reduced HDL ("good") cholesterol,⁷¹ increased triglycerides,⁷² and increased levels of other risk factors linked to heart attacks.⁷³ As a result, many doctors recommend that people reduce their intake of sugar despite the fact that high sugar intake appears to lead to only slightly higher risks of heart disease in most reports.⁷⁴

Nutritional supplements that may be helpful: Carnitine is an amino acid important for transporting fats that can be turned into energy in the heart. Several studies report that taking L-carnitine (4–6 grams per day) increases the chance of surviving a heart attack.^{75 76 77} In one double-blind trial, individuals with suspected heart attack were given 2 grams of L-carnitine per day for 28 days.⁷⁸ At the completion of this study, infarct size, as well as number of nonfatal heart attacks were lower in the group receiving carnitine versus the placebo group. Double-blind research using carnitine intravenously also shows promise.⁷⁹

Coenzyme Q10 also contributes to the energy-making mechanisms of the heart and has been reported to lower lipoprotein (a), a risk factor for heart disease.⁸⁰ Animal studies confirm coenzyme Q10’s ability to protect heart muscle against reduced blood flow.^{81 82} In one double-blind trial, 120 mg of coenzyme Q10 or placebo was given to people who recently survived a heart attack. Twenty-eight days later, the coenzyme Q10 group experienced fewer repeat heart attacks and deaths from heart disease, and less chest pain than the placebo group.⁸³ Coenzyme Q10 used with selenium (see below) has also been reported to increase survival from a heart attack.⁸⁴

Blood levels of the antioxidant nutrients vitamins A, C, and E, and beta-carotene are reported to be lower in people with a history of heart attack, compared to healthy individuals.⁸⁵ The number of free radical molecules is also higher, suggesting a need for antioxidants. Streptokinase, a therapy commonly used immediately following a heart attack, enhances the apparent need for antioxidants.⁸⁶

Taking antioxidant supplements may improve the outcome in people who have already had a heart attack. In one double-blind study, people were given 50,000 IU of vitamin A per day, 1,000 mg of vitamin C per day, 600 IU of vitamin E per day, and approximately 41,500 IU of beta-carotene per day or placebo.⁸⁷ After 28 days, the infarct size of those receiving antioxidants was significantly smaller than infarct size in the placebo group.

Supplementing with individual antioxidants may also help prevent heart attacks. One double-blind study found that people given 400–800 IU of vitamin E per day for one year had significantly fewer nonfatal heart attacks than those given placebo, though the number of fatal heart attacks was not reduced.⁸⁸ In fact, there appeared to be a higher death rate from heart attack in those assigned to take vitamin E in this study. A further analysis⁸⁹ shows that most of these deaths occurred in people who forgot to take their vitamin E—not in those who took it. Two large trials reported that people who took more than 100 IU of vitamin E per day for at least two years were at substantially lower risk.^{90 91} A study using only 50 IU of vitamin E per day did not report reduced risks.⁹²

A large double-blind trial found no benefit from vitamin E supplementation in the prevention of non-fatal heart attacks among people at high risk.⁹³ Participants, who had a history of diabetes or existing cardiovascular disease, took 400 IU of natural vitamin E per day for 4.5 years. It is not known why these results so strongly contradict previous findings of a protective effect from vitamin E.^{94 95 96 97} Some doctors will still recommend 400–800 IU of vitamin E per day to lower the risk of heart attacks. However, further studies are needed to resolve the conflicting findings of these large trials.

The relation between selenium and protection from heart attacks remains uncertain. Low blood levels of selenium have been reported in people immediately following a heart attack,⁹⁸ suggesting that heart attacks may increase the need for selenium. Another group of researchers claims that low selenium precedes, and is not a consequence of, a heart attack, suggesting that the lack of selenium might increase the risk of suffering a heart attack.⁹⁹ One report found low blood levels of selenium increased the risk of heart attack only in smokers,¹⁰⁰ and another found the link only in former smokers.¹⁰¹ Yet others have found no link between low blood levels of selenium and heart attack risk whatsoever.¹⁰² In a double-blind study, individuals who already had one heart attack were given 100 mcg of selenium per day or placebo for six months.¹⁰³ At the end of the trial, there were four deaths from heart disease in the placebo group but none in the selenium group (although the numbers were too small for this difference to be statistically significant). In other controlled research, a similar group was given 500 mcg of selenium six hours or less after a heart attack followed by an ongoing regimen of 100 mcg of selenium plus 100 mg of coenzyme Q10 per day.¹⁰⁴ One year later, six people died from a repeat heart attack in the placebo group, compared to no deaths from heart attack in the supplement group. Despite the lack of consistency in published research, some doctors recommend that people at risk for a heart attack supplement with selenium—most commonly 200 mcg per day.

Vitamin C has been reported to protect blood vessels from problems associated with heart attack risk in a variety of ways.^{105 106 107} However, research attempting to link vitamin C directly to protection from heart attacks has been inconsistent.^{108 109} The reason for this discrepancy appears related to the amount of vitamin C in question. True or marginal vitamin C deficiencies do appear to increase the risk of suffering heart attacks.^{110 111} However, in trials comparing acceptable vitamin C levels to even higher levels, additional vitamin C has not been protective.¹¹² Therefore, though many doctors suggest that people at high risk for heart attack take vitamin C—often 1 gram per day—most evidence currently suggests that consuming as little as 100–200 mg of vitamin C per day from food or supplements may well provide whatever protection against heart attacks vitamin C has to offer.

Low levels of beta-carotene in fatty tissue have been linked to an increased incidence of heart attacks, particularly among smokers.¹¹³ One population study found that eating a diet high in beta-carotene is associated with a lower rate of nonfatal heart attacks.¹¹⁴ However, beta-carotene supplementation may not offer the same protection provided by foods that contain beta-carotene. Most^{115 116} but not all studies¹¹⁷ have found that supplemental beta-carotene is not associated with a reduced risk of heart attacks.

Most,^{118 119 120 121} though not all,^{122 123} studies link high blood levels of an amino acid called homocysteine to an increased risk of heart attack. Folic acid,^{124 125} and vitamins B6 and B12 are known to lower homocysteine.¹²⁶ While there is no proof that taking these supplements, and thus lowering homocysteine levels, will reduce heart attack risk, many doctors and some cardiologists think such a scenario is likely. They therefore recommend 50 mg of vitamin B6, 100–300 mcg of vitamin B12, and 500–800 mcg of folic acid for people at high risk of heart attack.

Blood levels of magnesium are lower in people who have a history of heart attack.¹²⁷ Most studies have successfully used intravenous magnesium right after a heart attack occurs to decrease death and complications from heart attacks.¹²⁸ By far the largest trial did not find magnesium to be effective.¹²⁹ However, other researchers have argued that delaying the initial infusion of magnesium and not administering magnesium long enough may have caused this negative result.¹³⁰ People with a history of heart attack or who are at risk, should consult with their cardiologist about the possible use of immediate intravenous magnesium should they ever suffer another heart attack.

Except for a link between high levels of magnesium in drinking water and a low risk of heart attacks,¹³¹ little evidence suggests that oral magnesium reduces the risk of heart attacks. One trial found that magnesium pills taken for one year actually increased complications for people who have had a heart attack.¹³² While another study reported that 400–800 mg of magnesium per day for two years decreased both deaths and complications due to heart attacks, results are difficult to interpret because those taking oral magnesium had previously received intravenous magnesium as well.¹³³ While increasing dietary magnesium has reduced the risk of heart attacks,¹³⁴ foods high in magnesium may contain protective factors other than magnesium that might be responsible for this protective effect. Therefore, evidence supporting supplemental oral magnesium to reduce the risk of heart attacks remains weak.

In one study, intravenous injections of N-acetyl cysteine (NAC) decreased the amount of tissue damage in people who had suffered a heart attack.¹³⁵

Years ago, researchers reported that taking chondroitin sulfate for six years substantially reduced the risk of fatal and nonfatal heart attacks in people with heart disease.^{140 141 142} Chondroitin works by inhibiting atherosclerosis, and acting as an anticoagulant. The few doctors aware of these older studies sometimes recommend that people with a history of heart disease or at risk for heart attack take approximately 500 mg of chondroitin sulfate three times per day.

The possibility that vitamin D supplementation may increase the risk of heart disease remains an unproven but controversial issue. A preliminary study suggested that a high intake of vitamin D from both dietary and supplemental sources increased heart attack risk.¹⁴³ However, other researchers have found that blood levels of vitamin D are no higher in people who had suffered a heart attack when compared to controls.¹⁴⁴ Similarly, atherosclerosis does not appear to correlate with blood levels of vitamin D.¹⁴⁵ In fact, one trial found higher levels of activated vitamin D correlated with less artery-clogging calcium deposits in humans.¹⁴⁶

Relatively high blood levels of calcium—sometimes a marker for high vitamin D intake—have been associated with high risk of heart attacks in Sweden.¹⁴⁷ However, high dietary vitamin D intake in Sweden often comes from high-fat dairy products, so the high calcium levels might simply be a marker for eating more dairy fat and have nothing to do with vitamin D.

Despite the lack of consistent evidence, some researchers continue to have concerns. Vitamin D supplementation has reversed some of the beneficial effects of estrogen use in women on risk factors for heart disease,¹⁴⁸ an outcome confirmed by others using only 300 IU of vitamin D per day.¹⁴⁹ Further research is required to determine whether supplemental vitamin D increases heart attack risk.

Although several reports have linked unnecessary exposure to iron (both through diet and supplements) to increased risk of heart disease, a recent analysis of 12 trials has found no link whatsoever between iron status and risk of heart disease.¹⁵⁰ While it remains prudent for a variety of other reasons for no one to supplement iron unless a deficiency has been diagnosed, supplemental iron now appears unlikely to substantially increase the risk of suffering a heart attack.

Herbs that may be helpful: In one double-blind study, mustard oil was given to people who had suffered a heart attack. One year later, complications and repeat nonfatal heart attacks were significantly reduced.¹⁵¹ Mustard oil is high in the essential fatty acid alpha linolenic acid, which may explain its effectiveness. Further research is needed to confirm these findings.

Garlic has lowered cholesterol levels and reduced the chances of developing atherosclerosis and other risk factors for coronary heart disease (CHD), according to some published research.

One older, preliminary study found that supplementing garlic oil immediately following a heart attack increased the clot-dissolving ability of the blood.¹⁵² According to the authors, garlic may be a viable alternative to streptokinase, a common heart attack medicine and anticoagulant. However, more research is needed to determine how useful garlic supplementation is in preventing heart attacks or treating people who have suffered from a heart attack.

Preliminary clinical studies in China suggest that astragalus may be of benefit in people after they have suffered a heart attack, or those who have angina pectoris.^{153 154 155 156} These studies did not attempt to show any survival or symptom reduction benefit, therefore further research is needed to determine if astragalus would be of benefit in people with heart attacks or angina.

Information about the effects of a particular supplement or herb on a particular condition has been qualified in terms of the methodology or source of supporting data (for example: clinical, double blind, meta-analysis, or traditional use). For the convenience of the reader, the information in the table listing the supplements for particular conditions is also categorized. The criteria for the categorizations are: "Primary" indicates there are reliable and relatively consistent scientific data showing a health benefit. "Secondary" indicates there are conflicting, insufficient, or only preliminary studies suggesting a health benefit or that the health benefit is minimal. "Other" indicates that an herb is primarily supported by traditional use or that the herb or supplement has little scientific support and/or minimal proven health benefit.

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