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%.
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.
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.
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.
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)
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.
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.
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.