Cardiovascular Drugs and Therapy 16 411–415 2002

C 2003 Kluwer Academic Publishers. Manufactured in The Netherlands
SYMPOSIUM: VITAMIN THERAPY AND ISCHEMIC
HEART DISEASE
Antioxidant Vitamins and Risk of Cardiovascular Disease.
Review of Large-Scale Randomised Trials
Summary. People who consume a diet rich in fruit and veg-
etables have lower risks of cancer, cardiovascular disease
and all-cause mortality. Many prospective cohort studies
have reported inverse associations between dietary intake
or blood levels of beta-carotene and risks of cancer. Sev-
eral large-scale trials were set up to assess whether beta-
carotene supplementation might reduce the risk of can-
cer. Subsequently, evidence emerged from basic research
which indicated that oxidative modification of low-density
lipoprotein cholesterol increases its atherogenicity. The ev-
idence from basic research, and epidemiological evidence
for a possible protective effect of antioxidant vitamins for
cardiovascular disease was strongest for vitamin E. More
recently, further trials were set up to examine if supple-
mentation with anti-oxidant vitamins might also reduce the
risk of cardiovascular disease. This review summarises the
available randomised evidence from published trials of beta-
carotene supplementation involving 70,000 people from 3
large-scale trials in healthy populations and on vitamin E
supplementation involving 29,000 patients at high-risk of
cardiovascular disease from 5 large-scale trials. The results
of these trials have been disappointing and failed to confirm
any protective effect of these vitamins for either cancer or
for cardiovascular disease.
Key Words. antioxidant vitamins, clinical trials, cardiovas-
cular disease
Introduction
People who consume a diet rich in fruit and vegeta-
bles have lower risks of cancer, cardiovascular dis-
ease and all-cause mortality [1]. The initial observa-
tional epidemiological studies reported that people with
above average intakes of beta-carotene or above aver-
age blood retinol levels were at below average risks of
cancer [1]. This epidemiological evidence suggested an
inverse association of cancer with beta-carotene either
through diet or supplementation. However, such obser-
vational evidence does not constitute reliable evidence
for a protective effect, for the risk associations were at
best moderate and may not have been causal [2]. It is
possible that intake of beta-carotene is correlated with
some other dietary constituent that is protective; or
Robert Clarke and Jane Armitage
Clinical Trial Service Unit, Radcliffe Infirmary,
Oxford OX2 6HE, UK
people who consume a diet rich in beta-carotene may
consume less of some other food items that may be
related to increased risk of cancer. However, the in-
creased association between dietary beta-carotene in-
gestion might indeed be truly protective for cancer and
reliable evidence to confirm or refute this can only be
obtained from randomised trials of beta-carotene on the
incidence of cancers [1–4].
Subsequently, data emerged from basic research
which indicated that increasing dietary intake and
blood levels of several antioxidant vitamins may also
be protective for cardiovascular disease [3]. Analy-
ses were carried out in the large-scale trials of beta-
carotene supplementation for cancer prevention in
healthy populations to assess if beta-carotene might re-
duce the risk of cardiovascular events. More recently
large-scale trials were designed to assess if vitamin E
and other anti-oxidant vitamins may reduce the risks
of cardiovascular disease in high-risk populations.
The aim of this review is to summarise the available
randomised evidence from published trials of antioxi-
dant vitamins on risks of cardiovascular disease and of
cancer.
Atherosclerosis, Oxidative Stress
and Progression of Atherosclerosis
Atherosclerosis is a slowly progressive arterial disease
which begins in childhood and does not become clini-
cally manifest until middle age or later [3,4]. Human
atherosclerosis involves predominantly the medium
sized arteries, such as the coronary, carotid, or verte-
bral arteries, but also the aorta and the arteries sup-
plying the lower extremities. Atherosclerosis chiefly
involves the intima cell layer (i.e. the inner layer of the
arterial wall) and is believed to arise from the prolifer-
ation of fatty streaks into fibrofatty plaques. The fatty
Address for correspondence: Robert Clarke, MD, MRCP,
Clinical Trial Service Unit, Radcliffe Infirmary, Oxford OX2
6HE, UK. Tel.: 00-44-1865-557241; Fax: 00-44-1865-558817;
E-mail: robert.clarke@ctsu.ox.ac.uk
411
412 Clarke and Armitage
streaks are grossly visible as slightly raised yellow ar-
eas which are narrow and longitudinally oriented. Mi-
croscopically, they consist of aggregates of foam cells
(which are derived chiefly from macrophages and to
lesser extent from smooth muscle cells), whose cyto-
plasm are filled with cholesterol esters and free choles-
terol. Atheromatous plaques are usually rounded raised
lesions that protrude into the lumen and consist of an ac-
cumulation of lipid laden smooth muscle cells surround-
ing a core region of extra cellular lipids and a vari-
able amount of leukocytes and fibroblasts. Oxidative
modification of low-density lipoprotein (LDL) choles-
terol results in preferential uptake of LDL choles-
terol by macrophages, which become transformed into
foam cells [3,4]. These activated macrophages trigger a
chain of events resulting in the release of cytokines and
oxygen free radicals. The net effect of these events is
to promote central necrosis and rupture of atheroscle-
rotic plaques, which may present in patients as a heart
attack or stroke.
Antioxidant Vitamins
The major antioxidants include vitamin E, beta-
carotene, and lycopene and flavenoids which are
thought to protect polyunsaturated fatty acids in cell
membranes from becoming oxidised [5,6]. Antioxidant
vitamins are believed to act by neutralising the damag-
ing effects of “free radicals” and thereby protect cells
and tissues from oxidative damage. Vitamin E (chiefly
alpha-tocopherol) is the principal lipid soluble antioxi-
dant in the body and is present in all cell membranes and
circulating lipoproteins. Beta-carotene is also a lipid
soluble vitamin, which is carried with vitamin E in
the fatty core of lipid particles. In contrast, vitamin
C is a water soluble antioxidant vitamin, which is be-
lieved to regenerate vitamin E from its oxidised state
back to its activated state [7]. Table 1 shows selected
information on the dietary sources and intake of the
beta-carotene, vitamin E and vitamin C. Beta-carotene
Table 1. Selected characteristics of antioxidant vitamins
Vitamin Dietary source
Vitamin E Vegetable fats and seed oils
(corn, safflower and canola oils),
margarine, nuts, seeds,
wheat germ
Beta-carotene Carrots and dark green vegetables
Vitamin C Vegetables (tomatoes, potatoes),
citrus fruit, fruit juices and nuts
is chiefly found in high concentrations in carrots and
in dark green leafy vegetables. Vitamin E is found in
vegetable oils (corn, safflower, canola), nuts, seeds and
wheat germ and in green leafy vegetables. The princi-
pal sources of vitamin C are citrus fruits, tomatoes and
potatoes.
Supplementation with vitamin E at the doses simi-
lar to the doses used in the large-scale trials have been
shown to increase blood levels of vitamin E and dou-
ble the lag-time to LDL oxidation (i.e. the number of
minutes before polyunsaturated fatty acids begin to be
oxidised at a maximum rate as measured by diene con-
jugation) [4,6].
There is some evidence to suggest that vitamin C can
regenerate oxidised vitamin E back to its active state
(so supplementation of the combination of vitamin C
with vitamin E may be more effective supplementation
with either vitamin alone) [7].
Epidemiological Evidence for Risk
of Cardiovascular Disease
Many epidemiological studies have reported that pop-
ulations with higher intakes and higher blood levels of
vitamin E have lower risks of coronary heart disease,
even after corrections have been made for the other
known risk factors [8–13]. The most reliable epidemio-
logical evidence comes from prospective cohort studies,
where data on dietary intake and assessment of vitamin
status using blood measurements were all collected be-
fore the onset of disease [8–12]. These data have shown
an inverse association between CHD risk and dietary
intake of vitamin E and also with beta-carotene intake.
Typically, these prospective studies have demonstrated
that individuals in the top fifth of intake of these vita-
mins have about 30–40% lower risks of cardiovascular
disease. The epidemiological evidence was strongest for
vitamin E, and was at best moderate for beta-carotene
and was weaker for vitamin C.
Average daily intake
in UK diet (mg/day) Biochemical properties
10 The chief lipid soluble antioxidant
vitamin in cell membranes and
circulating lipoproteins.
Alpha-tocopherol accounts for
90% vitamin E
2 A lipid soluble antioxidant carried
with vitamin E in the fatty core of
LDL particles. It is a precursor of
retinol (vitamin A)
75 The chief water-soluble antioxidant.
It can regenerate vitamin E from
its oxidized state back to its active
state
 Antioxidant Vitamins and Risk of Cardiovascular Disease 413

Table 2. Effects of beta-carotene supplementation on all-cause mortality

Trial (year of No. of events/

publication) no. of participants Dose (mg/day) Duration (years) Relative risk (95% CI)

ATBC (1997) 3570/29133 20 6 1.08 (1.01–1.16)

CARET (1996) 764/18314 30 4 1.17 (1.03–1.33)
PHS (1996) 1947/22071 50/alt days 12 1.02 (0.93–1.11)
Total 6281/69518 1.07 (0.99–1.16)

Large Scale Trials of Beta-Carotene
Table 2 shows a summary of the results of trials of
beta-carotene supplementation on risks of all-cause
mortality [14–16]. Taken together, these 3 large-scale
trials include randomized evidence for the effects of
beta-carotene in almost 70,000 individuals. The Alpha-
Tocopherol, Beta-carotene Cancer (ATBC) Cancer Pre-
vention Study randomized 29,133 male smokers to re-
ceive either beta-carotene (20 mg daily) or placebo and
alpha-tocopherol (50 mg daily) or placebo for a 6 year
period [14]. The ATBC trial found no reduction in inci-
dence of cancer associated with either beta-carotene or
vitamin E and there were somewhat more lung cancers
among those who received beta-carotene than among
placebo. The Beta-Carotene and Retinol Efficacy Trial
(CARET) randomized 18,314 people who were for-
mer smokers and workers exposed to asbestos to re-
ceive a combination of beta-carotene (30 mg daily) and
vitamin A (25,000 I.U. of retinyl plamitate) or placebo
for a 4 year period [15]. The trial showed no benefi-
cial effect on all-cause mortality of beta-carotene and
vitamin A, and the authors suggested a possible ad-
verse effect on the incidence of lung cancer and car-
diovascular disease. In the Physicians Health Study
(PHS) 22,071 male physicians were randomized to re-
ceive either beta-carotene (50 mg on alternate days) or
placebo for a 12 year period. In the PHS trial among
healthy men, supplementation with beta-carotene pro-
duced neither benefit or harm in terms of cancer, car-
diovascular disease or all-cause mortality [16]. The dose
of beta-carotene used in these trials higher than the
level of dietary beta-carotene consumption that was as-
sociated with benefit in the observational studies and
was roughly equivalent in effects on blood levels of con-
sumption of about two carrots a day in PHS trial, three
carrots a day in the ATBC study and four carrots a day
in the CARET trail. The duration of the treatment in
these three trials varied from 4 to 12 year trials and
there was no evidence to suspect that more prolonged
treatment would alter the outcome. The compliance
with instructions to take trial treatment or placebo was
high in each individual trial.
Table 2 shows that 6,281 people died among 70,000
participants who were enrolled in these trials. There
was no significant heterogeneity between the results
of these trials (χ22 = 0.32, p = 0.98). Taken together,
these 3 trials demonstrate that the overall relative risk
for the effects of beta-carotene on all-cause mortality,
weighted for the number of events in each trial was
1.07 (95% CI: 0.99 to 1.16). The results for the effects
of beta-carotene on cardiovascular and cancer mortal-
ity were consistent with those reported for all-cause
mortality and no individual trial provided any evidence
for a protective or hazardous effect of beta-carotene on
cardiovascular mortality.
Large-Scale Trials of Vitamin E
Table 3 shows the effects of vitamin E supplementa-
tion on risk of total cardiovascular events in five large-
scale trials. In the Cambridge Heart Antioxidant Study,
2,002 patients with angiographically proven coronary
heart disease were randomly allocated to receive ei-
ther vitamin E (400 or 800 IU day) or placebo and
followed up for about 2 years [17]. The results sug-
gested an apparent protective effect of vitamin E, with

Table 3. Effect of vitamin E supplementation on risk of total cardiovascular eventsa

Trial (year of No. of events/

publication) no. of participants Dose (mg/day) Duration (years) Relative risk (95% CI)

CHAOS (1996) 105/2002 400/800 1.4 0.53 (0.34–0.83)

ATBC (1997) 424/1862 50 6.0 0.91 (0.63–1.32)
GISSI (1999) 1155/11324 300 3.5 0.88 (0.75–1.03)
HOPE (2000) 1511/9541 400 4.5 1.05 (0.95–1.16)
PPP (2001) 328/4495 300 3.6 1.07 (0.74–1.56)
Total 3523/29224 0.96 (0.79–1.15)
a
Total cardiovascular events include all cardiovascular deaths and non-fatal myocardial infarction and non-fatal stroke.
414 Clarke and Armitage
a relative risk for primary end-point of cardiovascu-
lar death and non-fatal myocardial infarction of 0.53
(95% CI: 0.34–0.83; p = 0.005). While the results of
the CHAOS trial prompted some optimism about pos-
sible beneficial effects of vitamin E, all subsequent tri-
als of vitamin E supplementation failed to confirm any
protective effect of vitamin E. Analyses were carried
out in the ATBC trial which showed no protective ef-
fect of beta-carotene on cardiovascular mortality [18].
The Italian GISSI-Prevenzione trial involving 11,324
post-myocardial infarction patients, found no protec-
tive effect of vitamin E (330 mg) on death, non-fatal
myocardial infarction or stroke [19]. The Collaborative
Group of the Primary Prevention Project (PPP) which
assessed the effects of 300 mg of vitamin E in people
at high risk of cardiovascular events also had a null re-
sult [20]. The results of the Heart Outcomes Protection
Study, which assessed the effects of vitamin E in 9,000
patients at high risk of cardiovascular disease, failed to
detect any beneficial effect on cardiovascular disease
[21]. Taken together, these five trials provide random-
ized evidence for the effects of vitamin E in over 29,000
patients at high risk of cardiovascular disease. There
was some evidence of heterogeneity between the re-
sults of these trials (χ42 = 11; P = 0.02), and this was
entirely explained by the results of the CHAOS trial.
The overall relative risk (weighted for the number of
events in each trial) for the effects of vitamin E as
total cardiovascular events was 0.96 (95% CI: 0.79 to
1.15). After exclusion of data from the CHAOS trial,
the data from the remaining trials yielded a relative risk
for cardiovascular events of 0.97 (95% CI: 0.81 to 1.16).
The dose of vitamin E used in individual trails varied
form 50 to 800 mg per day, and this dose was associated
with a doubling in the lag time of LDL oxidation.
Discussion
Observational studies have shown an inverse
association between dietary intake of vitamin E
(and beta-carotene) and cardiovascular disease. But
the overall results of published trials of vitamin E and
beta-carotene failed to confirm any protective effect
on mortality. The results of these trials do not indicate
any worthwhile effects on cardiovascular disease of
taking these vitamins. The analyses presented here
illustrate the importance of reviewing the totality of
the available evidence from large-scale trials when
addressing such questions. For example, the CHAOS
trial suggested a possible protective effect on risk of
total cardiovascular events associated with vitamin
E supplementation. However, these findings from
CHAOS were based on only 105 events among 2,002
patients treated for only 1.4 years. By contrast, the
available evidence for all published trials for vitamin
E supplementation include almost 29,000 patients and
taken together these trials do not show any beneficial
effect on risk of total cardiovascular disease.
When assessing the effects of beta-carotene, the
CARET study suggested possible hazard associated
with beta-carotene consumption, but the overall results
of the three trials involving 70,000 patients indicated
that beta-carotene is not effective in preventing car-
diovascular disease or cancer and is not associated with
any hazard. It is unlikely that results of these trials may
be altered by the duration of treatment.
The overall results of the published trials of antiox-
idant vitamins on fatal and non-fatal cardiovascular
disease were disappointing and differ from the claims
made from the observational epidemiology. It is likely,
therefore, that the people who consume high levels of
such vitamins may differ from those who do not in other
ways (such as by other aspects of diet, or by smok-
ing less or by taking more regular exercise). It is un-
likely use that the use of any particular stereo-isomer of
beta-carotene may account for the failure to observe a
protective effect. Furthermore, it is also unlikely that
the dose of beta-carotene used in these trials may ac-
count for an inhibition of any protective effect of this
vitamin. The final results of the MRC/BHF Heart Pro-
tection Study (HPS) trial, which are due to be published
in 2002, and which has randomized 20,536 patients at
high risk of CHD (coronary disease, either occlusive
vascular disease of non-coronary arteries or diabetes
mellitus) to 5 years of supplementation with antioxi-
dant vitamins are awaited. In the HPS trial, patients
were allocated to receive either antioxidants, vitamins
(600 mg of vitamin E, 250 mg vitamin C and 20 mg of
beta-carotene daily) or placebo. This trial is likely to
provide further evidence about the relevance of this
combination of antioxidant vitamins to risk of cardio-
vascular disease and of cancer in high-risk individuals.
In the USA, the Women’s Health Study (WHS) is in-
vestigating the effects of vitamin E or placebo, beta-
carotene or placebo, and aspirin or placebo on risks of
cardiovascular disease in 40,000 healthy women aged 50
years or older. The Women’s Antioxidant Cardiovascu-
lar Disease Study (WACS) is assessing the separate ef-
fects of three antioxidant vitamins (600 mg vitamin E
every other day, 500 mg/day of vitamin C and 50 mg
every other day of beta-carotene) and folic acid and
vitamin B-12 or placebo in a 2 × 2 × 2 × 2 factorial de-
sign in 8,000 women at high risk of cardiovascular dis-
ease. In France, the Supplementation Vitamins Miner-
als and Antioxidant trial (SUVIMAX) is testing a com-
bination of antioxidant vitamins including vitamin E, C
and beta-carotene in 15,000 healthy men and women.
However, the available results from completed trials
to date does not provide any evidence that antioxi-
dant vitamins can prevent cardiovascular disease, can-
cer or reduce all-cause mortality. Nevertheless, despite
failure to demonstrate any beneficial effects of taking
antioxidant vitamins, the available evidence does not
contradict the advice to increase consumption of fruit
and vegetables to reduce the risk of cardiovascular
disease.
 Antioxidant Vitamins and Risk of Cardiovascular Disease
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