Crafting a Comprehensive Cardiovascular Protocol

Seven science-backed interventions to tame inflammation, lower cholesterol, minimize cardiometabolic risk factors and support your patients’ heart health

Of all the disease and conditions practitioners face, cardiovascular health is one of the most complex and nuanced, influenced by factors ranging from gut health to genetics, an effective protocol requires a targeted, highly individualized approach.

“Precision and personalized cardiovascular medicine must be the new medicine of today and the future,” says Mark Houston, MD, Director of the Hypertension Institute. “This means every patient must have a complete genetic profile, a detailed medical history and a comprehensive physical examination, along with advanced cardiovascular labs and testing.”

In addition to a thorough evaluation, personalized protocols should include proven diet and lifestyle therapies shown to address various aspects of cardiovascular wellness, as well as effective, evidence-based nutraceuticals tailored to each patient’s specific needs. Seven science-backed interventions to tame inflammation, balance blood pressure, improve lipid profiles and promote overall heart health.

The right nutrition: Keto, gut health and meal timing.

Studies demonstrate the cardioprotective potential of a low-carb Keto diet. Slashing carbs influences a range of cardiovascular risk factors, including modulating inflammation, normalizing blood pressure, improving vascular endothelium function and benefiting lipid profiles. Compared to other dietary models, the Keto diet appears to be superior to in the prevention and treatment of cardiovascular diseases.^{1, 2}

In addition to lessening cardiovascular risk factors, the Keto diet also supports the gut microbiome. Dysbiosis is linked with the development of pathologies such as atherosclerosis, hypertension and heart failure, and recent research suggests favorable changes in certain bacteria may protect against heart disease. The metabolic potential of gut microbiota is a contributing factor: bioactive compounds generated by gut bacteria impact physiology, disrupting blood lipids and activating inflammatory pathways involved in the development of atherosclerosis. The Keto diet appears to have a positive influence on microbiome health, enhancing microbiota diversity, and reducing microbes associated with cardiac events like stroke, coronary artery disease and heart attack.^{3, 4, 5, 6, 7}

Specific dietary components are only part of the picture: the timing of meals may play a key role in cardiovascular health. Intermittent fasting is effective in improving lipid profiles, reducing total cholesterol, LDL and triglyceride levels and boosting suboptimal HDL. In other research, skipping breakfast is linked with higher rates of cardiovascular disease, including a significantly heightened risk of cardiovascular mortality. One study suggests skipping breakfast while eating late at night can increase the likelihood of coronary heart disease by 55 percent, and another study found overeating low-quality carbs and animal protein at dinner rather than breakfast was significantly correlated with higher cardiovascular disease risk.^{8, 9, 10, 11, 12}

Relaxation: yoga, meditation and stress reduction.

The relationship between emotional stress and cardiovascular risk factors is well established. Heightened stress is connected with higher inflammation, elevated heart rate and blood pressure, and a higher likelihood of cardiovascular events. Stress also triggers heightened sympathetic activity which impacts lipid metabolism, and studies link increased emotional stress with higher total cholesterol and LDL and lower HDL. Relaxation practices like meditation not only decrease heart rate and blood pressure but also normalize stress hormones, reduce inflammation and improve lipid profiles. Sympathetic nervous system overactivity is implicated in elevated cholesterol independent of diet. By blunting sympathetic activation, meditation can lower total cholesterol and triglycerides. In one meta-analysis, people engaged in regular meditation showed significant reductions in cholesterol levels compared to non-meditators, as well as favorable and even more pronounced impacts on triglycerides. In addition to static meditation practices, yoga not only decreased stress and blood pressure and other cardiometabolic risk factors, but also balanced lipid profiles. One review found movement-based meditation techniques like yoga were associated with significantly reduced total cholesterol and triglyceride levels. Similar effects have been seen in qigong.^{13, 14, 15, 16, 17}

Exercise: aerobics, endurance training and HIIT.

Besides improving cardiovascular function, slowing heart rate, lower blood pressure and inhibiting stress hormones, exercise also reduces LDL and triglycerides and increases HDL. The type of exercise is important: aerobic or endurance forms, like running, cycling, swimming, elliptical trainer, skiing or rowing, are shown to have most meaningful influence on blood lipids, raising HDL and decreasing total cholesterol, LDL and triglycerides. The greatest benefits are seen with moderate-intensity aerobic training 150 to 300 minutes a week, or 75 to 150 minutes a week for vigorous-intensity aerobic physical activity. Some studies suggest even 30 min of exercise per day may be sufficient to boost HDL.^{18, 19, 20, 21}

In other research, high-intensity interval training (HIIT) was superior to moderate-intensity continuous training in decreasing LDL and total cholesterol. Compared to MICT, HIIT significantly lowered total cholesterol, as well as LDL concentrations. And where patients exercise may play a role: outdoor activities or exercising in the sunshine promotes vitamin D synthesis: studies link higher serum vitamin D levels with better cardiorespiratory fitness.^{22, 23}

Red Yeast Rice: lipid-lowering stain alternative.

Derived from Monascus purpureus yeast grown on white rice, red yeast rice is a powerful tool for supporting cardiovascular health and normalizing lipids. The process of fermentation yields a variety of bioactive compounds, including sterols, flavonoids, lignans, polysaccharides and monacolins and polyketides, shown to influence cholesterol synthesis. Monacolin K, the most abundant monacolin in red yeast rice, is chemically similar to the cholesterol-lowering drug lovastatin and clinical trials demonstrate its ability to benefit lipid levels, even at low doses.^{24, 25, 26, 27, 28}

In numerous systematic reviews, red yeast rice supported healthy LDL and HDL, total cholesterol and triglycerides, with greater effects on patients with dyslipidemia. Red yeast rice also decreased ApoB, while slowing inflammation, stabilizing vulnerable atherosclerotic plaque and improving markers of arterial health. Other research shows significant reductions in the risk for mortality and major coronary events. Because it’s safe and well-tolerated in people intolerant to standard lipid therapy, red yeast rice offers a valuable alternative.^{29, 30, 31, 32, 33, 34, 35}

Phytosterols: anti-inflammatory complement to cholesterol drugs.

Naturally occurring in plant sources like vegetable oils, almonds, wheat germ and wheat bran, phytosterols have proven antioxidant, anti-inflammatory and lipid-lowering properties. B-sitosterol, campesterol, stigmasterol and other phytosterols are structurally similar to cholesterol, thus competing with dietary cholesterol for absorption. Unlike cholesterol, sterols are primarily pumped back into the intestinal lumen, and less than one percent of sterols are ultimately retained. Along with inhibiting intestinal absorption of dietary cholesterol, phytosterols also affect cholesterol metabolism, increasing its excretion and reducing the synthesis of VLDLs.^{36, 37, 38, 39, 40}

In dozens of studies, phytosterol treatment is correlated with significant decreases in LDL, total cholesterol and triglycerides, with some research showing 2 to 3 grams per day lowered LDL by 6 to 12 percent and triglycerides by 6 to 9 percent, with no significant effect on HDL. Phytosterol supplementation was also associated with reductions in ApoB, ApoE and the ApoB/ApoA-I ratio, as well as an increase in ApoA-I. Used in conjunction with standard lipid therapies, phytosterols further decrease total cholesterol and LDL, and when combined with red yeast rice, enhance the reductions of LDL and ApoB.^{41, 42, 43}

Garlic: wide-ranging cardioprotective benefits.

Well-known for its cardioprotective properties, garlic is rich in bioactive compounds, including alliin, allicin, S-allyl cysteine and diallyl trisulfide, shown to work through a variety of mechanisms, normalizing blood pressure, slowing inflammation, suppressing clot formation and protecting against atherosclerosis, and supporting healthy lipid profiles. Studies link garlic supplementation with significant reductions in C-reactive protein and TNF-α, and dozens of trials validate its efficacy in promoting normal LDL and total cholesterol levels. Garlic influences dietary cholesterol absorption and cholesterol synthesis, and one meta-analysis found that garlic supplementation reduced total cholesterol and LDL. In another meta-analysis, garlic supplementation lowered total cholesterol, LDL and triglycerides, and improved blood pressure, waist circumference and BMI. In people with coronary artery disease, garlic supplementation significantly decreased total cholesterol and LDL, increased HDL, minimized inflammation and improved coronary artery calcium scores.^{44, 45, 46, 47, 48, 49}

Aged garlic extract (AGE) appears to be especially cardioprotective. In one trial, AGE inhibited coronary artery calcium progression, while reducing inflammation, blood pressure and blood glucose in patients at higher risk for cardiovascular events. Another study found AGE significantly decrease systolic and diastolic blood pressure and improved central blood pressure and pulse wave velocity in patients with uncontrolled hypertension. In a systematic review of trials evaluating the efficacy of interventions on cardiovascular calcification, only AGE consistently showed benefit.^{50, 51, 52}

Berberine: traditional, plant-based lipid balance.

An isoquinoline alkaloid found in barberry, goldenseal and other plants, berberine has been used for centuries in traditional medicine. Current evidence validates its cardioprotective effects, with studies demonstrating its antioxidant and anti-inflammatory properties: research suggests berberine enhances the activity of antioxidant enzymes, regulates the production of cytokines and suppresses inflammatory responses. Berberine improves additional aspects of cardiovascular health, including blood pressure, BMI and glucose metabolism, attributed in part to its influence on gut microbiota composition and diversity. Berberine has also been shown to support healthy lipid profiles, decreasing LDL, triglycerides and ApoB, while increasing HDL.^{53, 54, 55, 56}

In one study, 500 mg of berberine twice a day had significant effects on lipids, including a 29 percent reduction in total cholesterol, a 25 percent reduction in LDL and a 35 percent reduction in triglycerides. In another study, 500 mg of berberine twice daily lowered LDL by an average of 23.8 percent. Berberine appears to impact lipids through different mechanisms than those of red yeast rice or statins. It’s thought to upregulate the expression of LDL receptors and suppress the expression of PCSK9. Because it works primarily by inhibiting PCSK9, berberine may also enhance the effectiveness of red yeast rice, as well as standard lipid-lowering drugs. In one study, a combination of simvastatin and berberine decreased LDL by an average of 31.8 percent, and other research suggests berberine is a viable alternative for patients who are intolerant to statins.^{57, 58, 59, 60, 61, 62}

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