quick takes

Hypertension, or high blood pressure is the most important modifiable risk factor for the development of atherosclerotic vascular disease (ASVD). ASVD includes coronary artery disease, which can lead to heart attacks, carotid artery disease, which can lead to strokes, and peripheral vascular disease, which can lead to limb loss. Nevertheless, it is one of the most underdiagnosed and undertreated risk factors.

For decades, salt has been considered a major contributor to hypertension. The majority of clinical trials strongly support such association. In 2001, the DASH-Sodium trial revealed that there is a synergistic positive effect on blood pressure reduction with the DASH diet, which was originally published in 1997 as an overall healthy lifestyle diet with emphasis on fruits, vegetables, and low-fat. This in itself led to a blood pressure reduction. With a restriction of sodium in the diet, there were further beneficial effects on both systolic and diastolic blood pressure.

In a separate study, the higher the starting blood pressure was, the more effective sodium restriction was.

Just presented at the American Heart Association Meeting, another cross-overstudy, (CARDIA-SSBP), showed that participants on a low sodium diet had a reduction of blood pressure. Once they switched to the second arm of the trial with a high sodium diet, there was an increase of blood pressure. The changes were significant and independent of age, sex, race, baseline blood pressure, or diabetes, and obesity.

High sodium ingestion by itself seems to have a deleterious effect on the vascular function with vascular stiffness, and independent of high blood pressure on the development of heart muscle thickness and loss of elasticity. 

Both are viewed as risk factors for cardiovascular disease.

In summary, if we accept the fact that high blood pressure is the largest modifiable risk factor for heart disease, and if we accept the results from multiple sodium/salt trials demonstrating deleterious effects on hypertension, then we can deduce that a high sodium intake is a strong contributor to the development of atherosclerotic vascular disease.

To me, the data goes beyond just an observational association, but rather is a causative correlation. Nonetheless, the critics will argue that there is no hard data proving that salt is a cause of myocardial infarction, strokes, and cardiovascular death, or death from other causes. I think, the cause and effect is hardly arguable. The results, however, are not seen overnight, but over the years.

Your routine may be different, but after I get up, and do my basic hygiene, I head to the kitchen, grab my Italian mocha pot, the classic one, which is essentially in every Italian household, and brew myself two cups of Italian style coffee, which permeates the kitchen with a wonderful aroma. I don't use any fancy coffee beans, just regular dark or medium roast, often, whatever is available at my local Costco store. The mocha pot is the average Joe's stove top "Espresso" coffee maker. Nothing fancy, $40-$50 will get you one. It is actually not a real espresso pot, as it doesn't make a crema, the characteristic dense foam layer, generated only with high pressure and high dollar espresso machines. But, the taste is still delightful. I prefer it to a drip coffee, although any style would be okay to prepare. I take it black - it has a lovely bitterness, however, sometimes I have a couple of walnuts and maybe a banana or a date with it; which mellows the bitterness and creates a pleasing flavor contrast for the taste buds. If you want to try a piece of dark chocolate with it, go for it; a doughnut? - I’ll give you that, but no more than once a week.

A couple minutes after the 1st cup, I feel a little buzz in my head, and my senses are being activated. It is almost like shifting into a higher gear. So, not only does it taste good, but it also has the caffeine driven energizing effect. As a matter of fact, legend has it, that the coffee plant was discovered around the 9th century by accident by an Ethiopian Goatherd, who noticed his goats being hyperactive after eating the coffee berries. This story, although funny, is not really historically firm. It was not until the 15th century that coffee began to be roasted into similar product, as we know it today. Nonetheless, the buzz and the satisfaction lasts for a couple hours, and around 11 o'clock in the morning, I usually have a little dip in my adrenaline level and crave another cup. Addiction? Maybe a little bit, but not a bad one.

I have had this routine for years, but not until recently have I learned, that coffee, as well as tea, have a real health benefit. In recent years, many high quality clinical studies have been published about coffee and tea, and across-the-board, they have all revealed beneficial effects on cardio-metabolic diseases. More specifically, habitual coffee drinking is associated with improved glucose metabolism, and reduction of the risk of diabetes by virtue of improving insulin sensitivity and reducing glucose release from the liver, just to name a few. The risk of dying, and specifically from cardiovascular diseases, is also significantly (10-20%) reduced. The thinking is, that many of the bio-active substances in coffee, like the polyphenols and flavonoids, have antioxidant and anti-inflammatory properties. Nowadays, we know that inflammation is a major part of chronic metabolic and cardiovascular diseases so such effect is quite plausible.

Many of you guys, and this is true for some physicians as well, are still experiencing the knee-jerk reaction that coffee might be detrimental in heart disease, raise blood pressure, and cause various rhythm disturbances. For habitual coffee drinkers, all of the above has been shown not to be the case. Now, there is a caveat to it, sporadic coffee drinkers who suddenly ingest a significant amount of caffeine may occasionally experience elevated heart rate, elevated blood pressure, and perception of heart pounding. In certain patients who have known arrhythmias, a sudden surge in stimulant level provided by caffeine could trigger an episode. However, in habitual coffee drinkers, there has been no association with an increased risk of heart events; such as angina (chest pain), heart failure, arrhythmias, or death, even if one already has underlying coronary artery disease or arrhythmias. Nothing in this world is 100% so, if you are the rare person who experiences such an exaggerated response to coffee (especially caffeinated), you may want to try to switch to decaffeinated or decaffeinated instant coffee. You will still derive the same benefits since it is known that the reduction of metabolic and cardiovascular problems are not related to caffeine, but highly likely to the approximately 100 bioactive substances i.e. Polyphenols and antioxidants, which are still present in decaffeinated brew.

If you enjoy coffee and the taste of it, then jump on the bandwagon, but avoid adding high amounts of sugar, creamers, artificial sweeteners, or full fat dairy i.e. heavy cream or half and half excessively. These, although they are delectable additives, will negate the heart healthy effects of coffee and tea.

It is also of interest, that many habitual coffee drinkers are also smokers. I hear it all the time, “I have to have my cigarette with my morning cup of coffee.” Such combo has been linked to increased risk of lung disease and cancer, not from the coffee, but from the cigarette. The coffee will not save you. So there's only one thing to do - ditch the cigarette and have an extra cup of coffee. 

One more caveat: Coffee has substances, more present in unfiltered coffee, called diterpenes; which were found in research to raise total cholesterol. However, the clinical significance of this is unclear and I, personally, doubt it is of any relevance since all published studies in reputable peer reviewed journals reveal beneficial effects on cardiovascular incidence and mortality as well as plaque formation in coronary arteries; as assessed by calcium score. This is regardless of the type of brew. Although cholesterol (particularly the bad cholesterol; LDL) is obviously an important risk factor for plaque formation (blockages) in the arteries, we are also learning now that not all cholesterol (bad or good) is equal and that sub-classes may have different clinical gravity on plaque development. So, across-the-board, the net-effect is a benefit. 

When compared to filtered and unfiltered coffee, it appears that the filter reduces the amount of diterpenes, however, that is dependent on the size of the pores in the paper filter as well as the ground coarseness of your coffee. If you want to be on the more safe side, use paper filter. Although I am a cardiologist, I stick with my Italian mocha pot.

If you don't like coffee, try tea, black or green, it has very similar antioxidants and polyphenols, and a recent, large, Chinese population study showed a 20% reduction in cardiovascular mortality in frequent tea drinkers, as well as a longer life. How much tea or coffee? It appears that two to four cups per day is probably the golden middle ground. 

So raise your cup, cheers, and enjoy!