What are complementary and alternative treatments for heart disease?

Overview

With the advent of lifesaving antibiotics in the early to mid-twentieth century, conventional or allopathic medicine became the preeminent form of health care in the United States. Although most of the other health care 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 by adherence to diets low in saturated fats and trans fatty acids, the aging process and hereditary factors predispose for risk factors that cannot be altered. Until the age of fifty years, 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 is 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, an example being aromatherapy, and alternative medicine is used in place of conventional medicine, an example being the Zone diet to lower LDL and raise HDL levels. 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 are based upon complete systems of theory and practice, such as homeopathic and naturopathic medicine in Western culture; non-Western systems include traditional Chinese medicine such as acupuncture and ancient Indian medicine such as Ayurveda, which originated 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. 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 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 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 a 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; 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 be of benefit to persons with hypertension.
Sixty men and women (twenty to sixty years of age) with stage I essential
hypertension were equally divided into groups of controls: those who did
slow-breathing exercises and those who did 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 include massage and therapeutic touch;
their clinical correlates to CVD unite both the social and the biological aspects
of CVD. The real benefit of energy treatments 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.

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, which use natural energy fields to promote health
and healing, include qigong, Reiki, therapeutic touch, and
acupuncture. Acupuncture has become increasingly popular among those
wanting to treat or prevent CVD. This ancient Chinese medicine employs tiny
needles that are carefully and strategically inserted in the body to improve
health. The basis for this improvement is the movement, throughout the body, of
energy that may have become blocked; it is believed that acupuncture helps to
unblock and redirect energy. 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 by acupuncture for angina recovered more quickly
from an attack than those who had been taking drugs. Reliable acupuncturists are
usually certified by the National Certification Commission for Acupuncture and
Oriental Medicine. Acupuncture is covered by some medical insurance; the cost of
visits varies widely, so one should consult several practitioners to find out
about their fees.

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 recent resurgence in popularity among consumers in the West; more than fifteen million people in the United States consume herbal remedies or high-dose vitamins, and the total number of visits to CAM providers far exceeds those to primary physicians, amounting to more than $34 billion in out-of-pocket costs for CAM annually. 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.

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 medications; manufacturers are exempt from premarket safety and efficacy testing and from any surveillance after marketing. Although herbal remedies are perceived as being natural, and therefore 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; also, patients rarely volunteer such information.

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 age fifty-five years and older 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 females or males.

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 U.S. 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.

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. Care should be taken, however, when taking hawthorn with drugs such as digitalis, beta-blockers, and anti-arrhythmics.

Vitamins. Vitamins used to prevent or treat CVD include B12, B6, and folate. Having elevated blood levels of the amino acid homocysteine (found in high amounts in animal protein) is 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 10 percent of the population, however, has a genetic propensity for elevated levels of homocysteine. Persons should consult their health care providers to determine homocysteine level; if above 7, activated folic acid (L-methyl folate), vitamin B12
, and vitamin B6
should be added to the diet.

Observational data suggest that fruit and vegetable consumption lower the risk of developing CVD. It has been postulated that the antioxidant component of fruits and vegetables accounts for the observed protection. 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 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. There
have been more than forty clinical trials of CoQ10 use in persons with
CVD, demonstrating both subjective and objective benefits. Both a recent review
and a meta-analysis have shown the benefits of CoQ10, which has also
been shown to significantly reduce 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

In 2006, American Heart Association (AHA) dietary guidelines underscored the importance of limiting “bad fats” and stated that less than 7 percent of calories consumed daily should come from saturated fats (and less than 1 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 7
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, and walnuts and almonds to lower
LDL (low-density lipoprotein), or bad cholesterol. Soy-based phytoestrogen foods
have been found to reduce oxidation of lipids. Favorable effects of soy
phytoestrogens on lipid profiles and thrombosis and vascular reactivity have been
reported. Intake of foods containing phytoestrogens have 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 play an important role in lowering the risk of heart disease. In a recent study, 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 foods (the amount of saturated fat or iron) or dietary patterns (Mediterranean-style diet or Western-style diet) and how they relate to heart disease risk. This study, 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 age thirty to fifty-five years in the Nurses’ Health Study (based at Brigham and Women’s Hospital) over a period of twenty-six years. 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.

A low-carbohydrate diet based on animal products was associated with higher all-cause mortality in both men and women. According to a study published in the September 7, 2010, issue of Annals of Internal Medicine, a low-carbohydrate diet may reduce the risk of death from all medical causes in both men and women, whereas a vegetable-based low-carbohydrate diet was associated with lower all-cause mortality and cardiovascular disease mortality. Researchers had followed more than 85,000 women for twenty-six years and 44,000 men for twenty years as a follow-up to earlier studies.

This wide-ranging study gives credence to the Eco-Atkins diet popularized by David Jenkins (Archives of Internal Medicine, 2009), who created a diet high in plant proteins, fruits, and vegetables. In the Jenkins study, forty-seven overweight hyperlipidemic men and women consumed one of two diets: a low-carbohydrate (26 percent of total calories), high vegetable protein (31 percent from gluten, soy, nuts, fruit, vegetables, and cereals), and vegetable oil (43 percent) plant-based diet or a high-carbohydrate lacto-ovo (milk and eggs) vegetarian style diet (58 percent carbohydrate, 16 percent protein, and 25 percent fat). The dieting lasted four weeks and had a parallel-study design. The study food was provided at 60 percent of calorie requirements. While the Jenkins study does not suggest that the diet will result in longevity, Eco-Atkins (the low-carbohydrate diet) was shown to improve cholesterol levels and promote weight loss.

The Ornish diet, designed by Dean Ornish, is a low-fat vegetarian
diet with less than 10 percent of daily calories derived from fat (an average of
15 to 25 grams per day), 70 to 75 percent from carbohydrates, and 15 to 20 percent
from protein. The diet encourages consumption of beans, fruits, vegetables, and
whole grains and restricts intake of processed foods, high-fat dairy products,
alcohol, and simple sugars. There are two versions of the Ornish diet: the
reversal diet, for people with existing heart disease wanting to reduce their risk
of heart attack or other coronary event, and the prevention diet, for otherwise
healthy persons with levels of LDL cholesterol greater than 150 milligrams per
deciliter or for those with a ratio of total cholesterol to high-density
lipoprotein (HDL, or good cholesterol) that is less than 3.0.

The Ornish diet is completely vegetarian. Excluded are cholesterol, saturated fat, and animal products, except egg whites and nonfat dairy products. All nuts, seeds, avocados, chocolate, olives, coconuts, and oils are eliminated too, except for a small amount of canola oil for cooking and for oil that supplies omega-3 essential fatty acids. The Ornish diet also prohibits caffeine but allows a moderate intake of alcohol and salt. There is no restriction on calorie intake, but the diet suggests several small meals each day rather than three large meals. Based on available research, the Ornish diet appears to be more successful in lowering the risk of heart disease than other diets, but it also has been described as one of the more difficult diets to follow.

The Zone diet, designed by Barry Sears, determines total daily caloric intake based on daily protein intake. Once the amount of daily protein is established, the next step is to divide this protein into “blocks,” each of which contains approximately 7 grams of protein, then divide the protein blocks into five or more meals to be eaten throughout the day. For example, one can consume four blocks at breakfast, three at lunch, two as afternoon snacks, four at dinner, and two as late-night snacks. For each protein block eaten, one carbohydrate block and one fat block should also be consumed. Each carbohydrate block contains 9 grams of carbohydrate, and each fat block has 1.5 grams of fat. Suggested daily protein intake will vary based on daily activity and lean body mass. For the average overweight American, total caloric intake might be 1,400 calories per day. For an average marathon runner, the daily intake might be about 1,750 calories per day. The program's daily protein recommendation is 75 grams for women and 100 grams for men.

The Pritikin diet is a low-fat diet largely based on vegetables, grains, and fruits. Fat in the diet accounts for 10 percent of daily intake. Nathan Pritikin promoted the concept of wellness through lowering cholesterol and helping diabetics normalize their blood sugar without taking insulin. That people lost weight was a plus. Pritikin’s son, Robert, then altered the diet; its staples remained the same plant-based foods of the original diet, and the fat content remained very low. Again altered by Robert, the diet now focuses on caloric density: Not just calories are important, but also how dense these calories are in a given food. For example, one pound of broccoli has fewer calories than one pound of cookies, which is also rich in simple sugars and saturated fat. Between 1975 and 2015, more than 100,000 people have attended Pritikin Longevity Centers.

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 overweight or obese adults age twenty-two to seventy-two years 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 groups: Atkins (carbohydrate restriction), Zone (macronutrient balance), Weight Watchers (calorie restriction), and Ornish (fat restriction) diet groups.

Each diet was found to significantly reduce the LDL/HDL-cholesterol ratio by approximately 10 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 with 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 at 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.

Those persons 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, and also specific therapy organizations such as the American Association of Oriental Medicine. One can also consult his or her health care provider for suggestions.

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