Complementary and alternative treatments of heart disease

DEFINITION: Complementary and alternative medicines and therapies to prevent and treat cardiovascular disease, or diseases of the heart

Overview

With the advent of lifesaving antibiotics in the early to mid-twentieth century, conventional or allopathic medicine became the preeminent form of healthcare in the United States. Although many other healthcare systems continued to function, they were deemed unscientific. Moreover, as a result of public health interventions, such as better sanitation, the populace enjoyed greater longevity. As the gradual aging of the population began to significantly increase the prevalence of chronic illnesses such as arthritis, diabetes, high blood pressure, and heart disease, mainstream medicine began to address these conditions.

Cardiovascular disease (CVD) is the leading cause of death in the United States. Of note, CVD includes all conditions affecting the heart and the blood vessels. While many risk factors for CVD may be addressed by lifestyle changes such as smoking cessation and eating a diet low in saturated and trans fats, the aging process and hereditary factors that lead to CVD can not be altered. Until age fifty, men are at greater risk than women of developing CVD, although once a woman enters menopause, her risk increases threefold.

Many people with CVD have low levels of high-density lipoproteins (HDL) or good cholesterol or high levels of low-density lipoproteins (LDL) or bad cholesterol (or both), and the levels of both are more specifically linked to CVD than total cholesterol. Atherosclerosis (hardening of the arteries) is the most frequent cause of heart attacks, and it usually occurs in persons with high cholesterol. Overweight persons are more likely to have additional risk factors related to heart disease, specifically hypertension, high blood sugar levels, high cholesterol, high triglycerides, and diabetes. Most often, recommended treatments for cardiovascular diseases by conventional physicians are invasive and include stents and bypass graft surgery. There are, however, instances when complementary and alternative medicine (CAM) or integrative therapies can augment or even preclude invasive measures.

CAM and Heart Health

The National Center for Complementary and Integrative Health (NCCIH), formerly known as the National Center for Complementary and Alternative Medicine (NCCAM), is a branch of the National Institutes of Health (NIH). NCCIH was established in 1998 to ensure that high-quality scientific research is conducted in CAM practices. Complementary medicine is used together with conventional medicine, while alternative medicine is used in place of conventional medicine. Integrative medicine is a combination of conventional medicine with therapies for which there is evidence of both safety and efficacy, such as relaxation and therapeutic touch, in addition to the administration of analgesics for postoperative pain. CAM may be classified into five types of therapy (some systems or therapies may fit into two or more categories) as they pertain to CVD: alternative medicine systems, mind/body medicine, manipulative and body-based systems, energy therapies, and biologically based therapies.

Alternative medicine systems. Alternative medicine systems are based upon complete systems of theory and practice. Examples such as homeopathic and naturopathic medicine in Western culture, while non-Western systems include traditional Chinese medicine and ancient Indian medicine such as Ayurvedaoriginating in India more than eight thousand years ago. Ayurveda uses an integrated approach combining meditation, exercise, lifestyle changes, diet, and herbs such as guggulipid (guggul) and its extracts, which have been used to lower lipids in persons with ischemic heart disease, hypercholesterolemia, and obesity. Clinical studies conducted in India have shown that guggul is effective in lowering triglycerides and total cholesterol. However, in the first clinical randomized trial of guggul in 103 healthy adults, no effect was observed on their lipids. Gastrointestinal upset, rash, headache, and nausea were noted. Guggul has also been shown to interfere with the prescription heart medications propranolol and diltiazem. The herbal/mineral abana formulation may lessen angina symptoms, reduce high blood pressure, and improve cardiac function.

Mind/body medicine.Mind/body medicine uses meditation, prayer, music therapy, and yoga to provide a positive influence upon the mind to improve a person’s health; mind/body medicine’s clinical correlates to CVD unite both social and biological aspects of CVD. An increasing body of evidence suggests that persons with depression are predisposed to cardiovascular events; persons with depression after myocardial infarction were shown to have greater mortality rates than their cohorts who were not depressed. Stress is another psychosocial determinant of cardiovascular pathology and disease, such as high blood pressure. In the Framingham study, high blood pressure was linked to more than 80 percent of all cardiovascular deaths and was at least twice as strong a predictor of death as high cholesterol levels or smoking.

Mind/body techniques have been used as adjuncts to traditional therapies in treating heart diseases. For coronary heart disease, these CAM techniques include stress reduction, meditation (yoga), and group support. CAM includes biofeedback, stress reduction, and group support for arrhythmia. It also includes guided imagery for presurgery therapy, stress reduction and meditation for elevated cholesterol levels, group support and biofeedback for congestive heart failure, and group support, biofeedback, meditation (yoga), and pet companionship for high blood pressure.

A 2009 study was undertaken to determine whether breathing exercises practiced in yoga meditations would benefit persons with hypertension. Sixty men and women between twenty and sixty with Stage I essential hypertension were equally divided into control groups: slow-breathing exercises or fast-breathing exercises. Subjects were assessed using parameters including baseline and postintervention measurements of blood pressure, standing-to-lying ratio, Valsalva ratio, and the hand-grip and cold pressor response; both types of breathing exercises appeared to benefit persons with hypertension. Improvement in both sympathetic and parasympathetic reactivity was associated with those in the slow-breathing group.

Manipulative and body-based systems:Manipulative and body-based systems include massage and therapeutic touch; their clinical correlates to CVD unite both the social and the biological aspects of CVD. Therapeutic touch was tested by meta-analysis; of the eleven trials evaluated, seven demonstrated a positive effect, including anxiety reduction in a coronary care unit, reduced need for postsurgical pain medications, and enhanced wound healing. Because many of these techniques are unproven or may result from a placebo effect, it is best to consult a physician before undergoing therapy.

Energy Therapies:Energy therapies that use supposed natural energy fields to promote health and healing, include qigong, Reiki, and acupuncture. While the energy concepts behind such techniques have not been supported by scientific research, the real benefit of these treatments (like manipulative and body-based systems) might be as adjuncts to improve optimism by restoring a sense of peace, serenity, and emotional connection. This approach may be helpful as long as it does not preclude conventional therapy and does no harm.

Acupuncture, in particular, has become increasingly popular among those wanting to treat or prevent CVD and has shown stronger evidence of direct health effects. This ancient Chinese medicine employs tiny needles that are carefully and strategically inserted into the body to improve health. Studies have shown that acupuncture can be used to reduce high blood pressure and reduce the incidence of angina and blood vessel spasms; those who were treated with acupuncture for angina recovered more quickly from an attack than those who had been taking drugs. Acupuncture's benefits have been replicated in several studies, but reliable scientific evidence fails to support its use. Reliable acupuncturists are usually certified by the National Certification Commission for Acupuncture and Oriental Medicine. Some medical insurance covers acupuncture, but the cost of visits varies widely, so one should consult several practitioners to determine their fees.

Biologically Based Therapies:Biologically based therapies use substances found in nature, such as vitamins, herbs, and omega-3 fatty acids, and special diets to lose weight or prevent CVD. Herbal supplements have been used for thousands of years in the East and have had a resurgence in popularity among consumers in the West. Multiple factors contribute to the increased use of CAM, including the obesity epidemic, the prevalence of chronic disorders and pain syndromes, anxiety, depression, the general desire for good health and wellness, disease prevention, the increasing cost of conventional medicines, and the often mistaken belief that CAM remedies are safer and more effective.

Regarding cardiovascular disease, many natural substances have been suggested for controlling risk factors such as hypertension and high cholesterol. However, studies of such purported effects are generally limited and show only relatively minor benefits. For example, soy and garlic have shown promise in reducing cholesterol but are far less powerful than medication. Similarly, flaxseed, fish oil, tea, and other substances may have small benefits on blood pressure, but results have been mixed, and most experts agree that more research is needed. Other natural substances promoted for heart health are discussed below.

Tetrandine. This vasoactive alkaloid is used in Chinese medicine to treat hypertension and angina. Because its vasodilation effect comes from the inhibition of the L-type calcium channels, there is possible competition with other calcium-channel blockers.

Aconite. Traditional Chinese practitioners use aconite for relief of pain caused by trigeminal and intercostal neuralgia, rheumatism, migraine, and general debilitation. Aconite is also a mild diaphoretic and is used to slow a rapid pulse. Atrial or ventricular fibrillation, however, may result from the direct effect of aconite on the myocardium. Side effects may occur following contact with leaves or sap from Aconitum plants and can range from bradycardia and hypotension to fatal ventricular arrhythmia.

Gynura. Widely used in Chinese folk medicine, Gynura purportedly improves microcirculation and relieves pain; however, it has been associated with hepatic toxicity and has been shown to inhibit angiotensin-converting enzyme activity, resulting in hypotension in animals.

Ginseng. To determine whether there was a link between ginseng intake and mortality in a Korean population, 6,282 persons over fifty-five were followed from March 1985 to December 2003. After adjusting for age, education, smoking, body mass index, and blood pressure, the all-cause mortality rate for males who used ginseng was lower. This effect was not observed in female cohorts. Mortality caused by cardiovascular disease was not related to ginseng consumption in either sex.

Ginkgo biloba. This herb has been used to treat intermittent claudication in persons with peripheral artery blockage. A meta-analysis looked at eight randomized, placebo-controlled, double-blind studies of 415 persons. The results from the trials showed that Ginkgo biloba significantly increased walking distance in tested persons by 111.54 feet. Ginkgo should not be given with digitalis, warfarin, aspirin, nonsteroidal anti-inflammatory drugs, or thiazide diuretics.

Cinnamon. Two daily doses of a dried water-soluble cinnamon extract seemed to lower the risk factors for heart disease and diabetes in a small study led by a US Department of Agriculture chemist. It was found that the daily doses of the cinnamon extract improved the antioxidant status of the subjects, a group of obese men and women, and also decreased their fasting blood sugar (glucose) levels. For this twelve-week study, the twenty-two participants were randomly divided into two groups; one group received 250 milligrams of cinnamon extract twice per day with their usual diets, and the other group was given placebos. The positive changes seen in the lab values of the cinnamon group suggested a reduction in the risk of both diabetes and cardiac disease. However, any effects are minor, and further research is needed before conclusions can be made.

Hawthorn. A peripheral vasodilator, hawthorn, has been used to treat high blood pressure, ischemic heart disease, arrhythmia, coronary heart disease, cor pulmonale (pulmonary heart disease), and atherosclerosis. Several double-blind studies of persons with heart failure have shown objective improvement in cardiac performance using bicycle ergometry. In some studies of persons with mild heart failure, hawthorn outperformed digitalis. However, longer-term studies have failed to confirm any benefits. It may interact harmfully with various drugs, including beta-blockers and antiarrhythmics, or cause side effects like dizziness, headache, sweating, heart palpitations, sleepiness, and gastrointestinal symptoms.

Vitamins. Vitamins used to prevent or treat CVD include B₁₂, B₆, and folate. Elevated blood levels of the amino acid homocysteine, found in high amounts in animal protein, are a strong risk factor for CVD. Studies have also shown that when high homocysteine levels are reduced, the incidence of heart attack is cut by 20 percent, the risk of blood-clot-related strokes by 40 percent, and the risk of venous blood clots elsewhere in the body by 60 percent. Studies have shown that dietary intake of vitamins B₁₂, B₆, and folate can help to lower elevated homocysteine levels, as can lowering the amount of animal-based protein ingested. At least ten percent of the population, however, has a genetic propensity for elevated levels of homocysteine. Persons should consult their healthcare providers to determine homocysteine levelif the level is above 7, activated folic acid (L-methyl folate), vitamin B12, and vitamin B6 should be added to the person's diet.

Observational data suggest that fruit and vegetable consumption lowers the risk of developing CVD. It has been postulated that the antioxidant component of fruits and vegetables accounts for the observed protection. A decreased risk of cardiovascular death has been associated with higher blood levels of vitamin C and coenzyme Q10 (CoQ₁₀). In addition, vitamin C, vitamin E, and CoQ₁₀ have demonstrated antioxidant effects, including beneficial effects on the oxidation of low-density lipoprotein. There is evidence that these vitamins may affect other risk factors for CVD, such as hypertension. Vitamin E may also reduce coronary artery blockage by decreasing blood platelet aggregation. Thus, supplementation with these antioxidants could decrease the risk of developing CVD.

CoQ₁₀ is produced in all body tissues, acting like a free-radical scavenger that can stabilize membranes. More than forty clinical trials of CoQ₁₀ used in persons with CVD have demonstrated both subjective and objective benefits. Both reviews and a meta-analysis have shown the benefits of CoQ₁₀, which has also been shown to significantly reduce the cardiotoxicity of cancer drugs such as Adriamycin (doxorubicin). Although not serious, side effects have been reported with CoQ₁₀ usage, most frequently insomnia, higher levels of liver enzymes, upper abdominal pain, sensitivity to light, irritability, headache, dizziness, heartburn, and extreme fatigue.

Heart Healthy Diets

American Heart Association (AHA) dietary guidelines have typically underscored the importance of limiting “bad fats” and stated that less than seven percent of calories consumed daily should come from saturated fatsand less than one percent from trans-fats. A range between 25 to 35 percent for total fat consumption is suggested for most people, not just for those trying to lose weight. Saturated fats are typically found in meat products and in tropical oils, such as coconut and palm oil. Trans-fat, also known as partially hydrogenated fat, is human-made and is found mostly in commercially baked goods.

The AHA promotes two types of dietary guidelines. The first restricts cholesterol consumption to less than 200 milligrams per day and less than seven percent of calories as saturated fat, and the second recommends eating foods such as margarine, which contains plant sterols. In 2010, a Tufts University study found that eating such margarine with three meals per day lowered LDL. Other suggestions include soy products, soluble fiber, walnuts, and almonds to lower LDL (low-density lipoprotein), or bad cholesterol. Soy-based phytoestrogen foods have been found to reduce the oxidation of lipids. Favorable effects of soy phytoestrogens on lipid profiles, thrombosis, and vascular reactivity have been reported. Intake of foods containing phytoestrogens has been linked to a favorable cardiovascular risk profile, as demonstrated by 939 postmenopausal women participating in the Framingham Off-Spring Study.

Eating protein-rich foods other than red meat could help lower the risk of heart disease. Harvard School of Public Health researchers found that women who consumed higher amounts of red meat had a greater risk of coronary heart disease (CHD). Substituting other foods high in protein, such as fish, poultry, and nuts, in place of red meat was associated with a lower risk of CHD. Eating one serving per day of nuts in place of red meat was linked to a 30 percent lower risk of CHD, substituting a serving of fish showed a 24 percent lower risk, poultry a 19 percent lower risk, and low-fat dairy a 13 percent lower risk.

Many previous studies have focused on either the nutrient composition of protein-rich foodsthe amount of saturated fat or ironor dietary patterns such as the Mediterranean-style diet or Western-style diet, and how they relate to heart disease risk. One, which appeared in the August 16, 2010, issue of Circulation, evaluated the substitution of one protein-rich food for another, which may be easier for a person to do, compared with substituting one nutrient or one dietary pattern for another, to reduce the risk of heart disease. The researchers followed 84,136 women aged thirty to fifty-five in the Nurses’ Health Study based at Brigham and Women’s Hospital over a twenty-six year period. The participants had no known cancer, diabetes, stroke, angina, or other cardiovascular disease. To assess diets, the participants filled out a questionnaire every four years about the types of food they ate and how often.

Many fad diets, including various versions of a low-carbohydrate diet, have alternately been promoted as improving or criticized for potentially worsening cardiovascular health. Most experts agree that while such diets may be effective for short-term weight loss, longer-term results are less clear. While maintaining a healthy weight level is a key component of heart health, a balanced diet and exercise are preferable to any extreme diet.

An article in the Journal of the American Medical Association (2005) reported on a single-center randomized trial at an academic medical institution in Boston of adults who were overweight or obese between twenty-two and seventy-two with known hypertension, dyslipidemia, or fasting hyperglycemia. The study compared the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction. The study set out to assess adherence rates and the effectiveness of the four popular diets for weight loss and cardiac risk factor reduction. A total of 160 people were randomly assigned to four diet groupsAtkins (carbohydrate restriction), Zone (macronutrient balance), Weight Watchers (calorie restriction), and Ornish (fat restriction) diet groups. Each diet significantly reduced the LDL/HDL-cholesterol ratio by approximately ten percent, with no significant effects on blood pressure or glucose at one year. The amount of weight loss was associated with self-reported dietary adherence but not diet type. For each diet, decreasing levels of total/HDL cholesterol, C-reactive protein, and insulin were significantly associated with weight loss, with no significant difference among diets. Each popular diet modestly reduced body weight and several cardiac risk factors in one year. Overall dietary adherence rates were low, although increased adherence was associated with greater weight loss and cardiac risk factor reductions for each diet.

The proliferation of diets, eating patterns, and lifestyles in the twenty-first century led to increased confusion and misinformation among consumers as well as healthcare professionals concerning heart health. To clarify the benefits of various diets based on scientific evidence, the American Heart Association reviewed ten popular diets and eating patterns in the early 2020s for their ability to promote cardiometabolic health. Diets found to meet heart-healthy guidelines included the Mediterranean, DASH (Dietary Approaches to Stop Hypertension)-style eating plans, pescetarian, and vegetarian diets. Paleo and ketogenic were not found to be beneficial.

These results were based on the AHA’s dietary guidelines, including consuming a wide variety of fruits and vegetables, choosing whole grains over refined, incorporating protein from plants, lean meats, and seafood, using liquid plant oils, and limiting salt, sugar, alcohol, and processed foods. DASH was the only diet that received a perfect score.

Safety

Individuals looking for a CAM practitioner who can address heart health should contact national organizations such as NCCIH, the American Heart Association, and the National Institutes of Health, as well as specific therapy organizations. One's healthcare provider can also offer suggestions and should be consulted and informed about any complementary or alternative medicine decisions.

The use of herbal remedies in the United States is widespread and increasing dramatically. Generally defined as any form of plant or plant product, herbs make up the largest proportion of CAM use in the United States. Because herbs are regarded as food products, they are not subject to the same scrutiny and regulation as traditional medicationsmanufacturers are exempt from premarket safety and efficacy testing and from any surveillance after marketing. Although herbal remedies are often perceived as natural and safe, many have adverse effects that can sometimes produce life-threatening consequences. Thus, one should consult a physician or other health-care professional about using herbs. Physicians are often unaware of their patients’ use of such products because they do not ask about it, and patients rarely volunteer such information.

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