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CME / ABIM MOC / CE

Do Multivitamins Promote Heart Health?

  • Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 8/10/2018
  • THIS ACTIVITY HAS EXPIRED
  • Valid for credit through: 8/10/2019
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Target Audience and Goal Statement

This article is intended for primary care clinicians, for cardiologists, dermatologists, diabetologists, endocrinologists, neurologists, nurses, pharmacists, public health officials, and other members of the healthcare team for patients considering vitamin supplementation to benefit heart health.

The goal of this activity is to provide medical news to primary care clinicians and other healthcare professionals in order to enhance patient care.

Upon completion of this activity, participants will be able to:

  • Describe potential associations between multivitamin/mineral (MVM) supplementation and coronary heart disease (CHD), stroke, and various other cardiovascular disease (CVD) outcomes, according to a systematic review and meta-analysis
  • Determine clinical implications of potential associations between MVM supplementation and CHD, stroke, and various other CVD outcomes, according to a systematic review and meta-analysis


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News Author

  • Megan Brooks

    Freelance writer, Medscape

    Disclosures

    Disclosure: Megan Brooks has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC

    Disclosures

    Disclosure: Laurie Barclay, MD, has disclosed the following relevant financial relationships:
    Owns stock, stock options, or bonds from: Pfizer

Editor/CME Reviewer/Nurse Planner

  • Amy Bernard, MS, BSN, RN-BC, CHCP

    Lead Nurse Planner, Medscape, LLC

    Disclosures

    Disclosure: Amy Bernard, MS, BSN, RN-BC, CHCP, has disclosed no relevant financial relationships.


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CME / ABIM MOC / CE

Do Multivitamins Promote Heart Health?

Authors: News Author: Megan Brooks; CME Author: Laurie Barclay, MDFaculty and Disclosures
THIS ACTIVITY HAS EXPIRED

CME / ABIM MOC / CE Released: 8/10/2018

Valid for credit through: 8/10/2019

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Clinical Context

In the United States and other developed countries, MVM supplement use is widespread, despite recommendations from the US Preventive Services Task Force and the National Institutes of Health against the routine use of such supplements to attempt to prevent chronic disease. Although previous research has examined the possible association between MVM supplementation and CVD outcomes, potential benefits are still unclear. To date, most research has shown a net neutral effect of MVM supplements on cardiovascular (CV) health, although several studies seem to indicate possible benefit for specific cardiovascular outcomes.

The goal of this systematic review and meta-analysis by Kim and colleagues was to identify and clarify potential associations between MVM supplementation and coronary heart disease (CHD), stroke, and various other CVD outcomes.

Study Synopsis and Perspective

Taking multivitamin/mineral (MVM) supplements does not prevent myocardial infarction, stroke, or death from a CV cause, according to a comprehensive meta-analytic review of relevant research.

"The take-home message is simple: there is no scientific evidence that MVM supplements promote cardiovascular health. We hope that our paper helps to settle the controversy on MVM use for CVD prevention," lead author Joonseok Kim, MD, University of Alabama at Birmingham, told theheart.org | Medscape Cardiology.

The study was published online on July 10, 2018 in Circulation: Cardiovascular Quality and Outcomes.[1]

"Vitamin and mineral supplements are taken by nearly half of US adults, yet few benefits have been documented," said JoAnn Manson, MD, who was not involved in the study and is chief of preventive medicine, Brigham and Women's Hospital and professor of medicine, Harvard Medical School, both in Boston, Massachusetts.

"Regarding multivitamins and cardiovascular disease, specifically, neither observational studies nor randomized clinical trials have demonstrated clear benefits for primary or secondary prevention," Dr Manson told theheart.org | Medscape Cardiology.

"Importantly, clinicians should emphasize with their patients that multivitamin supplements will never be a substitute for a healthful and balanced diet, which have many beneficial components for vascular health. Additionally, micronutrients in food are typically better absorbed by the body than those from supplements," she advised.

Dr Kim and colleagues did a systematic review and meta-analysis of 18 studies with more than 2 million adults (mean age, 57.8 years) with mean follow-up of 11.6 years. Eleven studies were from the United States, 4 from Europe, and 3 from Japan. Only 5 studies specified the dose and type of MVM supplement.

Overall, there was no association between MVM supplement use and CVD mortality, the investigators reported.

Table. MVM Supplementation and Outcome Risks

Outcome Relative Risk (95% CI)
CVD mortality 1.00 (0.97, 1.04)
Coronary heart disease mortality 1.02 (0.92, 1.13)
Stroke mortality 0.95 (0.82, 1.09)
Stroke incidence 0.98 (0.91, 1.05)

There was also no link between MVM supplements and CVD or coronary heart disease (CHD) mortality in prespecified subgroups categorized by mean follow-up; mean age; period of MVM use; sex; type of population; exclusion of patients with history of CHD; and adjustment for diet, smoking, physical activity, and study site.

Multivitamin/mineral supplement use did appear to be associated with a lower risk for CHD incidence (relative risk [RR]=0.88 [95% CI: 0.79, 0.97); however, this association did not remain significant in the pooled subgroup analysis of randomized controlled trials (RR=0.97 [95% CI: 0.80, 1.19]).

"It has been exceptionally difficult to convince people, including nutritional researchers, to acknowledge that multivitamin and mineral supplements don’t prevent cardiovascular diseases," Dr Kim said in a news release. "I hope our study findings help decrease the hype around multivitamin and mineral supplements and encourage people to use proven methods to reduce their risk of cardiovascular diseases -- such as eating more fruits and vegetables, exercising and avoiding tobacco."

The American Heart Association does not recommend use of MVM supplements for CVD prevention.

"Plausible but Failed Practice"

In a linked editorial, Alyson Haslam, MD, and Vinay Prasad, MD, both from Oregon Health & Science University in Portland, Oregon, noted that practices in biomedicine are often adopted because they "appeal to our hopes and there is biologic plausibility.[2]

"In the case of multivitamins, it is logical that some vitamins may reduce cardiovascular events because they are anti-inflammatory or more broadly improve health and well-being. Yet, in this case, it appears they do not, and as such, multivitamins for cardiovascular disease joins the list of plausible but failed practices in cardiology," they concluded.

Although multivitamins tend to be moderately dosed and are likely to be safer than megadoses of individual dietary supplements, "they are not completely free of risk in all patients," Dr Manson told theheart.org | Medscape Cardiology.

For example, dietary supplements may interact with some medications, such as vitamin K and warfarin; interfere with the measurement of some clinical laboratory tests, such as biotin and troponin levels; they also have adverse effects, such as gastrointestinal symptoms, for some patients, she explained. 

"Thus, routine multivitamin supplementation is not recommended for the general population, but a targeted approach is appropriate for certain life stages and high-risk groups," said Dr Manson.

Some examples of relevant life stages include pregnancy, where supplementation with folic acid/prenatal vitamins is of benefit, and in midlife or older adults, some of whom may benefit from supplemental vitamin B12, vitamin D, and/or calcium. High-risk groups, such as those with malabsorption syndromes, restricted eating patterns, osteoporosis, pernicious anemia, and age-related macular degeneration, and those with long-term use of metformin or proton-pump inhibitors also may benefit from dietary supplements, she said.

Dr Manson also noted that the Physicians’ Health Study II, a large-scale, randomized clinical trial of multivitamins in men, demonstrated that these supplements may modestly reduce the incidence of cancer.[3] This finding is being explored further in the ongoing COSMOS trial, which is testing whether multivitamins, with or without cocoa flavonols, can reduce the risk for cancer and CVD in older men and women.[4]

 "Results from the COSMOS trial are expected in 2 years, so stay tuned," said Dr Manson.

The study authors have disclosed no relevant financial relationships.

Circ Cardiovasc Qual Outcomes. Published online July 10, 2018.

Study Highlights

  • A thorough search of Medline, Embase, and the Cochrane Library from January 1970 through August 2016 identified 18 clinical trials and prospective cohort studies in the general population examining associations between MVM supplementation and CVD outcomes.
  • 2 authors independently performed data extraction and quality assessment, and a third author resolved discrepancies.
  • The total number of participants in the included studies was 2,019,862, with 18,363,326 person-years of follow-up.
  • Only 5 of the 18 studies specified the dose and type of MVM supplement.
  • Overall, no association was identified between MVM supplementation and CVD mortality (RR=1.00 [95% CI: 0.97, 1.04]), CHD mortality (RR=1.02 [95% CI: 0.92, 1.13]), stroke mortality (RR=0.95 [95% CI: 0.82, 1.09]), or stroke incidence (RR=0.98 [95% CI: 0.91, 1.05]).
  • In prespecified subgroups according to mean follow-up period, age, duration of MVM use, sex, type of population, excluding patients with CHD history, and adjustment for diet, smoking, physical activity, or study site, MVM supplements were not associated with CVD or CHD mortality.
  • Although MVM use appeared to be associated with a lower risk for CHD incidence (RR=0.88 [95% CI: 0.79, 0.97]), this association did not remain significant in the pooled subgroup analysis of randomized controlled trials (RCTs) (RR=0.97 [95% CI: 0.80,1.19]).
  • MVM supplement use was associated with lower risk for CHD incidence in studies performed outside of the United States.
  • According to their meta-analysis of clinical trials and prospective cohort studies, the investigators concluded that MVM supplementation does not improve CV outcomes in the general population.
  • They suggested their findings support present guidelines recommending against the routine use of MVM supplements to promote CV health.
  • Previous research has not shown better CV outcomes in the general population with therapeutic supplementation of deficient vitamins, such as vitamin D, and there is even less evidence of cardiovascular benefit in the general population without confirmed vitamin deficiency.
  • Nonetheless, laboratory studies have suggested possible theoretical benefits.
  • In contrast, several studies showed that routine MVM supplementation in the elderly and in certain other populations could actually result in worse outcomes.
  • This meta-analysis supported the authors’ hypothesis that in the general population, there is a neutral net effect of MVM supplementation for CVD prevention.
  • When all studies were considered, MVM supplement use was inversely associated with CHD incidence, but this association persisted only in cohort studies, which were subject to limitations, and not when subgroup analysis was conducted on RCTs.
  • Limitations of this meta-analysis include significant heterogeneity among the cohort studies (I2=67.5%) but not among RCTs (I2=0.0%); reliance on self-reporting for MVM supplement use in cohort studies, with data lacking with regard to type and dose in most of these studies; and possible residual confounding factors and inability to identify causation in cohort studies.
  • The investigators noted that MVM supplementation cannot substitute for a healthful and balanced diet, which contains many beneficial micronutrients that are usually better absorbed by the body than those from supplements.
  • To lower CV risk, patients should consume more fruits and vegetables, exercise, and avoid tobacco.
  • Multivitamins are generally taken at moderate doses and are likely safer than megadoses of individual dietary supplements, but they may interact with some medications, such as vitamin K interacting with warfarin.
  • They may also interfere with clinical laboratory tests, such as biotin and troponin levels, and adverse effects may include gastrointestinal symptoms in some patients.
  • Still, targeted MVM use may be appropriate in certain settings, such as folic acid and prenatal vitamins in pregnancy, and supplemental vitamin B12, vitamin D, and/or calcium in some midlife or older adults.
  • Dietary supplementation may also benefit certain patients at high risk, such as patients with malabsorption syndromes, restricted eating patterns, osteoporosis, pernicious anemia, age-related macular degeneration, and/or long-term use of metformin or proton pump inhibitors.
  • The Physicians’ Health Study II also showed that MVM supplementation in men may modestly lower cancer incidence, which is now being tested further in the ongoing COSMOS trial of MVM supplementation with or without cocoa flavanols to lower cancer and CVD risk among older men and women.
  • An accompanying editorial calls MVM supplementation a "plausible but failed [practice] in cardiology," according to their anti-inflammatory or otherwise health-promoting effects but their apparent lack of efficacy for CV prevention.

Clinical Implications

MVM supplementation does not appear to improve CV outcomes in the general population, according to a meta-analysis of clinical trials and prospective cohort studies.

The findings support present guidelines that recommend against the routine use of MVM mineral supplements to promote CV health.

Implications for the Healthcare Team: Targeted MVM use may be appropriate in certain settings, such as for certain patients at high-risk; folic acid and prenatal vitamins in pregnancy; and supplemental vitamin B12, vitamin D, and/or calcium in some midlife or older adults.

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