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    About atherosclerosis from Braunwald

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    © All Rights Reserved
    Download as PDF or read online from Scribd
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    31 views10 pages

    Alternative of Approach To CV Disease Pts

    Uploaded by

    Yudhajit Ain
    About atherosclerosis from Braunwald

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    © All Rights Reserved
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    CHAPTER 47 General Considerations, 1157 Applications of Complementary and Alternative Medicine, 1157 Stress Rell, 1157 Hypertension, 1158 pid Lowering, 1158 Periohetal Vascular Disease and ‘Venous Insufficiency, 1162 Heart Falure, 1162 Interactions with Anticoagulant Therapies, 1163 Cardiac Catheterization, 1163 Intensive Care Unis, 1164 Cadac surgery, 64 GENERAL CONSIDERATIONS Aging, 1164 References, 1166 with Heart Disease Complementary and alternative medicine (CAM) is the term currently used by the National Institute of Health (NIH) to describe this field of inquiry. Herbs, vitae mins, and nonherbal dietary products, as well ‘as therapies involving spirituality, dioenergetics (eg., acupuncture and energy fiolds), and mind-body, are all considered to be forms of complementary, alternative, or integrative medicine. ‘According to the National Center for Complementary and Alternative Medicine (NCCAM) and the National Center for Health Statistics (NCHS), 36, percent of American adults use some form of GAM! When prayer specifically for health reasons is included in the definition of CAM, that figure rises to 662 percent. Of note, CAM is being taught in some 25 medical centers in the country.” Listoning, trust, and compassion embody the principles used by great physicians caring for patients on physical, mental, and spiritual levels. Inte- grating CAM into medicine must be guided by compassion but enhanced by science and must remain meaningful through solid physicien-patient rela- tionships, because human caring and relationships are central to the health care process, Physicians must establish trust and a fooling of safe harbor for patients so that we may, by understanding their concerns and discovering their goals and desires, convey accurate and appropriate information when proposing @ reasonable, mutually agreeable plan of care. A great majority of our patients have become involved in CAM. It is therefore important, even if the physician has problems accepting CAM, to respect the patient's belief system and continue to have their trust so as not to drive the patient away. Im addition, because patients perceive that many physicians do not care about their involvement in CAM or the herbs or supplements they are taking, they fail to communicate this information to their physicians. This can result in detrimental adverse herbal or supplement allopathic drug interventions. Thus, it is extremely important for the physician to be aware exactly what their patients are taking to avoid these problems. ‘Successful treatment and prevention of complex chronic disease almost always require multi-component therapy, coupled with life-style modifica- tions, With only modest evidence-based data available to clinicians and their patients rogarding the benefits and potential risks of ditary supplements and erbal products, clinicians will need to become more attentive to recognizing and recording use of supplements and responding to patients’ inquiries and preferences. APPLICATIONS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE Stress Relief Stress relief is cleazly one of the major risk factors in cardiovascular disease, and mothods for dealing with stress are very important (see Chap. 85) Complementary and Alternative Approaches to Management of Patients John H. K. Vogel, Rebecca B. Costello, and Mitchell W. Krucoff IMPACT OF STRESS ON CARDIOVAS- CULAR DISEASE RISK FACTORS. Stress may lead to hypertension through repeated blood pressure elevations and by increas- ing the amount of vasoconstricting hor- mones (see Chap. 40), Stress factors leading to hypertension include job strain, social environment, emotional stress, race, and white coat hypertension. In the Framing- ham study* hypertension was involvod in over 80 percent of all cardiovascular deaths. In addition, hypertension was at least twice as strong @ predictor of death as smoking or elevated blood cholesterol level. Over 50 million Americans are cur- rently hypertensive. Stress Management PET OWNERSHIP. Pet ownership reduces seress and can convey a sense of companionship and purpose. Pet ownership has been shown 10 Increase heart rite variability see Chip. 52) 18 patients with cardiovascular disease’ ‘MINDFULNESS-BASED STRESS REDUC- ‘TION. Mindfulness-based stessceduetion (MBSR) uses the techniques of mindfulness meditation, ‘gentle Yoga, and coordinated deep breathing t0 Secrease puin and anxiety: In a metwanalysis, MBSR has been shown to help individuals alleviate sicess and suffering associated with various Siseases (GUIDED IMAGERY. Guided imagery isa thera peutie technique that allows a person use his Dt her own imagination o connect body and avin to achieve desirable outcomes, such as decreased pain perception and reduced anxiety. Guided Imagery has been studied for patients both pre: and postsurgical intervention. recent study of ‘cardiothoracic surgery patients demonstrated that both pain and ansiety decreased significantly swith guided imagery. An ongoing tial at Sipps Clinic using guided imagery and healing touch pre-and postcardiothoricie surgery has demon ‘Sirated a 50 percent reduction n pain and ansiety fn the wreatment group. ‘TRANSCENDENTAL MEDITATION. dental meditation (TVD offers a unique vechnique for meditation and relaxation andl is one of the most studied CAM therapies, with research Gating back to the 1970s. TM has been shown fot only to improve blood pressure but also the insulin resistance components of the mets boli syndrome and cardize autonomic nervous system tone." 1157 158 ca? BIOFEEDBACK. Biofeedback is 2 technique to exain people to ‘change habitual reactions to stress. In patients with coronary artery disease, biofeedback increases heart rate variability CIRV), DIETARY SUPPLEMENTS AND NATURAL PRODUCTS, number ‘of food components have been recommended and endorsed for lower ing the risk of cardiovascular disease, ineluding plan sterols and stil esters, soluble fers, omega fatty acids, garlic, soy; tea, and modes alcohol intake” The Dietary Supplement Health and Education Act (DSIIEA) of 1994 amended tie federal Food, Drug. and Cosmetic Aet by defining as a dietary supplement any product (other than tobacco) that contains a vitamin mineral, herb or other botanical, of amino ack and is intended asa supplement 0 the diet. Inthe United States today products intended to supplement the dict may be marketed as dietary supplements providing that their intended use isnot to diagnose, treat ‘eure, or prevent disease (a claim reserved for conventional drags) and that they not be represented as conventional foods The US Food an Drug Administration (FDA) has estimated that there were more than 29,000 different dietary supplement products on the market in 2000. ‘with an average of L000 new products heing added anual: Several countries e.g. Germany: France, sweden. Canada, and Austclia) have implemented strategies for licensing herbal remedies, including pre ‘market approval, However, premarket approval ad licensing are not required in the United States, “There are 2 number of approved drug substances that originate from plants, such as digoxin, atropine, reserpine, and amiodarone However, only a few commercial herbal products available in the United states have been tested for cardiovascular Indications: haw thom heart failure and coronary insufficiency), arti (atherosclero- sis). ginkgo (arterial occlusive disease), and horse ehestaut (chronic venous insufficiency), Few US. products benefit from rigorous charac: terization and standardization necessary for clinical study Herbal prod. Lets, unlike most conventional drugs, provide a comples mixture of bioactive entities, which may or may not have therapeutic activity The active ingredient Is frequently not known and complete characceriza ‘ion ofall the chemical constituents i lacking (Table 471). As with ‘conventional drags, many herbal products are therapeutic at one Jose and toxic at another. Concurceat use of herbs may mimic, magni. oF ‘oppose the effect of drugs. The importance of unrecognized interac tions between herbs and conventional drugs is particularly relevant in ‘cardiology because many cardiovascular drugs have a narrow ther ppevtie window (Table 472). Table 473 lists sources for more infor tion on dietary supplements and herbal medicines, ‘erbaldrug interactions can be characterized 2s pharmacodynamic fo pharmacokinetic. Pharmacodynamic interactions cin occur when Constituents of herbal products have synergistic of antagonist tivity in relaion to a conventional drug, thus altering the site of action at the receptor level. Parmacokinetie interactions result tom alterations of absorption, distribution, metabolism, and elimination of a conven- tional drug by a herbal product or dietary supplement. Hetbal products ‘contain several chemicals that are metabolized by phase 1nd phase 2 drugmetabolizing pathways, especially CYPSA4, and also serve as EE Drug Herbal ‘Active ingredient known Active ingredient often not known, marker compounds act as surrogates for consistency Pure compound available Pure compound not avaliable, often as Composition constant Composition variable, because of ‘season, cemperature, and harvest conditions Mechanism often known Mechanism often unknown “Tosicology often known, bur atleast evaluated “Typieally, ashore fradition of use Frequently, a narrow Generally, © wide therapeutic window therapeutic window ‘Adverse effects Frequent Adverse eects rare Toxicology often nor sted Substrates for certain transporters and P-glycoprotein (PGP; sce Chap ©). In vivo and in vitro studies have indicated that PGP mediated efflux and/or CYPmediated nietabolist s hkely to be a potential candidate for drugherbal interactions, adversely affecting drug efficacy and/or foxicity: Clinical implications of such drugherba interactions depend ‘various fictors such as dose, frequency and timing of hezbal intake dosing regimen, route of drug administration, and therapeutic range Additionally. use of herbal products may signiictnty alter laboratory results, Abnormal laboratory test results may indicate that clinicians should ascertain a detalled history ofthe use of herbal prosucts and etary supplements from theit pitients. A herbal product can affect Clinical laboratory test results by direet assay interference. most com :monty with an immunoassay, exert physiologic effects through rosielty fr enzyme induction, and iaterfere by the presence of contaminants, Hypertension (soo Randomized clinical trials for hypertension have been con- ducted with garlic (Allium sativum), ginkgo (Ginkgo biloba), hawthom (Crataegus), pycnogenol or French maritime pine bark extract (Pinus maritima), olive leaf extract (Olea euro- aed), Asian ginsong (Panax ginseng), coenzyme QiO, calcium, and magnesium. The tesulis have been variable and modest. A meta-analysis has shown that compared with placebo, garlic produced average blood pressure (BP) reductions of 8 mm Hg (systolic) and 5 mm Hg (diastolic). However, an evidence-based review of 27 small, random- ized, placobo-controlled trials, all but one in adults and of short duration, reported mixed but never large effects of various garlic preparations on blood pressure outcomes, Most studies have not found signilicant differences betweon subjects randomized to garlic compared with those random- ized to placebo.” Adverse effects of oral ingestion of garlic are objectionable breath and body odor. Other possible but not proven adverse effects have included flatulence, esopha- geal and abdominel pain, small intestinal obstruction, Contact dermatitis, rhinitis, asthma, bleeding, and myocar dial infarction. ‘A systematic review of coenzyme Qi0 in hypertension that evaluated eight studies documented a mean decrease in systolic blood pressure of 16 mm Hg and a decrease of 10 mm Hg in diastolic blood pressure, but only half of these studies were placebo-controlled.’' A recent Cochrane review has confirmed a lack of effect of combined calcium, magne- sium, and potassium supplementation for the management of primary hypertension in adults Chap. 41) Lipid Lowering (00 Conventiona] and dietary supplements for hyperlipidemia include products reported to decrease liver production of lipids, such as artichoke extract (Cynara scolymus), garlic, policosanol, and red yeast rice (Monascus purpureus) Prod ucts reported to decrease the absorption of lipids include stanol and sterol esters, chitoson, barley, psyllium, and oat bran fibers. Additionally, fish oils, docosahexaenoic acid (DHA), and eicosapentaenoic acid (EPA) and soy have boon extensively studied in clinical trials Guggulipid (Com- miphora guggul) and policosanol will be described here, hap. GUGGULIPID (Commiphora guggul). Guggulipid has » tong. history of use in ayurvedic medicine. In the fist randomized con trolled trial of guggulipid in the United Stites, 103 healthy adults swith bbypercholesteroiemia given 1000 of 2000 mg gugaulipid containing 25 percent guggulsterones experienced no improvement in ther lipid levels A ypersensitvity cash was reported ina sail numberof sb: jects" Erfects of uggulipids on high-density lipoproteins (HDLs) were ‘mixed. A standard dose of gugguisterones containing 73 to 150 mg his ‘been given 2s 1000 to 2000 mg gusgulipia two or three times daily Guggulipids can cause gastrointestinal upset. headache, mild nausea belching, hiccups. and rash, Concomitant oral administration can Text continues on p. 1162. 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Guggulipid may aso exert antiplate Jet and anticoagulant effects. Definitive safety and efficacy data are Jacking in subjects on Western diets, 'POLICOSANOL. Policosarol is derive from a sugar cane extract or ‘wheat germ oll extract that contains @ mistre of aliphatic alcohols Lipidowering effects may involve inhibition of cholesterol synthesis inthe liver and increasing degeadation ofow-density lipoprotein (LDL) Cholesterol. Over 1000 subjects have been studied for periods of 6 ‘weeks to I year in 15 randomized, placebo-controlled trials using pol ‘cosunol (5 10 20 mg/day) for lipid lowering. At dosiges of 10 0 20 mg/ ay, significant reductions were observed for total cholesterol 17 0 21 percent) and LDL cholesterol Ci to 29 percent, with increases in HDL cholesterol (@ vo 15 pereend)” There are no dats on efficacy determined by clinical endpoints. Although policostnal appears to be ‘well tolerated, caution should be exercised when combining poicoss nol with antiplatelet or anticoagulant agents, inclding garlic, ginkgo, and high doses of vitamin E.” because policosanol has been shown to Inhibic plaelet aggregation in healthy and diseased patients. Indepen: ent verification is needed before its use can be recommended Peripheral Vascular Disease and Venous Insufficiency (see Chap. 57) Compounds studied for a role in moderating peripheral vas- cular disease include garlic, ginkgo, omege-3 fatty acids, Padma 28 (@ herbal mixture containing 22 different ingre- dients) and vitamin E, Available data from randomized controlled trials, systematic reviews, and meta-analyses have suggested that ginkgo is effective compared with placebo for patients with intermittent claudication. Padma 28 was also found to be effective, although the data are limited." Horse chestnut seed extract has beon studied and found to be effective for the relief of venous insufficiency, GINKGO LEAF EXTRACT (Ginkgo biloba). Ginkgo has been used for relief of intermiteat claudication in patients with peripheral arte- ‘al ocelusive disease (PAD). The reviewed data have suggested that Gnnkgo biloba extracts effective compared with placebo for patients ‘with intermittent claudication (PAD Fontaine stage II), Dosages used Ja clinical trials ranged from 120 to 160 mg/d, Psin-tree walking dis: tance and maximal walling distance were often che monitored out: ‘comies of interest. Ginkgo leat and its extracts conta several bioactive cconstivems including flavonoids, cerpenoids, and organic acids, The mala active principles are bilobilde and ginkgolides, As with other phytomedictnes, several constiwents of ginkgo extracts may contrib. lte to its therapeutic effect Ginkgo does not appear to interact or adversely affect concomitant therapy with cardiac glycosides, Ginkgo appears to provide a small Beneft in the treatment of PAD,” possioly by free radical scavenging. antiplatelet actions, antiinflammatory actions, visodilation, and decreased blood viscosity. The most common dosage is 10 mg of standardized extract of ginkgo leaf three rimes daily Ginkgo is considered relatively safe, witha few documented adv eilfects being mild gastrointestinal upset, nausea. dyspepsia, and head: ache. Ginkgo has been reported to increase the risk of bleeding, Rs concomant use with aspirin, nonsteroidal antiinflammatory drugs (SSAIDs), and anticoagulants, such as warforin and heparin, is Not advised.” HORSE CHESTNUT (Aesculus bippocastanum). Horse chestnut seed extract (HCSE) contains saponins, coumarins, davonoids, and tannins, Its biological activity has been shown to be related to the saponins, notably aescin, A systematic review of 17 randomized placebo-controlied trials was recently completed.” Leg pain assessed in six tals (V= 543) showed significant reduction compared 19 placebo, Four of five trials (N'= 420) reported significant eduction in ‘edema in patient treated with HCSE compared with placebo. Calf and ankle citcumference was also reduced by HCSE. One tial found HCSE to beas efficacious as treatment with compression stockings, An elfcc- tive dase of HCSE is seandadized t9 100 #0 150 mg aeseia daily. Symmp- toms such as pruritus and feelings of fatigue and tenseness were also reduced with HCSE. Side effects are uncommon but ichide gastroin testinalicritation, dizziness, nausea, headache, and pruritus. Two cases of toxic nephropathy have been reported. Contraindications to its use Include hypersensitivity 10 aescia or horse chestaut and renal or hhepatie dysfunction. Aescin, the main saponin component in HCSE. binds to plasma protein and may affect the binding of other drugs HSE has also been suspected of causing hypoglycemic eflects. The German Commission Eas approved the use of HSE in chan venovis insufficiency and commercial preparations are availabe inthe United sates Heart Failure (see Chap. 29) Several diotary supplements have been used in patients with mild heart failure. Some of those products may affect, or modulate the enin-angiotensin-aldosterone systom (¢., Leazginino), act as diuretics (eg., dandelion, corn silk, sting ing nettle), or as positive inotropes similar to digoxin (e.g. oleander, pheasant’s eye, squill) and hawthorn, Lastly, coon- zyme Qu0 has boon used for support of cellular metabolism. Magnesium and thiamine have been used to replenish body stores of these nutrients caused by wasting and polyphar- ‘macy common in patients with heart failure. Of those sup- plements identified here, hawthorn, coanzyme Quo and L-carnitine have been evaluated in randomized controlled clinical trials HAWTHORN (Crataegus). Orally, hawthorn leaf extract has Deen tased for congestive heart failure, cor pulmonale, ischemic. heart disease, aebythmias, blood pressure redtction, atherosclerosis, and cerebral Insufficienes: Preparations made from flowers with leaves are Sold as prescripiion medications in parts of Europe and Asia, Hawthorn may have clinical value in congestive heart faluce a8 an adjunct to Standard treatment "ayzhorn has pastive inotropic elects and isa peripheral vasodil tor. Ie increases mvecardial perfusion and stroke volume and reduces afterfoad. Hawethoca may offer some advantages over digoxin ia mil hheae failure. Compared with digitalis, hawthorn has a wider therapes: tie range, lower isk in ease of toxicity has less arti thmogente poten- tal, is safer to use in renal Impairment, and can be safely used with sureties andhlaatives, However, hawthorn could enhance the activity fof digitalis and care should be taken when combining it with beta blockers snd Class IT antiarrhythmics. A recent systemitic review hnas Hlentitied 29 clinical stadies using singlevagcedient hawthorn: contalaing preparations. Data on adverse etfects {vom 557” patients noted 166 adverse events, B of which were severe, and were associated ‘ith one particular branded extract preparation. The dally dosage and uration of treatment ranged from 160 to 1800 mg of extract a from 5 € 24 weeks, respectively. There were, however, no reports of drag actions noted” Most frequent adverse events associated with hnawthor include dizziness, vertigo, headaches, migraines, and palpi tations. A treatment period of at least 6 weeks is recommended £0 ‘establish efficacy, Hawthorn tse shoud be supervised by a clinician, COENZYME Q10. (CBIQUINONE). Coenzyme Ql0’(Co-QU) is Involved in oxidative phosphorylation and the generation of ATP. In alition, Co-Q10 acts asa feee radical seavenger and membrane stabi lizer. These have been over 40 controlled trials ofthe clinial effects ‘of Co-Q10 on cardiovascular disease, Early studies have shown benefit in subjective (@g., quality of life, decrease in hospitalizations) and objective (eg. increased let ventricular ejection fraction, LVEF, stroke index) parameters, but more recent studies have been less supportive. ‘A recent review of nine randomized wials of Co-QI0 in heart fahare ‘oneladed there were nonsignificant trends toward increased ejection fraction and reduced mortality. but there were insufficient numbers of patients for meaningful results. Mortality benefit has not been estab- Iished. Case reports have associated Co-Q10 therapy with decreased International normalized ratio INK) in patients on warfarin therapy: however, 100 mg of Co-Q0 daily liad no effect on the INR in patients fon warfurin in 2 randomized, double-blind, placebo-controlled cross: ‘over tal Typical doses range from 100 to 200 mg, divided, two 10 three times daily. Caution is advised if patients take Co-QI0 and warfarin, because Co-QUO may decrease the effectiveness of warFrin Selydroxy-3-metbylglutaryl-coenzyme 4 (HMG-CoA) reductase inhibi ‘may inhibit the natural symess of Co-Q1O, and reduced levels of ‘Go-Qi0 have been documented in small controlled clinical trials in Patients on statin therapies." Reduced levels of Co-QlO may place ‘he patient at increased ssk for myopathy, but studies of supplemental (Co-Qi0 for decreasing myalgias and myvsitis have not been define. (One unique formulation of Co-QI0 has received FDA orphan drug satus for treating micochondrial disorders, Interactions with Anticoagulant Therapies (see Chap. 02) An estimated 4 million patients are receiving longterm antithrombotic therapies (anticoagulants and/or antiplatelet agents) to manage or treat their disease condition and ere at highest risk for drug-supplement interactions. Dietary sup- plements are used by approximately 36 to 52 percent of the general population and are taken concurrently with pre- scription drugs by approximately 16 percent of the popula- tion." Many supplements have been reputed to interact with, antithrombotic therapies, although relatively little data are available concerning the scope of the problem. Supplements that can affect normal coagulation and platelet activity include danshen (Salvia miltiorhiza), garlic, Ginkgo biloba, Panax ginseng, and St. John's wort (Hyperi- cum perforatum). Many of these supplements have also been reported to interact with coumarin anticoagulants, In addi- tion to supplement heterogeneity, individual patient rosponses also reflect specific gonetic polymorphisms in the cytochrome P-450 system and other metabolic pathways that can alter the metabolism of warfarin and/or dictary supple- monts. Given the variety of dietary supplements available, fan important espect of the management of patients on oral anticoagulant therapy remains a regular assessment of sup- plement usa, and physicians should ensure that patients ara aware of the potential risks and benefits of taking supple- ments in conjunction with their prescribed medications. Herbals can affect the pharmacokinetics of warfarin by decreasing its absorption from the gastrointestinal (GI) tract orby altering its metabolic clearance. Other possible meche- nisms include decreased platelet aggregation, decreased serum levels of thromboxane, prostaglandin, or phospholi- pase A;, decreased synthesis of cyclooxygenase, inhibition of platelet-activating factor, conversion of fibrin to fibrino- gen, and inhibition of CYP2Ce and vitamin K and coumarin content, The main enzyme responsible for S-warfarin metabolism is CYP2C9, and any factor that modifies the expression and activity of this enzyme can influence the anticoagulant response. Cardiac Catheterization (see Chap. 16) Patients undergoing invasive diagnostic and interventional percutaneous procedures are generally awake in both the poriprocedural and intraprocedural periods. Anticipation leading up to the procedure includes personal concerns about death, stroke, and myocerdial infarction, and have been characterized repeatedly for their potential to induce ischemic episodes.” Tho interplay of emotional states with physical discomforts may promote exaggerated reactions that interfere with the conduct of the procedure or. worse, actually result in complications. ‘Techniques that foster relaxation. support and epirtual faith could be fertile areas of adjunctive care. Mechanisti cally. noetic care paradigms that systematically integrate compassion, love, companionship, touch, faith. music, light, and even architectural space have the potential to affect processes mediated at @ cellular level through intangible means and could effect perception and comfort, clinical outcomes, or both. NOETIC THERAPIES. Noctic(¢., mental ot intellectual) therapies ‘include a broad range of healing disciplines mtetaphorially considered to make use ofthe human spirit or other intangible naman capabilities such as vital energy Cehi’), including gi gong. reiki, healing touch, healing. prayer, music. imagery, stees relasation, and_ pranayama Gelaxed abdominal) breathing techniques. among others. Obser¥s ‘onal studies of guided imagers relaxation techniques. and music it ‘conjunction with invasive radiological procedures have reported” an analgesic effect mensured by a subjective pala scale and reduced use ‘of nareoties, predominantly in conjanetion with the artesiotomy inset ‘Thae largest overall published experience with patients in the cathe ‘eerization laboratory bas come from the Monstering and Aetwalization ‘of Noctie Trainings (MANTRA) project.” In the MANTRA pilor study. 150 patients presenting with acute coronary syniromes who required coronary care unit management and scheduled for urgent but not emergent catheterization and PCI were randomized t0 five parallel therapies, including standard care, or one vf four noetie therapies ‘euided imagery, healing touch, stress relaxation, of cstant interces- Sory pruyer. Patients randomized to standard care and distant prayer remained blinded to their treatment assignment, whereas pavients assigned imagery. touch, or stress relaxation interacted with a tained practitioner a8 open label interventions prior t0 catheterization and percutaneous intervention (PCI). Based on the limitations of the pilot Study Ce. small denominator. single center, parallel treatment ass rents unable to assess synengy), the MANTRA Il study> was designed with the power to show signifeance if 30 percent treatment effect ‘was repraciicible. MANTRA Twas a multicenter study of 748 patients Undergoing elective PCT, fellowed for 6smonth MACE, alleause hosp Laliatton, and Jeath, Prespeciied secondary endpoints examining dif ferent temporal periods or mechanistic differences folowing stenting included iavhospital MACE, G-month eehospitalization and death, and ‘G-month mortality. Following the cultural paradigm, in whieh prepro> cedural support often consisted of both bedside and distant noetic lncerventions, 2 22 factorial design Was used to provide 1-1 random: lation ofall patients © double-blinded distant praverand, ln audition, 111 randomization ofall patients to open label bedside aoetie therapy ‘Ths, 28 percent of patiens received both, 28 pencent received nekiner (Gcandard care group), 28 percent received only the bedside inerven- tion, ancl 25 percent received only the distant blinded moet interven. tion. For the bedside intervention, all practitioners were required 19 have atleast Healing touch level I certification, Because MANTRA Id patients were in elective care settings, a longer period of 45 minutes ‘sas allowed, The bedside intervention in MANTRA I incorporated the tse of rapport development and relaxed abomtinal breathing, with a ‘combination, of musi. imagery, and touch therapy (MT), The masie Fnnagery serie was delivered by Sony Walkman using cai headphones so that patient and practitioner could listen together. followed by the healing’ touch session swith music in the buckground. If the patient esired he oF she was allowed 10 wear the headphones and listen the muse Inthe catheterization laboratory as well ‘The praver intervention for the fist to thitds of MANTRA Mt enrollment was simila to the multiethnic, multi-time zone approach Used in the pilot sty: however, the number of prayer groups was expanded from 8 t0 12. A higher “dose” Was established at the Co: thirds point by adding a second 12prayer group, who prayed for the prayers othe first 12 congregations who were praying forthe patients by name a socalled two tered or ampliser approach Nelthercistant ‘double blinded intercessory praver. betside MIT. nor the combination ff both showed any effect on the primary composite endpoint which ‘occurred in 3° percent of patients overall, The authors noted that off protocol praver by friends, family. or chaplains increased from 38 percent in the urgent setting of the MANTRA pilot to 89 pescent the clective PCL population of MANTRA I. although 4 much smaller sample size wis exposed to the higltdose two-tiered prayer, a trend toward outotospital benefit in the secondary -nonth rehospitali tion and death endpoint was observed in the high-dose prayer group. possibly suggesting a threshold effect relative to the singletiered oF lower dose prayer therapy ‘Opportunities for farther understanding and clinical investigations {nto the optimal catheterization liborarary envigonment, to enhance qualitative personal coniort of 10 improve clinical outcomes assoc sed with Invasive procedares in patients with heart disease. can be ‘Mentiied by shifting the peripnoceduril vision from the purely allo pathic technlea] perspective t0 a more holisue view of the interplay between somatic pathophrsiological processes, emotional and spit ‘wal states, often referred to as the minu-body-spiieequilioium, Inf. ‘ences on pai, vascular tone, platelet activation, and immune-mediated Jnlammatory responses can be attributed to this entre ringe of human Psyehoneurophysiology. Thus, the potential for advancing novel cave Strategies that systematically use intangible human eapacites that are Currently more cukurally than scientifically Integrated into medical practice can be identified From 2 holistic perspective. the question is not how to replace lnvasive imerventional technology with intangible therspeuties, but 1163 aa 2suasic.ueapt yal siuoteg Jo auowsieueyy 02 sypeoaddy aaneurany pur dremouoqdw0, 1164 car hhow to augment our best technology with unique endogenous resources vision of optimal catheterization laboratory care as @ sanctuary of ‘high tech-high touch’ cardiovascular care. late absence ‘of any defined mechanisms through Which such interventions might ‘measurably exert thee effects, however, systematic study of safety and effectiveness will remain critical to the real integration of CAM into the catheterization laborstory Intensive Care Units ‘The idea that an environment of care could affect patients! recovery and staff morale is intuitive but has net been given aproper consideration in ourculture. Cardiovascular centers can change to a healing environment by renovating physical space using principles of feng shuf, an ancient Chinese art and science of living in harmony with the environment, to direct the flow of chi, or energy. Patients stay in the same area or, at least, are not to be transferred more than once during their hospitalization, In addition, including integra- tivemedicine consultations, massage and reflexology. guided imagery and music therapy, and breathing meditation can aid in recovery, as can a program run by a dedicated staff of holistic nurse practitioners, registered nurses trained in various modalities of CAM, and experienced massage thera- pists, The uso of pain and antisnxiety medications cen decrease and patient satisfaction scores can increase. The program enables patients to teke an active role in their recov- ery as well as make changos toward life-long wellness and disease prevention, empowering them to enhance their quality of life at present end in the future. In addition to the best medical care, key concepts include nutrition, exercise, stress management, relaxation, and spiritual Cardiac Surgery (soe Chaps. 27 end 29) ‘The use of CAM is not only for primary care diseases. As shown by a study of 376 consecutive patients undergoing cardiac surgery, many cerdiac surgery patients use some form of CAM but do not discuss its use with their physi- cians.” Among patients surveyed, 78 percent admitted the use of alternative medical therapy (44 porcent without prayers and vitamins), but only 17 percent had discussed CAM use with their cardiac physicians, and 48 percent did not want to discuss it with any physicians. The most common CAM practices that cardiac surgeons need to understand are generally grouped into mind-body therapies and vitamin and herbal supplements. MIND-BODY THERAPIES. The use of these therapies before ‘uring, and after cardiac surgery may’ occur in roughly 50 percent of patients undergoing sucgere. Depression is common in patients with hhenet disease and cardiac surgery, and is associated with adverse 01 ‘comes and increased long-term mortality In addition, the cost of ‘ng cardiac patients with mild to moderate depression is 11 percent higher in the first year following a major cardiac event, including surgery." Type A behavior is thought to predispose to heart disease. Hostility andangerare associated with increased risk of sete coronary events, asare anxiety, panic symptoms and, periaps, vital exhaustion Social isolation and lack of social support are more powerful risk factors than some traditional isk fictors, such as ssoking. The auto nomic nervous system (ANS) is sensitive to thoughts and emotions, With negative reactions creating disorder and imbalance in the ANS snd postive feelings such as appreciation creating order and balance In addition, chronic stress clevates basil cortisol, Impaies the body's ability 10 respond to acute stressors, and can lel to poor heling and recovery following surgery. Tinus, many mind-body therapies have potential usefulness follow ing or in conjunction with eardiae songery Religious practice, beliet patteras, guided imagery during cardiac surgery, and the related social support appear to play a positive role such as promoting recovery after eardiae surgery and hanting postop. erative length of say SPECIFIC HERBALS TO AVOID PERIOPERATIVELY, Significant problems have been associated with the use of ephedra products for ‘weight loss. Ephedra acts as a sympathomimetic, leading to increased arterial blood! pressure, iacreased heart rate, increased Oxygen con sumption in heart muscle, and vasoconstriction, Dandelion. herbal is protorypicil of potassium-wasting herbals, of whieh there have been numerous anecdotal and other reports. Most importantly for cardine surgeons, over 40 dhifereat herbs have anticoagtlane effects of theit ‘owa and thus could inevease the ssk of adverse bleeding events, Other ‘popular hetbs have been associated with decreased activity of warfa ia. eis imperative to ask all persons taking aspirin or warfarin abut the use of plancbased medicines, AGING Much has been written about the aging process (so Chep. 75), Weil” has presented @ number of suggestions: eating an antiindlammatory diet, using dietary supplements wisely to support the body’s defenses and natural healing power, using preventive medicine intelligently, knowing the risks of age-related disoase, gotting appropriate diagnostic and screening tests and immunizations, treating problems such as hypertension and abnormal lipid levels in the early stages, getting regular physical activity throughout life getting adequate rest and sleep, learning and practicing methods of stress reduction, exercising the mind as well as the body, maintaining social and intellectual connections throughout life, being flexible in mind and body, learning to adapt to losses and to let go of behaviors no longer appro- priate for your age, thinking about and trying to discover the benefits of aging, not denying the reality'of aging nor putting energy into trying to stop it, using the experience of aging as a stimulus for spiritual awakening and growth, and keeping records of the lessons learned, the wisdom gained, and the value held. At critical points in life, this list can be revised and shared with loved ones. Vogel” has added admonitions about eating less, exercising more, not smoking, slowing one’s heart rate, procreating later, taking a statin, and having one drink per day. In extending the lives of so many pationts, we now have millions who have entered a terminal stage of their disease with high mortality rates and considerable torment (see Chup. 30), Thus, itis our responsibility to develop methods, tools, and approaches that can provide a more positive end- oflite experience for our pationts. To deal with this, it is important to listen to the patients, develop a discussion, and review their personal desires, The Five Wishes document® helps people express how they should be treated if seriously. ill and unable to speak for themselves 1s unique entong living wills and similar forms because it includes all of our needs—medical, personal, emotional, and spiritual. The Five Wishes encoureges a discussion of the patient's wishes ‘with family and physician, End-of life directives are imper- ative, The Five Wishes also lets the patient's family and physicians become aware of the following: 1, Who the pationt wants to make health care decisions when the patient can't make them. 2, The typo of medical treatment that the patient wants or doesn’t want. 3, How comfortabie the patient wants to be. 4. How the patient wants people to treat him or her. 5. What the patient wants loved ones to know. Thus, the physician should listen carefully, trying to understand the patient’s viewpoint. Listening does not require the physician to agree with the patient or misrepre- sent his oz her own views. Patients and families who believe that the physician understands them and cares about them ‘will result in trust between the physician and patient and thus there will be a more successful conclusion to treat- ‘ment, By responding to patients’ spiritual and religious con- cerns and needs, physicians may help them find comfort and closure near the end of life. mua) ‘BOOKS AND PUBLICATIONS. Barrett M: The Handbook of Clinically Tested Herbal Remedies. Vols. 1 ‘and 2, Binghamton, NY, Haworth Herbal Press, 2004, ISBN: 0789027232 Description: A thorough, informative, in-depth texc for cinicians Searching for accurate information on herbal clinical tial. Fugh-Berman A: The §-Minuce Herb and Dietary Supplement Clinical Consul. Philadelphia, Lippincott Willams & Wilkins, 2003. ISBN: 0883302736 Description: Includes herbs, minerals, vitamins, amino acids, and Tniymes and their ures to €eat common problems and improve health Blumenthal M, Brinkmann j, Wollschlaeger B: The ABC Clinical Guide to Herbs, Austin, TX, American Botanical Coun, 2003, ISBN: 1588901572 Description: Provides health professionals wih informasion on 29 of ‘the most popular herbs, and ether herbal products. Information includes usage, dosage, contraindications, adverse effect, drug interactions, and pharmacological effects. ‘Coates PM, Blackman MR, Cragg GM, eta (eds): Encyclopedia of ‘Dietary Supplements. New Yors, Marcel Dekker, 2005, ISBN: 0824755049 Deseription: Provides detailed scientific information on over 75 cletary Supplements, including description and chemical composition, mechanisms of action, pharmacology, usage anc dosage, safety, dverse effects, and regulacory sues. Katz DL: Nutrition in Clinical Practice. A Comprehensive, Evidence: Besed Manual forthe Practitioner. 2nd ed. Phiadelphia, Lippincote Willams & Wilkins, 2007. 52555213 jon: Nutation information provided slong with information on Supplements (nutraceuticals). Nutrient and supplement reference tables included ‘Simon M, Bone K: The Essential Guide to Herbal Safery. New York, ‘Churchill Livingstone, 2004, (SBN: 0443071713, Deseription: This guide contains comprehensive reviews, in monograph format, of the published safety dass for 125 herbs. Covers issues of quality, interactions, adverse reactions, toxicity allergie contact Sensithity, and idiosyncratic reactions ‘Schule V, Hansel R, Blumenthal M, Tyler VE: Rational Phytotherapy: A Physician's Guide to Herbal Medicine Sched. New York, Springer Verlag, 2004, tgBN: 3540408320 DDeseription: Reviews the pharmaceutical aspects of phytotherapy. “Thrombosis Research: Special Issue, Papers From the NIM Conference ‘on Dietary Supplements, Coagulation, and Anechromborie Therapies. 117(1-2): 2005. EVIDENCE-BASED REVIEWS ‘Agency for Heakthcare Research and Quality (AHRQ): hep: //ahrq.gov "and http /preventveservices.ahra.gov Description: AHRQ supports research designed to improve the Toutcomes and quality of heath care, reduce its costs, address patient Safety and medical errors, and broaden access to effective serves Available Reviews: Effect of Supplemental Antioxidants Vieamin C, Vitamin €, and ‘Coenzyme Qi0 forthe Prevention and Treatment of Cardiovascular Disease: ntp://www.abrg gov/elinie/epesums/antioxsum htm Garlic: Effects on Carciovascular Risks and Disease, Procective Effects Against Cancer, and Clinical Adverse Effects: http//wv arg gow cliie/epesums/garlcsum. hem ‘omegars Farry cies Health Effects: hrep://www.ahrq gov/clni/tp/o3cardep-hem Risk Factors: hetp www ahng gov/clini/tp,e3cardeskep.rem ‘Arrhythmias: http wow ahrq gov/elnic/tp/o3arrep hem Effeccs of Soy on Health Outcomes: hetp//ww- arg govcliic) epesums/soysumahem eee kes ‘Multivitamin and Mineral Supplements and Prevention of Chronic Disease: neepi//wnwarg gow clinic /tp/muliveep nem Cochrane Systematic Reviews: http//www.cochrare.org/index.htm Description: The Cochrane Collaboration isan international nonprofit, ‘independent organization I produces and eisseminates systematic ‘eviews of healthcare interventions and promotes the search for (idence in the form of elinial tials and other studies of Lichtenstein AM, Appel W, Brands M, eal: AMA Scientific Statement. (er and Lifestyle Recommendations Revision 2008. A scientific statement from the American Heart Association Nusriton Commiteee, Circulation 14:82, 2006, National Center for Complementary and Alcermative Medicine (NCCAM), hetpi/necam.nih gov/research/polices/guideonct.htm. NIH Guidanee on Designing Clinical Tals of CAM Therapies: Determining Ose Ranges. Vogel JHK, Bolling SF, Costello RB, eal Incegrating complementary ‘medicine inte cardiovascular medicine: A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Wriing Committee t9 Develop an Expert ‘Consensus Document on Complementary and integrative Medicine) Am Coll Cardiol 46:184, 2005 DATA BASES [AltMedDex System: hecp//wwrmicromedex.com/procuets/altmeddex/ (by subscription) Description: Referenced information on herbals, vieamins, minerals, ‘cher dietary supplements, Chinese medicine, acupuncture and tore. Includes data on cosing, Pharmacokinetics, and clinical applications International Bibliographic Information on Dietary Supplements (UbIDS} Database: herp: /ods.o4.rih.gov/ Health. Information IBIOS. aspx. National Instures of Health, Office of Dietary Supplements, and the ‘National Agricultural Library, Food and Nutrition Information Center Description: '610S is a comprehensive bibliographic data base chat Telps health care providers, researchers, and consumers find credible, Scientific literature on dietary supplements. Current) the data base Contains dietary supplement citations and abstracts from MEDLINE, AGRICOLA, and AGRIS, and selected nutrition journals from CAB ‘Abstracts and CAB's Global Health daca bases, dating from 1986 co the present Natural Medicines Comprehensive Database: woyw.NaturalDarabase ‘com (by subscription) “The Pharmacists Leiter The Preseriber'sLeter, updated year Description: Referenced, peer-reviewed, continuously undated online ‘data baze. Search by keyword or by brand name products. Includes Srug-herb inersezions end coneitions [MEDLINEPIus for Herbal Information: heep://wwwrim nih gov mediineplus/herbalmedicine hem Description: Contains up-to-date, quality healthcare information on Terbs and herbal medicine from the Nationa Library of Medicine at the National Insciutes of Health MEDLINEDus for Dietary supplements: beep ‘medlngplus/dietarysupplements.heml Description: Links including che latest research, on dietary Supplements from the National Library of Medicine atthe National Inseiutes of Heath MONOGRAPHS, ‘American Herbal Pharmacopeia and Therapeutic Compendium (AHP): Tntp/wwrsnerbal-chp org. Description: The Amerivan tierbal Pharmacopoeia began developing (alltarive ané therapeutic monographs in 1994, and will produce 300 monographs on botanicals, incling many ofthe Ayurvedic, ‘Chinese, and Western herbs most Frequertly used in the United States swim. nih go Tobie contioues 1165 Har sony pure Aserwawiydaios, aseasicl uray) iit siubneg Jo awoussBeueyy 07 soypeouddy an MIA TABLE 47-3 | Reference Sources for information on Dietary Supplements and Herb car ‘The Complete German Commission E Menographs: Therapeutie Guide to Herbal Medicines ‘Mark Blumenthal, German Federal Institute for Drugs and Medical Deviees Commission €, American Botanical Council, Inegiasive Medicine Communications, Werner R. Busse, |. Kisin, Ravert Rister (editors Segre Klein, Chance Rigging ‘Austin, TX, American Botanical Council Boston, MA: integrative Medicine Communications, 1998. 685 pp. ISBN: 095555550x Web site: wor herbalgram.org Description: The German government's Commission € findings regarding the approved uses, contraindication, side effects, dosage, sug interactions, and other therapeutic effects of 300 herbs and phytomedisines, Health Canada, Natural Health Products Compendium of Monographs: huspi/worwhe-se gcca/chp-mps/prodnatur applications lcerered) monograph, /indexe hem! Acknowledgment The authors thank Erminte Guamerl, MD, RN, MBA, lor their help with this chapter, REFERENCES General Considerations 4, Barnes? PowellGuneeB MeFane K, Nebin Re CDG Advanced Data Report 643 [mplomentrs sad atte sdicine ne song ast dy 272008 Voge [Bolling SF. 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Bepet Camarasa Bocureats sing Comte to Delay ne Expect Consvanas Dice nent en Coplomentery snd Integvave Misia! | Avy Coll Cmte! secoe, Eine E: Complomenteraltrstin medicine for hypertension: 4 inion ‘Wien Sed Worbenseh 18308, 2005, ‘Mulrow ,Layrones V Ackarnonn ot Galle: fete on cadlovasculas sks ‘ed dieu proteciv tlais agent cates, a clinics seein slats Ev Rap Technol Asses (sm) 20, 3900 Roveafet F,HitonD, Pepe 5, Kr H: Stalemate rr fell of cooneyine {Qi in physica oxeeie Se petesion, apd hou face, Bleicors s 200, Beyer FR Dickinson HO, Nealon Dieta Combiard cairn, agnosie nd ottasizm supplementation othe management primary hypermail (ochrane Databsse Stem Rev conus 2000 FACC, end Cathy Young, Ss Those Surg ee Description: The Health Canada Natural Health Products Directorate, ‘Healeh Canaéa, 2003, developed the Compendium of Moncgraphs a5 {001 forthe timely and efficient evaluation ofthe safety and efficacy ‘of many commonly used meicinal ingredients found in natural health products eee proses (CME PROGRAMS Sponsor: chives of Incernal Medieine:hesp//mejama-archives mma ‘assn.org/cgi/hierarchy/amacme_courtejarchintet 65/10/1098 May 28, 2005: Systemacic Overview of Warfarin and its Food and Drug Interactions Sponsor: College of Pharmacy, University of illinois at Chicago: husps// ‘wonwie.edupharmaey/eonted Preceptorshio! Antchrombosis Management Boraricals for Women's and Men's Health ‘Sponsor: Northwest AHEC, Wake Forest University School of Medicine: hetpss/norehwestahecwfubme.edu/leart/herbs ce/inden fmm Curriculum on Herbs and Dietary Supplements 15, Seapary PO We i. Hledan tal: Gaga forthe toute of hy pecho leserolmin:Arandomfandconteled tal JAMA 20078, 2008 NB HK. UnverosbesS.Doeabards Ro a: Bort ofthe poco aa ty iid ug aate with hypercholseolmia ar cmbine periphery ruosiand comraled wa JAMIA S082 208 1, Atrsneabala ML Molina. Mos, tal: Asta offs of plioranol 2 and 4 gid) In helt vluntws nd delphi patient lin Exp Pharmacol Ptr MEL Eras E Complemeotay theapnt fer piper ata disease: Sse enti roview.aberorlerne Te. 208 Erne & The nsksonelt prose of commenly weed here sheraiex: Gino, St. Ishns Wort Giasng, Bchinses. Set Palit, and Kava, An ner Meds Illa 3 a: Nature Medicines Cmpreesive Database, ha Stockton. Ca Tenapeti sect Faculty 3008. ‘lle MI Ent Horse chesnut ved extract or chon venous isuleieney Cochrane Datta Sst Rev CDDUazH0, 2008 Dini Mazeot .Por Mi raat Es Adcrse-cent rae of Cotas pp A Sistematc esate Dru Sut 583, 2008, Eogeson Nielsen J, Winter Ki Ect of Comayise Qia and Ginkgo bile on ‘atari dosage i sable. langserm wef std oul 4 ood

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