Sinn oder Unsinn? Vitamine und Supplemente in der Kardiologie

Zusammenfassung

„Eine ausgewogene Ernährung reicht“ – da weder definiert ist, was eine ausgewogene Ernährung ist, noch wozu sie reicht, ist diese vielfach akzeptierte Feststellung nur ein unbelegtes und unbelegbares Dogma. Veränderungen in unserem Lebensstil und in unserer Ernährung haben dazu geführt, dass weite Teile der Bevölkerung niedrige Spiegel von Vitamin D und/oder marinen Omega-3-Fettsäuren aufweisen. Statintherapie senkt die Spiegel von Coenzym Q10, was für muskuläre Beschwerden unter Statintherapie verantwortlich gemacht wird. Ein Anheben niedriger Spiegel von Vitamin D bessert Knochenstruktur, Muskelkraft und mindert Stürze; Interventionsstudien zu weiteren Endpunkten laufen. Das Anheben niedriger Spiegel mariner Omega-3-Fettsäuren bessert komplexe kognitive Leistungen, Interventionsstudien zu kardiovaskulären Endpunkten hatten wohl aus methodischen Gründen neutrale Ergebnisse, wobei allerdings bei Herzinsuffizienz Mortalität und Krankenhauswiederaufnahmen gesenkt wurden. Treten unter Statintherapie muskuläre Beschwerden auf und sind die Spiegel niedrig, so lohnt sich der Versuch mit Coenzym Q10. Bei Herzinsuffizienz kann Coenzym Q10 jetzt schon empfohlen werden. Die europäische „Food Safety Authority“ hält die Gabe von Vitamin D bis 100 IE/d, von marinen Omega-3-Fettsäuren bis 5 g/d und von Coenzym Q10 bis 200 mg/d für sicher, was eine therapeutische Entscheidung erleichtert. Wegen Problemen der Bioverfügbarkeit sollten bei den 3 genannten Substanzen ca. 3 Monate nach Therapiebeginn die jeweiligen Spiegel kontrolliert werden. Die Datenlage für andere Substanzen ist weniger klar. Das Dogma, dass eine „ausgewogene Ernährung reicht“, wird abnehmend haltbar.

Abstract

While it has not been defined what a balanced diet is nor what it provides, there is a dogma that a balanced diet provides everything we need. Due to changes in our lifestyle and diet, substantial proportions of the population have low levels of vitamin D and/or marine omega-3 fatty acids. Statin therapy lowers levels of coenzyme Q10, thought to be responsible for muscle issues during statin therapy. Increasing low levels of vitamin D improves bone structure, muscle strength and reduces falls; intervention studies with other endpoints are currently ongoing. Increasing low levels of marine omega-3 fatty acids improved complex brain activities, intervention studies with cardiovascular endpoints had neutral results, probably due to methodological issues, while mortality and rehospitalizations were reduced in patients with congestive heart failure. In case of muscular problems during statin therapy combined with low levels of coenzyme Q10, a trial of coenzyme Q10 appears worthwhile. In congestive heart failure, Conzyme Q10 can be recommended already now. The European Food Safety Authority considers a daily uptake of up to 100 IU Vitamin D, 5 g/d marine omega-3 fatty acids, and 200 mg coenzyme Q10 as safe, facilitating therapeutic decisions. Problems of bioavailability of all three substances mentioned suggest controlling levels after approximately three months of increased intake. Current data for other nutrients are less clear. The dogma that a balanced diet provides everything we need becomes difficult to maintain.

Schlüsselwörter

Vitamine - Fettsäuren - kardiovaskuläre Erkrankungen

Key words

vitamins - fatty acids - cardiovascular diseases

• Literatur

• 1 Grammer TB, Kleber ME, Delgado G et al. Vitamin D und kardiovaskuläre Erkrankungen: Standortbestimmung 2014. Herzmedzin 2014; 31: 20-32
• 2 Hollick MF. Vitamin D deficiency. N Engl J Med 2007; 357: 266-281
• 3 von Schacky C. Nahrungsergänzung mit Omega-3 Fettsäuren?. Herzmedizin 2014; 31: 6-10
• 4 von Schacky C. Omega-3 fatty acids in cardiovascular disease – An uphill battle. Prostaglandin Leukotr Ess Fatty Acids 2014; DOI: 10.1016/j.plefa.2014.05.004.
• 5 Perk J, De Backer G, Gohlke H et al. European Association for Cardiovascular Prevention & Rehabilitation (EACPR); ESC Committee for Practice Guidelines (CPG). European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). The Fifth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of nine societies and by invited experts). Eur Heart J 2012; 33: 1635-1701
• 6 Fortmann SP, Burda BU, Senger CA et al. Vitamin and mineral supplements in the primary prevention of cardiovascular disease and cancer: An updated systematic evidence review for the U.S. Preventive Services Task Force. Ann Intern Med 2013; 159: 824-834
• 7 Martí-Carvajal AJ, Solà I, Lathyris D et al. Homocysteine-lowering interventions for preventing cardiovascular events. Cochrane Database Syst Rev 2013; (1) CD006612
• 8 Manson JE, Bassuk SS, Lee IM et al. The VITamin D and OmegA-3 TriaL (VITAL): rationale and design of a large randomized controlled trial of vitamin D and marine omega-3 fatty acid supplements for the primary prevention of cancer and cardiovascular disease. Contemp Clin Trials 2012; 33: 159-171
• 9 Im Internet: http://www.dge.de/modules.php?name=News&file=article&sid=1245 ; Stand: 16.11.2014
• 10 Chowdhury R, Warnakula S, Kunutsor S et al. Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis. Ann Intern Med 2014; 160: 398-406
• 11 Threapleton DE, Greenwood DC, Evans CE et al. Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis. BMJ 2013; 347: f6879
• 12 Hartley L, Flowers N, Holmes J et al. Green and black tea for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2013; (6) CD009934
• 13 Semba RD, Ferrucci L, Bartali B et al. Resveratrol levels and all-cause mortality in older community-dwelling adults. JAMA Intern Med 2014; 174: 1077-1084
• 14 Ried K, Toben C, Fakler P. Effect of garlic on serum lipids: an updated meta-analysis. Nutr Rev 2013; 71: 282-299
• 15 Joseph J, Loscalzo J. Selenistasis: epistatic effects of selenium on cardiovascular phenotype. Nutrients 2013; 5: 340-358
• 16 Del Gobbo LC, Imamura F, Wu JH et al. Circulating and dietary magnesium and risk of cardiovascular disease: a systematic review and meta-analysis of prospective studies. Am J Clin Nutr 2013; 98: 160-173
• 17 Reid IR. Should we prescribe calcium supplements for osteoporosis prevention?. J Bone Metab 2014; 21: 21-28
• 18 Genser B, Silbernagel G, De Backer G et al. Plant sterols and cardiovascular disease: a systematic review and meta-analysis. Eur Heart J 2012; 33: 444-451
• 19 Potgieter M, Pretorius E, Pepper MS. Primary and secondary coenzyme Q10 deficiency: the role of therapeutic supplementation. Nutr Rev 2013; 71: 180-188
• 20 Mortensen SA, Rosenfeldt F, Kumar A et al. Q-SYMBIO study investigators. The effect of coenzyme Q10 on morbidity and mortality in chronic heart failure: results from Q-SYMBIO: a randomized double-blind trial. JACC Heart Fail 2014; DOI: 10.1016/j.jchf.2014.06.008.
• 21 Mortensen SA, Rosenfeldt F, Kumar A et al. Q-SYMBIO Study Investigators. The effect of coenzyme Q10 on morbidity and mortality in chronic heart failure: results from Q-SYMBIO: a randomized double-blind trial. JACC Heart Fail 2014; DOI: 10.1016/j.jchf.2014.06.008.
• 22 Graudal N, Jürgens G, Baslund B et al. Compared with usual sodium intake, low- and excessive-sodium diets are associated with increased mortality: a meta-analysis. Am J Hypertens 2014; 27: 1129-1137
• 23 Patel AY, Pillarisetti J, Marr J et al. Ezetimibe in combination with a statin does not reduce all-cause mortality. J Clin Med Res 2013; 5: 275-280
• 24 Scientific opinion on the tolerable upper intake level of vitamin D. EFSA Journal 2012; 10: 2813
• 25 Scientific opinion on the tolerable upper intake level of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) and docosapentaenoic acid (DPA). EFSA Journal 2012; 10: 2815