The document discusses the use of herbal medicine for cardiovascular health, detailing specific herbs such as ginkgo biloba and lesser periwinkle, which are noted for improving cerebral circulation and cognitive function. It outlines their mechanisms of action, indications, dosages, and potential adverse effects, emphasizing the importance of dosage and caution with drug interactions. Additionally, it addresses other herbal treatments for hypertension, angina, and hyperlipidemia, highlighting the therapeutic properties of garlic, hawthorn, and other botanicals.

1. Herbal medicine
Cardiovascular system
CVS
By
Dr. Mostafa Mahmoud Hegazy ( PH.D.)

2. Peripheral and cerebral insufficiency
Ginkgo leaves
Lesser periwinkle

3. Ginkgo leaves ( Ginkgo biloba )
‫الجنكة‬ ‫أوراق‬

4. standardized ginkgo extract
• USP 31 (Ginkgo). The dried leaf of Ginkgo biloba (Ginkgoaceae)
containing not less than 0.5% of flavonoids, calculated as flavonol
glycosides, with a mean molecular mass of 756.7, and not less than
0.1% of terpene lactones, both on the dried basis. The leaf is khaki
green to greenish-brown. Protect from light and moisture.
• Ginkgo Biloba is a 50:1 leaf extract standardized to 24%
ginkgoflavonglycosides and a minimum of 6% terpene lactones.
• the ratio 50:1, that means 50 grams of ginkgo biloba leaves is
equivalent to 1 gram of standardized ginkgo biloba extract.

5. Constituents:
• 1- Flavonoids
- Kaempferol, quercetin, isorhamnetin
- myricetin, 3- methylmyricetin
- biflavonoids, catechins and proanthocyanidins
• 2- Diterpene lactones
• Ginkgolides A, B, C, J and M
• 3- Sesquiterpene lactone
• Bilobalide

6. Mechanism of actions:
1- increases blood flow,
2- increases tissue oxygenation and nutrition,
3- Prevention of membrane damage caused by free radicals.
4- Enhances memory and cognitive function, especially in the elderly.
5- Has platelet-activating factor (PAF) antagonism;
The PAF antagonism: Platelet -activating factor (PAF) is an ether-linked
phospholipid which is formed by platelets, basophils, neutrophils,
monocytes and macrophages. It is a potent platelet-aggregating agent
and inducer of systemic anaphylactic symptoms.
The ginkgolides are potent and specific PAF antagonists.

7. Indications:
1- Disorders and symptoms due to restricted cerebral blood flow (memory
impairment, dizziness, tinnitus, anxiety /depression, fatigue and stroke).
2- Early stages of primary degenerative dementia (Alzheimer-type)
3- Effects of high altitude (altitude sickness) or hypoxia.
4- Disorders due to reduced retinal blood flow, senile macular degeneration.
5- Inner ear disorders of vascular origin: tinnitus and vertigo
6- Peripheral arterial disease (particularly intermittent claudication).
7- May also be used for disorders due to restricted peripheral blood flow
(including diabetic vascular disease, atherosclerosis, Raynaud's syndrome);
8- Osteoarthritis.
9- protection against ischemia and reperfusion injury.
10- Powerful antioxidant;

8. • Dosage: Usually the daily dose is 120 mg of a ginkgo standardized extract
equivalent to 27-30 mg ginkgo flavone glycosides and about 10 mg terpenoids
per day (this corresponds to 4-8 g of leaf, depending on the quality).
• Proprietary names: Ginko®, Tanakan®, Tebonina forte®, Brain Power®, Ginkor
fort®.
• Adverse Effects: include headaches, dizziness, palpitations, gastrointestinal
disturbances, bleeding disorders, and skin hypersensitivity reactions.
• Poisoning: convulsions induced by ingestion of large amounts of ginkgo seeds.
Convulsions were thought to be due to the presence of 4-methoxypyridoxine, a
competitive antagonist of pyridoxine; giving suitable quantities of a vitamin-B6
source may be of benefit in preventing such convulsions.
• Interactions: It has been suggested that ginkgo biloba should be used with
caution in patients receiving anticoagulants or drugs that affect platelet
aggregation. For reference to a possible interaction with warfarin.

10. Lesser periwinkle (Vinca minor )

11. Constituents:
Alkaloids: Vincamine (the principle alkaloid), vincine, vincaminine, vincinine and
vincanorine.
Vincamine
Mechanism of actions:
1-Vincamine is claimed to increase cerebral circulation and utilization of oxygen
2- The total alkaloids of Vinca minor show a pornounced hypotensive effect.

12. • Indications:
• 1- Disorders and symptoms due to restricted cerebral blood flow.
• 2- Age related troubles, such as memory troubles, concentration disorders,
attention and awareness disorders;
• 3- Degenerative trophic diseases e.g. diabetes, and atherosclerosis;
• 4- After acute cerebral accidents e.g. post-traumatic, post-apoplectic and
hypertensive encephalopathy.
• 5- Dizziness, vertigo, vascular headache and migraine;
• 6- Hearing and Visual troubles of vascular origin;
• 7- Psychiatric disorders e.g. space-time orientation and emotional disturbances
• 8- To improve the intellectual capacity in children and adolescents.

13. • Dosage:
• Crude drug: 3.0 g /day orally.
• Vincamine has been given by mouth in doses of 40 to 80 mg daily and
has also been administered intramuscularly and by intravenous infusion.
• Children: 5 mg three times daily. Adults: 10-20 mg three times daily
• Proprietary names: Oxybral®, Depovinc®.

14. Vinpocetine is a derivative of vincamine (above) that has been given orally in
cerebrovascular disorders and dementia.
Good evidence to support its use in cognitive impairment is lacking.

15. Essential hypertension
Treatment:
a) Diet and lifestyle
b) Herbal drugs
1- Rauwolfia
2- Mistletoe
3- Valerian
4- Olive leaves
5- Coleus forskohlii
6- Cramp bark
7- Yarrow
8- dandelion leaves

16. Rauwolfia ( Rauwolfia serpentina )
USP 31: The dried roots of Rauwolfia serpentina (Apocynaceae). It contains
not less than 0.15% of reserpine-rescinnamine group alkaloids calculated as
reserpine. Store at 15° to 30° in a dry place.

17. • Constituents: Alkaloids, the most important are
reserpine (antihypertensive) and ajmaline (anti-
arrhythmic).
Reserpine
• Mechanism of Action
• Reserpine irreversibly blocks the vesicular monoamine
transporter (VMAT). This normally transports free
norepinephrine, serotonin, and dopamine from the
cytoplasm of the presynaptic nerve terminal into
storage vesicles for subsequent release into the
synaptic cleft (exocytosis) .Unprotected
neurotransmitters are metabolized by MAO as well as
by COMT in the cytoplasm and consequently never
reach the synapse.
• It may take the body days to weeks to replenish the
depleted VMAT, so reserpine's effects are long-lasting.

18. • Indication:
1- Anti-hypertensive
• Dosage:
• Whole extract: 2mg, given once a day to begin with and several times daily later.
• Pure alkaloid reserpine: initial 0.2 -0.3 mg is given three times daily to begin with,
0.1- 0.2 mg twice daily for maintenance.
2- As a tranquillizers for ttt of chronic psychoses in daily doses of up to 1 mg.

19. Mistletoe ( Viscum album )
• it is semi-parasite plant, It occurs as a mixture of
broken stems and leaves and occasional fruits ?.
• Constituents:
• These are alkaloids, viscotoxins (cause hypotension,
acetylcholine agonists), and lectins. All of Three
classes are cytotoxic compounds.
• Action and uses:
1- Mild anti-hypertensive drug. Choline derivatives are
known to effect parasympathetic stimulation and
vasodilation.
2- preparations have been given by injection in a
number of neoplastic diseases.

20. • Blood pressure tea:
• mistletoe for its gentle hypotensive effect, hawthorn to improve coronary
circulation, and melissa as a heart sedative:
• Mistletoe herb, Hawthorn leaves and flowers and Melissa leave equal parts to
make 100.0
• One cup morning and night prepared by infusing of 2 teaspoons of the mixture
for 5 -10 minutes taken in sips while still warm.
• Antihypertonicum S Schuck, Ger.
• Betula ; crataegus ; mistletoe; olive; rhododendron leaf; rutoside; proxyphylline.
• Atherosclerosis; hypertension.
• Cefalektin Cefak, Ger.
• Mistletoe.
• Malignant neoplasms.

21. Valerian (Valeriana): whether this drug acts as a peripheral or central vasodilator or if the activity is due to a
general calming effect on the nervous system is not known. It is usually prescribed for stressed patients.
Olive leaves (Olea europaea ): has been proven to lower high blood pressure in clinical trials provided the dose is
sufficiently high. Constituents: Choline-type substances and glycoside, oleoside.
Coleus forskohlii: can have a pronounced lowering effect on high blood pressure. Only varieties containing
forskolin should be used. Coleus also has pronounced antiplatelet activity, which may be desirable in some cases.

22. Cramp bark ( Viburnum opulus ):
this herb is thought to relax smooth
muscle and has been used to
augment antihypertensive
prescriptions as a vasorelaxant.
Yarrow ( Achillea millefolium ): is
used by some herbalists to
specifically; lower an elevated
diastolic blood pressure.
Taraxacum officinale (dandelion
leaves) has diuretic activity and high
levels of potassium and can be
useful especially for the treatment
of elevated systolic pressure in the
elderly.

23. Crataegus (hawthorn): as well as reducing high blood pressure this herb has a
trophic effect on the heart muscle.
This is important because left ventricular heart failure is often caused by
prolonged hypertension, The leaves are apparently more potent than the
berries for reducing high blood pressure.
Allium sativum (garlic): as well as confirmed antihypertensive effects this plant
also favorably influences other, cardiovascular risk factors. Allicin-releasing
preparations are most proven in blood pressure management.

24. Angina
Treatment:
• a) Diet and lifestyle
• b) Herbal drugs

25. Hawthorn Berry
‫األودية‬ ‫زعرور‬
• Ph. Eur. 6.2 (Hawthorn Berries). The dried false fruits of Crataegus
oxyacantha (C. laevigata), or C. monogyna, or their hybrids or a
mixture of these false fruits. They contain not less than 1% of
procyanidins, calculated as cyaniding chloride with reference to
the dried drug. Protect from light.
• Ph. Eur. 6.2 (Hawthorn Leaf and Flower). The whole or cut, dried
flower bearing branches of Crataegus oxyacantha (C. laevigata), or
C. monogyna, or their hybrids or, more rarely, other European
Crataegus species including C. pentagyna, C. nigra, and C. azarolus.
It contains not less than 1.5% of flavonoids, calculated as
hyperoside calculated with reference to the dried drug. Protect
from light.

26. constituents:
- Flavonoids ( including hyperoside , rutin , and vitexin) and oligomeric
proanthocyanidins (largely responsible for action of drug).
- Biogenic amines (such as tyramine)(some of cardiotonic action)
- Triterpenes
hyperoside vitexin

27. Mechanism of action;
- Inhibition of phosphodiesterase activity in tissue with a subsequent inhibition of cAMP is
believed to be the mechanism of action.
- Hawthorn does not have a digitalis-like effect, but the drug have a completely different site
of action in the myocardium. Hawthorn does not exert its action in the contractile system of
the myocardium, but improves the myocardial energy metabolism. This probably explains
why hawthorn requires a much Longer time than digitalis to take effect and why myocardial
reactivity must exist in order for the herbal drug to take effect.
- Hawthorn's biological profile of action summarized as follows:
1- Hawthorn increases coronary and myocardial circulation.
2- Hawthorn improves myocardial contractility (slightly positive inotropic).
3- It has a eurhythmic effect on certain types of electrical heart instabilities.
4- Hawthorn increases myocardial tolerance to oxygen deficiency.
5- Hawthorn increases cardiac output, reduces peripheral resistance (a parameter of after-
load), and increases cardiac performance.

28. Indication:
- Cardiotonic (mild), cardioprotective, hypotensive, antiarrhythmic. i.e. increases force of
myocardial contraction, increases coronary blood flow, reduces myocardial oxygen demand,
protects against myocardial damage, improves heart rate variability. Can be used for
congestive heart disease due to ischemia or hypertension; cardiac insufficiency.
- Reduction of cholesterol.
- Stabilization of connective tissue tone (collagen stabilizing);
- Antioxidant activity; co-factor for vitamin C intake;
Interactions:
Hawthorn may act in synergy with digitalis glycosides, beta-blockers and other hypotensive
drugs. Modification of drug dosage may be required.

29. Dosage:
a) 1.5 - 3.5 g of dried berry, flower or leaf per day, as infusion or decoction.
b) Hawthorn tablets (1 g leaves and flowers, standardized to 15-20 mg oligomeric
procyanidins and 6-7 mg flavonoids) 2-3 times per day.
c) 3 - 6 ml of 1: 2 liquid extract of hawthorn leaf per day,
3 - 7 ml of 1: 2 liquid extract of hawthorn berry per day,
7.5 - 15 ml of 1: 5 tincture of hawthorn leaf per day,
7.5 - 17.5 ml of 1: 5 tincture of hawthorn berry per day.
Higher doses than these may be necessary for effective control of hypertension.
- There is no restriction on the long-term use of hawthorn and, if used to treat heart
conditions, it should be prescribed over a period of at least 2 months.

30. Garlic (Allium sativum)
Constituents:
Alliin, allicin, S-propylcysteinesulfoxide and 5-methylcysteine-sulfoxide.
Action and uses:
Garlic (Allium sativum) has Protective effects against stroke, coronary thrombosis,
atherosclerosis, platelet aggregation.
- Antibacterial, antifungal, antiviral, antioxidant, antineoplastic, hypolipidemic, antiarthritic
actions and hypoglycemic functions.
- General tonic effect thought stimulation of hypophyseal function.
Dosage:
Bulb: 10 - 25 g;
Alliin: 10 mg;
Allicin: 4 mg.

31. Preparations:
1- Carefully dried garlic powder which preserves the compound alliin (S-
allylcysteine sulphoxide) and the enzyme alliinase. On disintegration of tablets
or capsules containing this powder in the digestive tract, alliin comes into
contact with alliinase and is converted to allicin.
2- Aged garlic extracts or 'odorless' garlic products which are produced by a
fermentation process. These preparations contain modified sulfur compounds
such as S-allylcysteine.
3-Steam-distilled preparations of garlic (garlic oil) which are rich in diallylsulfides.

32. Arnica (Arnica montana)
• Constituent
• - Sesquiterpene lactones helenalin dihydrohelenalin
and their esters). - Flavonoids
Indications:
Arnica may be used on the same indications as the
hawthorn- senile hearts and coronary artery disease
with or without angina.
There are, distinct differences between the two;
Arnica has rapid stimulant action, is generally given more
to treat acute short-term weakness of the heart.
Hawthorn, is predominantly used in the long-term
treatment of coronary artery disease.

33. - Salvia miltiorrhiza (dan shen) is a Chinese herb, which has been
clinically studied for angina and other heart conditions. Its benefits
include cardioprotective, vasodilator and anti-platelet activities.
- Grape seed extract (100 mg/day) can provide a suitable in reducing
heart disease.
- Capsicum spp. (cayenne) has fibrinolytic activity and was traditionally
used to improve myocardial blood supply.
-Anti-platelet herbs such as Coleus forskohlii. Allium sativum (garlic),
Zingiber (ginger) and Curcuma longa (turmeric) may have value even
if the patient is taking aspirin. They also have other properties which
may be beneficial; e.g. coleus is a vasodilator and curcuma is
antioxidant However, care should be taken to ensure that bleeding
time is not excessively prolonged.
- Other vasodilating and relaxing herbs which are prescribed include
Tilia species (lime flowers) and Viburnum opulus (cramp bark).

34. Hyperlipidemia

35. Gymnema (Gymnema sylvestre)
‫الغورمار‬(‫باركستا‬)‫السكر‬ ‫حارق‬ ‫أو‬
• Constituents:
• Saponins (Gymnemic Acids), alkaloids, flavones and anthraquinones.
• Action and uses:
• Saponins have been reported to
- Decrease plasma-cholesterol levels.
- Decrease blood glucose levels.
- Antiobesity.

36. • Mechanism of actions:
• Saponins decrease intestinal absorption of cholesterol and glucose and increases
insulin secretion in human β-cells. It has anti-sweetness (which decrease the
appetite
• Dosage:
• - 200-400 mg of extract taken by mouth twice daily
• - 2 ml of an aqueous decoction (10 grams of shade-dried powdered leaves per
100 milliliters) three times daily have been studied.

37. Statins(HMG-CoA reductase inhibitors):
• Inhibiting cholesterol synthesis
• Increasing LDL uptake: draw cholesterol out of the circulation.
• 1- Lovastatin
It was isolated in the 1970s in the broths of Monascus ruber (red yeast rice),
Aspergillus terreus and Pleurotus ostreatus (oyster mashroom). Lovastatin, the
first commercially marketed statin, was approved by the FDA in 1987.

38. Simvastatin
A semi-synthetic derivative of
lovastatin is simvastatin, a
major hypocholesterolemic drug,
selling for US$7 billion per year
before becoming generic.
Mevastatin ( compactin)
The first member
of the group (compactin; mevastatin)
was isolated as an
antibiotic product of Penicillium
brevicompactum and later from
Penicillium citrinum.
Pravastatin
Another statin, pravastatin (US$3.6
billion per year), is made through
different biotransformation
processes from compactin by
Streptomyces carbophilus and
Actinomadura sp.
A synthetic compound, modeled from the structure of the natural statins, is atorvastin,
which has been the leading drug of the entire pharmaceutical industry in terms of market
share (approximately US$14 billion per year) for many years.

39. Varicose veins
• Causes
• Weakness of the vein wall and poor venous tone can lead to venous
valves becoming incompetent.

40. Horse-chestnut seed
(Aesculus hippocastanum)
‫الحصان‬ ‫كستناء‬
• Constituents:
• Saponins (3- 6%) (the mixture of saponins collectively referred to as escin; α- and -escin as
major glycosides), Coumarins, flavonoids and tannins.
• Action and uses:
- It can be used for chronic venous insufficiency, varicose veins, edema of the lower limbs.
• - It is used as prophylactic to decrease the incidence of deep venous thrombosis following
surgery.
• - Topically for hematoma, contusions, non-penetrating wounds and injuries involving
edema.
- Skin care products: for normal skin, baby skin, sensitive skin; to tone the skin; as an anti-
inflammatory; to treat fragile capillaries, pimples, sunburn or cellulite.

41. • Mechanism of actions:
• (Increases venous tone, increases capillary resistance, decreases capillary permeability,
improves circulation by toning veins; decreases edema from lymphatic congestion or of
inflammatory origin, i.e. venotonic, anti-edematous, anti-inflammatory)
• Dosage:
• Dried seed: 1 - 2 g per day.
• Horse-chestnut tablets (200 mg of 5 : 1 concentrated extract, standardized to contain 40
mg escin): 2-3 tablets per day.
• Proprietary names:
• Reparil® Tablets, Reparil® gel, Escinogel® gel, Prostatin® suppositories

42. Melilot (Melilotus officinalis)
‫الملك‬ ‫إكليل‬ ‫أو‬ ‫الطبي‬ ‫الحندقوق‬
• Constituents:
• Melilot contains coumarin and flavones.
• Action and uses:
• Internally in the treatment of varicose veins and thrombophlebitis.
• Preparations:
• Melilot tea, 1-2 teaspoons to a cup of boiling water, left to infuse,
taking 3-4 cups daily.

43. Flavonoids as Polyphenolic compounds e.g.
anthocyanins and maintaining healthy circulation.
• Anthocyanins could also reduce the incidences of fragility of capillaries, inhibit
blood platelet aggregation, and strengthen the collagen matrix which is a
component of the connective tissues.
• These polyphenolics such as anthocyanins and flavonoids might also act as the
beneficial in vivo inhibitors of LDL oxidation.
• In fact, the “French paradox” which represents the apparent compatibility of a
high fat diet with a low incidence of coronary atherosclerosis has daily been
attributed to the regular drinking of the red wines.
• ex. bilberry and grape seeds extract.

44. Rue (Ruta graveolens)
‫الرائحة‬ ‫شديد‬ ‫سذاب‬
• Constituents and uses:
• It contains rutin, considered to be a compound with vitamin P activity.
• Preparations:
• Ruta C tablets® and Rutin C tablets® contain 50 mg of rutin (rutoside),
so that the drug is easy to prescribe.

46. Functional heart disease,
nervous heart
Cardiovascular disease of functional origin is extremely common nowadays.
The drugs used in these cases should have a gentle cardiotonic and sedative
action. They are therefore also known as cardiosedatives. The plant kingdom
provides a number of drugs for this purpose, all of which have stood the test of
time.
Motherwort and convallaria (Lily of the valley) are gentle and Intermediate
cardiotonics respectively .

47. Motherwort (Leonurus cardiaca)
‫األسد‬ ‫ذنب‬

48. Constituents:
Alkaloids: leonurine Stachydrine, betonicine, and turicin ; flavonoids; iridoids; tannins;
terpenoids ... etc.
Uses:
Mainly for functional heart complaints due to autonomic imbalance. It appears to be
predominantly sedative, similar to valerian. It is necessary, however, to take the drug for
a long period, over months.
A tea combining the drug with convallaria and melissa (as a sedative) is very useful.
Motherwort herb
Lily of the valley herb
Melissa leaves
equal parts to make 100.0
Infuse two teaspoons in a cup of boiling water, 1 cup to be taken regularly morning and
night for some weeks.

49. Lily of the valley (Convallaria majalis)
‫الوادي‬ ‫زنبق‬

50. Constituents:
Cardiac glycoside: Convallamarin and Convallarin convallatoxin , trace of volatile oil,
tannin
Uses:
cardiac tonic and diuretic.
Mechanism of actions:
The action of the drug closely resembles that of Digitalis, though it is less powerful
Dose
The infusion of 3 teaspoonful of herb to 2 cup of boiling water is also taken in
tablespoonful doses

51. A cardiotonic glycoside obtained from the leaves of Digitalis lanata
(Scrophulariaceae).
Digoxin

52. Digoxin in Pharmacopoeias.
•Ph. Eur. 6.2 (Digoxin). A white or almost white powder or colourless
crystals. Practically insoluble in water; slightly soluble in alcohol; freely
soluble in a mixture of equal volumes of dichloromethane and methyl
alcohol. Protect from light.
•USP 31 (Digoxin). A cardiotonic glycoside obtained from theleaves of
Digitalis lanata (Scrophulariaceae). Clear to white, odourless, crystals, or
a white, odourless, crystalline powder. Practically insoluble in water and
in ether; slightly soluble in diluted alcohol and in chloroform; freely
soluble in pyridine. Store in airtight containers.

53. Uses:
Digoxin is a cardiac glycoside used in the management of
1-supraventricular arrhythmias, particularly atrial fibrillation
and
2- in heart failure .
•Pharmacology
The principal actions of digoxin are
1- an increase in the force of myocardial contraction
(positive inotropic activity) ,
2- decrease heart rate (negative chronotropic effects ) and
3- decreased AV nodal activity(negative dromotropy).

54. 1-By inhibiting the Na+/K+-ATPase, cause increase intracellular sodium
concentration, which leads to an accumulation of intracellular calcium via the Na+-
Ca++exchange system. Increased intracellular calcium.
A-In the heart, increases contractility (positive inotropic activity).
B-In vascular smooth muscle causes smooth muscle contraction and
vasoconstriction.
2-By mechanisms that are not fully understood, digoxin also increase vagal
efferent activity to the heart. This parasympathomimetic action of digoxin
(decreases heart rate; negative chronotropy) and reduces conduction velocity
of electrical impulses through the atrioventricular node (negative
dromotropy).

55. products examples
Egypt : Lanoxin® tab & amp and Cardixine® tab France:
Hemigoxine Nativelle tab ® Germany : Lanicor® tab ® UK:
Lanoxin® tab & amp USA: Digitek® tab.