Garlic for treating hypercholesterolemia

terol levels, regardless of gender and age, and even in the absence of CVD or other risk factors. Perspectives: Although the cost estimates were based on the Canadian health care system in 1996, these findings lend pharmacoeconomic support for the guidelines that encourage the assumption that diabetics have subclinical coronary disease. In addition to controlling glucose intolerance with diet, exercise and weight control, treatment with a statin should be considered in diabetic men and women with an LDL-C ⬎125 mg/dL, with a treatment goal of less than 100 mg/dL. MR

primary and secondary prevention strategies in women. MR

Garlic for Treating Hypercholesterolemia Stevinson C, Pittler MH, Ernst E. Ann Intern Med 2000;133;420 – 429. Study Question: To review the available pertinent evidence regarding the effects of garlic on total cholesterol levels. Methods: A standard literature based meta-analysis was performed of those randomized, double blind, placebo controlled trials of garlic in persons with a cholesterol greater than 200 mg/dL. Additionally, manufacturers of commercial garlic were asked about published and unpublished trials. Results: There were 13 trials considered acceptable. Garlic reduced the total cholesterol from baseline significantly more than placebo. The weighted mean difference was ⫺15.7 mg/dL (CI, ⫺25.6 to ⫺5.7 mg/dL). The average dose of garlic was 900 mg/d. There was no benefit found in the six highest-quality diet-controlled studies. Conclusions: Available data suggest garlic is superior to placebo in reducing cholesterol levels. However the robustness of the effect is modest and the use of garlic for hypercholesterolemia is of questionable value. Perspectives: The majority of studies from which conclusions were drawn were parallel design, on usual diet, lasted 4 months and enrolled less than 100 patients with cholesterol levels ranging from 200 to 350 mg/dL. Although the meta-analysis does little to encourage or discourage garlic supplements, it does provide a perspective for responding to the commercial advertising. MR

Effects of Estrogen Replacement on the Progression of Coronary Artery Atherosclerosis Herrington DM, Beboussin DM, Brosnihan KB, et al. N Engl J Med 2000;343:522–529. Study Question: The Heart and Estrogen/Progestin Replacement Study (HERS) found no benefit of long-term estrogen/ progestin therapy in post-menopausal women with coronary disease. Yet in animal models estrogens have a favorable effect on experimental atherosclerosis. The Estrogen Replacement Study (ERS) was designed to assess the effect of estrogen therapy on coronary atherosclerosis as measured by quantitative coronary arteriography. Methods: 309 post-menopausal women undergoing coronary arteriography and found to have at least one 30% stenosis were randomized to conjugated 0.625 mg of estrogen, estrogen plus 2.5 mg of medroxyprogesterone or placebo. The primary end point was evidence for new epicardial coronary lesions or progression in established lesions on follow-up coronary arteriography performed at an average of 3.2 ⫾ 0.6 yrs. Results: Mean age was 65.8 years and 70% of women had a least one 50% stenosis. Compared to the placebo, estrogen and estrogen/progestin resulted in a significant decrease in LDL-C (10-15%) and increase in HDL-C (14-18%) and mild increase in triglycerides. Despite the favorable effect on lipid parameters, there was no treatment effect on coronary artery mean luminal diameter or change (average was 0.09 mm) and no difference in coronary disease end points. Unopposed estrogen was associated with considerably more endometrial hyperplasia and bleeding. Conclusions: Based on this angiographic trial and HERS, there appears to be no cardiovascular protective benefit of estrogens in older women with coronary disease. Perspectives: Considering the experimental and epidemiologic evidence of cardiovascular protective effects, the failure of estrogen therapy in established coronary disease is not readily explained. Possible explanations include both a prothrombotic effect and the recent finding that estrogen therapy results in higher levels of C-reactive protein and may be pro-inflammatory. The results of HERS and ERS should serve to promote lifestyle change and the proven

Effect of Folic Acid and Antioxidant Vitamins on Endothelial Dysfunction in Patients with Coronary Artery Disease Title LM, Cummings PM, Giddens K, Genest JJ, Nassar BA. J Am Coll Cardiol 2000;36:758 –765. Study: Increasing levels of plasma homocysteine have been associated with coronary and peripheral atherosclerosis and mortality. This study was designed to determine whether folic acid or folic acid in combination with antioxidants improves endothelial function in patients with coronary disease. Methods: A double-blind, placebo-controlled trial was performed in 75 patients with CAD and a homocysteine level ⬎9 umol/L. Patients were randomized to one of three groups: folic acid with 800 IU of vitamin E and 2000 mg of vitamin C, 5 mg of folic acid or matching placebos. The effect on endothelial function was determined as the change in flow-mediated vasodilation (FMD) of the brachial artery following release of an occluding cuff from baseline to after 4 months of therapy. Results: The baseline homocysteine levels averaged 12 umol/L, and no subjects were micronutrient deficient. Folic

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