Metabolic Cardiology Basics

By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.

(1) Metabolic Cardiology is “the New Cardiology.”

Cardiovascular disease, which encompasses all heart and blood vessel conditions, has for decades been the number one cause of death in the U.S.1 Since, approximately 50 percent of the time, the first symptom of cardiovascular disease is sudden death, preventing it is the safest solution.

Read “Heart Attack Symptoms”

Metabolic Cardiology is “the new cardiology”: it is an emerging field concentrated on the prevention, management and treatment of cardiovascular disease through bioenergetic interventions which immediately improve energy metabolism in heart cells. A metabolic cardiologist views prevention and treatment of cardiovascular disease through the eyes of both a cellular biochemist and a physician. In doing so, s/he can compliment, and perhaps prevent, pharmaceutical and surgical interventions through targeted nutritive support. As conventional therapies often result in unpleasant side effects due to nutrient depletion, metabolic cardiology is the most ethical, as well as logical, approach for prevention and treatment of cardiovascular disease.

(2) Bioenergetics is at the Core of Metabolic Cardiology.

Bioenergetics is the study of energy synthesis and utilization in the body. Understanding how the body most efficiently generates and uses energy at the cellular level, as well as how such metabolism changes with age, is crucial to the prevention and treatment of cardiovascular disease. By employing therapies already native to the human body, cardiologists can help patients naturally strengthen, nourish, and rebuild heart and arterial cells, as well as increase metabolism within these cells, all without negative side effects associated with pharmacologic interventions.

Adenosine triphosphate (ATP) is at the center of cellular bioenergetics. While scientists are generally familiar with ATP metabolism in the heart, cardiologists may not be aware of the potential role of ATP in their clinical practices. Well-intentioned physicians, for example, might prescribe inotropic agents to improve heart function. These drugs can cause stronger heartbeats in an energy deficient heart, causing more ATP depletion and resulting in vital exhaustion. The heart needs a constant supply of energy substrates to support ATP production, and thus pulsation.

(3) Metabolic Cardiology is “All About ATP.”

Adenosine triphosphate (ATP) is a compound which provides energy for virtually all the body’s processes. Its role in health maintenance, especially with regard to heart health, cannot be underestimated. Among other crucial functions, ATP is responsible for the heart’s continual cadence. The human heart contains approximately 700 mg of ATP, enough to fuel one heartbeat per second for ten seconds, and needs a minimum of 6,000 grams of ATP per day to function. As the universal cellular energy currency, ATP is constantly spent and re-made within the body.

The ATP molecule is comprised of adenine (the purple), ribose (the red), and 3 phosphate groups (the red and yellow). When the body needs energy, enzymes will break the high energy bonds between phosphate groups and recycle the remaining product (adenosine diphosphate, or ADP) back into ATP. This cycle of energy utilization and regeneration, is called respiration (because it involves oxygen), and occurs millions of times per second in every cell of the body. Most often, respiration occurs in cellular organelles called mitochondria.

How much ATP the body needs, as well as how efficiently it produces ATP, depends on the availability of oxygen and various nutrients in the blood, as well as the heart’s ability to continually circulate blood. Maintaining a healthy cardiovascular system through a heart-healthy lifestyle, inhaling enough oxygen, and obtaining appropriate nutrients through the diet and nutraceutical supplementation are essential means of staying energetic and maintaining wellness.

(4) If Our Mitochondria Are Healthy, Then So Are We.

Our health is directly related to the integrity of our mitochondria. Mitochondria, “powerhouse” organelles within all of our cells, are responsible for producing 90 percent of the body’s energy. Highly concentrated in the heart, mitochondria comprise 35 percent of myocyte, or heart, cells. While a skeletal muscle cell will only contain, on average, 200 mitochondria, a typical myocyte contains approximately 5,000 mitochondria.

Structurally, mitochondria have outer and inner membranes through which nutrients, ATP and ADP molecules, and waste products such as carbon dioxide and water are exchanged. To be used for energy by the cell, ATP produced in the mitochondria must be transported out into the cytosol, or surrounding fluid portion of the cell. As well, the resulting ADP (energy substrate) must enter the mitochondria to be recycled back into ATP.

Protecting the integrity of mitochondrial membranes is central to health maintenance. Free radicals produced during respiration and other metabolic processes and ingested or inhaled toxins can degrade mitochondrial membranes and DNA. While healthy membranes permit the continual, cyclic exchange of nutrients for waste products, as well as ATP production, damaged membranes inhibit energy production and permit the build-up of toxic chemical waste within cells which can ultimately lead to disease.

(5) The “Awesome Foursome” Can Boost ATP Production and Help Prevent Degenerative Diseases.

Supporting biochemical processes by which cells produce energy for vital activities is a primary means of preventing degenerative diseases. While we cannot take an ATP pill, we can do the next best thing by supporting our bodies in producing it. As we can fertilize a garden so that it blooms, we can enrich our mitochondria with essential nutrients that facilitate ATP production and protect mitochondrial structures. I strongly suggest doing so with nutrients I call the “awesome foursome”: coenzyme Q10 (CoQ10), L-carnitine, D-ribose, and magnesium.

This dream team of metabolic cardiology features individual talents which best work synergistically. As transporters of vital substances like electrons and fatty acids, CoQ10 and L-carnitine are responsible for several facets of the ATP production process. Additionally CoQ10 acts as an antioxidant to protect mitochondrial membranes from free-radical damage. A sugar, D-ribose supports CoQ10 and carnitine’s abilities by maintaining a healthy pool of energy substrates.By partnering in over 300 enzymatic reactions in the body, including ATP production and muscle relaxation, magnesium helps improve metabolic efficiency.

Ingesting the awesome foursome becomes especially important when our energy demands start to exceed our natural production of ATP; increasing age, illness, a lack of oxygen (ischemia), and nutritional deficiencies can all contribute to ATP imbalance in the body. Supplementing with, and consuming through food, the “awesome foursome,” as well as essential fatty acids and low-glycemic, vitamin-filled sources of glucose can help us boost ATP production, and therefore help prevent and treat degenerative diseases like cardiovascular disease.


1. Ahmedin Jemal, DVM, PhD, Elizabeth Ward, PhD, et al.  Trends in the Leading Cause of Death in the U.S. 1970-2002 JAMA 2005;294:1255-1259.

© 2010 HeartMD Institute. All rights reserved.

Leave a Reply


  1. John

    on January 29, 2014 at 11:39 am

    Thanks, doc;
    I’ve learned a lot from what you’ve shared.
    I’m having trouble understanding this ATP thing
    I realize our bodies are amazing machines, but my common sense screams that the math in this article just can’t be right.
    You write;
    “..needs a minimum of 6,000 grams of ATP per day to function.”
    Just off the top of my head, 6000 grams is 13-14 POUNDS!
    Per day?
    I Goggled the sentence. says
    “About 1020 molecules per second, equivalent to a turnover rate of ATP of 65 kg per day.”

    The Handy Biology Answer Book says
    “Roughly 1 x 1023 molecules. In the span of twenty-four hours, 100 trillion cells produce about 441 lbs (200 kg) of ATP.”

    Vitamin Pros says
    “When resting we need around 88 Lbs of ATP every 24-hours.”
    How is this possible?

  2. Johanne Møldrup

    on May 8, 2015 at 2:14 pm

    Can you take L-Carnitine and D-Ribose (and Q10 and Magnesium) together with blood thinners a.o. drugs for heart disease? Doctors here are not interested in supplements a.o.

  3. Sandra Lindsay

    on June 7, 2015 at 8:25 am

    I have atrial fibrillation was on antiarrythmia drugs which I cannot tolerate (Flecainide gave me proarrythmia and Propafenone so many bad side effects that I was determined to reduce the dosage (slowly) from 3 x 150gm tabs daily. I began taking the ‘awesome foursome’, along with taurine and some hawthorn, also high dosage vitamin C. My energy and excercise tolerance have improved remarkably. My Propafenone is now only half a tablet daily, divided into two quarters (every 12 hrs). Thank you Dr Sinatra for this valuable information.

  4. Sandra Lindsay

    on June 7, 2015 at 8:28 am

    Forgot to say – I have had no atrial fibrillation episodes since changing to this regime!

  5. Bev H.

    on October 5, 2018 at 6:43 pm

    I have hypothyroidism how can I and on Synthroid medication and low dose aspirin,. I have been diagnosed with a diastolic dysfunction can I incorporate the Awesome Foursome
    into my supplement regimine.
    It is said that it inhibits absorption of my thyroid medication.

  6. PAUL M

    on September 1, 2019 at 10:38 am


  7. rose

    on January 24, 2020 at 7:48 am

    dr. oz recommends unrefined coconut oil its heart healthy, I got my brother off insulin and metformin, he is bedbound and checked every month by va nurse practitioner. I give my 87 yr old mom unrefined coconut oil has to be unrefined dr. oz said and she is doing great has dementia and is not on any dementia medication, I been taking it over 10 yrs have lots of energy to care for both am 68. research the benefits of coconut oil the miracle. hopes this helps most stores sell it in cooking oil dept.

  8. Roger

    on February 23, 2020 at 2:18 pm

    I have diastolic dysfunction and am taking the traditional medecines. I also have renal failure # 3.
    Can I take the awesome four ?
    Please give me an answer.

  9. HeartMD Editor

    on March 13, 2020 at 6:34 pm

    Hi Roger, You can take THREE of the Awesome Foursome: CoQ10, L-carnitine, and D-ribose. Do NOT take the magnesium. It is contraindicated in renal insufficiency, which you have. Best wishes

  10. Martin

    on June 21, 2020 at 12:42 pm

    Would PQQ be of benefit on top of the other neutraceuticals ? In theory it should support the process. I am a basic scientist and this in interest me.

  11. Sandi

    on July 1, 2020 at 11:47 am

    Hi Martin,
    Thanks for reaching out. This is what Dr. Sinatra had to say: “PQQ is a nutrient I’ve looked at for several years as it’s synergistic with CoQ10 in supporting mitochondrial function. I’ve always believed that supporting mitochondrial activity {Mitochondrial Biogenesis} is the essence in delaying aging. Since PQQ also protects against environmental toxicity– esp. mercury— I see no reason not to take 10-20mg. daily. This is one nutrient along with NAD+ that may be incorporated into my Heathy Directions family of supplements, perhaps in the Omega Q series.”

  12. Martin

    on July 1, 2020 at 1:02 pm

    Thank you Dr. Sinatra, I look forward to the release of your formulation. I have been using your metabolic cardiology approach for years now and kept my heart function and structure normal (Idiopathic DCM diagnosis). I am on the standard of care (beta blocker and ACE inhibitor), but your approach took me to higher levels of function, as I have assessed with cardiovascular athletic performance. I thank you for your pioneering work.

  13. Linda Evans

    on April 11, 2021 at 3:22 pm

    Just found out I have CHF…my doctors want me to have a defibrillator wife wants me to take the fabulous four ,instead…..I’m on warfarin for a st Jude valve and have an aortic aneurysm which is being far it’s staying within a good range..would these four supplements be good for me? I have no blockage ..found out after an angiogram…

  14. Martin

    on June 24, 2021 at 8:08 am

    Would the new class of medications SGLT2 inhibitors be compatible with metabolic cardiology? These drugs like Farxiga have been shown to switch the energy consumption of the heart from fatty acid oxidation to ketone bodies. Would this not negatively impact the effects of metabolic therapy?

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