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Exploring the yin and yang of coffee for cardiovascular prevention

Comment by Giuseppe Biondi-Zoccai, Population Science and Public Health Section

"If this is coffee, please bring me some tea; but if this is tea, please bring me some coffee."
Abraham Lincoln

Rehabilitation and Sports Cardiology

Coffee represents a uniquely successful beverage, which has withstood the passing of time similarly to tea, wine, beer and other key ones.(1) Its main component for many users is caffeine, a methylxanthine with stimulating effects on the central and peripheral nervous systems, but of course coffee is not simply a liquid containing caffeine, but much more. Several means of coffee preparation are available, from filtered (in which coffee passes through a paper filter which captures most oils) to unfiltered ones (including those using a metal filter such as moka or the Italian espresso), up to the recent coffee capsules.

Indeed, it is difficult to disentangle the complex interplay between coffee and human history, recent and past, with its pros supporting its regular consumption, but also the risk of dependency and side effects, as epitomised by the famous quote by Lincoln, detailed above. The key question cardiovascular practitioners are being asked more and more commonly is indeed: “is coffee beneficial for cardiovascular prevention?”.

This simple issue begets many complex arguments and uncertain answers, as coffee consumption has many subtleties and, most importantly, long-term randomised trials are lacking and only observational studies are available to inform us, without clear individualised evidence.(2) Notwithstanding the risks of publication bias, residual confounding, and spurious precision, the totality of evidence suggests that coffee, especially used in moderate amounts, is indeed clinically beneficial.(3) Yet, the jury is still out, and every new piece of evidence can guide us in decision making and in supporting our recommendations.(4)

Tverdal and colleagues come in our support with a novel epidemiologic study appraising the impact of coffee consumption and mortality, all cause as well as due to cardiovascular disease, ischaemic heart disease, or stroke.(5) They found that filtered coffee, if consumed in moderation, was associated with a significantly lower risk of death, including cardiovascular death (Figure 1). Conversely, excessive daily uptake of any coffee, even filtered, was not beneficial, suggesting a J- or U-shaped relationship between coffee use and fatality. Finally, unfiltered coffee was not clearly associated with favorable outcomes, and was even detrimental at some analyses.

A careful perspective on this work is also provided in the same issue of the Journal by Fukumoto.(6) Despite Tverdal et al’s work strengths, we cannot exclude residual confounding, and indeed coffee consumption could be a proxy for other healthy habits. In any case, this work is a poignant reminder of the importance of diet, including micronutrients, in shaping our health, even in the COVID-19 era.(7)

In conclusion, we may suggest informing our patients that moderate consumption of filtered coffee is likely going to be beneficial for their cardiovascular health, while definitely being tasty and pleasurable.



Figure 1. Graphical summary of the main take-home messages from the work by Tverdal and colleagues on coffee for cardiovascular prevention.(5)


Giuseppe Biondi-Zoccai commented on these articles:

5. Tverdal A, Selmer R, Cohen JM, Thelle DS. Coffee consumption and mortality from cardiovascular diseases and total mortality: Does the brewing method matter? Eur J Prev Cardiol. 2020 Dec;27(18):1986-1993. doi: 10.1177/2047487320914443. Epub 2020 Apr 22. PMID: 32320635.

6. Fukumoto Y. Filtered, not unfiltered, coffee in cardiovascular disease. Eur J Prev Cardiol. 2020 Dec;27(18):1983-1985. doi: 10.1177/2047487320920415. Epub 2020 Apr 22. PMID: 32320627.

1. Pendergrast M. Uncommon Grounds: The History of Coffee and How It Transformed Our World. London: Basic Books; 1999.
2. Ambrosini S, Mohammed SA, Costantino S, Paneni F. Disentangling the epigenetic landscape in cardiovascular patients: a path toward personalized medicine. Minerva Cardioangiol. 2020 Sep 30. doi: 10.23736/S0026-4725.20.05326-8. Epub ahead of print. PMID: 32996305.
3. Poole R, Kennedy OJ, Roderick P, Fallowfield JA, Hayes PC, Parkes J. Coffee consumption and health: umbrella review of meta-analyses of multiple health outcomes. BMJ. 2017 Nov 22;359:j5024. doi: 10.1136/bmj.j5024. Erratum in: BMJ. 2018 Jan 12;360:k194. PMID: 29167102; PMCID: PMC5696634.
4. Whayne TF Jr. Coffee: A Selected Overview of Beneficial or Harmful Effects on the Cardiovascular System? Curr Vasc Pharmacol. 2015;13(5):637-48. PMID: 25277696.
7. Infusino F, Marazzato M, Mancone M, Fedele F, Mastroianni CM, Severino P, Ceccarelli G, Santinelli L, Cavarretta E, Marullo AGM, Miraldi F, Carnevale R, Nocella C, Biondi-Zoccai G, Pagnini C, Schiavon S, Pugliese F, Frati G, d'Ettorre G. Diet Supplementation, Probiotics, and Nutraceuticals in SARS-CoV-2 Infection: A Scoping Review. Nutrients. 2020 Jun 8;12(6):1718. doi: 10.3390/nu12061718. PMID: 32521760; PMCID: PMC7352781.

Notes to editor

Note: The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology