© Whole Foods Magazine

January 2004

Coenzyme Q-10 and Heart Health

An interview with Dr. Stephen Sinatra: Part 1

By Richard A. Passwater, Ph.D.

When we started this series about CoQ in January 2002 with an interview with Dr. Bill Judy, I mentioned that CoQ would be gaining wider usage over the next few years. Well, the November 2003 issue of this magazine reports that worldwide consumption of CoQ has indeed tripled in that time ( Shortage of CoQ-10 Material Rocks Industry Manufacturers, WholeFoods, November 2003, Page 28).

The article cites three reasons for the increase. One reason is that consumers taking statin drugs to control elevated cholesterol levels are learning that they need supplemental coenzyme Q-10 to offset the side effects of the drugs (See the February 2003 interview with Dr. Emile Bliznakov entitled Donít Take Cholesterol-Lowering Drugs Unless You Also Take Coenzyme Q-10, WholeFoods, February 2003, Page 61). The other two reasons cited were the new studies showing that high doses of coenzyme Q-10óup to 1,200 mg per dayóhave had positive effects on Parkinsonís disease and that coenzyme Q-10 is now sold over the counter instead of by prescription at high doses in Japan.

As we continue with this series, we now have the opportunity to chat with cardiologist Dr. Stephen Sinatra. We will explore the many benefits of coenzyme Q-10 in heart health and normalizing blood pressure. Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., is a board-certified cardiologist and a certified bioenergetic psychotherapist, with more than 25 years of experience in helping patients prevent and reverse heart disease. He also is certified in anti-aging medicine. He is a fellow of the American College of Cardiology and former chief of cardiology at Manchester Memorial Hospital where he was director of medical education for 18 years. Dr. Sinatra is also assistant clinical professor of medicine at the University of Connecticut School of Medicine.

At his New England Heart & Longevity Center in Manchester, CT, Dr. Sinatra integrates conventional medical treatments for heart disease with complementary nutritional, anti-aging and psychological therapies that help heal the heart. He is uniquely qualified to give advice on nutritional supplements and the heart. Dr. Sinatra is one of the few medical doctors who formulates his own vitamins. He is expert in dosage, absorption, how to pick quality ingredients, and the effects of combining supplements with cardiac medications.

Dr. Sinatra has authored and/or co-authored several books on heart disease and is the editor of the monthly newsletter on heart health, The Sinatra Health Report. His most recent book, co-authored with his wife, Jan Sinatra A.P.R.N., is Lower Your Blood Pressure in Eight Weeks (Ballantine Books, 2003). Additional information can be found on his website at www.drsinatra.com.


Passwater: Dr. Sinatra, why did you become a cardiologist and not a singer?

Sinatra: I didnít know what I wanted to be when I grew up. I finished a year of internship and completed six months of psychiatry, six months of medicine and then two years of straight medicine but I had no idea about which specialty I was going to go into. I was thinking of going into gastroenterology at Yale; I had good connections and spent several months of my residency training there, but it didnít feel quite right.

It was New Yearís Eve 1974. I was in a Veterans Hospital and a guy went into complete heart block. It was really interesting. A patient in his 40s came into our Critical Care Unit with an acute myocardial infarct. It wasnít really a major heart attack, but a minor one. However, it was enough to put him into complete heart block, which means his heart rate dropped to the high teens and we had to summon the cardiologist on call. It was a snowy night and there was a huge delay before the cardiologist arrived at the hospital. Meanwhile, the patient was dying and we kept resuscitating him on and off. I was only about 28 at that time and the patient was in his young 40s. I remember intubating him as he was going in and out of consciousness. Finally, the on-call cardiologist arrived. It took him three hours to get a pacemaker in, but the patient pulled through. All of a sudden a message was sent to me. I wanted to learn how to do that, but instead of three hours, I want to be able to do it in three minutesóand eventually, I did. It was that one patient that inspired me that night to become a cardiologist.

I started my formal training in cardiology early in April of 1975. As fate would have it, my first two years were in invasive cardiology. In 1977, my first year of practice, I put in 119 emergency pacemakers. My average procedure time was about a minute, not a few hours. I became very skilled at invasive cardiology.

The flip side of that was I often reflected on why I had chosen cardiology; unconsciously I must have wanted it. I realized that I thrived on the action and that came out of my athletic training. All through high school and college I had been active in sports, football and wrestling. In college I was a Division One wrestler and my team wrestled a tough schedule, including Army, Navy, Pitt, Penn State, Syracuse, and Lehigh. As an athlete, you want to win. To me, there is no better specialty than cardiology where actions can be lifesaving and there are but a very few seconds for decision making. You have to make a decision, make it quick, and you have to win. So I was in the right specialty. In other words, winning was the only thing, and I feel blessed that I went to cardiology.

For about 10 or 15 years, I was an invasive cardiologist, taking care of thousands and thousands of sick people. I did lots of coronary angiograms, put in lots of (emergency) pacemakers, and treated a lot of cardiogenic shock. It prepared me to be a preventive cardiologist later on in the future.

Passwater: I can see the natural progression. First, emergency care, then surgical correction, and finally the desire to prevent all of this in the first place.

Sinatra: Yes, when you are taking care of some really sick people so much, you just want to find a way to prevent all that suffering before it begins. By the way, we share a similar path. I got involved with preventive cardiology in the 1970s. Do you remember Dr. Jacob Rinse?

Passwater: Yes, he developed the Dr. Rinse Breakfast for a healthy heart. We were friends. I met him after one of my lectures in the mid-1970s and wrote about his heart-healthy diet in Supernutrition for Healthy Hearts in 1978. He had angina at the age of 51 and had developed a breakfast rich in lecithin, vitamins, minerals and other natural nutrients that restored his health. People liked his variations of the Dr. Rinse breakfast and they reported that they were helped by it. He devised a series of breakfast foods ranging from cereal to pancakes to muffins that were rich in lecithin, brewerís yeast, wheat germ and bone meal. He was sharp.

Sinatra: He was 91 when he last called me. He first called me in 1978. I will never forget how sharp he was. If I ever make it to 90, I want to be like him. He was very instrumental in getting me involved in preventive cardiology in the late 70s.

Passwater: Isnít that something?

Sinatra: Itís a small world! Dr. Rinse was very involved with phosphatidylcholine (PC).

Passwater: Lecithin and PC were important factors in his Dr. Rinse Breakfast. As a physical chemist, he saw a link between cholesterol solubility and lecithin and suggested that this link may be important in preventing atherosclerosis. The biochemistry may not be as simple as the physical chemistry suggested, but the fact remains that his breakfast and diet were beneficial for healthy arteries and heart. It may have been a serendipitous event, as I think his diet worked more as a result of other factors than simple cholesterol solubility or transport.

Sinatra: I agree. What really causes coronary disease is inflammation. What is more important than the blood level of cholesterol is the blood level of the inflammatory index, c-reactive protein. Dr. Rinse was speaking about cholesterol with PC and phosphatidylserine. They are excellent membrane stabilizers and reduce the effects of inflammation. When there is occult inflammation, some of the ingredients he mentions will help deter some of those inflammatory components. It will help build cells. Itís kind of interesting. Dr. Rinse was positioned more or less as Pfizer and Merck are today. They have great drugs that lower blood cholesterol levels, but it is not really the level of blood cholesterol that causes heart disease. It is really the drugsí additional ability to lower inflammation that produces the results.

Passwater: I have stressed that oftenómost recently in a discussion of the statin drugs with Dr. Emile Bliznakov, but in more detail in an earlier chat with Jack Challem about his book called The Inflammation Syndrome (WholeFoods, March 2003, Page 56). Finally, inflammation is being recognized as a leading risk factor in heart disease. For about 50 years, various versions of the cholesterol theory were popular. First, it was dietary cholesterol, then blood cholesterol, and then HDL/LDL ratio. Merged in between, were various fat theories, first saturated fat, then unsaturated fat to saturated fat ratio, and finally total fats. The first cholesterol-lowering drugs were virtually ineffective because thatís all they did. Now, the cholesterol-lowering statin drugs are proving to be of wide benefit, not because they lower cholesterol (which they do indeed do), but primarily because they are anti-inflammatory. Inflammation generates billions of free radicals that do the damage leading to various forms of heart disease.

Sinatra: The Southern Medical Journal asked me to review a very standard cholesterol-lowering article with statins. I made so many comments and questions for the author, that the Journal asked me to write an editorial. It took me 60 hours to write the editorial, but I proved in the editorial that we are lowering cholesterol for all the wrong reasons.

The article was entitled, "Is cholesterol lowering with statins the gold standard for treating patients with cardiovascular risk and disease?" (South Med J. 2003; 96(3):220-2).

Passwater: The cholesterol theory just didnít make sense with the evidence they had. It wasnít that I was against the cholesterol theory, I was upset that they had jumped the gun so much, took great leaps of faith, and then spoke of it as if it was the absolute unquestionable truth. It isnít the main cause of heart disease as they proclaimed it was. I am still marveling over the fact that Dr. Rinse was the one who got you interested in preventive cardiology. We owe him even more than I thought.

Sinatra: I was board-certified in cardiology in 1977. In 1978, I spoke with Dr. Rinse, and he opened my eyes to the fact that there could be an alternative way of looking at cardiology. So since 1978 I have been involved with cardiovascular disease prevention.

Passwater: In 1978, we didnít really know a lot about coenzyme Q-10 and heart disease. When did you become involved with coenzyme Q-10?

Sinatra: During the late 1970s and early 1980s, when I was recommending vitamins E and C, the standard nutrients nutritional biochemists such as yourself and nutritionally-oriented physicians recommended back then for cardiovascular prevention. I came across an article in The Annals of Thoracic Surgery by Dr. J. Tanaka and other Japanese physicians in 1982 about using coenzyme Q-10 in patients coming off the heart/lung machine (Ann Thorac Surg 1982; 33:145-51). We were doing a lot of bypass surgery in our institution. I asked myself, "How can a nutrient help you come off the heart/lung pump more easily?"

I clipped the article. I donít remember reading it, but I stored it away in one of my folders. Then in 1985, I was taking care of an African American minister who had blown out his mitral valve. He had mitral valve prolapse and ruptured a chord. He went into to severe mitral regurgitation. I catheterized him and found that he had normal coronary arteries but a failing mitral valve. He required immediate mitral valve replacement, which we accomplished. The horror was that we couldnít get him off the heart/lung machine. We lost him, and I was distraught. I was absolutely mortified, and so were the surgeons.

This happens to a cardiologist once in a lifetime. It happened to me pretty early in my career, about 10 years after I finished my training. I kept wondering over and over if there was anything else I could have done for this guy in retrospect. I remembered that article I had clipped in 1982. At this time it was 1986 and Dr. Emile Bliznakovís book The Miracle Nutrient had been published. I realized that the article in The Annals of Thoracic Surgery discussed coenzyme Q-10. I went back to the article, and sure enough, the Japanese were using coenzyme Q-10 in helping these patients.

What the article stated, and what I later observed on my own, is that coenzyme Q-10 lowers what we call pulmonary capillary wedge pressure and it makes it easier for the patient to come off the heart/lung machine. It supports the patient so the patient doesnít have to struggle as much. I said, "Oh, my gosh, if only I had known this prior to the ministerís ordeal we might have saved him." I read Dr. Bliznakovís book. It was very timely, and ever since 1986, coenzyme Q-10 has been an important tool in my practice.

At that time, only small dosages were available, and it was very expensive. In 1986, I started using 10 mg of coenzyme Q-10 three times a day as a standard for all of my patients and tripled it to 30 mg three times a day for all my patients undergoing bypass or vascular surgery. I was giving Co-Q10 prophylactically because of this one article and because of that horrible experience Iíd had. By 1987, I had increased the coenzyme Q-10 dosage to 30 mg three times a day, and I also broadened my use of it to a whole host of cardiological conditions.

I started presenting papers at the Coenzyme Q-10 Association meetings about my success using it with my patients. While at these meetings, I learned more and more about Co-Q10. That was in the 1990s. Now, I am very active with coenzyme Q-10 through my lecturing and writing. So it was 1985 and 1986 where the real transition happened. We are now almost at the end of 2003 and I have been using the nutrient for almost 20 years on a day-to-day basis in my practice. I have recommended coenzyme Q-10 to thousands of patients I see in my practice and to many thousands of subscribers who read my monthly newsletter, The Sinatra Health Report.

This has allowed me to witness the myriad of heart benefits that coenzyme Q-10 provides. Most of the heart-health benefits of this coenzyme are due to its ability to directly support energy production in heart cells, and all cells for that matter, to stabilize cell membranes, and to reduce blood platelet size, distribution and stickiness. The latter action normalizes activated blood platelets, which can initiate the process leading to a heart attack. Of course, coenzyme Q-10 also acts to reduce artery damage and plaque formation via its antioxidant action. It also has a remarkable affinity to protect heart cells that are deficient in oxygen.

Another thing I would say is that for all my patients with cardiac disease, there are two nutrients that I must useóone is coenzyme Q-10, and the other is the omega-3 fish oils. I recommend them wholeheartedly for any cardiac patient. Not every one of my patients follows my advice, but I would say over 90% do. I would say I have more than 90% of my cardiac practice on coenzyme Q-10 and omega-3 fatty acids.

Passwater: What dosages of coenzyme Q-10 do you use for the various types of cardiac disorders?

Sinatra: The dosage is tailored to the patient depending on several factors, but in general, my recommendations to help prevent cardiovascular or periodontal disease, and to patients taking Hmg-CoA reductase inhibitors such as the statins are to take between 60 and 100 mg of coenzyme Q-10 daily. For the treatment of angina pectoris, cardiac arrhythmia, high blood pressure or gingival disease, I normally recommend 90 to 180 mg of coenzyme Q-10 a day. And, for congestive heart failure and dilated cardiomyopathy, I recommend raising the daily intake to 180 to 360 mg of coenzyme Q-10. Of course, for patients with severely impaired immune systems such as in cancer or AIDS, even higher dosages of coenzyme Q-10 are required.

Passwater: You mentioned that you often use coenzyme Q-10 together with omega-3 fish oils. What other nutrients do you recommend for your patients who have arrhythmias (irregular heart beats) or high blood pressure?

Sinatra: First of all, let me says that I always measure coenzyme Q-10 blood levels with my patients, especially with heart failure, because if you have a blood level less than 3.5 mcg per milliliter, you are really not therapeutically treating them. Unfortunately, that is one of the reasons why there have been some negative trials with Co-Q10, because the researchers didnít get the blood levels high enough. People vary in their ability to absorb coenzyme Q-10. Also, dietary factors, including the fat needed to absorb coenzyme Q-10, play an important role, as does the form and bioavailability of the supplement.

Let me now address your question about which nutrients I use to treat various conditions. I see a lot of people with high blood pressure who want to get off drugs. That is the subject of my most recent book, entitled Lower Your Blood Pressure in 8 Weeks. For arrhythmia, and I also see a lot of people who have intermittent atrial fibrillation, the heart is beating regularly and then, all of a sudden, it beats fast and irregularly. The "cocktail" I use to keep the heart stable includes coenzyme Q-10, L-carnitine, magnesium and fish oil. They all work differently, but they all help stabilize the heartbeat and heart rhythm. I use them in many of my patients.

For congestive heart failure, I utilize a combination of high-dose coenzyme Q-10, intended to significantly raise coenzyme Q-10 blood levels, as well as L-carnitine, hawthorn and magnesium. I substitute magnesium for fish oil and I use hawthorn in that cocktail as well. For people who have devastating heart failure who I canít help with coenzyme Q-10, or carnitine, or hawthorn and magnesium, I use high-dose taurine; sometimes I go to L-arginine, and rarely to growth hormone.



Passwater: The basic ingredients of your cocktails are coenzyme Q-10 and L-carnitine.

Sinatra: Yes, and if the condition doesnít improve, then Iíll add hawthorn. Normally, Iíll go to 1.5 grams of hawthorn. Hawthorn, for some reason, works very well with coenzyme Q-10 and L-carnitine. There are publications in the German medical literature showing that hawthorn helps in heart failure.

Passwater: I want to chat with you about your research on high blood pressure, but letís hold that off for later. Right now, I want to discuss the report you gave at one of the International Coenzyme Q-10 Association meetings. You did a review of the studies and found something like only 1.7 or some very low number of participants and low number of studies that did not produce beneficial effects.

Sinatra: Not only did I report on it at the meeting, but I also wrote about it in a peer-reviewed journal called Heart Disease. Basically, there have been about 43 controlled trials of coenzyme Q-10, and 39 of them have shown benefit while four have shown no benefit. The problem is that in the two major trials that showed no benefitóone was done in Australia and the other was done in Marylandóthe levels of coenzyme Q-10 in the blood were not raised to therapeutic levels. Both trials were well designed; they had a control group and an experimental group. But, I believe they must have used inferior quality CoQ-10 because they could only get the patientsí blood levels of coenzyme Q-10 up to two mcg per milliliter of blood. Now, in preventing cardiovascular disease or trying to prevent lipid peroxidation, a blood level of two mcg of coenzyme Q-10 per milliliter of blood is OK; but for patients with class three and class four heart failure, a blood level of two mcg of coenzyme Q-10 per milliliter of blood will do nothing!

Unfortunately, that article reporting no benefit got a lot of press. A lot of cardiologists quote that study saying CoQ-10 doesnít work. I wrote a letter to the editor of The Annals of Internal Medicine stating that the bio-sensitive amount of coenzyme Q-10 was lacking and also they used beta-blockers in those patients as well. As you know, beta-blockers, statin drugs, oral hypoglycemics and antidepressants, inhibit the endogenous synthesis of coenzyme Q-10. This is one reason why many people are deficient in coenzyme Q-10óand serious deficiencies exist.

Therefore, in the so-called negative study, they used a drug that inhibits the natural production of coenzyme Q-10 in the body and they also used a supplementation level that got the blood level to only two mcg per milliliter. So this study was doomed to fail from the beginning, and that is why they didnít have a therapeutic response. Unfortunately, those are the studies that doctors quote.

Passwater: On that important point, letís take a break and continue our discussion in our next column. WF

© 2004 Whole Foods Magazine and Richard A. Passwater, Ph.D.

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