Caldwell B.

Esselstyn Jr,
MD; Gina Gendy, MD;
Jonathan Doyle, MCS;
Mladen Golubic, MD,
PhD; Michael F. Roizen,
MD
The Wellness Institute
of the Cleveland Clinic,
Lyndhurst, Ohio
[email protected]
The authors reported no
potential conflict of interest
relevant to this article.

Original Research

A way to reverse CAD?

Though current medical and surgical treatments manage
coronary artery disease, they do little to prevent or stop
it. Nutritional intervention, as shown in our study and
others, has halted and even reversed CAD.

ABSTRACT
Purposeu Plant-based

nutrition achieved
coronary artery disease (CAD) arrest and reversal in a small study. However, there was
skepticism that this approach could succeed in
a larger group of patients. The purpose of our
follow-up study was to define the degree of
adherence and outcomes of 198 consecutive
patient volunteers who received counseling
to convert from a usual diet to plant-based
nutrition.
Methodsu We followed 198 consecutive
patients counseled in plant-based nutrition.
These patients with established cardiovascular
disease (CVD) were interested in transitioning
to plant-based nutrition as an adjunct to usual
cardiovascular care. We considered participants adherent if they eliminated dairy, fish,
and meat, and added oil.
Resultsu Of the 198 patients with CVD,
177 (89%) were adherent. Major cardiac
events judged to be recurrent disease totaled
one stroke in the adherent cardiovascular
participantsa recurrent event rate of .6%,
significantly less than reported by other studies of plant-based nutrition therapy. Thirteen
of 21 (62%) nonadherent participants experienced adverse events.
Conclusionu Most of the volunteer patients
with CVD responded to intensive counseling,
and those who sustained plant-based nutrition for a mean of 3.7 years experienced a
low rate of subsequent cardiac events. This dietary approach to treatment deserves a wider

356

test to see if adherence can be sustained in

broader populations. Plant-based nutrition
has the potential for a large effect on the CVD
epidemic.

n a 1985 program initiated at the Cleveland Clinic, we examined whether plantbased nutrition could arrest or reverse
advanced coronary artery disease (CAD) in
22 patients.1 One patient with restricted myocardial blood flow documented by positron
emission tomography (PET) showed reperfusion on a repeat scan just 3 weeks after starting our nutritional intervention (FIGURE 1 ).2
Within 10 months of the start of treatment,
another patient with severe right calf claudication and a quantifiably diminished pulse
volume experienced total pain relief and exhibited a measurably increased pulse volume
amplitude.2 Thus encouraged, we followed
the small cohort of patients (adding cholesterol-lowering drugs in 1987) and reported
results after 5 and 12 years of follow-up.1,3 Of
the 22 patients, 17 were adherent to the protocol, and their disease progression halted.
In 4 of the 12, we angiographically confirmed
disease reversal,4 which can be striking
(FIGURE 2 ).4
zThe significance of these findings.

CAD remains the number one killer of women and men in western civilization despite
40 years of aggressive drug and surgical interventions.5 These approaches can be lifesaving
in the midst of a heart attack. However, the

The Journal of Family Prac tice | JULY 2 0 1 4 | V o l 6 3 , No 7

FIGURE 1

FIGURE 2

Restoration of myocardial
perfusion2

Reversal of coronary
artery disease4

Figure 1 from: PREVENT AND REVERSE HEART DISEASE by Caldwell B. Esselstyn, Jr., M.D., copyright 2007
by Caldwell B. Esselstyn, Jr., M.D. Used with permission of Avery Publishing, an imprint of Penguin
Group (USA) LLC.

Before Rx

After Rx
Positron emission tomography performed on a
patient with coronary artery disease shows an area
of myocardium with insufficient blood flow (top).
Following only 3 weeks of plant-based nutritional
intervention, normal blood flow was restored (bottom).

elective use of percutaneous coronary intervention (PCI) shows little protection from
future heart attacks or prolongation of life,6
perhaps because it does not treat the major
cause of this disease. Such palliative treatments also carry significant risk of morbidity and mortality and lead to unsustainable
expense.7
zGetting at the root cause of CAD requires a different approach. CAD begins

with progressive endothelial injury,8 inflammatory oxidative stress, diminution of nitric

oxide production, foam cell formation, and
development of plaques that may rupture to
cause a myocardial infarction (MI) or stroke.9
This cascade is set in motion in part by, and
is exacerbated by, the western diet of added
oils, dairy, meat, fowl, fish, sugary foods (sucrose, fructose, and drinks containing those,

jfponline.com

Coronary angiography reveals a diseased distal left anterior

descending artery (A). Following 32 months of a plantbased nutritional intervention without cholesterol-lowering
medication, the artery regained its normal configuration (B).

refined carbohydrates, fruit juices, syrups,

and molasses) that injures or impairs endothelial function after each ingestion, making
food choices a major, if not the major, cause
of CAD.8,10-12
zThe study we report on here. In a continuation of the clinical strategy employing a
plant-based nutrition intervention for CAD,
we studied a separate cohort of 198 participants to determine if they could voluntarily
adhere to the necessary dietary changes and
to document their cardiovascular outcomes.

METHODS
Participants
This report reviews the outcomes of 198 consecutive nonsmoking patients with multiple
comorbidities of hyperlipidemia (n=161), hypertension (n=60), and diabetes (n=23) who
voluntarily asked for counseling in plant-

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357

based nutrition for disease treatment. These

self-selected participants requested consultation after learning about the program through
the Internet, the media, prior scientific publications, the senior authors book (CBE Jr),
other authors supportive comments, or word
of mouth.2,13 A preliminary 25- to 30-minute
telephone conversation established disease
presentation and severity by eliciting reports
of symptoms, history of MI, stress test and
angiogram results, interventions undertaken,
family history, lipid profile, and the presence
of comorbid chronic conditions. In these
calls, we outlined the program, established
rapport, and documented the need for additional patient information. The Cleveland
Clinic Institutional Review Board determined
that these were acceptable outcome measurements to evaluate the nutrition program.

The impetus for

this study was
an earlier small
trial in which
17 patients with
CAD had their
disease halted
after following
a plant-based
nutritional
intervention.

358

Intervention
We explained to each participant that plantbased nutrition typically succeeded in arrestingand sometimes reversingCAD in our
earlier study.
zThe core diet. Whole grains, legumes,
lentils, other vegetables, and fruit comprised
the major portion of the diet. We reassured
patients that balanced and varied plantbased nutrition would cover their needs for
amino acids, and we encouraged them to
take a multivitamin and vitamin B12 supplement. We also advised the use of flax seed
meal, which served as an additional source
of omega-6 and omega-3 essential fatty acids.
zFoods prohibited. Initially the intervention avoided all added oils and processed
foods that contain oils, fish, meat, fowl, dairy
products, avocado, nuts, and excess salt. Patients were also asked to avoid sugary foods
(sucrose, fructose, and drinks containing
them, refined carbohydrates, fruit juices, syrups, and molasses). Subsequently, we also
excluded caffeine and fructose.
Exercise was encouraged but not required. The plan also did not require the practice of meditation, relaxation, yoga, or other
psychosocial support approaches. Patients
continued to use cardiac medications as prescribed, monitored by their (other) physicians.
zPre-intervention training. Each participant attended a single-day 5-hour coun-

seling seminar (9 am-2 pm) with, at most,

11 other participants. Each participant was
encouraged to invite a spouse or partner. The
5-hour program profiled plant-based cultures that have virtually no cardiovascular
illness, in contrast to non-plant-based cultures where CAD is ubiquitous (confirmed
by autopsy of young adults).14 We referenced
the plummeting death rates from strokes and
heart attacks in Norway during World War
II when the German occupying forces confiscated their livestock, limiting Norwegians to
plant-based nutrition.15
We emphasized the cellular components and mechanisms responsible for
vascular health: the endothelial cell, endothelial progenitor cell, high-density lipoprotein
cholesterol (HDL-C), and inhibition of dimethylarginine dimethylaminohydrolase that
causes vasoconstriction. These were discussed
in considerable detail, as were nutrition strategies to enhance endothelial health and to
avoid endothelial dysfunction and injury. Participants viewed angiograms of CAD reversal
from prior intervention participants.
An associate with several decades of
experience with plant-based nutrition discussed plant food acquisition (including
food label reading) and preparation. Participants learned how to alter common recipes
to meet program standards. They received a
44-page plant-based recipe handout, 2 scientific articles confirming plant-based nutrition
effectiveness,4,16 and, after 2007, a copy of Prevent and Reverse Heart Disease.2 The seminar
concluded with a testimonial by a prior participant, a plant-based meal, and a questionand-answer session. We asked participants
to complete and return a 3-week diet diary
following the seminar. They were invited to
communicate concerns via e-mail or phone,
and to forward copies of subsequent lipid
profiles, stress tests, cardiac events, angiograms, and interventions.
Study data acquisition
In 2011 and 2012 we contacted all participants
by telephone to gather data. If a participant had
died, we obtained follow-up medical and dietary information from the spouse, sibling, offspring, or responsible representative. Patients
who avoided all meat, fish, dairy, and, know-

The Journal of Family Prac tice | JULY 2 0 1 4 | V o l 6 3 , N o 7

a way to reverse CAD?

TABLE 1

Baseline characteristics of study participants

Total, N

198

Men, N (%)

180 (91)

Age, mean SD

62.9 10.0

Months follow-up, mean SD

44.2 24.1

Adherent to intervention, N (%)

177 (89)

Diagnosis of CAD, N (%)*

195 (98)

Angiography/CT angiography

180

Stress test

74

Myocardial infarction

44

CAD, coronary artery disease; CT, computed tomography; SD, standard deviation.
* Three patients had documented peripheral artery disease or cerebral or carotid vascular stenosis, but no CAD.
Many patients had more than one test done to establish the diagnosis of CAD.

ingly, any added oils throughout the program

were considered adherent. We inquired about
weight change, lipid profiles, further stress tests
or angiograms, major cardiac events, interventions, and any change in symptoms.

RESULTS
Characteristics of participants
Baseline characteristics of participants are
shown in TABLE 1 . (Two patients from the
original group of 200 were lost to follow-up.)
The remaining 198 participants for whom
data were available had CVD, were mostly
men (91%), averaged 62.9 years of age, and
were followed for an average of 44.2 months
(3.7 years).
Three patients had noncoronary vascular disease: 1 cerebral vascular disease,
1 carotid artery disease, and 1 peripheral arterial disease. In the remaining 195 patients, angiogram results confirmed the diagnosis of CAD
in 180 (92%). With the other 15 participants,
electrocardiography, failed stress tests, or a history of enzyme-documented MI confirmed the
diagnosis of CAD. Of the 195-patient cohort,
44 (23%) had an MI prior to counseling.
Outcomes for nonadherent
CVD participants
Twenty-one patients (11%) were nonadher-

ent with dietary intervention. Thirteen of

these patients experienced at least 1 adverse
event each2 sudden cardiac deaths, 1 heart
transplant, 2 ischemic strokes, 4 PCIs with
stent placement, 3 coronary artery bypass
graftings (CABGs), and 1 endarterectomy
for peripheral arterial diseasefor a patient
event rate of 62% (TABLE 2 ).
Outcomes of adherent CVD participants
In the group of 177 (89%) adherent patients, 112 reported angina at baseline and
104 (93%) experienced improvement or resolution of symptoms during the follow-up
period. An additional patient with claudication also experienced symptom relief (TABLE
2 ). Of adherent patients with CAD, radiographic or stress testing results were available
to document disease reversal in 39 (22%).
Twenty-seven CAD participants were able to
avoid PCI or CABG that was previously recommended. Adherent patients experienced
worse outcomes significantly less frequently
than nonadherent patients (P<.001, Fishers
exact test). In addition, for 135 patients for
whom body weight was available, the average
weight loss was 18.7 lbs.
Among the 177 patients who reported
adherence to the dietary intervention, there
were 5 noncardiac deaths (3 cancers, 1 pulmonary embolus, and 1 case of pneumonia).

The core diet

included whole
grains, legumes,
lentils, other
vegetables,
and fruit, and
avoidance of all
oils, fish, meats,
dairy products,
avocado, nuts,
sugary foods,
and excess salt.

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359

Only 1 major
cardiovascular
event (stroke)
was related
to disease
progression
in patients
adherent with
the dietary
intervention.

Also, 9 CAD patients required vascular intervention: 1 CABG for disease progression,
1 CABG for malpositioned dissecting stents
placed just prior to enrollment into the program, 1 stenting procedure and 2 CABGs
before valve repair, 2 stenting procedures to
correct grafted artery closing, and 2 CABGs
for asymptomatic patients persuaded of the
need by their primary caregivers. Two patients experienced a nonfatal stroke (one
after refusing warfarin for atrial fibrillation,
the second because of progression of CVD,
and one had stent thrombosis with acute MI
after discontinuing clopidogrel as advised by
the primary care physician. One patient had
3 stents placed before entering our study;
1 occluded at 3 years into the study, necessitating restenting (TABLE 2 ).
Thus, only 1 major cardiovascular event
(stroke) was related to disease progression
in patients adherent with the dietary intervention. This is a recurrent event rate of
0.6%. Thus, 99.4% of adherent patients avoided major cardiac events. This result clearly
contrasts with that of other key peer-reviewed
studies of nutrition interventions for patients
with CAD6,17-22 (TABLE W3 at www.jfponline.
com), although the disease burden and the
presence of comorbid conditions may not be
comparable. Even if all events had been attributable to diet, the 10% (18/177) event rate
(Worse group in TABLE 2 ) over an average of
3.7 years is much below that reported in the
literature23 and the 62% of the nonadherent
group.

DISCUSSION
This program of treating the presumed cause
of CAD has yielded significant findings and
raised practice implications. First, and quite
compelling, is that 89% of patients were willing to make a substantial lifestyle transition
to plant-based nutrition and sustain it for
an average of 3.7 years (for some patients
up to 13 years). Most participants saw this
as taking control of their disease (anecdotal
reports).
Second, the results of this evaluation
provide further evidence that plant-based
nutrition may prevent, halt, and reverse CAD.
This process of halting and reversing CAD

360

has been validated with a high probability

by epidemiologic studies, including those of
wartime deprivation, our previous noncontrolled study, and both randomized and
nonrandomized controlled studies where a
similar plant-based diet was a part of a comprehensive lifestyle modification in conjunction with otherwise standard pharmaceutical
medical therapy.3,15,17,18,24-26
zLarge cohort studies support nutritional intervention. In addition, 2 large

prospective cohort studies have recently emphasized the importance of nutrition in decreasing the risk of recurrent CVD events in
people with CVD or diabetes and decreasing
the risk of developing CVD among healthy
individuals. Dehghan and colleagues27 followed 31,546 participants with CVD or diabetes over 4.5 years and divided them into
quintiles of nutritional quality. Reduction in
CVD-related risk within the healthiest quintile was 35% for death, 14% for MI, and 19%
for stroke. They found this protective association was maintained whether or not patients
were receiving medications.
Crowe and colleagues28 followed
44,561 men and women enrolled in the European Prospective Investigation into Cancer
and Nutrition. Thirty-four percent (15,151)
were vegetarians, consuming neither meat
nor fish. During an 11.6-year follow-up, they
found vegetarians had a lower mean body
mass index, lower non-HDL-C level, lower
systolic blood pressure, and a 32% lower risk
of developing ischemic heart disease.28 These
combined studies of 76,107 individuals support an assertion of the power of nutrition for
primary and secondary prevention of cardiovascular illness.
By way of contrast are findings associated with a typical western diet. Wilkins and
colleagues29 assessed lifetime risk and years
lived free of total CVD by reviewing data from
905,115 person-years from 1964 to 2008. They
assessed risk factor presence and subsequent CVD. While lifetime risk estimates for
total CVD for all individuals was >30%, the
study found that even those men and women
55 years of age with optimal risk factors had a
40% and 30% likelihood of total CVD, respectively, by age 85. It would appear that even
optimal risk factors are no guarantee that the

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a way to reverse CAD?

TABLE 2

Outcomes for patients enrolled in nutritional intervention for CVD

Characteristics
Total, N (%)
Men, N (%)
Age (mean SD)*

Adherent patients

Nonadherent patients

177 (89)

21 (11)

164 (93)

16 (76)

63.0 10.1

62.3 9.0

144 (81)

0 (0)

105 (94)

0 (0)

Outcomes
Improved
Symptom reduction

Reversal

39 (22)

Stable

15 (8)

8 (38)

Worse

18 (10)

13 (62)

Adverse outcomes unrelated to

nutritional intervention
1

Patient stopped clopidogrel on PCP recommendation, resulting in stent

closure and MI.

Patient with atrial fibrillation refused warfarin and suffered a nonfatal

stroke.

Asymptomatic patients with stable CAD persuaded by their PCP to

undergo CABG.

Patients underwent CABG to qualify for valvular repair surgery.

Patient underwent PCI with stenting to qualify for valvular repair

surgery.

Patients underwent PCI with stenting for occluded grafted LIMA.

Disease progression

Stroke

CABG

Restenting

Death

11
2

Stroke

PCI with stent

CABG

Endarterectomy for PAD

Heart transplant

Noncardiac**

Cardiac

CABG, coronary artery bypass grafting; CAD, coronary artery disease; CVD, cardiovascular disease; LIMA, left internal mammary artery; MI, myocardial infarction;
PAD, peripheral arterial disease; PCI, percutaneous coronary intervention; PCP, primary care physician; SD, standard deviation.
* Data missing for 5 adherent patients and 1 nonadherent patient.
Percentage of 112 patients who complained of angina at the start of intervention.
One patient with atrial fibrillation had documented angiographic reversal after 5 years in the study, then refused warfarin 2 years after last angiogram and
suffered a nonfatal stroke.
Adherent patients experienced worse outcomes significantly less frequently than nonadherent patients (P<.001, by Fishers exact test).
One patient enrolled into the program with malpositioned dissecting stents that required CABG.
# Before study enrollment, the patient had 3 stents placed; one occluded at 3 years in the study and was restented.
** Includes 3 cancer-related deaths, 1 fatal pulmonary embolism, and 1 case of pneumonia.

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typical western diet wont eventually result

in CVD.
zWhy are our results particularly favorable? While nutritional modification is

For adherent
participants, the
adverse event
rate was, at
most, 10%.

362

beneficial, the question remains whether it

has been optimized to its fullest potential in
other studies. First, no other nutrition study
has completely eliminated oils (including
food products that may contain even small
quantities of added oil of any kind), and
all animal, fish, and dairy products, which
would avoid foods known to injure endothelial cells, as well as exogenous cholesterol
and saturated fat. In avoiding exposure to
lecithin and carnitine contained in eggs, milk
and dairy products, liver, red meat, poultry,
shellfish and fish, participants in our study
were unlikely to have intestinal flora capable
of producing trimethylamine oxide (TMAO),
a recently identified atherogenic compound
produced by the intestinal flora unique to
omnivores that ingest animal products.30-32
(Vegans do not possess the detrimental bacterial flora.)
A second reason for our favorable results
is the intensive, single-day, 5-hour counseling seminar that conveyed the message of
nutritional intervention with depth, clarity,
power, and completeness through a PowerPoint presentation, recipe handouts, books,
video, strategies for plant food acquisition
and preparation, and testimonials by prior
participants. Thus informed, participants
grasped in detail the importance of the endothelial cell and its product, nitric oxide. They
were educated to fully comprehend which
foods injure endothelial cells and how transitioning to a whole-food, plant-based diet
empowers them as the locus of control to halt
and potentially reverse their disease. The preseminar phone consultation, the seminar
itself, and follow-up psychological support
resulted in an adherence of 89% during this
3.7-year-long follow-up.
We believe food may be the most important lifestyle factor in establishing the
presence or absence of disease.15,24-26 The
adverse event rate among nonadherent participants was 62%. For adherent participants
(119 experienced intervention prior to counseling: 75 had PCI with stent placement, and
44 suffered MI), the adverse event rate was

at most 10% (Worse group in TABLE 2 ). An

additional 27 counseled participants did not
require previously recommended interventions. These data on required interventions
and interventions recommended but found
to be unnecessary (146/177; 82%), testify to
the severity of illness in this cohort and illustrate the remarkable comparative lack of
subsequent cardiovascular events in the 89%
who complied with plant-based nutrition.
zLess need for stenting? The prompt
improvement (within 3 weeks) confirmed
by PET scan documentation of myocardial
reperfusion (FIGURE 1 ), resolution of angina,
and angiographic evidence of disease reversal (FIGURE 2 ) demonstrated in our earlier
studies involving plant-based nutritional intervention argue against elective deployment
of stents for reperfusion. Successful nutritional treatment of CVD, coupled with standard medical therapy, may extinguish major
cardiac event progression in the vast majority
of patients.
zEnabling the body to correct harmful processes. Future discoveries may help to

explain why plant-based nutrition is so effective, yet we can postulate likely mechanisms.
When foods that injure or cause endothelium
dysfunction are avoided, the body readily
restores the capacity of endothelial tissue to
produce nitric oxide. Such change reduces
production of vasoconstricting endothelin
and thromboxane by injured endothelial
cells.
Our insistence on daily ingestion of generous portions of green leafy vegetables favors an improved population of endothelial
progenitor cells.33 Moreover, reductions in
lipid, homocysteine, and triglyceride levels
and insulin resistance enhance dimethylarginine dimethylaminohydrolase to enzymatically reduce asymmetric dimethylarginine
and optimize nitric oxide synthase availability in nitric oxide production. The blood
level of HDL-C may decrease with this antiinflammatory, plant-based nutrition. Nevertheless, the efflux capacity of HDL-C may be
unrelated to blood concentration and could
be significantly enhanced by the intervention to enable disease arrest or reversal.34,35
Consumers of plant-based nutrition do not
harbor the intestinal flora unique to om-

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a way to reverse CAD?

nivores that enables production of proatherogenic TMAO. The standard nutritional,

pharmaceutical, and surgical interventions
of present cardiovascular medicine may
not sufficiently address these protective
mechanisms.
zThis study had several limitations.

First, it included self-selected, very determined patients. Without a control group, it

is challenging to establish causality and assess how much of the observed changes are
specifically due to the diet. Only some of
the observed beneficial outcomes may have
been due to the diet. This study was not prospectively randomized. Nevertheless, this
fact does not detract from proof of concept
that major cardiovascular events occurred
in probably <1% (and certainly <10%) of the
entire adherent cohort, compared with 62%
of the nonadherent cohort (TABLE 2 ). These
data convey a strong message of patients
accepting empowerment to be the locus of
control to arrest their disease and confirm
that patients will adopt a significant lifestyle
transition to plant-based nutrition to halt
and regress what we believe is a largely foodborne illness.
The past several decades have witnessed
a substantial and sustained reduction in
CAD. Nevertheless, CAD remains the number
one killer of women and men in this country.
Thousands of stable patients having stents
experience no reduction in major cardiac
events.6 While drugs have some effects on

disease initiation and progression, these interventions do not address disease causation.
Not surprisingly, most patients experience
disease progression, more drugs, more imaging, repeat interventions, progressive disability, and, too often, death from a disease of
western malnutrition, the cause of which has
been largely left untreated. We have in press
several patient experiences that exemplify
the repeated failure of present-day cardiac
drugs and procedural interventions, and that
confirm the capacity of whole-food plantbased nutrition to restore health in there is
nothing further we can do situations.36
In summary, the present cardiovascular
medicine approach tested beyond 40 years
can neither cure the disease nor end the epidemic and is financially unsustainable. The
safety, diminished expense, and prompt,
powerful, and persistent results in treating
the cause of vascular disease by whole-food
plant-based nutrition offer a paradigm shift
from existing practice. We think the time is
right for a controlled trial. But in the meantime, the data are sound and strong enough
that patients should be informed of this
option.
JFP

The present
cardiovascular
medicine
approach can
neither cure the
disease nor end
the epidemic
and is financially
unsustainable.

Correspondence

Caldwell B. Esselstyn Jr MD, The Wellness Institute, The

Cleveland Clinic, 1950 Richmond Road, TR2-341, Lyndhurst,
OH 44124; [email protected]
Acknowledgements

We are grateful to all participants in the program,

Jacqueline Frey, Ann Crile Esselstyn, and Jim Perko.

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a way to reverse CAD?

TABLE W3

Key peer-reviewed studies of nutritional intervention for CAD patients

Trial

Population

Dietary intervention

Outcomes

Significance of changes

Burr ML et al, Diet and

Reinfarction Trial (DART),
198921

2033 men who

survived MI

Advice or no advice
(controls) on 3 dietary
factors: reduced fat,
increased fish, increased
fiber

All deaths, ischemic

heart disease deaths,
and nonfatal MI

No significant
differences in incidence
of reinfarction plus
cardiac death by any of
the dietary regimens

Randomized, 2 yrs
Ornish D et al, The
Lifestyle Heart Trial,
199817

Cardiac events (MI,

coronary angioplasty,
CABG, cardiac-related
hospitalizations,
and cardiac-related
deaths)

48 patients with
moderate to severe
CAD

Randomized, 5 yrs
28

Experimental diet was

vegetarian with 10%
calories from fat*

25 events; 0.89 events

per patient

20

Control diet per advice

of patients personal
physician

45 events; 2.25 events

per patient

Risk ratio=2.47; 95% CI,

1.48-4.20; P<.001

Ornish D et al,
Multicenter Lifestyle
Demonstration Project,
199818

333 patients eligible

for revascularization
by medical and
insurance criteria

Cardiac events (MI,

stroke, noncardiac
death)

No significant difference
in cardiac events per
patient-year of follow up

Average savings in
avoiding
revascularization,
$29,529/patient

Nonrandomized, 3 yrs
194

Experimental diet was

vegetarian with 10%
calories from fat*

31 patients
underwent PTCA and
26 had CABG

139

Control diet per advice

of patients personal
physician

66 patients
underwent PTCA and
73 underwent CABG

de Lorgeril M et al, Lyon

Diet Heart Study, 199919

423 consecutive
patients who survived
a first MI

Randomized, 3.7-4 yrs

Composite outcome
of MI + CVD death

219

Experimental group
followed Mediterranean
diet

1.24

Risk ratio=0.28; 95% CI,

0.15-0.53; P=.0001

204

Control group followed

dietary advice per
patients physicians

4.07

Singh RB et al,
Indo-Mediterranean Diet
Heart Study, 200220

1000 patients with

angina, MI, or
surrogate risk factors
for CAD

Randomized, 2 yrs

Total cardiac
endpoints (nonfatal
MI + fatal MI + sudden
cardiac death)

499

Experimental diet was

NCEP step I diet plus
fruits, vegetables and
nuts, whole grains,
legumes, mustard seed
and soybean oil
(Indo-Mediterranean
diet)

39

Adjusted risk ratio= 0.48;

95% CI, 0.33-0.71; P<.001

501

Control NCEP step I diet

76

c o ntin u e d

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Vol 63, No 7 | JULY 2014 | The Journal of Family Practice

364a

TABLE W3

Key peer-reviewed studies of nutritional intervention for CAD patients (cont'd)

Kappagoda CT et al,
200622
Dietary intervention vs
nonadherent patients,
2 yrs

Cardiac events (cardiac

death, MI and stroke)

134 consecutive
patients with
angiographically
confirmed CAD
77

Vegetarian diet, <10%

calories from fat*

1.5%

P<.02

57

Nonadherent patients

18%

Boden WE et al,
COURAGE Study, 20076

2287 patients with

myocardial ischemia
and significant CAD

Randomized, 4.6 yrs

Cumulative primary
event (composite of
death from any cause
and nonfatal MI) rates

1138

Optimal medical therapy

(diet and exercise per
recommended practice
guidelines)

19.5%

No significant
difference in recurrent
major cardiac events

1149

Optimal medical therapy

plus PCI

20%

Esselstyn C et al, 2014

198 consecutive
patients with CAD

Cardiac events (MI,

stroke, CABG, PCI,
CVD death)

Dietary intervention vs
nonadherent patients,
3.7 yrs

177

Adherent patients
followed a vegan diet
with 10% of calories from
fat and no added oil

2.2%

21

Nonadherent

62%

P<.001

CABG, coronary artery bypass grafting; CAD, coronary artery disease; CI, confidence interval; CVD, cardiovascular disease; MI, myocardial infarction; NCEP, National
Cholesterol Education Program; PCI, percutaneous coronary intervention; PTCA, percutaneous transluminal coronary angioplasty.
* Patients in the experimental group also participated in exercise, stress management, and support group.
Per 100 patients per year of follow-up.
In both groups 2/3 of patients were vegetarians.

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