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Herbal Medicine for Cardiovascular disease.pdf
1.
Herbal Medicine for
the Treatment of Cardiovascular Disease Clinical Considerations Nick H. Mashour, MD; George I. Lin, MD; William H. Frishman, MD H erbs have been used as medical treatments since the beginning of civilization and some derivatives (eg, aspirin, reserpine, and digitalis) have become mainstays of hu- man pharmacotherapy. For cardiovascular diseases, herbal treatments have been used in patients with congestive heart failure, systolic hypertension, angina pectoris, ath- erosclerosis, cerebral insufficiency, venous insufficiency, and arrhythmia. However, many herbal remedies used today have not undergone careful scientific assessment, and some have the poten- tial to cause serious toxic effects and major drug-to-drug interactions. With the high prevalence of herbal use in the United States today, clinicians must inquire about such health practices for car- diac disease and be informed about the potential for benefit and harm. Continuing research is nec- essary to elucidate the pharmacological activities of the many herbal remedies now being used to treat cardiovascular diseases. Arch Intern Med. 1998;158:2225-2234 Since the beginning of human civiliza- tion, herbs have been an integral part of society, valued for both their culinary and medicinal properties. Herbal medicine has made many contributions to commercial drug preparations manufactured today in- cluding ephedrine from Ephedra sinica (ma-huang), digitoxin from Digitalis pur- purea (foxglove), salicin (the source of as- pirin) from Salix alba (willow bark), and reserpine from Rauwolfia serpentina (snakeroot), to name just a few. A natu- rallyoccurringb-adrenergicblockingagent with partial agonism has been identified in an herbal remedy.1 The recent discov- ery of the antineoplastic drug paclitaxel from Taxus brevifolia (pacific yew tree) stresses the role of plants as a continuing resource for modern medicine. However, with the development of patent medicines in the early part of the 20th century, herbal medicine has been losing ground to new synthetic medi- cines touted by scientists and physicians to be more effective and reliable. Never- theless, about 3% of English-speaking adults in the United States still report having used herbal remedies in the pre- ceding year.2 This figure is probably much higher for non–English-speaking Americans. Despite this heavy use of herbal medicines in the United States, health practitioners often fail to ask about their use when taking clinical his- tories. It is imperative that physicians become more aware of the wide array of herbal medicines available, as well as learning more about their beneficial and adverse effects.3 Part of the problem for both consum- ers and physicians has been the paucity of scientific data on herbal medicines used in the United States.4 As a result, those who wish to obtain factual information regard- ing the therapeutic use or potential harm of herbal remedies would have to obtain it from books and pamphlets, most of which base their information on traditional repu- tation rather than relying on existing sci- entific research. One may wonder why the herbalindustryneverchosetosimplyprove its products safe and effective. The answer is primarily economical. With the slim chance of patent protection for the many herbs that have been in use for centuries, pharmaceutical companies have not pro- vided financial support for research on the merits of herbal medicine.5 At the same time, the National Institutes of Health have only been able to offer limited funding for this purpose. From the Department of Medicine, The Albert Einstein College of Medicine, Bronx, NY (Dr Mashour); the Department of Family Medicine, Columbia Presbyterian Medical Center, New York, NY (Dr Lin); and the Departments of Medicine and Pharmacology, New York Medical College/Westchester Medical Center, Valhalla, NY (Dr Frishman). REVIEW ARTICLE ARCH INTERN MED/VOL 158, NOV 9, 1998 2225 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Amit Mishra on 04/17/2023
2.
This review examines
herbal medicines that affect the cardiovas- cular system both in terms of effi- cacy and safety as gleaned from the scientific literature that is avail- able. These herbs are categorized un- der the primary diseases they treat. However, most herbal medicines have multiple cardiovascular ef- fects that frequently overlap. The purpose of this organization is to simplify, not to pigeonhole herbs un- der specific diseases. In general, the dilution of active components in herbal medicines results in fewer ad- verse and toxic effects in compari- son with the concentration of ac- tive components in the allopathic medicines. However, these adverse effects and drug interactions should not be overlooked; cardiovascular disease is a serious health hazard and no herbal remedy regimen should be initiated without careful consider- ation of its potential impact (Table). CONGESTIVE HEART FAILURE A number of herbs contain potent cardioactive glycosides, which have positive inotropic actions on the heart. The drugs digitoxin, derived from either D purpurea (foxglove) or Digitalis lanata, and digoxin, de- rived from D lanata alone, have been used in the treatment of congestive heart failure for many decades. Car- diac glycosides have a low therapeu- tic index, and the dose must be ad- justed to the needs of each patient. The only way to control dosage is to use standardized powdered digi- talis, digitoxin, or digoxin. When 12 different strains of D lanata plants were cultured and exam- ined, their total cardenolide yield ranged from 30 to almost 1000 nmol/1 g.6 As is evident, treating congestive heart failure with non- standardized herbal drugs would be dangerous and foolhardy. Some common plant sources of cardiac glycosides include D pur- purea (foxglove, already men- tioned), Adonis microcarpa and Ado- nis vernalis (adonis), Apocynum cannabinum (black Indian hemp), Asclepiascurassavica (redheaded cot- ton bush), Asclepias friticosa (bal- loon cotton), Calotropis precera (king’s crown), Carissa spectabilis (wintersweet), Cerebra manghas (sea mango), Cheiranthus cheiri (wall- flower), Convallaria majalis (lily of the valley, convallaria), Cryptoste- gia grandiflora (rubber vine), Hel- leborus niger (black hellebore), Hel- leborus viridus, Nerium oleander (oleander), Plumeria rubra (frangi- pani), Selenicerus grandiflorus (cac- tus grandiflorus), Strophanthus his- pidus and Strophanthus kombe (strophanus), Thevetia peruviana (yellow oleander), and Urginea mar- itima (squill).5,7-15 Even the venom glands of the animal Bufo marinus (cane toad) contain cardiac glyco- sides.8 Recently, the digitalislike ste- roid in the venom of the B marinus toad was identified as a previously described steroid, marinobufa- genin. Marinobufagenin demon- strated high digoxinlike immuno- reactivity and was antagonized with an antidigoxin antibody.16 Accidental poisonings and even suicide attempts with ingestion of cardiac glycosides are abundant in the medical literature.17-21 Some herbal remedies (eg, Siberian gin- seng) can elevate synthetic digoxin drug levels and cause toxic ef- fects.22 In the United States, there are about 15000 intoxications due to ac- cidental or intentional ingestion of poisonousplantsannually.23 In1993, 2388 toxic exposures in the United States were reported to be due to plant glycosides. Of these, the larg- est percentage were attributed to ole- ander (ie, 25%).24 In the case of ole- ander, all plant tissues, including the seeds, roots, stems, leaves, berries, and blossoms, are considered ex- tremely toxic.19 In fact, death in hu- mans has been reported following in- gestion of as little as 1 oleander leaf.25 The clinical manifestations of ole- ander intoxication, as well as other natural glycosides, is virtually iden- tical to digoxin overdose. Morbid- ity and mortality are mainly related to cardiotoxic adverse effects that usually include life-threatening ven- tricular tachyarrhythmias, brady- cardia, and heart block. The diag- nosis should rely on the clinical presentation of unexplained hyper- kalemia, and cardiac, neurologic, and gastrointestinal symptoms.19 The diagnosis can be further supported by the detection of the substance digoxin in a radioimmu- noassay for digoxin. However, the extentofcross-reactivitybetweenthe cardiac glycosides from herbal sources and antibodies used in the radioimmunoassays has not been clearly defined.26 For this reason, di- goxin assays may serve to confirm the suspected diagnosis but not to quantify the severity. Once the di- agnosis has been established, the use of digoxin-specific Fab antibody fragments may be helpful in the treatment of severe intoxication. Other modalities, such as dialysis, cannot be easily facilitated be- cause, like digoxin, natural glyco- sides are distributed extensively into peripheral tissues. HYPERTENSION The root of R serpentina (snake- root), the natural source of the alka- loid reserpine, has been a Hindu Ayurvedic remedy since ancient times. In 1931, Indian literature first described the use of R serpentina root for the treatment of hypertension and psychoses; however, the use of Rauwolfia alkaloids in Western medicine did not begin until the Herbs for Cardiovascular Conditions With Severe Adverse Reactions or Notable Drug Interactions* Herbal Medicine Adverse Reaction/Drug Interaction Treatment Natural cardiac glycosides (.20 plant sources) Ventricular tachyarrhythmia, bradycardia, and heart block Digoxin-specific Fab antibody Veratrum (hellebore) Bradycardia, A-V dissociation, hypotension, and (rarely) seizures ECG changes responsive to atropine Crataegus (hawthorn) Potentiates digitalis activity NA Salvia miltiorrhiza (dan-shen) Potentiates warfarin activity NA Aesculus hippocastanum (horse chestnut) Renal and hepatic toxic effects Dialysis to reduce toxic levels *A-V indicates arteriovenous anastomosis; ECG, electrocardiographic; and NA, data not applicable. ARCH INTERN MED/VOL 158, NOV 9, 1998 2226 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Amit Mishra on 04/17/2023
3.
mid1940s.27 Bothstandardizedwhole root preparations of
R serpentina and its reserpine alkaloid are officially monographed in the United States Pharmacopeia.28 A powdered whole rootof200to300mgorallyisequiva- lent to 0.5 mg of reserpine.29 Reserpine was one of the first drugsusedonalargescaletotreatsys- temichypertension.Itactsbyirrevers- ibly blocking the uptake of biogenic amines(norepinephrine,dopamine, andserotonin)inthestoragevesicles of central and peripheral adrenergic neurons, thus leaving the catechol- amines to be destroyed by the intra- neuronalmonoamineoxidaseinthe cytoplasm.Thedepletionofcatechol- aminesaccountsforreserpine’ssym- patholytic and antihypertensive ac- tions.Reserpine’seffectsarelonglast- ing, since recovery of sympathetic function requires synthesis of new storagevesicles,whichtakesdaysto weeks.Reserpinelowersbloodpres- surebydecreasingcardiacoutput,pe- ripheralvascularresistance,heartrate, and renin secretion. With the intro- duction of other antihypertensive drugswithfewercentralnervoussys- tem adverse effects, the use of reser- pine has diminished. The daily oral dose of reserpine should be 0.25 mg orless,andaslittleas0.05mgifgiven withadiuretic.Usingthewholeroot, theusualadultdoseis50to200mg/d administered once daily or in 2 di- vided doses.27-29 Rauwolfia alkaloids are contra- indicated for use in patients with previously demonstrated hypersen- sitivity to these substances, in pa- tients with a history of mental de- pression (especially with suicidal tendencies), in patients with active peptic ulcer disease or ulcerative co- litis, and in patients receiving elec- troconvulsive therapy. The most common adverse effects are seda- tion and inability to concentrate and perform complex tasks. Reserpine maycausementaldepression,some- timesresultinginsuicide,anditsuse mustbediscontinuedatthefirstsign of depression. Reserpine’s sympa- tholytic effect and its enhancement of parasympathetic actions account foritswell-describedadverseeffects: nasal congestion, increased gastric secretion, and mild diarrhea.27-30 Stephania tetrandra is an herb sometimes used in traditional Chi- nese medicine to treat hyperten- sion. Tetrandrine, an alkaloid ex- tract of S tetrandra, has been shown to be a calcium ion channel antago- nist, paralleling the effects of verap- amil. Tetrandrine blocks T and L cal- cium channels, interferes with the bindingofdiltiazemandmethoxyver- apamil at calcium-channel binding sites,andsuppressesaldosteronepro- duction.31,32 Aparenteraldose(15mg/ kg) of tetrandrine in conscious rats decreases mean, systolic, and dias- tolic blood pressures for more than 30 minutes; however, an intrave- nous40-mg/kg dose killed the rats by myocardial depression. In stroke- prone hypertensive rats, an oral dose of25or50mg/kgproducedagradual and sustained hypotensive effect af- ter48hourswithoutaffectingplasma renin activity.33 In addition to its cardiovascular actions, tetrandrine has reported antineoplastic, immu- nosuppressive, and mutagenic effects.31 Tetrandrine is 90% protein- bound with an elimination half-life of 88 minutes, according to dog studies; however, rat studies have shown a sustained hypotensive ef- fect for more than 48 hours after a 25- or 50-mg oral dose. Tetran- drine causes liver necrosis in dogs orally administered 40 mg/kg of tet- randrine 3 times weekly for 2 months, reversible swelling of liver cells with a 20-mg/kg dose, and no observable changes with a 10- mg/kg dose.31 Given the evidence of hepatotoxicity, many more studies are necessary to establish a safe dos- age of tetrandrine in humans. More recently, tetrandrine has been implicated in an outbreak of rapidly progressive renal failure, termed Chinese herb nephropathy. Numerous individuals developed the condition after using a combina- tion of several Chinese herbs as part of a dieting regimen. It has been hy- pothesized that the cause may be at- tributed to misidentification of S tet- randra; nonetheless, questions still remain as to the role of tetrandra in the development of this serious toxic effect.34-37 TherootofLingusticumwallichii is used in traditional Chinese medi- cineasacirculatorystimulant,hypo- tensive drug, and sedative.38 Tetra- methylpyrazine,theactiveconstitu- entextractedfromLwallichii,inhibits plateletaggregationinvitroandlow- ersbloodpressurebyvasodilationin dogs. With its actions independent oftheendothelium,tetramethylpyr- azine’svasodilatoryeffectismediated bycalciumchannelantagonismand nonselective antagonism of a- adrenergicreceptors.Someevidence suggeststhattetramethylpyrazineacts onthepulmonaryvasculature.31 Cur- rently, there is insufficient informa- tiontoevaluatethesafetyandefficacy of this herbal medicinal. Uncaria rhynchophylla is some- times used in traditional Chinese medicine to treat hypertension. Its indole alkaloids, rhynchophylline and hirsutine, are thought to be the active principles of U rhynchophyl- la’s vasodilatory effect. The mecha- nism of U rhynchophylla’s actions is unclear. Some studies point to an al- teration in calcium ion flux in re- sponse to activation, whereas oth- ers point to hirsutine’s inhibition of nicotine-induced dopamine re- lease.31 One in vitro study has shown U rhynchophylla extract relaxes nor- epinephrine-precontracted rat aorta through endothelium-dependent and -independent mechanisms. For the endothelium-dependent com- ponent, U rhynchophylla extract ap- pears to stimulate endothelium- derived relaxing factor and/or nitric oxide release without involving mus- carinic receptors.39 Also, in vitro and in vivo studies have shown that rhynchophylline can inhibit plate- let aggregation and reduce platelet thromboses induced with collagen or adenosine diphosphate plus epi- nephrine.31 Safety and efficacy can- not be evaluated at this time be- cause of a lack of clinical data. Veratrum (hellebore) is a pe- rennial herb grown in many parts of the world. Varieties include Vera- trum viride from Canada and the eastern United States, Veratrum cali- fornicum from the western United States, Veratrum album from Alaska and Europe, and Veratrum japoni- cum from Asia. All Veratrum plants contain poisonous alkaloids known to cause vomiting, bradycardia, and hypotension. Most cases of Vera- trum poisonings are due to mis- identification with other plants. Although once a treatment for hy- pertension, the use of Veratrum al- ARCH INTERN MED/VOL 158, NOV 9, 1998 2227 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Amit Mishra on 04/17/2023
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kaloids has lost
favor owing to a low therapeutic index and unaccept- able toxicity, as well as the intro- duction of safer antihypertensive drug alternatives.40 Veratrum alkaloids enhance nerve and muscle excitability by in- creasing sodium ion conductivity. They act on the posterior wall of the left ventricle and the coronary si- nus baroreceptors, causing reflex hy- potension and bradycardia via the vagus nerve (Bezold-Jarisch re- flex). Nausea and vomiting are sec- ondary to the alkaloids’ actions on the nodose ganglion.40 The diagnosis ofVeratrum tox- icity is established by history, iden- tificationoftheplant,andstrongclini- calsuspicion.Clinicalsymptomsusu- ally occur quickly, often within 30 minutes.41 Treatmentismainlysup- portive and directed at controlling bradycardia and hypotension. Veratrum-inducedbradycardiausu- allyrespondstotreatmentwithatro- pine;however,thebloodpressurere- sponse to atropine is more variable andrequirestheadditionofpressors. Otherelectrocardiographicchanges, suchasatrioventriculardissociation, mayalsobereversiblewithatropine.42 Seizures are a rare complication and maybetreatedwithconventionalan- ticonvulsants.Forpatientswithpre- existingcardiacdisease,theuseofb- agonistsorpacingmaybenecessary. Nauseamaybecontrolledwithphe- nothiazineantiemetics.Recoveryusu- ally occurs within 24 to 48 hours.40 Evodia rutaecarpa (wu-chu- yu) is a Chinese herbal drug that has been used as a treatment for hy- pertension. It contains an active vasorelaxant component called ru- taecarpine that can cause endothe- lium-dependent vasodilation in experimental models.43 ANGINA PECTORIS Crataegus hawthorn, a name encom- passing many Crataegus species (such as Crataegus oxyacantha and Crataegus monogyna in the West and Crataegus pinnatifida in China) has acquired the reputation in modern herbal literature as an important tonic for the cardiovascular system that is particularly useful for an- gina. Crataegus leaves, flowers, and fruits contain a number of biologi- cally active substances, such as oligo- meric procyanins, flavonoids, and catechins. From current studies, Crataegus extract appears to have an- tioxidant properties and can in- hibit the formation of throm- boxane as well.44,45 Also, Crataegus extract antago- nizes the increases in cholesterol, tri- glyceride, and phospholipid levels in low-density lipoprotein (LDL) and very low-density lipoprotein in rats fed a hyperlipidemic diet; thus, it may inhibit the progression of ath- erosclerosis.46 This hypocholester- olemic action may be due to an up- regulation of hepatic LDL receptors resulting in greater influx of plasma cholesterol into the liver. Cratae- gus also prevents cholesterol accu- mulation in the liver by enhancing cholesterol degradation to bile ac- ids, as well as suppressing choles- terol biosynthesis.47 Accordingtoanotherstudy,Cra- taegus extract, in high concentra- tions, has a cardioprotective effect on ischemic-reperfused hearts without causinganincreaseincoronaryblood flow.48 On the other hand, oral and parenteral administration of oligo- meric procyanins of Crataegus has been shown to lead to an increase in coronary blood flow in both cats and dogs.49,50 Double-blind clinical trials havedemonstratedsimultaneouscar- diotropic and vasodilatory actions of Crataegus.51 In essence, Crataegus in- creasescoronaryperfusion,hasamild hypotensive effect, antagonizes ath- erogenesis, and has positive inotro- pic and negative chronotropic ac- tions.46,52 In a recent multicenter, placebo-controlled, double-blind study, an extract of Crataegus was shown to clearly improve the car- diac performance of patients with New York Heart Association class II heart failure. In this study, the pri- mary parameter analyzed was the heart rate product (systolic blood pressure 3 heart rate).53 Recent stud- ies have suggested that the mecha- nism of cardiac action for Crataegus species may be due to the inhibition of the 39, 59-cyclic adenosine mono- phosphate phosphodiesterase.54 Hawthorn is relatively devoid of adverse effects. In fact, in com- parison with other inotropic drugs such as epinephrine, amrinone, mil- rinone, and digoxin, Crataegus has a potentially reduced arrhythmo- genic risk because of its ability to prolong the effective refractory pe- riod, while the other drugs men- tioned previously all shorten this pa- rameter.55,56 Also, it should be noted that concomitant use of hawthorn with digitalis can markedly en- hance the activity of digitalis.5,57 Un- doubtedly, more studies are needed to show that hawthorn can be used safely and effectively. Because of its resemblance to Panaxginseng(Asianginseng),Panax notoginseng has acquired the com- mon name of pseudoginseng, espe- cially since it is often an adulterant of P ginseng preparations. In tradi- tional Chinese medicine, the root of P notoginsengisusedforanalgesiaand hemostasis. It is also often used in the treatmentof patients withanginaand coronary artery disease.38 Panax no- toginseng has been described as a cal- cium ion channel antagonist in vas- cular tissue. More specifically, its pharmacological action may be as a novel and selective calcium ion an- tagonistthatdoesnotinteractwiththe L-typecalciumionchannelbutrather may interact with the receptor- operated calcium ion channel.58 Although clinical trials are lack- ing, in vitro studies using P notogin- seng suggest possible cardiovascular effects. One study that used purified notoginsenoside R1, extracted from P notoginseng, on human left umbili- cal vein endothelial cells showed a dose- and time-dependent synthesis of tissue-type plasminogen activat- ing factor without affecting the syn- thesis of plasminogen activating in- hibitor. Thus, fibrinolytic parameters were enhanced.59 Another study sug- geststhatPnotoginsengsaponinsmay inhibit atherogenesis by interfering with the proliferation of smooth muscle cells.60 In vitro and in vivo studies using rats and rabbits dem- onstrate that P notoginseng may be useful as an antianginal drug, since it dilates coronary arteries in all con- centrations. The role of P notogin- seng in the treatment of hyperten- sionislesscertain,sincePnotoginseng causes vasodilation or vasoconstric- tion depending on the concentra- tion and target vessel.61 The results of these in vitro and in vivo studies areencouraging;however,clinicaltri- als will be necessary to make a more ARCH INTERN MED/VOL 158, NOV 9, 1998 2228 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Amit Mishra on 04/17/2023
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informed decision regarding
the use of P notoginseng. Salvia miltiorrhiza (dan- shen), a relative of the Western sage Salvia officinalis, is native to China. In traditional Chinese medicine, the root of S miltiorrhiza is used as a cir- culatory stimulant, sedative, and cooling drug.38 Salvia miltiorrhiza may be useful as an antianginal drug because it has been shown to dilate coronary arteries in all concentra- tions, similar to P notoginseng. Also, S miltiorrhiza has variable action on other vessels depending on its con- centration, so it may not be as help- ful in treating hypertension.61 In vitro, S miltiorrhiza, in a dose- dependent fashion, inhibits plate- let aggregation and serotonin re- lease induced by either adenosine diphosphate or epinephrine, which is thought to be mediated by an in- crease in platelet cyclic adenosine monophosphate caused by S milti- orrhiza’s inhibition of cyclic aden- osine monophosphate phosphodi- esterase.62 Salvia miltiorrhiza appears to have a protective action on ische- mic myocardium, enhancing the recovery of contractile force on reoxygenation.63 More recently, S miltiorrhiza has been shown to pro- tect myocardial mitochondrial mem- branesfromischemia-reperfusionin- jury and lipid peroxidation because of its free radical–scavenging ef- fects.64 Qualitatively and quantita- tively, a decoction of S miltiorrhiza was as efficacious as the more ex- pensive isolated tanshinones.59 Clinical trials will be neces- sary to evaluate the safety and effi- cacy of S miltiorrhiza. Of note, it has been observed clinically that when S miltiorrhiza and warfarin sodium are coadministered, there is an in- creased incidence in warfarin- related adverse effects; in rats S milti- orrhiza was shown to increase the plasma concentrations of warfarin as well as the prothrombin time.65 ATHEROSCLEROSIS In addition to its use in the culi- nary arts, garlic (Allium sativum) has been valued for centuries for its me- dicinal properties. Garlic is one of the herbal medicines that has been examined more closely by the sci- entific community. In recent de- cades, research has focused on garlic’s use in preventing atheroscle- rosis. Garlic, like many of the other herbal medicines discussed previ- ously, has demonstrated multiple beneficial cardiovascular effects. A number of studies have demon- strated these effects that include low- ering blood pressure, inhibiting platelet aggregation, enhancing fi- brinolytic activity, reducing serum cholesterol and triglyceride levels, and protecting the elastic proper- ties of the aorta. Consumption of large quanti- ties of fresh garlic (0.25 to 1.0 g/kg or about 5-20 average sized 4-g cloves in a person weighing 78.7 kg) has been shown to produce the ben- eficial effects mentioned earlier.66 In support of this, a recent double- blind cross-over study was con- ducted on moderately hypercholes- terolemic men that compared the effects of 7.2 g of aged garlic ex- tract with placebo on blood lipid lev- els. This study found that there was a maximal reduction of 6.1% in to- tal serum cholesterol levels and 4.6% in LDL cholesterol levels with gar- lic compared with placebo.67 However, despite positive evi- dence from numerous trials, some investigators have been hesitant to outright endorse the routine use of garlic for cardiovascular disease be- cause many of the published stud- ies had methodological shortcom- ings,6 6 , 6 8 - 7 2 perhaps because constituent trials were small, lack- ing statistical power. Also, inappro- priate methods of randomization, lack of dietary run-in period, short duration, or failure to undertake in- tention-to-treat analysis may ex- plain the cautious acceptance of pre- vious meta-analyses.73 In fact, one recent study found no demon- strable effect of garlic ingestion on lipid and lipoprotein levels. This study used a cross-over design pro- tected by a washout period to re- duce between-subject variability as well as close assessment and report- ing of dietary behavior, which had been lacking in previous trials.74 An- other study found no effect of gar- lic on cholesterol absorption, cho- lesterol synthesis, or cholesterol metabolism.71 As is evident, the pre- cise extent of garlic’s impact on ath- erosclerosis remains controversial; larger, more rigorously designed tri- als may be necessary to better de- termine its utility in preventing car- diovascular disease. Garlic has also been studied in hypertensive patients as a blood pressure–lowering agent. Similar to its lipid effects, no conclusive stud- ies have been conducted and many methodological shortcomings exist in study designs. The results of one meta-analysis that considered 8 dif- ferent trials suggest some clinical use for patients with mild hyperten- sion, but there is insufficient evi- dence to recommend its use as rou- tine clinical therapy.68 Garlic has also been shown to possess antiplatelet activity. In the past, this action was mostly documented in vitro.75 A new study examined the effect of the con- sumption of a fresh clove of garlic on platelet thromboxane produc- tion and showed that after 26 weeks, serum thromboxane levels were re- duced about 80%.76 This may prove to be beneficial in the prevention of thrombosis in the future. Recently, the effect of long-term garlic intake on the elastic properties of the aorta was also studied. Participants in the trial (limited to those aged 50-80 years) consumed 300 mg/d of stan- dardizedgarlicpowderformorethan 2 years. The results showed that the pulse-wave velocity and standard- ized elastic vascular resistance of the aorta were lower in the garlic group than in the control group. Conse- quently, long-term garlic powder in- take may have a protective effect on the elastic properties of the aorta re- lated to aging.77 In these ways, gar- lic has shown numerous beneficial cardiovascular effects that need to be investigated further to determine its therapeutic utility. Intact cells of garlic bulbs in- clude an odorless, sulfur-contain- ing amino acid known as allinin. When garlic is crushed, allinin comes into contact with allinase, which converts allinin to allicin. Al- licin has potent antibacterial prop- erties, but it is also highly odorifer- ous and unstable. Ajoenes, self- condensation products of allicin, appear to be responsible for garlic’s antithrombotic activity. Most au- thorities now agree that allicin and its derivatives are the active con- stituents of garlic’s physiological ac- ARCH INTERN MED/VOL 158, NOV 9, 1998 2229 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Amit Mishra on 04/17/2023
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tivity. Fresh garlic
releases allicin in the mouth during the chewing pro- cess. Dried garlic preparations lack allicin but contain allinin and allin- ase. Since allinase is inactivated in the stomach, dried garlic prepara- tions should be coated with enteric so that they pass through the stom- ach into the small intestine where al- linin can be enzymatically con- verted to allicin. Few commercial garlic preparations are standard- ized for their allicin yield based on allinin content, hence making their effectiveness less certain.5 How- ever, one double-blind, placebo- controlled study involving 261 pa- tients for 4 months using one 800-mg tablet of garlic powder daily, standardized to 1.3% allinin con- tent, demonstrated significant re- ductions in total cholesterol (12%) and triglyceride levels (17%).78 Aside from a garlic odor on the breathandbody,moderategarliccon- sumption causes few adverse ef- fects. However, consumption in ex- cess of 5 cloves daily may result in heartburn, flatulence, and other gas- trointestinal disturbances. Some people have reported allergic reac- tions to garlic, most commonly al- lergic contact dermatitis. Patch test- ing with 1% diallyl disulfide is recommended when garlic allergy is suspected.79 Becauseofitsantithrom- botic activity, garlic should be used withcautioninpeopletakingoralan- ticoagulants concomitantly.5,80 The resin of Commiphora mukul (gugulipid), a small, thorny tree na- tive to India, has long been used in Ayurvedic medicine to treat lipid dis- orders. The primary mechanism of action of gugulipid is through an in- crease in the uptake and metabo- lism of LDL cholesterol by the liver.81 In a double-blind, cross-over study completed in 125 patients taking gu- gulipid compared with 108 patients taking clofibrate, the average de- crease in serum cholesterol and tri- glyceride levels was 11% and 16.8%, respectively, with gugulipid com- pared with 10% and 21.6%, respec- tively, with clofibrate. In general, hy- percholesterolemic patients responded more favorably to gugu- lipid therapy than hypertriglyceride- mic patients.82 Moreover, it was shown in another randomized, double-blind trial that C mukul also decreased LDL cholesterol levels by 12.5%andthetotalcholesterol–high- density lipoprotein cholesterol ratio by11.1%,whereasthelevelswereun- changed in the placebo group.83 Besidesbeingpotentiallyaseffec- tive in lowering blood lipid levels as modernhyperlipidemicdrugs,gugu- lipid may even be safer. In the trial mentionedpreviously,compliancewas greater than 96%, with only the ad- verse effects of headache, mild nau- sea,andhiccupsnoted.83 However,it has been shown that gugulipid may affectthebioavailabilityofothercar- diovasculardrugs,namely,proprano- lol hydrochloride and diltiazem hy- drochloride.Gugulipidsignificantly reduced the peak plasma concentra- tionandareaunderthecurveofboth thesedrugs,whichmayleadtodimin- ishedefficacyornonresponsiveness.84 Undoubtedly, gugulipid is a natural lipid-loweringdrugwithpotentialfor therapeutic use, but rigorous, larger clinicaltrialswillbenecessarytofur- therevaluateitssafetyandefficacybe- fore it can be endorsed as an alterna- tive therapy for hyperlipidemia and prevention of atherosclerosis. Maharishi amrit kalash-4 and Maharishi amrit kalash-5 are 2 com- plex herbal mixtures with signifi- cant antioxidant properties that have been shown to inhibit LDL oxida- tion in patients with hyperlipid- emia. In experimental studies, the herbalmixtureshavealsobeenshown to inhibit enzymatic- and nonenzy- matic-induced microsomal lipid per- oxidation and platelet aggregation.85 CEREBRAL AND PERIPHERAL VASCULAR DISEASE Having existed for more than 200 million years, Ginkgo biloba (maid- enhair tree) was apparently saved from extinction by human interven- tion, surviving in Far Eastern temple gardens while disappearing for cen- turies in the West. It was reintro- duced to Europe in 1730 and be- came a favorite ornamental tree.38,86 Although the root and kernels of G biloba have long been used in tradi- tional Chinese medicine, the tree gained attention in the West dur- ing the 20th century for its medici- nal value after a concentrated ex- tract of G biloba leaves was developed in the 1960s. At least 2 groups of substances within G bi- loba extract (GBE) demonstrate ben- eficial pharmacological actions. The flavonoids reduce capillary perme- ability as well as fragility and serve as free radical scavengers. The ter- penes (ie, ginkgolides) inhibit plate- let-activating factor, decrease vas- cular resistance, and improve circulatory flow without apprecia- bly affecting blood pressure.57,87 Con- tinuing research appears to sup- port the primary use of GBE for treating cerebral insufficiency and its secondary effects on vertigo, tinni- tus, memory, and mood; also, GBE appears to be useful for treating pe- ripheral vascular disease, includ- ing diabetic retinopathy and inter- mittent claudication.5,57,87-91 In a randomized, placebo- controlled, double-blind study, EGb 761, which is a standardized ex- tract of G biloba with respect to its flavonol glycoside and terpene lac- tone content, was shown to signifi- cantly decrease the areas of ische- mia as measured by transcutaneous partial pressure of oxygen during ex- ercise. Because of its rapid anti- ischemic action, EGb 761 may be valuable in the treatment of inter- mittent claudication and periph- eral artery disease in general.92 Also, studies have been exam- ining the cardioprotective efficacy of EGb 761 in regard to its anti–free radical action in myocardial isch- emia–reperfusion injury. In vitro studies with animal models have shown that this compound may ex- ert such an effect.93,94 A clinical study of 15 patients undergoing coronary bypass surgery demonstrated that oral EGb 761 therapy may limit free radical–induced oxidative stress oc- curring in the systemic circulation and at the level of the myocardium during these operations.95 It re- mains to be studied whether ex- tracts of G biloba may be used as pharmacological adjuvants to limit tissue damage and metabolic alter- ations following coronary bypass surgery, coronary angioplasty for acute myocardial infarctions, or even in managing coronary thrombosis. Although approved as a drug in Europe, Ginkgo is not approved in the United States and is instead marketed as a food supplement, usually supplied as 40-mg tablets ARCH INTERN MED/VOL 158, NOV 9, 1998 2230 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Amit Mishra on 04/17/2023
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of extract. Since
most of the inves- tigations examining the efficacy of GBEs used preparations such as EGb 761 or LI 1370, the bio- equivalence of other GBE prod- ucts has not been established. The recommended dosage in Europe is one 40-mg tablet taken 3 times daily with meals (120 mg/d).5,87 Adverse effects due to GBE are rare but can include gastrointesti- nal disturbances, headache, and allergic skin rash.5,87 Known mostly as a culinary spice and flavoring agent, Rosmari- nus officinalis (rosemary) is listed in many herbal sources as a tonic and all-around stimulant. Tradition- ally, rosemary leaves are said to en- hance circulation, aid digestion, el- evate mood, and boost energy. When applied externally, the volatile oils are supposedly useful for arthritic conditions and baldness.5 Although research on rose- mary is scant, some studies have fo- cused on antioxidant effects of di- terpenoids, especially carnosic acid and carnosol, isolated from rose- mary leaves. In addition to having antineoplastic effects, antioxidants in rosemary have been credited with stabilizing erythrocyte membranes and inhibiting superoxide gener- ation and lipid peroxidation.96,97 Essential oils of rosemary have dem- onstrated antimicrobial, hypergly- cemic, and insulin-inhibiting prop- erties.98,99 Rosemary leaves contain high amounts of salicylates, and its flavonoid pigment diosmin is re- ported to decrease capillary perme- ability and fragility.57,100,101 Despite the conclusions de- rived from in vitro and animal stud- ies, the therapeutic use of rosemary for cardiovascular disorders re- mains questionable, because few, if any, clinical trials have been con- ducted using rosemary. Because of the lack of studies, no conclusions can be reached regarding the use of the antioxidants of rosemary in in- hibiting atherosclerosis. Although external application may cause cu- taneous vasodilation from the coun- terirritant properties of rosemary’s essential oils, there is no evidence to support any prolonged improve- ment in peripheral circulation.5 While rosemary does have some car- minative properties, it may also cause gastrointestinal and kidney disturbances in large doses.5,101 Un- til more studies are done, rosemary should probably be limited to its use as a culinary spice and flavoring agent rather than as a medicine. VENOUS INSUFFICIENCY The seeds of horse chestnut, Aescu- lus hippocastanum, have long been used in Europe to treat venous dis- orders such as varicose veins. The sa- ponin glycoside aescin from horse chestnut extract (HCE) inhibits the activityoflysosomalenzymesthought to contribute to varicose veins by weakening vessel walls and increas- ing permeability, which result in di- lated veins and edema.5 In fact, re- cent research has shown that A hippocastanum inhibits only against hyaluronidase but not elastase, and thisactivityislinkedmainlytothesa- ponin escin.102 In animal studies, HCE,inadose-dependentfashion,in- creasesvenoustone,venousflow,and lymphatic flow. It also antagonizes capillary hyperpermeability in- duced by histamine, serotonin, or chloroform. This extract has been shown to decrease edema forma- tion of lymphatic and inflamma- tory origin. Horse chestnut extract has antiexudative properties, sup- pressing experimentally induced pleurisyandperitonitisbyinhibiting plasma extravasation and leukocyte emigration, and its dose-dependent antioxidantpropertiescaninhibitin vitro lipid peroxidation.103,104 Ran- domized, double-blind, placebo- controlled trials with HCE show are eduction in edema, measured using plethysmography.105,106 In another recent random- ized, placebo-controlled study, the efficacy and safety of class 2 com- pression stockings and dried HCE were compared. Both HCE and the compression stockings decreased lower leg edema after 12 weeks of therapy; the results showed an av- erage 43.8-mL reduction with HCE and 46.7-mL with compression stockings, while the placebo group showed an increase of 9.8 mL. Both HCE and compression therapy were well tolerated, with no serious ad- verse effects. This study may indi- cate that both of these modalities are reasonable alternatives for the effec- tive treatment of patients with chronicvenousinsufficiency.107 Also, HCE has been shown to markedly improve other symptoms associ- ated with chronic venous insuffi- ciency, such as pain, tiredness, itch- ing, and tension in the swollen leg, in a case-observation study.108 Aside from effects on venous insuffi- ciency, prophylactic use of HCE has been thought to decrease the inci- dence of thromboembolic compli- cations of gynecological surgery. However, since this issue is still con- troversial,109 this does not appear to be the case.109 StandardizedHCEispreparedas anaqueousalcoholextractof16%to 21% of triterpene glycosides, calcu- lated as aescin. The usual initial dos- ageis90to150mg/dofaescin,which may be reduced to 35 to 70 mg/d if clinicalbenefitisseen.5 Standardized HCEpreparationsarenotavailablein the United States, but nonstandard- ized products may be available. Some manufacturers promote theuseoftopicalpreparationsofHCE for treatment of varicose veins as well ashemorrhoids;however,atleastone study has demonstrated poor aescin distributionatsitesotherthantheskin andmuscletissuesunderlyingtheap- plication site.110 Moreover, the in- volvement of arterioles and veins in the pathophysiology of hemor- rhoidsmakestheeffectivenessofHCE doubtful, since HCE has no known effects on the arterial circulation. For now,researchstudieshaveyettocon- firm any clinical effectiveness of topi- cal HCE preparations. Although adverse effects are un- common, HCE may cause gastroin- testinal irritation. Parenteral aescin has produced isolated cases of ana- phylactic reactions, as well as he- patic and renal toxic effects.5,111-113 In the event of toxicity, aescin can be eliminated via dialysis, with elimina- tion dependent on protein-bind- ing.114 Horse chestnut extract is also one of the components of veno- curan, a drug marketed as a treat- ment for venous disorders. In 1975, venocuran was determined to cause a pseudolupus syndrome character- ized by recurrent fever, myalgia, ar- thralgia, pleuritis, pulmonary infil- trates, pericarditis, myocarditis, and mitochondrial antibodies in the ab- sence of nuclear antibodies after pro- ARCH INTERN MED/VOL 158, NOV 9, 1998 2231 ©1998 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by Amit Mishra on 04/17/2023
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longedtreatment.115,116 Venocuranhas since been withdrawn
from the mar- ket; however, the nature of its patho- physiologic action is still unknown. Like A hippocastanum, Ruscus aculeatus (butcher’s broom) is also known for its use in treating ve- nous insufficiency. Ruscus aculea- tus is a short evergreen shrub found commonly in the Mediterranean re- gion. Two steroidal saponins, rus- cogenin and neurogenin, extracted from the rhizomes of R aculeatus are thought to be its active compo- nents.101 In vivo studies on hamster cheek pouch reveal that topical Rus- cus extract dose dependently antago- nizes histamine-induced increases in vascular permeability.117 More- over, topical Ruscus extract causes dose-dependent constriction of ven- ules without appreciably affecting ar- terioles.118 Topical Ruscus extract’s vascular effects are also tempera- ture dependent and appear to counter the sympathetic nervous system’s temperature-sensitive vas- cular regulation: venules dilate at a lower temperature (25°C), con- strict at near physiologic tempera- tures (36.5°C), and further con- strict at higher temperatures (40°C); arterioles dilate at 25°C, are unaf- fected at 36.5°C, and remain unaf- fected or constrict at 40°C, depend- ingonRuscusconcentration.119 Based on the influence of prazosin, diltia- zem, and rauwolscine, the periph- eral vascular effects of Ruscus ex- tract appear to be selectively mediated by effects on calcium chan- nels and a1-adrenergic receptors with less activity at a2-adrenergic re- ceptors.117,118 Also, R aculeatus ex- hibits strong antielastase activity and has little effect on hyaluronidase in direct contrast to A hippocastanum. This activity may contribute to their efficacy in the treatment of venous insufficiency since these enzyme sys- tems are involved in the turnover of the main components of the peri- vascular amorphous substance.102 Several small clinical trials us- ing topical Ruscus extract support its role in treating venous insuffi- ciency. One randomized, double- blind, placebo-controlled trial in- volving 18 volunteers showed a beneficial decrease in femoral vein diameter (median decrease, 1.25 mm) using duplex B-scan ultrason- ography. The decrease was mea- sured 2.5 hours after applying 4 to 6 g of a cream containing 64 to 96 mg of Ruscus extract.120 In another small trial (N = 18) it was shown that topical Ruscus extract may be help- ful in reducing venous dilation dur- ing pregnancy.121 Oral agents may be useful as topical drugs for venous in- sufficiency, although the evidence is less convincing.122 Although capsule, tablet, oint- ment, and suppository (for hemor- rhoids)preparationsofRuscusextract areavailableinEurope,onlycapsules are available in the United States. Thesecapsulescontain75mgofRus- cusextractand2mgofrosemaryoil.101 Asidefromoccasionalnauseaandgas- tritis,adverseeffectsfromusing Racu- leatushaverarelybeenreported,even in high doses.57 Nevertheless, one should be wary of any drug that has notbeenthoroughlytested.Although thereisampleevidencetosupportthe pharmacologicalactivityofRaculea- tus, there is still a relative deficiency of clinical data to establish its actual safety and efficacy. Until more stud- ies are completed, no recommenda- tionsregardingdosagecanbeoffered. ARRHYTHMIA In traditional Chinese medicine, ar- rhythmias are categorized by the characteristic symptoms of palpita- tions and abnormal pulse. Numer- ous Chinese herbal medicines are identified to have antiarrhythmic ef- fects, such as xin bao, ci zhu wan, bu xin dan, and several others.123 However, few clinical trials have been conducted to study their ef- fects and safety. Xin bao is one agent that has begun to be examined. The mechanism of action of xin bao is thought to be through its stimula- tion and increased excitability of the sinuatrial node.124 In one observa- tional study, the effects of xin bao were documented in 87 patients with sick sinus syndrome. Xin bao was administered orally 2 to 3 times per day for 2 months. Patients with ma- jor symptoms of sick sinus syn- drome, which included dizziness, palpitations, and chest pressure, im- proved significantly after treat- ment.124 No serious adverse effects were noted. This study suggests a possible role of xin bao in the treat- ment of sick sinus syndrome. How- ever, more scientific research on xin bao and other antiarrhythmic Chi- nese herbs mentioned previously are necessary before any recommenda- tions can be made for their routine use in patients with sick sinus syn- drome or other arrhythmias. COMMENT With the high prevalence of herbal medicine use in the United States, health practitioners should remem- bertoinquireaboutsuchhealthprac- ticeswhentakingclinicalhistoriesand remain informed of the beneficial or harmful effects of these treatments. Continuing research is necessary to elucidate the pharmacological activi- ties of the many cardiopotent herbal medicines and to stimulate future pharmaceuticaldevelopmentofthera- peutically beneficial herbal drugs. However, such research is currently lacking in the United States and re- quires more support from govern- ment agencies before the full poten- tial of these types of treatments can be determined. At the same time, le- galsurveillanceofherbalmedicineuse with low safety margins should be in- stituted for the sake of public health; this is especially imperative for those herbs with adverse cardiovascular re- actions125 and drug interactions. As more information becomes available regarding the safety and efficacy of herbal medicines through new clini- cal trials, research-supported claims mayonedaybecomeavailabletocon- sumers and physicians in a manner similar to the allopathic medicines. Accepted for publication July 23, 1998. Reprints: William H. 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