THE BOTANICAL PRACTITIONER'S PERSPECTIVE

Heart disease is perhaps the most overt example of pathology representing a confluence of influences that conspire to create disease: diet, exercise, sleep, stress and coping mechanisms, spirituality, culture, family, and environmental conditions—all of which also can work in concert to affect healing.

Botanical medicine offers a number of herbs that have been used historically and traditionally for the treatment of cardiovascular disease. Every medical and herbal student learns the story of William Withering, who learned of the cure for dropsy (edema caused by CHF) from a local herb woman, and from which the modern mainstay drug digoxin was derived. However, determining the appropriate role for botanical therapies in treating the patient with CVD can be difficult. A number of herbs with cardiovascular effects have now been well studied, and have been found to improve cardiovascular wellness. Several have been demonstrated to have actions that parallel those of conventional pharmaceuticals, often with fewer adverse effects. For example, garlic, fenugreek, and guggul have demonstrated positive effects on cholesterol levels, whereas hawthorn has been shown to have positive inotropic effects and be beneficial in the prevention of CHF, and none have remarkable adverse effects associated with their use. However, whether these herbs are a suitable substitute for patients with heart disease is undetermined. There are, for example, a number of effective herbal diuretics, most notably dandelion leaf, which is rich in potassium and therefore may offer diuresis without potassium depletion. Unfortunately, its diuretic effects are more difficult to predict, control, and quantify than a standard pharmaceutical dose of a diuretic; therefore, although pharmaceutical diuretics certainly have more side effects, they may be easier to control in terms of dose and results. Because the potential for interactions exists between herbs and drugs, and because the effects on both patient safety and medication efficacy—either of the herb or the drug—when taken combined is largely unknown, it is advisable not to combine the two.

Therefore, for patients dependent on medications for basic cardiac functioning, it is probably best to take a conventional pharmaceutical treatment route;however, for patients in need of CVD prevention, or with only mild disease, that is., moderate hypertension, and who wish to avoid medications, a trial of botanical medicines along with therapeutic lifestyle change might be entirely safe and appropriate. Such decisions need to be made individually for each patient. Close monitoring of patients is important.

The importance of therapeutic lifestyle changes in altering the course of cardiovascular disease also cannot be overemphasized. Even walking briskly for as little as 3 hours per week can reduce a woman's risk of heart attack by about 40%!163 Similarly, dietary changes, stress reduction, treatment for depression, and perhaps most significantly, smoking cessation, can be life saving. Therapeutic lifestyle changes are always the first line approach in any nonemergent medical setting, as well as in the herbal clinic. The possible actions of herbs and their effects on the cardiovascular system are presented in Table 19-11 and are discussed in the following. This section focuses on those herbs used directly to prevent and treat mild cardiovascular disease. Treatment of concurrent problems, for example, diabetes, polycystic ovarian syndrome (PCOS), or insulin resistance, which are known to increase risk of cardiovascular problems, is essential.

For botanical options for stress, readers are directed to other chapters for discussions on herbs for treating depression, relieving anxiety, promoting sleep, and improving the stress response.

Patients with a history of cardiovascular disease, a suspected cardiovascular problem, or who are currently being treated for cardiovascular disease, are advised to work in conjunction with a physician when using botanicals. It is generally recommended that cardiotonic herbs (e. g., hawthorn) and cardioactive herbs (containing cardioactive glycosides) (e. g., lily of the valley) not be combined with cardioactive medications caused by possible potentiation of actions.

Black Cohosh

Traditionally, black cohosh was used by the Eclectics for a wide range of disorders, including emotional complaints associated with the perimenopause, as well as cardiovascular symptoms such as palpitations, arrhythmias, and hypertension caused by ''nervous stimulation'' of the heart. It was used in the treatment for angina and cardiac arrhytmias.551 Primarily used for management of vasomotor symptoms commonly associated with the peri-menopause, black cohosh also appears to increase the blood flow through peripheral vessels at doses of 0.5 mg/kg.551 Animal studies have demonstrated a dose-dependent hypotensive effect; however, this has never been observed in human studies.551 The primary use of black cohosh in a contemporary herbal approach to CVD is in combination with other herbs for its anxiolytic effects, relaxation of nonpathologic palpitations, and for concomitant relief of menopausal complaints. It is commonly given in tincture or capsule form. Recently raised concerns regarding the possible risks of hepatotox-ity associated with black cohosh use are discussed in Plant Profiles: Black Cohosh.

Coleus

Valued by herbalists for its hypotensive actions, coleus also may contribute to the prevention of CHD through its antiplatelet activity.552 Its constituent forskolin has been subject to in vitro and in vivo (by injection) investigation and has demonstrated hypotensive activity,

1 TABLE

Herbs Used in the Prevention and Management of CAD in Women

THERAPEUTIC ACTIVITY

BOTANICAL NAME

COMMON NAME

Anticholesterolemic

Allium sativum

Garlic

Commiphora mukul

Guggul

Cynara scolymus

Globe artichoke

Salvia miltiorrhiza (dan shen)

Salvia

Trigonella foenum-graecum

Fenugreek

Antihypertensive

Allium sativum

Garlic

Actaea racemosa

Black cohosh

Coleus forskohlii

Coleus

Viburnum opulus

Cramp bark

Positive inotrope, cardiotonic

Crataegus oxyacantha

Hawthorn

Antithrombotic

Allium sativum

Garlic

Angelica sinensis

Dong quai

Salvia miltiorrhiza (dan shen)

Salvia

Relieve palpitations

Leonurus cardiaca

Motherwort

Crataegus oxyacantha

Hawthorn

Prevent CHF

Crataegus oxyacantha

Hawthorn

Convallaria majalis

Lily of the valley


Forty-


Positive inotropic action on isolated heart muscle, and increased cerebral blood flow with vasodilatation. No clinical studies have been conducted using coleus. Although a closely related species is used in traditional Ayurvedic medicine, this species is used only as a condi-ment.531 Coleus extracts containing a quantified level of forskolin are recommended, and it is not advisable to use this herb with other cardiac medications or without the advice or a qualified practitioner.531 This herb, like the others in this section, should not be used with conventional cardiac medications. It is used in the form of a hydroethanolic extract, and is generally included as less than 20% of an herbal formula.

Cramp Bark

Considered a ''vasorelaxant,'' this herb has been identified as having possible usefulness as an adjunct in the treatment of hypertension.552,553 No clinical trials have evaluated the effects of cramp bark on blood pressure or cardiovascular measures. It is a highly respected musculoskeletal relaxant and is commonly combined in formula for the treatment of stress, chronic pain, and insomnia.

Dong Quai

Animal and in vitro studies have found that dong quai may exert a cardioprotective effect, increasing myocardial blood supply, decreasing myocardial oxygen consumption, and reducing oxidative damage to ischemic myocardial tissue. In addition, studies have shown that it can act to inhibit platelet aggregation, increase prothrombin time, decrease peripheral vascular resistance and arterial blood pressure, and inhibit experimentally induced arrhythmias and ventricular fibrillation. Butylidenephthalide and sodium ferulate have been found to inhibit platelet aggregation in vivo and in vitro, primarily by interrupting arachidonic acid metabolism. Ferulic acid has been shown to increase coronary blood flow in vitro, and sodium ferulate may have antiarrhythmic affects. In addition, butylidenephthalide has shown hypotensive effects in vivo. Most of these proposed cardiovascular and hemorrheologic effects of dong quai or its constituents are consistent with the TCM use of this herb to ''quicken the blood.'' Only three human controlled clinical trials evaluating dong quai's effects on cardiovascular disease were identified. The studies, of variable quality (e. g., one study lacks a placebo arm), show some vasodilatory effects and possible improvement in post ischemic stroke neurologic and hematologic perameters.554

Fenugreek

A systematic review by Thompson, Coon, and Ernst identified five randomized clinical trials using fenugreek for control of hypertension. The trials involved a total of 140 patients;all but one trial was conducted in India. Although the methodologic quality of the studies was considered generally poor in four of the trials, statistically significant reductions occurred in total serum cholesterol of between 15% and 33% compared with baseline. Commonly reported side effects included mild gastrointestinal symptoms, although none was severe enough to cause participant withdrawal.555 This herb, like the others in this section, should not be used with conventional cardiac medications. Fenugreek has a pleasant taste to most, and is used as tea, in tincture, or finely ground in capsules of even in foods.

Garlic

Garlic has an extensive reputation for prevention and treatment of cardiovascular disorders. The fresh or dried cloves are used. (The cloves are secondary bulbs and make up the larger bulb.)106 Approved by the German Commission E for the prevention of dyslipidemias in aging and the treatment of hyperlipidemia, it is popularly used for the treatment of mild hypertension and the prevention of atherosclerosis and CAD. The primary active constituent is considered to be allicin, produced when the clove is chopped or crushed.556 Garlic has been shown to inhibit enzymes involved in lipid synthesis, decrease platelet aggregation, prevent lipid peroxidation of oxidized erythrocytes and LDL, increase antioxidant status, and inhibit angiotensin-converting enzyme (ACE). Numerous studies point to the fact that garlic reduces cholesterol, inhibits platelet aggregation, reduces blood pressure, and increases antioxidant status.557 Like statins, garlic appears to inhibit cholesterol biosynthesis through inhibition of HMG-CoA reductase.5 four percent of the clinical trials conducted since 1993 have indicated a reduction in total cholesterol, and the most profound effect has been observed in garlic's ability to reduce platelet aggregation. Inconsistent results have been seen in the area of blood pressure and oxidative-stress reduction, with very few studies addressing these. Negative findings from some clinical trials may have resulted from variations in the garlic preparations used, short trial durations, and other methodologic limita-tions.557 Although the WHO cautions against the use of garlic in patients taking warfarin and other anticoagulant medications, clinical trials and adverse events reports thus far do not support these concerns. However, increased clotting time has been reported in patients taking garlic supplements; therefore, it is recommended that garlic supplementation be discontinued for at least one week prior to any surgical procedures, and it is prudent for patients on anticoagulant therapies to avoid garlic other than in common food quantities.472 One clinical trial of HIV patients (n = 9) on saquinavir found significantly decreased serum levels of the medication after garlic ingestion.565 Garlic breath and GI complaints are the most commonly reported adverse effects; contact dermatitis has been reported with prolonged exposure. The German Commission E and ESCOP both state that there are no known contraindications to garlic use.106,186 This herb, like the others in this section, should not be used with conventional cardiac medications. Garlic make be eaten fresh in the diet in any number of foods, or may be taken in a variety of extracts, capsules, or other products available on the market. Which products are most efficacious remains a matter of some debate, with several types of preparations yielding positive results in clinical trials.472

Globe Artichoke

Prized for centuries as a medicinal plant used to ''tonify the liver,'' globe artichoke extracts have been shown to produce various pharmacologic effects, including marked choleretic activity and inhibition of cholesterol biosynthesis and LDL oxidation.566 It is considered safe when used in food or therapeutic amounts, and is not known to interact with foods, drugs, or lab tests. The only adverse reaction noted is allergic response, primarily in persons allergic to the Asteraceae/Compositae family of plants. It is not recommended for use when there is obstruction of the bile duct, and should be used with caution when gallstones are present. Of two clinical trials (n = 187), one (n = 44) showed some reduction in total serum cholesterol in patients with a baseline of over 5.4 mmol/L, and the other showed reductions in total serum cholesterol of 18.5% for artichoke and 8.6% for placebo.567 This herb, like the others in this section, should not be used with conventional cardiac medications.

Guggul

Resin from the guggul tree, a native of western India, has been used in Ayurvedic medicine since at least 600 bce. In 1986, guggul oleoresin was approved in India for marketing as a lipid-lowering agent. Studies have shown that gugulsterones are antagonist ligands for the bile acid receptor farnesoid X receptor (FXR), which is an important regulator of cholesterol homeostasis.568,569 A review by Thompson, Coon, and Ernst identified six randomized clinical trials of guggul, involving 388 patients with different diagnoses. Five of the studies were conducted in India and one in the United States; four were placebo controlled; and one compared guggul with two reference compounds. Results suggest reductions in total serum cholesterol from 10% to 27% compared with baseline levels. A statistically significant decrease in lipid peroxide levels was reported in one study, with no corresponding change in the placebo-treated group.555 Because guggul is associated with numerous side effects, including abdominal discomfort, diarrhea, headache, hypersensitivity rash, nausea, and hiccups. The herb is typically recommended in a standardized form, gugulipid, standardized to 25 mg gugulsterones per tablet, with an oral dose of 75 mg in three divided doses daily, or two tablets twice daily.570 It is estimated that the onset of action is approximately 2 to 4 weeks. The use of guggul may decrease the bioavailability of propranolol, diltiazem, and thyroid medication, and caution is advised with concomitant use.570 This herb, like the others in this section, should not be used with conventional cardiac medications.

Hawthorn

Hawthorn, widely accepted in Europe as a treatment for mild congestive heart failure and minor arrhythmias, is one of the most important herbs in the materia medica for the prevention and treatment of cardiovascular dis-ease.163 Some consider it so beneficial that is has been called a ''food for the heart'' and suggested that everyone over 50 should take hawthorn daily! Much like red wine and green tea, hawthorn is rich in flavonoids (with the glycosides catechin and epicatechin) and oligomeric proanthocyanidins (OPCs), although amines and triter-pene saponins are found as well.472,571 It is thought to possess cardiotonic, coronary vasodilatory, and hypotensive actions. Traditionally, hawthorn has been in the treatment of heart failure, myocardial weakness, paroxysmal tachycardia, hypertension, and arteriosclerosis. The pharmacologic actions of leaf with flowers include increase in cardiac contractility, increase in coronary blood flow and myocardial circulation, protection from ischemic damage and decrease of peripheral vascular resistance. There have been no reported adverse reactions to the use of berries; however, there have been reports of nausea and gastrointestinal discomfort, as well as palpitations, headache, dizziness, sleeplessness, agitation and some circulatory disturbances when preparations containing the leaves and flowers have been taken, even in recommended therapeutic doses.571 Presently, hawthorn is used as a cardiac tonic for mild heart disorders including CAD and angina, arrhythmias, hypertension, myocardial weakness, and prevention of arterial degeneration, well supported by scientific literature. Hoffman combines hawthorn with lime blossom, mistletoe, and yarrow in a formula to manage hypertension and circulatory system disorders.530 In addition to the use of this plant as a cardiac tonic, it has been traditionally used as a diuretic. Current research supports the use of hawthorn extracts for the treatment of CAD and angina, ischemia-induced arrhythmias, dyslipidemias, hypertension, and early-stage congestive heart failure. Modes of action suggested by animal and in vitro studies include positive inotropic activity (increased cAMP, similar to cardiac glycosides), reducing peripheral vascular resistance and increased coronary and peripheral blood flow, increased integrity of vessel walls, decreased oxygen demand by the myocardium, protection against myocardial damage through antioxidative properties, protection against arrhythmias (through lengthening the refractory period), and antiinflammatory effects. There is also some evidence through animal studies that hawthorn may lower serum lipid levels and improve hypertension, perhaps through the release of the potent vasodilator nitric oxide. Inhibition of platelet aggregation has been an additional observed effect of hawthorn in vitro. Although most of the science we have on hawthorn is from animal and in vitro studies, there have been extensive human trials investigating the use of hawthorn in early congestive heart failure. Preliminary studies by the German pharmaceutical company Schwalbe using an extract of hawthorn leaves and flowers (WS® 1442) indicated the product was safe and effective to treat CHF in humans. Standardized to contain 18.75% oligomeric procyanidins, this product was found to increase exercise tolerance and decrease symptoms of CHF. Zapfe, in a recent randomized, double-blinded, placebo-controlled study using WS® 1442 on 40 patients (75% women) with New York Heart Association (NYHA) class II mild, chronic CHF, confirmed a 10% improvement in exercise tolerance compared with a 15% reduction in the placebo group.472,571 This herb, like the others in this section, should not be used with conventional cardiac medications.

Change of Heart Cordial


This cordial was created by herbalist Amanda McQuade Crawford to safely prevent or reduce hypertension, calm heart palpitations, support the hormonal changes of menopause, and to calm and relax the nerves. Combine:

Hawthorn tincture (Crataegus oxyacantha)  4 oz

Motherwort tincture  (Leonurus cardiaca) 2 oz

Chaste berry  (Vitex agnus-castus) 2 oz

Blackstrap molasses  2 oz

Blackberry juice  2 oz

Concentrate

Dose: 1 tsp twice daily diluted in water, juice, or tea;

12 oz will last 30 days.


Lily of the Valley

Lily of the valley is a cardioactive herb mostly used in European herbal medicine.572 Its actions are considered similar to those of digitalis, although it is significantly less cumulative and apparently has a vastly broader therapeutic window. The plant contains approximately 40 glycosides, the principal three being convallatoxin, con-valloside, and lokunjoside.572 Cardiac glycosides improve the efficiency of the myocardium without increasing the need for oxygen, thus lessening the workload on the heart. Although US herbal practitioners seem wary of its use caused by concerns over potential toxicity, UK herbalists continue to use it, respectfully, primarily for the treatment of mild heart failure and bradycardia, considering it to complement well with hawthorn.36 It has a rapid onset and a very short half-life.573 Evans' reports that the toxicity of this herb is often overemphasized, citing publication in the United States of 2,639 case reports of ingestion, with 6.1% of patients experiencing symptoms, but only 3 showing severe side effects.574 Lily of the valley, however, can induce side effects associated with cardiac glycosides including nausea and vomiting, although reported to be rare and mild.36 This is a scheduled herb in the United Kingdom, and should be prepared as a 1:10 tincture and given only in low doses. This herb, like the others in this section, should not be used with conventional cardiac medications. This herb should be used only by a professional trained and skilled in its application, and in conjunction with medical evaluation of cardiac effects.

Motherwort

Ever since Gerard wrote his famous herbal text in the late sixteenth century, motherwort has had a reputation of usefulness in cardiac disorders, and although beneficial for men and women alike, has had an association as a ''women's herb.'' Motherwort is approved by the German Commission E for heart palpitations occurring with anxiety. Direct myocardial action of motherwort was noted by Newall in 1992, with stimulation of both alpha and beta adrenoceptors and inhibition of calcium chloride effects. Another exploratory study by Bradley noted alkaloids contained in this plant depress the central nervous system and lower blood pressure. No modern studies have evaluated this herb clinically. Overall, however, this herb is little studied. It is quite safe and may be used in tinctures for anxiety, palpitations, and as a general cardiotonic, the latter especially when combined with hawthorn. As tea, motherwort is quite bitter, but some herbalists prepare a motherwort infused honey, a teaspoon of which can be added to other teas.

Salvia (Danshen)

Danshen, the root of Salvia miltiorrhiza, has a long history of use in TCM as a blood moving herb, activating circulation and dispersing ''stasis.''575,576 It continues to be widely used in China and, to a lesser extent, in Japan, the United States, and other European countries for the treatment of cardiovascular and cerebrovascular diseases. In China, the specific clinical use is angina pectoris, hyperlipidemia, and acute ischemic stroke.577 It is thought to be capable of improving microcirculation, causing coronary vasodilatation, suppressing the formation of thromboxane, inhibiting platelet adhesion and aggregation, and protecting against myocardial ischemia, and is used alone and in combination with other herbs for the treatment of CAD.576 It is conspicuously advertised in the Chinese Journal of Cardiology, which is the official publication of the Chinese Society of Cardiology.576 Animal experiments evaluating cardiovascular effects report prevention of intrauterine growth retardation (compound product), blood pressure reduction, reduction of low-density lipoprotein oxidation and atherosclerosis, prevention of oxidative stress, protection from liver fibrosis and renal failure, and vaso-dilatation.578-583 Although the effects of danshen have not been investigated in human clinical trials, several herb-drug interactions reported in the literature, when combining danshen with warfarin suggest strong antiplatelet activity, and also emphasizes the need to avoid combining danshen with anticoagulant therapies.576,584 The traditional dose of dried root is 6 to 15 g daily in decoction.575 Reported adverse effects are pruritus, gastric discomfort, and appetite reduction.575 In addition to cautions regarding combining danshen with anticoagulant and antiplatelet medications (including aspirin), it should not be combined with benzodiazepines caused by possible potentiation on depressant CNS effects. Because it is commonly included in TCM herbal formula, and is even found in certain Chinese cigarette brands, practitioners should be aware that patients may be

Taking this herb unbeknown to them.576,585

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