SHOW NOTES

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
  • Celiac disease lowers immunity. Previous podcast:  https://drrobertpastore.com/podcasts/043-on-nutrition-deficiencies-and-increased-infection-risk-for-the-celiac-population
  • Suppressed immunity and consuming gluten increases changes of viral infection. Having a viral infection as a celiac increases the risk of pericardial effusion
• 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]

• If you have cardiovascular disease and it’s not normal in your family history, get tested for celiac disease
  • https://drrobertpastore.com/articles/2019-08-26-what-do-you-do-if-you-think-you-may-have-celiac-disease
• If you have celiac disease and were not tested for cardiovascular risk factors in your original diagnosis, routinely request cardiovascular tests

• 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]

• Be an advocate for your own health
• www.drrobertpastore.com
• @drrobertpastore

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