Dr. Robert Pastore, PhD, CNS


#067 - On Celiac Disease and Cardiovascular Disease

Dr. Pastore discusses the connection between celiac disease and cardiovascular disease that many physicians miss when treating a patient with either. He covers how gluten consumption can affect the cardiovascular system, arteries, and veins; cause physical structure and electrical changes of the heart; and increase the risk of a heart attack. If you have cardiovascular disease, get tested for celiac disease. If you have celiac disease, request that your cardiovascular health be evaluated.

2020-06-1211 min read

The Pastore Podcast


The connection between celiac disease and cardiovascular disease [0:45]

  • First study of the connection came out in the 1970’s
  • Symptoms of undiagnosed celiac disease can present as cardiovascular issues, like Dr. Pastore experiences in his teens
  • More published papers appeared in 1998
  • The year 2015 had roughly 90 papers around the topic

  • Studies have shown that certain cardiovascular ailments that are more prevalent in individuals with celiac disease compared to individuals without the disease [2:00]
    • Cardiomyopathy - an enlargement of the heart
    • Myocarditis - inflammation of the middle layer of the heart wall
    • Arrhythmias - heart beating out of sync
    • Premature atherosclerosis - early onset arterial thickening

What are the effects of celiac disease on the cardiovascular system? [2:50]

  • Inflammation throughout the body as a celiac consumes gluten
  • Causes abnormalities of arteries and veins throughout the body (not just in the heart)
  • Serological changes / changes in blood work
  • Physical structural changes to the heart
  • Electrical changes to the heart - changes heart beat rhythm
  • Increased risk of myocardial infarction (heart attack)
    • Stops heart from beating

Changes to the arteries with celiac disease [4:20]

  • Multifactorial depending on the type of abnormality
    • Proinflammatory state due to the consumption of gluten
    • Inability to arrest/stop certain free radicals that are damaging to arterial lining
      • Unable to stop free radicals due to inflammation
    • Nutritional deficiencies due to obliterated villi unable to absorb nutrients in small intestine (such as a Vitamin B12 deficiency)
  • One area of focus for celiac disease and cardiovascular disease is arterial function
  • Arteries carry blood away from the heart, contains oxygen
    • With the exception of pulmonary artery blood flow
  • Arterial system is the high-pressure portion of the circulatory system
    • Top number in blood pressure is systolic pressure - the peak arterial pressure during heart contraction
    • Bottom number in blood pressure is diastolic pressure represents the minimum arterial pressure between contractions, when the heart expands and refills
  • Main artery of the body is the aorta
    • Connects to the upper left ventricle of the heart, which is connected to the aortic valve
    • Blood pumps through the valve to the aorta to the rest of body

In untreated celiac disease, aortic function can deteriorate [7:00]

  • Deterioration is predictive of subclinical atherosclerosis & future cardiovascular events
  • In undiagnosed, untreated celiac disease aortic abnormalities include:
    • Worsening of the aortic stiffness index (gets significantly higher)
      • Arteries need to be flexible
    • Higher level of aortic stiffness increases risk for coronary artery disease

Cardiovascular symptoms of undiagnosed/untreated celiacs can accumulate and present in as little as months [8:00]

  • Risk in undiagnosed pediatric (child) celiac disease patients leading to early onset atherosclerosis
    • Mimics effects of being incredibly unhealthy, no exercise, sitting all day and eating nothing but fast food
    • Happening in children/teenagers/early 20’s of untreated celiacs
  • “Silent killer” - all can transpire in as little as one year’s time
  • May not even feel any symptoms
    • Hypertension / blood pressure elevated
      • Pressure in head
      • Frequent headaches
    • High aortic stiffness
    • Calcification of aortic arch
  • Can be independent of angina (tightness in chest)
  • If you are a diagnosed celiac, you should see a cardiologist for a full work up
  • Don’t just depend on family doctor

Untreated celiac disease can lead to…. [11:40]

  • The occlusion / obstruction of the brachiocephalic trunk
    • Artery that brings blood to the right arm, and the neck & head
  • Tightening of right and left common carotid artery
    • Carotid arteries found in neck that supply blood & oxygen to brain
  • Spontaneous coronary artery dissections
    • Tear in an artery in the heart, causing blood to pool in the layer of the heart
    • Can lead to hematoma (blood clot), leading to heart attack

**Important note: even after being diagnosed with celiac disease & following a gluten free diet, there is a lack of a reduction in aortic elastic properties. Previous damage cannot be un-done. Some risk of cardiovascular disease may persist** [13:05]

  • Do everything in your power moving forward not to make it worse
  • Not just following a gluten-free diet, avoid processed foods & trans fats
  • Visit a cardiologist to ensure your heart & cardiovascular system is healthy & you’re doing what you can to ensure physical health

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. [16:00]

  • Ask doctor for Carotid intima-media thickness test (CIMT)
    • Measures carotid atherosclerotic vascular disease
    • Measures the thickness of the intima and media of the carotid artery
    • Patient may have no symptoms
  • Diabetes & celiac disease are connected genetically

Untreated celiac disease youth can have an increased risk of developing early atherosclerosis [18:25]

  • Disease of the arteries
  • Deposition of plaques of fatty material on their inner walls
    • Disrupts/reduces blood flow
    • Plaques similar to what makes a scab when a child gets cut
    • Narrows artery
  • Can cause thrombotic affect - part of plaque breaks off and travels through body before getting stuck somewhere & causing blockage (embolism)
    • Stroke in the brain
    • Clogged blood flow to the heart (heart attack)

Untreated celiac disease patients can have mesenteric ischemia [19:30]

  • Occurs when damaged, narrowed or blocked arteries restrict blood flow to small intestine
  • Small intestine already damaged from gluten consumption & flattened villi
  • Decreased blood flow has a strong potential to permanently damage the small intestine separate from celiac disease
  • May require intestinal resection
    • Cut out dead section of tissue, reconnect the healthy parts together

Effects of untreated celiac disease on veins in the body [21:20]

  • Veins carry low oxygenated blood from the body back to the heart for reoxygenation
  • Cardiovascular system is more than just the heart
    • encompasses circulation
  • Cardiovascular disease includes conditions that transpire in other parts of the body
  • At risk for venous thrombosis
    • Blood clot in the veins that can lead to a pulmonary embolism
      • When a clot blocks a blood vessel in the lungs
      • Life threatening
      • Can happen to those without celiac disease too
    • Clot can be anywhere in the body causing other complications - brain & body to disrupt blood flow
  • Celiac disease is linked to venous thrombosis in the clinical literature
    • Main connection is inflammation and nutrient deficiencies

Serological (Blood Test) Changes in the untreated/undiagnosed celiac disease patient [25:00]

  • Warning signs to look out for
  • Abnormally elevated homocysteine levels
    • Homocysteine is an amino acid (broken down protein) that is made endogenously (within the body) in error if there is a B vitamin deficiency
      • Particularly B12, B6, folate
        • Highly common deficiencies for undiagnosed celiacs
    • Increases the risk of heart disease and stroke if level elevated
    • Can damage lining of arteries
    • Homocysteine and vitamins such as B12 can all be tested at the same time
  • Erythrocyte sedimentation rate
    • Erythrocytes (red blood cells) settle at the bottom of a test tube that contains a blood sample
    • Normally, red blood cells settle relatively slowly
    • A faster-than-normal rate may indicate inflammation in the body
    • Well-known measurement for inflammatory & autoimmune diseases such as lupus & pelvic inflammatory disease
    • In a celiac disease patient, can identify total-body inflammation
      • Diagnosed or undiagnosed for celiac or cardiovascular disease
  • C-reactive protein (CRP)
    • Blood test marker for inflammation in the body
    • Either a CRP test
    • or a high-sensitivity C-reactive protein (hs-CRP) test
      • more sensitive than a standard CRP test
      • Should be below 0.5
      • can evaluate your risk of developing coronary artery disease (condition in which the arteries of your heart are narrowed)
    • If a diagnosed celiac patient has elevated levels of CRP or hs-CRP & starts following a gluten-free diet, you can normalize those levels very quickly
  • Insulin levels
    • insulin levels may, along with inflammation, can be contributive to arterial stiffening
  • Essential fatty acids
  • Nutrients beyond B6/B12/folate
    • Magnesium, selenium
      • Low selenium alone can cause structural heart changes in celiacs

How can celiac disease impact the physical structure of the heart? [30:00]

  • Pericardial effusion occurs more frequently in celiac disease patients
    • An excess buildup of fluid between the heart and the sac surrounding the heart, known as the pericardium
    • Restricts space around the heart
    • Risk factors / contributors for pericardial effusion in celiac disease include:
  • Vessel dysfunction in the presence of high antibody titer (celiac disease antibodies)
  • Selenium deficiency
  • Iron deficiency
  • Viral infection (like the common cold) due to reduced immune system functioning
  • Diminished ability to eliminate toxic free radicals

Celiac disease patients have a higher risk of cardiomyopathy [34:25]

  • Ability of the heart to pump blood decreases
  • Easy to see in an echocardiogram
  • Very strong correlation to celiac disease
  • 3 types connected to celiac disease
  • Dilated cardiomyopathy (DCM)
    • 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
    • Enlarged left ventricle that is stretched and weakened
    • Loses the ability to contract efficiently
  • Ischemic cardiomyopathy (CM)
    • Type of dilated cardiomyopathy, more “extreme” case
    • Occurs with coronary artery disease (clogged arteries) or after a heart attach
    • Blocking of an artery to the heart, preventing oxygen rich blood from entering the heart
    • Results in an dilated heart muscle

Other physical heart structure changes connected with celiac disease [36:30]

  • Autoimmune myocarditis
    • Dr. Pastore has seen 5 cases in his career, as the ONLY celiac symptom
    • Presents with inflammation of the heart muscle
    • Autoimmune disease of the heart muscle
      • can be caused by eating gluten
  • Atrial septal defect
    • "Hole" in the wall that separates the top two chambers of the heart
    • Changes the pressure & how the heart functions
    • Mainly found in pediatric cases
    • Can be corrected on its own if caught & corrected early, but may need surgery
      • Diagnosis of celiac disease, removal of all gluten consumption & whole food diet

What about heart attack and stroke? [39:10]

  • Heart attack is known as acute myocardial infarction
  • Silent killer, can happen at any time
  • Risk for heart and/or stroke due to atrial fibrillation caused by celiac disease
    • Heart does not beat in rhythm
      • the atrium beats out of coordination with the ventricles
    • Flutter & acceleration of heart rate
    • Atrial fibrillation is higher in celiac patients due to slower atrial electrical conduction
    • Associated with an increased risk of ischemic stroke and heart failure.

  • Celiac disease patients may be at risk for Acute myocardial infarction (heart attack) with ST-elevation and spontaneous coronary artery dissection (tear in the artery) at the same time
    • Major artery that supplies nutrients & oxygen to the heart is blocked
    • ST-elevation is an abnormality detected through echocardiogram
    • Can occur in “healthy” undiagnosed celiacs
    • Chronic hypocalcemia (low calcium) in untreated celiac patients can result in electrocardiographic changes that mimic acute myocardial infarction
      • Calcium deficiency due to poor absorption of minerals
      • Electrocardiogram (ECG) mimics signs of heart attack

Can going gluten-free help celiacs with cardiovascular disease? [44:00]

  • Yes, to an extent
  • Healthy, gluten-free diet starts reduction of inflammation
  • Oxidative stress decreases
    • High accumulations of free radicals increases oxidative stress
    • Contribute to inflammation, damages types of cholesterol that damage arteries and increase arterial plaque
    • Going gluten-free can reduce this oxidative stress
  • Normalizing insulin resistance
    • when unchecked can lead to atherosclerosis.
  • Can revert cardiovascular functions in less than one year of nutritional and lifestyle changes
    • World Journal of Cardiology metaanalysis
    • Dr. Peter Green

Consuming gluten (knowingly or not) as a celiac and the effects on pre-existing cardiovascular disease [47:50]

  • Symptoms will return
  • Be extra-cautious with cardiovascular disease and diabetes and celiac, or when combined with other autoimmune disorders
  • Prepare all of your own food the first year of diagnosis

Simply going gluten-free as a celiac with risk factors for cardiovascular disease will not fix everything - must follow a healthy diet [50:05]

  • Gluten-free junk food, over-consumption of simple carbohydrates, highly processed fatty acids and sugars will still contribute to cardiovascular disease
    • This applies for non-celiacs too
    • Can result in increased triglycerides and insulin resistance
  • Must focus on whole foods - fruits, vegetables, proteins, nuts, seeds
  • “Certified Gluten Free” does not mean it’s healthy

Should cardiovascular disease patients be tested for celiac disease? & what should the newly diagnosed celiac disease patient do for their cardiovascular health? [52:40]

  • A gluten free diet can reverse some, but not all of the cardiovascular involvement associated with the disease
  • It is essential to act quickly in obtaining a diagnosis and starting treatment in cases of cardiovascular disease.

Wrap Up [55:20]

If you were recently diagnosed with celiac disease, or want to evaluate your cardiovascular health, request the following from your physician:

  • All standard lipid panels
  • HS-CRP
  • Fibrinogen
  • SED rate
  • Homocysteine
  • Essential Fatty Acids, and Omega-3 Index (goal should be greater than 8).
  • Test for as many nutrients as possible, but at least:
    • Folate
    • B12
    • B6
    • Vitamin D
    • Magnesium
    • Calcium
    • Selenium
    • Iron
  • Have an ECG and perhaps an echocardiogram based on your doctor’s recommendations
    • most covered by insurance for celiacs in the US