According to a new study, erythritol, a sugar replacement, is associated with blood clotting, stroke, heart attack, and death.

Individuals with existing risk factors for heart disease, such as diabetes, were twice as likely to have a heart attack or stroke if they had the highest amounts of erythritol in their blood, according to a study published in the journal Nature Medicine.

Dr. Stanley Hazen, head of the Center for Cardiovascular Diagnostics and Prevention at the Cleveland Clinic Lerner Research Institute and principal author of the study, stated that the level of risk was "not modest."

Blood platelets appeared to coagulate more quickly when erythritol was present, according to additional laboratory and animal experiments included in the publication. Clots can fragment and go to the heart, triggering a heart attack, or to the brain, causing a stroke.

The correlation between erythritol and cardiovascular problems was discovered accidentally.

Hazen's research had a straightforward objective: to identify unidentified molecules or compounds in a person's blood that could forecast his or her risk for a heart attack, stroke, or death within the next three years. To do so, the scientists began examining 1,157 blood samples collected between 2004 and 2011 from adults at risk for cardiovascular disease.

"We found this substance that seemed to play a big role, but we didn't know what it was," Hazen said. "Then we discovered it was erythritol, a sweetener."

The human body naturally produces erythritol, but in such minute quantities that scientists could not account for the levels they detected, he explained.

To validate the findings, Hazen's team evaluated another set of blood samples from over 2,100 individuals in the U.S. and an additional 833 samples collected by European colleagues through 2018. Almost three-quarters of the individuals in all three populations had cardiovascular disease or hypertension, and one-fifth had diabetes, according to Hazen. More than half were men in their 60s and 70s.

Higher erythritol levels were associated with an increased risk of heart attack, stroke, or death within three years in each of the three populations studied.

Researchers conducted more animal and laboratory testing and determined that erythritol "provoked enhanced thrombosis," or blood clotting, as explained by Hazen.

Erythritol is also the most abundant ingredient by weight in a number of "natural" stevia and monkfruit products, according to Hazen. Because stevia and monkfruit are around 200 to 400 times sweeter than sugar, only a tiny quantity is required in any product. The majority of the product consists of erythritol, which imparts a sugar-like crystalline appearance and texture.