The heart of the matter: some supplements work ... others are worthless.

Some 1,400 Americans will die of heart disease today. That's about how many died yesterday and how many will die tomorrow.

With a toll that high, it doesn't make sense to waste precious time and money on worthless supplements. But that's just what millions of people do. Little do they know that some supplements really can lower your LDL ("bad") cholesterol or triglycerides. Or that others really can raise your HDL ("good") cholesterol. Or that still others may even slash your odds of dying of cardiac arrest.

So the next time the vitamin-store clerk tells you that vitamin E or garlic or guggulipids or tocotrienols are just what the doctor ordered for your heart, say no thanks. Then pick up something that really works.

FISH OIL

"Studies show that eating fish, especially higher-fat fish, at least twice a week cuts the risk of dying from a heart attack by a quarter to a half, even in people who don't already have heart disease," says William Harris of the University of Missouri-Kansas City School of Medicine.

What about fish oil supplements? Researchers haven't tested them on healthy people, but they have looked at people who have survived a heart attack. In a large Italian study, 2,800 heart attack survivors were given a daily dose of fish oil that contained 850 milligrams of omega-3 fats. Over the next 3 1/2 years, they suffered 20 percent fewer deaths from heart disease than 2,800 survivors who weren't taking fish oil. (1)

The only problem: the study didn't compare the fish oil takers to placebo takers, so it's impossible to say whether it was the fish oil--or just the fact that people were taking a pill--that led to the decline. Still, the evidence is promising.

"The risk of dying from a heart attack in the Italian study began to drop within the first three months of taking the fish oil," notes Harris.

Fish oil may act quickly by preventing sudden death heart attacks. According to the American Heart Association (AHA), 250,000 Americans die each year of cardiac arrest before reaching a hospital. In most cases, sudden death occurs following an arrythmia--when the heartbeat becomes chaotic.

The two omega-3 fatty acids in fish oil, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), seem to have a unique ability to stabilize arrythmias. "They become part of the heart's muscle cells and can stop a sudden heart arrythmia from becoming fatal," says Harris.

The AHA advises heart disease patients who don't eat fish regularly to talk with their doctors about taking a daily supplement with one gram (1,000 mg) of omega-3 fats. While larger amounts--two to four grams a day--can reduce blood triglyceride levels (which may lower heart disease risk even further), three grams a day or more causes internal bleeding in a small number of people.

(To figure out how many fish oil capsules to take, add up the amount of EPA and DHA in the per capsule or per serving information that's listed on the label.)

(1) Lancet 354: 447, 1999.

PSYLLIUM 

The soluble fiber psyllium, which is the main ingredient in the bulk-forming laxative Metamucil, is a proven LDL lowerer.

In 197 men and women with high cholesterol who took two teaspoons of Metamucil (about seven grams) before breakfast and before lunch every day for six months, LDL dropped seven percent more than in 55 similar people who took four teaspoons of a placebo every day. (1) The psyllium takers were no more likely to complain of diarrhea or constipation than the placebo takers.

The Food and Drug Administration allows manufacturers to claim that consuming at least seven grams a day of soluble fiber from psyllium may help reduce the risk of heart disease.

(1) American Journal of Clinical Nutrition 71: 1433, 2000.

NIACIN (Vitamin B-3)

At very high doses, it really acts as a drug, not a vitamin. But whatever you call it, niacin is the most potent pill you can take to raise your HDL ("good") cholesterol. Megadoses (500 milligrams to 1,000 milligrams a day) can boost HDL by 15 to 35 percent and can lower triglycerides by 20 to 50 percent. (The government's recommended daily intake for niacin as a vitamin is 20 mg.)

"But using niacin effectively is complicated," says John Pieper, dean of the University of New Mexico College of Pharmacy in Albuquerque. "So you need to work with a physician who knows what he or she is doing."

Many people can't tolerate its side effects. "The most troublesome and common one," says Pieper, "is a painful facial flushing that feels like someone is sticking pins into your skin." That can sometimes be prevented by starting with a low dose, taking aspirin or ibuprofen 30 minutes before the niacin, and taking the niacin with meals.

"Sustained-release niacin, which is absorbed much more slowly, doesn't produce as much flushing, but it can cause reversible liver damage in some people," cautions Pieper. A new "extended-release" niacin, available by prescription as Niaspan, produces less flushing and less liver toxicity than the other forms of niacin, says Pieper.

The take-home message: If you have high triglycerides or low HDL, niacin works. But don't take high doses of any form of niacin without a doctor's supervision.

PHYTOSTEROLS

"Plant sterols are more effective in lowering LDL than all the currently available dietary supplements," says endocrinologist Ronald Ostlund of Washington University in St. Louis. "By interfering with the absorption of cholesterol from the intestinal tract, they can reduce LDL by about 10 percent." (Statin drugs like Lipitor and Pravachol lower LDL by 20 to 40 percent, depending on the drug and the dosage.)

Small amounts of plant sterols (they're also called phytosterols) occur naturally in pine trees and foods like soybeans, nuts, grains, and oils. Manufacturers concentrate them to create supplements or margarine-like "cholesterol-lowering" spreads like Benecol, Take Control, and Smart Balance OmegaPlus. Last fall, Minute Maid introduced "Heart Wise," a phytosterol-fortified orange juice.

The evidence is so clear that the Food and Drug Administration (FDA) allows foods that contain at least 400 milligrams of phytosterols per serving to claim that they can help prevent heart disease (though you need at least 800 mg a day to get the benefits, says the FDA). And the National Cholesterol Education Program (NCEP) now recommends two grams (2,000 mg) of plant sterols every day as a way to lower LDL if changes in diet aren't sufficient.

"If your cholesterol is high, plant sterols may not lower it enough," says Ostlund. "But if you're on statins, taking plant sterols will lower your cholesterol even more because they work in different ways."

ASPIRIN

It may be an over-the-counter medicine, not a dietary supplement, but odds are you've got a bottle of aspirin sitting next to your vitamins. And odds are you take it--or have heard that you should take it--every day to lower your risk of having a heart attack. Should you? It depends on who you are.

"Taking aspirin regularly has been proven to reduce the risk of having a second heart attack by 34 percent and a second stroke by 22 percent in both men and women," says researcher Charles Hennekens of the University of Miami School of Medicine, who led some of the landmark studies on aspirin and heart disease. "And aspirin can lower the risk of dying from a heart attack by 23 percent if it's taken during the attack and afterwards."

Should you take it regularly if you've never had a heart attack or stroke? Not necessarily. Aspirin is a double-edged sword. While it can prevent the clots that block arteries and cause heart attacks and strokes, it can also cause bleeding in the intestinal tract and, rarely, in the brain.

"The American Heart Association has concluded that if your risk of having a first heart attack is 10 percent or more over the next ten years, then the benefits of aspirin outweigh the risks, whether you're a man or woman," says Hennekens. Doctors determine ten-year risk using data from the Framingham Heart Study (to calculate your risk on-line, go to www.cspinet.org/nah/10_01/heartattackrisk.html).

"But the final decision should be made by the health-care provider, not the patient," cautions Hennekens. "The doctor can weigh aspirin's benefits and side effects against the patient's overall risk."

How much aspirin works? "For prevention, 75 milligrams a day is as good as 325," says Hennekens. "You see more side effects when you exceed 325 milligrams a day." (A full-strength aspirin has 325 mg. A baby aspirin has 81 mg, as do products like Bayer Low Strength Aspirin Regimen.)

"If you're having a heart attack," Hennekens adds, "you should take a regular 325-milligram aspirin." That dose seems to inhibit clotting within minutes, while a baby aspirin may take days.

FOLIC ACID & B-12

People who have higher levels of homocysteine in their blood have a higher risk of dying of heart disease. Whether lowering homocysteine reduces that risk is still an open question. But the ability of the B-vitamin folic acid to lower homocysteine isn't.

A daily dose of 500 micrograms of folic acid lowers homocysteine levels by 25 percent, according to the pooled results of 12 studies. (1) (That's close enough to the 400 micrograms that are in most multivitamins.) Combining folic acid with 20 micrograms of vitamin B-12 lowers homocysteine by an additional seven percent.

(1) British Medical Journal 316: 894, 1998.