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myocardial infarction (heart attack) by 77%, without an effect on mortality.  This reduction was due to a sig- nificant decrease in non- fatal heart attack, with no difference in cardiovascular death.  However, this trial was followed by two large randomized trials that have been less supportive.  The Heart Outcomes Prevention Evaluation Study (HOPE) examined 9,541 patients with either known heart disease or diabetes mellitus who received 400 IU of natural vitamin E for a mean of 4.5 years (59).  There was no reduction in heart attack, stroke or death for the patients taking vitamin E instead of placebo.  In the GISSI-Prevention study, 11,000 patients who had recently survived a heart attack were given 300 mg of synthetic vitamin E for a mean of 3.5 years (60). Again, there were similar rates of heart attack, stroke and death for patients tak- ing synthetic vitamin E instead of placebo. Therefore, no clear benefit of vitamin E has been established for patients who already know they have heart disease or are at very high risk. Unfortunately, this study utilized synthetic vitamin E, which is felt to be less prevention of cardiovascu- lar disease may not be as great as originally predict- ed this isn't to say that benefit does not remain for select patients utilizing the correct form, dosage, and potentially the correct combination of antioxidant supplements.  Thus, while the debate rages on, vita- min E supplementation with 400 IU may be the best course of preventa- tive action.   Vitamin C may not be what the heart needs. This vitamin is involved in many cellular processes and acts as an antioxidant. Vitamin C consumption is certainly essential, and vitamin C levels within the blood have been inversely correlated with the inci- dence of coronary heart disease, the lower the level, the higher the inci- dence of disease (64,65). However, there really is no clinical research which has found that vitamin con- sumption actually reduces your risk of developing cardiovascular disease. Today's best advice is to eat plenty of fruits, espe- cially citrus fruits, as well as vegetables rich in vita- min C.  Additional supple- mentation cannot be sup- ported for the prevention of CHD. effective than the natural form, and therefore may have minimized the benefit of E vitamins in high-risk patients. They also studied a very high risk group of patients who may have already had advanced plaque formation within their heart arteries, thus mitigating the potential benefit of early prevention with supplementation.   Perhaps a combination of antioxidants may be required to reduce plaque formation. Vitamins E and C have been studied in the Antioxidant Supplement Atherosclerosis Prevention (ASAP) Study. In this trial, high-risk men taking vitamin E (200 mg daily) and vitamin C (500 mg daily) for three years had a 45% reduc- tion in the progression of ath- erosclerosis (coronary artery plaque) (61).  A reduction in cardiovascular events and death from all causes was also found in over 11,000 eld- erly persons taking a combi- nation of vitamins E and C (62).  However, a combination of vitamin E and beta- carotene has not been shown to affect symptoms or disease progression (63).   As the above discussion indi- cates, vitamin E supplemen- tation for CHD prevention remains controversial. Although the widespread ben- efits for vitamin E for the

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