Alternative Therapies & Cardiovascular Concerns
St. John's Wort
Coenzyme Q10
Hawthorne
St.
John's wort
St. John's wort has been legitimately
useful as an antidepressant. A meta-analysis of 15 placebo-controlled
trials (BMJ.1996;313:253-58) revealed that use of St. John's wort
was as effective as conventional antidepressants for the management
of depression. Sales in Europe in 1998 were estimated to total
approximately $6 billion. While there appears to be little doubt
about its efficacy, there are now concerns about its safety.
Concerns: The use of St. John's wort has been implicated as
the etiology of two heart transplantation rejections in association
with subtherapeutic cyclosporine concentrations. (Lancet. 2000.
355:548-549).
There
is now evidence to suggest that St. John's wort acts as an inducer
of the hepatic enzyme cytochrome P450 3A4 (cyp3A4). Agents such
as amiodarone, amlodipine, atorvastatin, cerivastatin, diltiazem,
felodipine, lidocaine, losartan, lovastatin, nifedipine, propafenone,
simvastatin, tacrolimus, and verapamil are all substrates of this
enzyme. As such, patients taking any of these medications would
be at risk for exacerbation of an arrhythmia, angina, or hypertension
should they decide to begin taking St. John's wort at the same
time.
In 2 patients previously stabilized
on digoxin, following 10 days of concurrent therapy, peak and
trough levels of digoxin fell by 26% and 33%.
Coenzyme Q10
Other name: Ubiquinone
General: Q10 is a coenzyme found in all tissues of the body with
increased concentrations in the heart, liver, and pancreas. Essential
for certain metabolic reactions, its cardiac use stems from its
antioxidant effects, stabilization of the NaK-ATPase and its effects
on calcium channels.
Possible benefits: The product has been suggested to be beneficial
for patients with CHF. It has been observed to be markedly lowered
in advanced heart failure and the extent of deficiency has been
shown to correlate with the clinical severity of CHF. In Japan,
it has been approved for the treatment of heart failure.
Clinical trials so far have yielded conflicting results. Although
the clinical benefits of Q10 supplementation have not been clearly
proved, some trials have shown improvement in ejection fraction,
increased stroke index at rest and at work, improved cardiac index
and end diastolic volume, exercise tolerance, and subjective improvement
in quality of life. Two studies showed no improvement in these
parameters, even though the serum concentrations of coenzyme Q10
increased over twofold.
Possibly, modest at best, Q10 has
a beneficial role in the management of heart failure. No adverse
side effects have been noted at doses of 100 mg daily for six
years or 200 mg daily for one year.
The continuing concern is
that patients might discontinue conventional therapy in favor
of alternative treatment which can result in acute exacerbation
of heart failure or loss of control of ventricular rate in patients
with atrial fibrillation.
Hawthorn
General: The hawthorne plant is a white-bloomed shrub native
to Europe. The leaves, berries, and blossoms are used medicinally.
The active ingredients are procyanidins (catechins, flavanoids,
cardiotonic amines, catechols, and triterpene acids). Deemed benefits
are varied which include: stabilization of collagen, scavenging
of free radicals, suppression of inflammation, increase coronary
blood flow through coronary dilatation, positive inotropism and
chronotropism, inhibition of angiotensin-converting enzyme activity,
lowering of cholesterol and possible potentiation of cardiac glycoside
activity.
Trials: German trials have shown improvement in pressure-heartrate
product with subjective improvement in quality of life and well-being.
It is deemed an effective, low-risk phytotherapeutic form of treatment
in patients with stage II CHF. In the United States, there have
not been any double-blind, randomized, placebo-controlled, cross-over
trials documenting echocardiographic improvements or improvements
in exercise tolerance.
In Europe and Asia, hawthorne is
sold as a prescription medication. In Germany, it has been approved
and is prescribed for mild cardiac insufficiency.
Caution: Hawthorn may potentiate the action of cardiac glycosides
and patients on digitalis have been advised to avoid hawthorn
use. However, clinical studies documenting this potential interaction
are lacking. It may act synergistically with beta blockers and
other hypotensive agents. There is a 1.3% incidence of GI upsets,
nausea, palpitations, dizziness, migraine, headache, facial flushing,
epistaxis and insomnia.
Dosage: 160 to 900 mg daily of an extract of leaves and
flowers (standardized to 4-30 mg of flavanoids or 30-160 mg of
procyanidins) for a minimum of six weeks.
Garlic
General: Early studies suggested a lipid-lowering and anti-hypertensive
effect. Commission E approved garlic for treatment of hyperlipoproteinemia
and arteriosclerosis, recommending a daily dosage of 4 g, the
equivalent of 1 fresh, average-size clove. However, more
recent, rigorous studies have failed to substantiate its benefits
as an hyperlipidemic agent.
A clinical trial showed garlic
use associated with inhibition of platelet aggregation affecting
prothrombin times and INR. Users are continued to be cautioned
on its use with anticoagulants.
Soy
The mechanism for its lipid-lowering effect is unclear. Possibly,
it may decrease cholesterol absorption, decrease bile reabsorption
in the gut or through endocrine effects from its isoflavone contents.
Studies have shown a decrease in total cholesterol and LDL levels.
The evidence is strong enough that the FDA authorized a health
claim label that allows soy foods to be marketed as "heart-healthy."
Such labeled foods must contain at least 6.25 g of soy per serving
and be low in saturated fat and cholesterol. (See: Soy.html)
Cholestin
General: Cholestin is a fermented product of rice on which
red yeast is grown. The "red yeast product," used in
China for centuries, contains starch, protein, fiber, and at least
eight statin compounds, which function as HMG-CoA reductase inhibitors.
Chinese studies claiming an 11 to 32 % reduction in total cholesterol
has recently been verified ay U.S. studies that showed about 11%
reduction in total cholesterol and about 22% reduction in LDL
cholesterol. These are similar to reductions obtained with prescribed
"statins;" and to boot, at some cost-savings.
Safety: To date, no adverse effects reported. As in prescription
statins, monitoring of liver functions is suggested.
Fenugreek
General: Fenugreek, a legume sold as a dried seed, is native
to Asia and southeastern Europe. It contains fiber and active
steroid saponins that have been documented to have a anti-hyperlipidemic
effect and a hypoglycemic effect in mild cases of type2 diabetes.
A recent study showed a decrease
in total cholesterol and triglycerides with fenugreek use. A 1990
study showed signifcant decreases in total cholesterol, LDL, and
VLDL. Well-designed clinical trials are awaited.
Gugulipid
Other name: Guggul gum
General: Guggul gum is widely used in India for hypercholesterolemia.
Studies in India showed reductions in cholesterol from 11 to 22
percent, LDL by 12 percent, and triglycerides from12 to 25 percent.
Side effects: No different than placebo and markedly lower than
available statin drugs.
Dose: Suggested
dosage is the equivalent of 75 mg of guggulsterone daily.
