Lipid-lowering therapy. Mediterranean diet for myocardial infarction

For the purpose of secondary prevention of coronary heart disease, it is necessary to normalize the lipid spectrum of a patient who has had myocardial infarction. In the 90s, many randomized  
  studies in which the role of lipid-lowering drugs (primarily the most powerful of them – statins) was studied both in slowing the progression of atherosclerosis (according to angiography or ultrasound scanning), and for the purpose of primary and secondary prevention of coronary heart disease. The manual “Diagnosis and treatment of dyslipidemia” (V. A. Kryzhanovsky, 1995) was devoted to questions of diet therapy, the selection of adequate medical treatment for lipid metabolism disorders, as well as the analysis of the results of the largest multicenter clinical studies. Let us dwell briefly on the results of the largest randomized trials on the secondary prevention of coronary heart disease with statins.

The question of how much cholesterol contained in low-density lipoproteins should be reduced in patients with coronary heart disease remains open. It became especially relevant with the advent of such powerful statins as atorvastatin and cerivastatin. The results of the Post-CABG study (Post Coronary Artery Bypass Graft, The Post Coronary Artery Bypass Graft Trial Investigators, 1998) indicate, for example, the possibility of significantly slowing the process of atherosclerotic lesion of venous shunts after coronary artery bypass grafting (CABG), lowering the level of cholesterol contained in low density lipoproteins <85 mg / dl (2.2 mmol / L), in particular with lovastatin.  

An “aggressive” reduction in cholesterol contained in low density lipoproteins was achieved in the AVERT (Atorvastatin versus Revascularization Treatment) study. By administering 80 mg of atorvastine per day, the level of cholesterol contained in low-density lipoproteins was reduced to an average of 77 mg / dl (2 mmol / L). As a result, in patients with a stable course of coronary heart disease (without severe angina pectoris, and also with a left ventricular ejection fraction> 40%), there was a tendency to a decrease in the need for angioplasty, coronary artery bypass grafting, and a decrease in the frequency of hospitalization compared with the group of patients who underwent planned angioplasty followed by conventional treatment (B. Pitt et al. for the AVERT Investigators, 1999). 

Mediterranean diet for myocardial infarction

The results of the Lyon study of “core diets”, intended for the secondary prevention of coronary heart disease, did not receive the proper resonance among the “medical community”. In this study, 605 patients who had myocardial infarction observed an average of 27 months. 

The Mediterranean diet meant more bread, root vegetables, green vegetables, fruits, fish and less meat (poultry was preferred), special margarine, rich in ss-linolenic acid, instead of butter and sour cream. The salad was seasoned with olive and rapeseed oil. Allowed moderate wine consumption. A rich cc-linolenic acid Mediterranean diet allowed (compared with the usual post-infarction diet) to reduce overall mortality by 70% (M. de Lorgeril et al., 1994). Moreover, the groups did not differ in terms of blood pressure, lipid spectrum and body mass index. 

In contrast to the use of lipid-lowering drugs for the secondary prevention of coronary heart disease, when, after a couple of years of observation, the difference in mortality was only beginning to appear, with diet therapy such a huge shift was achieved much earlier.  

The beneficial effects of the Mediterranean diet remained valid after the observation period was extended to an average of almost 4 years – 46 months (M. de Lorgeril et al., 1999). Interestingly, the significant difference in mortality again did not depend on the level of cholesterol in the blood, which did not differ in both groups. This suggests that for the success of secondary prevention of coronary heart disease after myocardial infarction, it is important to influence factors other than blood cholesterol (A. Leaf, 1999).  

Vegetable oils (in particular, olive) and oslinolenic acid-rich margarine were more effective in the secondary prevention of coronary heart disease after myocardial infarction than the previously tested fish (fatty) diet (P. McKeigue, 1994). However, one should not forget that the Mediterranean diet also includes fatty varieties of fish. In the DART (Diet and Reinfarction Trial) study, the overall mortality rate among patients with myocardial infarction who ate 2-3 times a week eating fatty fish varieties decreased by 29% over 2 years (M. L. Burr et aL, 1989). The menu, in particular, included mackerel, herring, salmon, trout, sardines. 

A direct comparison of the effect of breakfast consisting of 50 g soaked in olive oil bread and a hearty breakfast of salmon alone on blood triglycerides and endothelial function was in favor of salmon (RA Vogel et al., 1999). The endothelial function was evaluated by ultrasound according to the degree of vasodilation of the brachial artery against hyperemia (one minute after 5 minutes of clamping it with the tonometer’s cuff). The intake of olive oil caused a more significant (almost 2 times) increase in the level of triglycerides in the blood and impaired endothelial function. The addition of vitamins C (1 g) and E (800 IU) to olive oil removed its negative effect on endothelial function. 

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