|Managing Heart Disease|
Cardiovascular disease is the leading cause of death in South Africa and accounts for the largest disease care expenditure in most westernised countries.
The most common cardiovascular problem directly causing death is coronary heart disease and myocardial infarction. While the conventional viewpoint is that high cholesterol is the major risk factor and needs to be controlled aggressively with drugs, there are in fact a multiple of risk factors and cholesterol may not be the most important.
How did cholesterol come to be so central in the story of heart disease? When an idea becomes popular and an enormous amount of money is invested in that idea then research work is guided by the idea and the money and work which supports that idea is highlighted and taken up by the media until everyone believes in that particular idea. Negative results and exceptions to the rule tend not to reported and other risk factors are downgraded and even ignored. The public is also at fault. It is easier to take a pain pill which treats the symptoms than deal with the cause. Expensive and invasive surgery is often chosen when lifestyle modifications could have made a major difference.
South Africa has the third highest incidence of coronary heart disease world wide behind Northern Ireland and Scotland with Japan, France and Italy at the lower end.[i]
The low incidence in France and Italy has made popular the ‘Mediterranean Diet’ and there is good evidence that such a diet and other lifestyle changes can even reverse narrowing of the coronary arteries yet few specialist pay much attention to these facts.
Atherosclerosis, which is the underlying condition affecting the blood vessels causing heart attacks and strokes, is actually a systemic disease. This means that it is not strictly speaking a disease of the blood vessels per se but a metabolic disturbance of the blood which eventually has an effect on the blood vessels. Cholesterol is an anti-oxidant and a normal and necessary chemical within the body. It is when it becomes rancid or oxidised that it becomes a problem.
Consider the following quotation from a prestigious medical journal: “The present study shows that people aged 85 with high total or fractionated cholesterol levels have a lower risk of mortality, because of their protective effects against death from infectious disease. In addition low HDL cholesterol level, but not high LDL or high total cholesterol, is a risk factor for fatal coronary artery disease and stroke.”[ii] Cholesterol of itself is not a poison unless it is oxidised. Many people with myocardial infarction may also have normal blood cholesterol levels. Unoxidised cholesterol cannot damage the blood vessels. Not only must the cholesterol be oxidised, but free radical damage can also occur to other blood and plasma components. Professor Ali calls this process a state of oxidosis in the blood. It is this process in the blood which eventually causes damage to the blood vessels. So atherosclerosis begins in the blood and eventually causes damage to the blood vessels.[iii]
Atherosclerosis of the blood vessels is merely describing an end point condition. Long before this happens there is a metabolic disturbance in the body and blood. This metabolic disturbance can be prevented and corrected. It is therefore important to recognize the risk factors and the conditions in which this metabolic disturbance can occur. It is clearly not good medicine to merely tell a person that his tests are normal when his lifestyle carries major risk factors for developing the metabolic disturbance, especially when the condition is very slow in developing and early signs and symptoms may not yet be present. Nor is it good medicine to tell the person that his blood vessels show evidence of narrowing, but surgery is not indicated yet because the condition is not bad enough to warrant surgery.
Despite the fact that lifestyle changes are well recognized as effective in the long-term management and survival of heart patients, few general practitioners are able to provide patients with information in this regard. Even fewer are able to advise patients on nutritional supplements that can prevent and possibly reverse degenerative changes in the heart and vascular system.
While conventional treatment of heart disease may improve symptoms it does not change the underlying disease process and there is generally a bias towards cardiac surgery when these procedures are available.[iv]
The conventional treatment of heart disease will often include a number of different preparations such as a diuretic, antihypertensives, anti-cholesterol drugs, drugs to control the rhythm of the heart and often drugs to treat anxiety, depression and insomnia. In general most patients with heart disease will be taking an average of three drugs. With the large amount of drugs on the market and the highly competitive nature of this market combined with each doctors own bias there is no standard formula that cover everyone with heart disease. Right across the world there will be many differences in the way heart disease is treated.
Each patient with heart disease has a combination of different factors attached to the diagnosis. One person may have heart disease with hypertension, another heart disease with hypertension and high cholesterol and yet another may have heart disease with an irregular heart disease.
There is also the uniqueness of each individual. This means that the way the body responds to a drug will vary. It is for this reason that prescribing is so difficult and fraught with lurking dangers and why doctors often have to change their prescription and use drugs they are less familiar with.
Side effects are common. This is not surprising given the hit and miss nature of prescribing when more than one drug is used. No one knows how the drugs will mix together, or how the body will respond. While doctors will often convince patients to continue the therapy despite the ‘minor’ side effects, it is important to understand that any side effect is a poison effect, and even if the dose is ‘low’, nevertheless any side effect still remains a poison effect of that drug. Even the lowering of the blood pressure is a poison effect and cannot strictly speaking be called a healing response, but rather is just symptomatic treatment of an end point and has nothing to do with healing the problem.
Is the risk of taking the drug worth the benefit and should the impotence that often accompanies many of the antihypertensive drugs be accepted as par for the course. There is no easy answer to this question and each person must make their own calculated decision. What follows is only my personal viewpoint.
Heart disease is a relatively new condition and was virtually unknown 100 years ago.
I believe that its very rapid increase in incidence is probably related to lifestyle factors which include the refining of foods and include the refining of oils and the manufacture of ‘new foods’ such as margarine. In addition we have the introduction of ‘junk food’ and an increasing amount of pollution. All this is enough to be the cause of heart disease and cancer and many other degenerative diseases.
So the number ONE management protocol is to change one’s lifestyle.
The SECOND management protocol for heart disease is to improve and maximize health through appropriate supplements.
The THIRD management protocol is to use a range of valuable techniques which may include acupuncture, chelation therapy, hypnosis, detoxification approaches to support health.
The FOURTH protocol is stress management. It has been demonstrated for example that following a heart attack, people who have high levels of stress have a three-fold higher mortality rate in the 5 years after the infarct compared to controls.[v]
Optimism has been shown to result in a 50% reduction in surgery and coronary artery disease related hospitalization compared with pessimistic attitudes.[vi]
If all these approaches don’t work, then and only then should one consider using drugs in a supportive way, but still consider whether the risks are worth the benefits.
Doctors must be aware of the risk factors and understand how to talk the person through lifestyle management. Preventive medicine is part of good medicine, but few doctors understand about good health and have little training in preventive medicine and lifestyle management. In a country such as ours where heart disease is the major cause of sudden death, it is important that increasing the level of awareness amongst doctors and the general population around adopting healthy lifestyle options early in life becomes a major concern.
The emphasis on using statins to treat high cholesterol or the recent recommendations to treat anyone at high risk even when cholesterol is normal [vii] is not taking responsibility for dealing with the problem. It is a quick fix solution supporting the industry and draining money away from where it should be going, ie towards improving lifestyle.
The recommendation to use statins in high risk individuals even when cholesterol is normal also supports the evidence that the positive effects of statins are not from the cholesterol-lowering effects but because these class of drugs also act as anti-oxidants which supports the Oxidosis theory of Professor Ali. In other words it may not be the cholesterol lowering which is beneficial, but the antioxidant effect.
It is therefore possible that natural antioxidants will do the same duty as statins without the side effects. This research is not being done, ie comparing statins to a good quality antioxidant because drug companies which finance most research have no incentive to do this kind of research for very obvious reasons.
While lifestyle changes are noted and emphasised in most papers published in the medical literature, the fact is that on the ground level very little is being done. Few medical doctors spend the time to discuss this with their patients and few doctors will try and assess the risks. People clearly prefer pill popping and their doctors are happy not to spend the time discussing lifestyle or considering the risk of taking medication.
US health-care spending has reached $1.6 trillion in 2003, which represents14% of the nation’s gross national product. Despite this enormous expense the United States ranks an average of 12th (second from the bottom) for 16 available health indicators. One can only wonder what the health of the nation would look like if half that amount was being used to support health rather than treating disease. Again, no one knows because research is not geared to improving health but to treating ill health.
Recently I saw a man who had had a mild heart attack a year ago with evidence of narrowing of his coronary blood vessels. He was taking two drugs for blood pressure, aspirin, a drug for lowering cholesterol and a drug for sleeping. This is standard fare for many heart patients.
While this may seem like good medicine to many doctors it should be clear that the metabolic disturbance is not being managed at all. Diet has never been discussed nor has he ever been told that the above medication would probably have to be taken for the rest of his life. While doctors may tell him about the good science around these drugs, there is no science in the use of this particular combination of 5 drugs in this particular person. Each person is unique and will therefore respond differently to any combination of medicines.
We all have choices and there will never be any guarantees. Improve health (with lifestyle changes and natural medicines) or treat disease (with drugs and surgery) - or even find a nice balance that works for you.
1. LIFESTYLE CHANGES
This includes diet such as a vegetarian diet or the Mediterranean diet, exercise, weight reduction and stress management.
According to Dr Mercola cutting out all grains and sugar from the diet will help to reduce the blood pressure. He believes that high insulin levels caused by the grains and sugars maintain the blood pressure high.
Coffee and other stimulants will also tend to raise the blood pressure.
Meditation has been shown to lower blood pressure and reduce the internal level of stress. In a Duke University study in post infarct patients there was a 75% reduction in medical events compared to standard medical care and/or exercise in those doing meditation.[viii]
In the Life Style Heart Trial of Dr Ornish and his group there was a whopping 91% reduction in angina in the group of patients maintaining his lifestyle programme for one year. Angiographic studies of the heart vessels showed a reversal of narrowing of the vessels.[ix]
Later studies confirmed these results and even showed a 37% reduction in LDL cholesterol without statin therapy.[x]
2. NUTRITIONAL SUPPLEMENTS
“There is enough nutrition in food to prevent deficiency states but to open the doors to a much higher level of benefit requires supplementation with vitamins and minerals. The supplements are high powered medicine.” - Dr Joe Goldstrich MD Specialist Cardiologist
This naturally occurring antioxidant may perhaps be one of the most important nutrients for the heart and plays an important role in the production of ATP in the mitochondria, which is so essential for muscle activity. It also stabilizes the cell membranes and protects the heart cells from oxidative damage during episodes of poor blood perfusion which occurs during attacks of angina. Anyone taking anti-cholesterol drugs should always take Coenzyme Q10, as these drugs cause a deficiency of this nutrient by blocking the ability of the body to produce it. Coenzyme Q10 may also contribute to lowering the blood pressure.[xi]
The dose is from 60mg to 600mg per day.
Another nutrient found in large amounts in the heart and not well known to doctors yet like Coenzyme Q10 plays a key role in heart function. Transports fatty acids into the mitochondria (fatty acids are a primary source of energy for the heart).
Carnitine has antioxidant properties and can also limit damage to the heart in the event of a heart attack. It also increases the amount of work the heart can do before angina pain occurs. The nutrient is often found to be low in patients with heart disease
It also has an effect on lowering bad cholesterol and raising the good cholesterol.
Start with 500mg per day and increase to 2gms per day.[xii]
Another essential nutrient for heart function. Magnesium plays a role in about 300 different enzyme systems so that any shortage will stress the body and may play a role in the development of cardiovascular disease. Poor absorption and inadequate intake are associated with the development of hypertension, cardiomyopathy, stroke and atherosclerosis. Low magnesium may increase the risk of arrhythmias. Magnesium is a vasodilator, relaxes smooth muscles and therefore may be beneficial in persons with hypertension.[xiii]
Flavanoids are the plant pigments found in fruit and vegetables. A simple vegetarian diet can reverse the arteriosclerotic lesions found in the blood vessels and this is partly due to the flavanoid content. Flavanoids decrease capillary fragility, preventing venous connective tissue breakdown and improve the tone of the vascular smooth muscle.
They thus appear to have a protective effect on the vasculature. Flavanoids also decrease the incidence of ventricular fibrillation and tachycardia and decrease the amount of free radicals in heart muscle fluid and reduce the amount of oxidized cholesterol. Grape seed extracts contain a number of flavanoids known to be good antioxidants, cardioprotective and supporting the health of the vascular system.[xiv]
This water soluble vitamin cannot be made by the body and therefore its presence in the diet is essential. It is destroyed by cooking, storage of food and processing of food so that while few people today have scurvy suboptimal amounts in the body are common. It is a powerful antioxidant and has a myriad of functions in the enzyme systems of the body which in turn may affect the integrity of the cardiovascular system.[xv]
Dr Joe Goldstrich (cardiologist) has this to say of vitamin E in his book on the natural treatment of heart disease: “In all my years of practising medicine, there has not been a medicine, a drug or a substance that has impressed me more than vitamin E”. Vitamin E has recently had some negative studies but I don’t believe that one or two negative studies negate hundreds of positive studies. Negative studies are part of the scientific process, which itself is imperfect. Perhaps one should keep in mind that vitamin E should always be in the natural form and that vitamin E is a family of molecules and that the whole family should be included if taken long term.
Vitamin E is a potent lipid soluble antioxidant and increases the resistance to oxidation.[xvi]
Inflammation is a recognised underlying cause of atherosclerosis. Fish oils have powerful anti-inflammatory effects and have been shown to cause a significant decrease in death from cardiovascular disease, sudden death and even total mortality.[xvii]
Vitamins B6, B2, B12 and folic acid are inversely associated with the level of homocysteine in the blood. Some doctors regard homocysteine as a more important risk factor than cholesterol in cardiovascular disease. Homocysteine is a by-product of methionine which is found in high levels in certain foods such as cheddar cheese, eggs, chicken, and beef.[xviii]
A number of herbs are also of special interest in cardiovascular disease.
Craetagus oxyacantha (Hawthorne )
Improves coronary circulation, has a direct effect on heart muscles, enhancing activity and has a long term sustained effect on preventing degeneration and age related changes in the heart muscles. It also decreases the incidence of arrhythmias especially extrasystoles of various origins.
Craetagus is slow acting and has a very low side effect profile. It should be used long term. It has a mild hypotensive effect which makes it especially valuable in patients with hypertension and heart failure.
This is an amazing food with over 200 different compounds within it. These compounds are antibacterial, antimycotic, lipid lowering, inhibit platelet aggregation, enhance fibrinolytic activity.
This article would not be complete without mentioning Chelation therapy. While this therapy has had a very uphill battle to be accepted by the medical industry it has according to its advocates saved thousands of lives. Chelation refers to the ability of certain chemicals to bind with calcium, iron, and other metals and remove them from the body. While the initial theory was that the chelating agent was removing the calcium from the arteriosclerotic plaques and in this way slowly opening the blood vessels it now seems that the process in which chelation helps is much more complex. What does seem to be true however is that people with severe narrowing of their blood vessels, given a course of chelation, will regularly be saved the need for an operation. I have never used this technique but have many collegues who are convinced of its efficacy. Professor Ali in America is a strong advocate of this method and has a room full of patients receiving the intravenous drips daily.
While the intravenous route is regarded as the most efficient, an oral route can also be used. The intravenous programme may require 20 or more treatments and is expensive. The oral route is less expensive, slower and may require 8 months to a year of treatment.
The treatment choices one makes should take the following into account:
1. The quality of the diet consumed.
The studies of Ornish and others using the Mediteranean Diet have shown the critical role of diet in the preventions and treatment of heart disease. Green tea, red wine and olive oil should all be part of that diet. While I prefer grape seed extract to the red wine story nevertheless study after study have shown the value of one to two glasses of red wine per day.
The better the diet the less nutrients are necessary and the lower the amounts needed. There are many combination remedies on the market which are useful and keep the costs down. Remember however that most research showing the value of a remedy has been done using single nutrients in high therapeutic doses. A combination remedy uses a mixture of nutrients at relatively low doses. These combination remedies for heart and circulation are great for prevention and when diet is good. If diet is poor, then use the maximum dose on the label. If disease has been diagnosed then it may be better to take single remedies in higher therapeutic doses. Consult with a doctor of Integrative Medicine.
2. The level of stress
Deal with the stress and add a natural herbal or homoeopathic remedy. This can be combined with the above remedies. Remember that doctors don’t have a problem combining drugs, which are much more powerful together.
3. What can one afford?
Quality is important. The natural medicine market has become so competitive that some companies are cutting corners and reducing quality and the product may not contain what is claimed.
4. What are you prepared to take
Many people may believe that natural remedies are just expensive urine. I would suggest that having expensive urine and a healthy body is a very good option. Nutritional deficiencies are endemic and everyone should be taking supplements.
5. Can the nutrients be taken together with drugs?
As indicated above doctors don’t have a problem combining drugs and even prescribing 3 or 4 drugs together. Drugs are powerful and have major metabolic effects on the body. Nutrients such as vitamin E or Coenzyme Q10 are not drugs, but nutrients. They support health and feed the body. They are bio-identical ie they are body friendly and recognized as nutrients and identical to that present in food.
Herbs are different, but nevertheless they also are natural and closer to foods than to drugs. No one would regard taking food and drugs together as problematic and I don’t think that in general terms taking herbs with drugs should be a problem. Having said that, there may be certain circumstance when this may not be appropriate and this would apply especially to drugs like Warfarin which affect blood clotting. Consult the information leaflet about precautions.
For any heart problem the combination of Coenzyme Q10 with carnitine and Craetagus is a good combination. Add grape seed extract as a useful extra.
If the underlying cause is atherosclerosis then add garlic, vitamin C and natural vitamin E.
Check for homocysteine levels and add the vitamin Bs if appropriate.
In serious cases chelation therapy may be life saving.
If hypertension is present, then magnesium would be beneficial.
Remember however that lifestyle management is the key to success and this means a change in diet, exercise, weight reduction and stress management.
[i] DiBianco R A review and strategy to reduce the morbidity and mortality from coronary heart disease. A MASA publication September 1995
[ii] Rijnsburger AWE et al High density vs low density lipoprotein cholesterol as the risk factor for coronary artery disease and stroke in old age. Arch Intern Med 2003:163; 1549-1554
[iii] Ali Majid Integrative Cardiology The principles and practice of Integrative Medicine volume IV 2003 Capital University Press NY
[iv] [Krumholz HM Editorial:Cardiac procedures, outcomes and accountability. New Eng J Med 336;21:1522-23]
[v] [Roganski A et al Impact of psychological factors on the pathogenesis of cardiovascular disease and implication for therapy. Circulation 99:2192-2217.1999]
[vi] [Scheier MF et al Optimism and rehospitalization after coronary bypass graft surgery. Arch Int Med. 159.829-835.1999]
[vii] Burgess LJ et al Primary prevention of atherosclerosis vascular disease. ME April2006 vol24 No4 page 200-207
[viii] [Blumenthal J et al Usefulness of psychosocial treatment of mental stress induced myocardial ischemia in men Am J Cardio. 89;164-168.2002]
[ix] [Ornish D et al Can lifestyle changes reverse coronary atherosclerosis? Lancet 336;129-133.1990]
[x] [Ornish D et al Intensive life style changes for reversal of heart disease. JAMA 28;2001-2007.1998]
[xi] Langjoen et al Usefulness of coenzyme Q10 in clinical cardiology: A long term study.
Mol Aspects Med(England) 1994.15 Suppl;165-75
[xii] Rizos I et al Three year survival of patients with heart failure caused by dilatated cardiomyopathy and L-carnitine administration. Am Heart J 2000 :139;(2 Pt 3): S120-3
[xiii] Ford ES Serum magnesium and ischemic heart disease. Findings from a national sample of US adults. Intl J Epidem 1999:28:645-651
Douban S et al Significance of magnesium in congestive heart failure. Am Heart J 1996.132(3):664-71
[xiv] Bagchi D et al Molecular mechanisms of cardioprotection by a novel grape seed proanthocyanidin extract. Mutat Res 2003,Feb-March;523-524,87-97
[xv] Estrom JE et al Vitamin C intake and mortality among a sample of the United States population. Epidemiology 1992 ;3:194-202
Nyyssonen K et al Vit C deficiency and risk of myocardial infarction. Prospective population study of men from Eastern Finland. BMJ 1997.314:634-638
Cheraskin E Vitamin C and coronary artery atherosclerosis . J Advancement Medicine 9:133; 1996
[xvi] Stevens NG et al Randomised controlled trial of vitamin E in patients with coronary disease: Cambridge Heart antioxidant study 1996 Lancet 347:781-786
Interpretation:” In patients with angiographically proven symptomatic coronary atherosclerosis, alpha-tocopherol treatment substantially reduces the rate of non-fatal MI, with beneficial effects apparent after 1 year of treatment”.
Stampfer MJ et al Vitamin E consumption and the risk of coronary disease in women. New Eng J Med 1993:328:1444-9
Interpretation: “We observed a risk of major coronary disease among women who took vitamin E supplementation that was 40% lower than the risk in women who did not take these supplements”.
[xvii] Harper CR et al The usefulness of omega 3 fatty acids and the prevention of coronary heart disease .Am J Cardiol 2005 Dec 1;96(11):1521-9
Madsen T. et al C-reactive protein, dietary n-3 fatty acids and the extent of coronary artery disease Am J Cardiol.2001 nov 15,88(10):1139-42
[xviii] Krishnaswamy K et al Role of nutritional supplements in reducing the levels of homocysteine. J Assoc Physicians India 2002 Jan:52(1) 16-18