Studies have indicated that certain cardiovascular maladies, including cardiomyopathy, myocarditis (Inflammation of the middle layer of the heart wall), arrhythmias, and premature atherosclerosis, are more prevalent in individuals with celiac disease as compared to their non-celiac disease counterparts.

Historically it is important to note the first few published studies on celiac disease and cardiovascular disease were in published in the 1970s. There was a decent body of published peer-reviewed literature around 2015 to clearly see the connection.

Impact of Celiac Disease on the Cardiovascular System

There are negative changes that appear to the arteries, veins, serology, physical structure of the heart, electrical changes of the heart, and increase the risk of myocardial infarction (heart attack).

Artery Changes and Celiac Disease

One area of focus for celiac disease and cardiovascular disease is arterial function. As many will know arteries carry blood away from the heart and other than the pulmonary artery blood flow, arterial blood is oxygenated. The arterial system is the high-pressure portion of the circulatory system and many people are aware of this when they have their blood pressure checked. The upper number of a blood pressure reading, known as the systolic pressure is the peak arterial pressure during heart contraction. And the bottom number, which is called the diastolic pressure represents the minimum arterial pressure between contractions, when the heart expands and refills. The main artery of the body is the aorta. It connects to the upper left ventricle of the heart and at that connection is the aortic valve. So blood pumps through the valve to the aorta to the body.

The following can transpire as a result of celiac disease:

• In undiagnosed celiac disease, aortic function can deteriorate, and this deterioration is predictive of subclinical atherosclerosis and future cardiovascular events.
• Aortic stiffness index is significantly higher, in untreated CD patients vs controls. Celiac disease patients are at increased risk for coronary artery disease.
• Occlusion of the brachiocephalic trunk and right and left common carotid artery has been noted in celiac disease.
• Spontaneous coronary artery dissections have been observed as a cause of acute myocardial infarction in celiac disease patients. This is when a tear forms in an artery inside the heart and results in blood pooling in the area between the layers. This can result in a hematoma (blood clot).
• Important note: even after a gluten free diet, the lack of a significant reduction in aortic elastic properties suggests that some risk of cardiovascular disease may persist.
• Carotid intima-media thickness values are significantly higher in patients with diabetes and celiac disease as compared to those patients with diabetes or celiac disease alone. The carotid intima-media thickness test (CIMT) is a test to measure carotid atherosclerotic vascular disease. The test measures the thickness of the intima and media of the carotid artery.
• Celiac disease in the youth has been associated with increased risk of developing early atherosclerosis (a disease of the arteries characterized by the deposition of plaques of fatty material on their inner walls).
• Mesenteric ischemia risk is increased by celiac disease. It occurs when damaged, narrowed or blocked arteries restrict blood flow to your small intestine with the strong potentially to permanently damage the small intestine separate from celiac disease.

Celiac Disease and the Veins

Veins are blood vessels low oxygenated blood from the body back to the heart for reoxygenation. We also need to keep in mind that while cardiovascular diseases make us think of the heart, it encompasses circulation and that includes conditions that transpire in other parts of the body such as venous thrombosis which is a blood clot in the veins that can lead to a pulmonary embolism (when a clot blocks a blood vessel in the lungs. It is life threatening). There are other complications of thrombosis.

• Celiac disease is linked to venous thrombosis in the clinical literature and the main connection is inflammation and nutrient deficiencies.

Celiac Disease and Cardio Specific Serology

In an adult celiac disease patient there can be the presence of:

• Abnormal homocysteine (Homocysteine is an amino acid that is made endogenously in error in the presence of a deficiency of B vitamins, particularly folate and B12, but also B6). It may increase the risk of heart disease and stroke if level elevated.
• Erythrocyte sedimentation rate is the measurement of erythrocytes (red blood cells) settling at the bottom of a test tube. Normally, red blood cells settle relatively slowly. A faster-than-normal rate may indicate inflammation in the body. Erythrocyte sedimentation rate may provide evidence of coronary heart disease.
• C-reactive protein (C-reactive protein (CRP is a blood test marker for inflammation in the body) or high-sensitivity C-reactive protein (hs-CRP) test, which is more sensitive than a standard CRP test, can be used to evaluate the risk of developing coronary artery disease.
• Elevated insulin levels may, along with inflammation markers above, contribute to arterial stiffening.
• Other nutritional factors, such as low B12, folate, omega 3 fatty acids, magnesium, selenium, etc., may contribute to cardiovascular disease.

Celiac Disease and the Physical Structure of the Heart

There are some key structural changes of the heart that can transpire as a complication of celiac disease. I will list the most common ones below.

1. Pericardial effusion occurs more frequently in celiac disease. A pericardial effusion is when there is an excess buildup of fluid between the heart and the sac surrounding the heart, known as the pericardium.

Risk factors for pericardial effusion in celiac disease include:

• Vessel dysfunction in the presence of high antibody titer (celiac disease antibodies).
• Selenium and or iron deficiency (caused by celiac disease).
• Viral infection due to reduced immune system functioning (higher risk in celiac disease).
• Diminished ability to eliminate toxic free radicals.

2. Celiac disease patients have a higher risk of dilated cardiomyopathy, idiopathic cardiomyopathy and ischemic or valvular cardiomyopathy

• Dilated cardiomyopathy (DCM) is a condition in which there is an enlargement of the left ventricle of the heart. This enlargement reduces the heart's ability to pump blood.
• Idiopathic cardiomyopathy is a condition the presents with an enlarged left ventricle that is stretched and weakened, losing the ability to contract efficiently.
• Ischemic cardiomyopathy (CM) is a type of dilated cardiomyopathy. The main characteristic is the blocking of an artery to the heart, typically post heart attack, preventing oxygen rich blood from entering the heart resulting in a dilated heart muscle.

3. Autoimmune myocarditis may be a complication of celiac disease and presents with inflammation of the heart muscle.

4. Celiac disease patients are more prone to have atrial septal defect as compared to controls. In an atrial septal defect there is a hole in the wall that separates the top two chambers of the heart (the atrium).

Celiac Disease and Heart Attack or Stroke

1. Celiac disease patients may be at risk for acute myocardial infarction with ST-elevation and spontaneous coronary artery dissection. This is a very serious type of heart attack. An ST-segment elevation is an abnormality detected on an electrocardiogram.

However, chronic hypocalcemia (low calcium) in untreated celiac disease patients due to poor absorption of the mineral can result in electrocardiographic changes that mimic acute myocardial infarction. This echoes my podcast where I constantly refer to the importance of measuring nutrient status of the celiac disease patient, and suspected celiac disease patient.

2. There is a higher prevalence of atrial fibrillation among celiac disease patients because in celiac disease there is a higher risk of having a slower atrial electrical conduction, which may also increase the risk of atrial fibrillation. In atrial fibrillation the atrium (upper chambers of the heart) beats out of coordination with the ventricles (lower chambers of the heart). Atrial fibrillation is associated with an increased risk of ischemic stroke and heart failure.

3. Celiac disease also presents with an increased general risk for stroke. It is such a strong connection that researchers believe celiac disease should be considered as a possible etiology for stroke cases of unknown cause, particularly in the young, whether gastrointestinal manifestations are evident or not. The reasons can be a clinical B12 deficiency and hyperhomocysteinemia (high homocysteine), which can be secondary to a folate deficiency.

How can a gluten free diet help those with celiac disease induced cardiovascular disease?

• A healthy gluten free diet enables a reduction in inflammation, oxidative stress, and insulin resistance. Each of these are linked to increased risk of cardiovascular disease if not managed.

How long after being diagnosed with celiac disease can it take to heal some cardiovascular disease risk factors?

• Cardiovascular dysfunction can be reverted in less than one year in diagnosed celiac disease patients adopting a healthy, whole foods, gluten free diet.

However, there are some caveats to the gluten free diet that can compound problems. There is the strong potential to over consume simple carbohydrates, highly processed fatty acids and sugars on a gluten free diet. Markets are replete with such products and overconsumption can result in elevated triglycerides and insulin resistance, which are risk factors on the path toward cardiovascular disease.

Why is it important for someone with cardiovascular disease get tested for celiac disease?

Incredibly, the treatment of celiac disease patients with a healthy, whole foods, gluten free diet can reverse some, but not all of the cardiovascular involvement associated with the disease. Therefore, it is essential to act quickly in obtaining a diagnosis and start treatment in cases of cardiovascular disease.

• Have a full cardiovascular work up if you were recently diagnosed with celiac disease. Include all standard lipid panels and fractionated lipid panels and speak with your physician about the following:
  • Carotid intima-media thickness test (CIMT)
  • Coronary artery calcium test (CAC) which measures the amount of calcium in the walls of the arteries.
  • hs-crp
  • Fibrinogen
  • SED rate
  • Homocysteine
  • Test for as many nutrients as possible, but at least: folate, B12, B6, magnesium, calcium, selenium, percent of omega 3 fatty acids.