PHILADELPHIA—Holistic medicine is often considered more preventive than therapeutic, especially when it comes to cardiovascular disease. But even patients with advanced heart disease can benefit greatly from multimodal natural therapeutics.
“Even an interventional cardiologist like me can practice holistically,” said Howard Sacher, DO, at a conference on holistic primary care sponsored by the Philadelphia College of Osteopathic Medicine and the American Board of Holistic Medicine. “I put in pacemakers and defibrillators, and I have a lot of patients at the ends of their lives. And yet I still feel I can make a difference in their lives, their health, and their longevity with holistic approaches.”
Dr. Sacher, Chief of Cardiology, New York College of Osteopathic Medicine, believes many cardiologists are coming around to a more comprehensive, non-drug, non-invasive orientation even for patients with advanced disease. “We’re beginning to understand what is really happening, and validating and vindicating a lot of so-called ‘alternative’ approaches.” Cardiology is nothing if not pragmatic, and seeing is definitely believing. “When my colleagues see that my patients are doing a bit better and living longer, they start to realize that maybe some of these things really do make sense.”
Dr. Sacher offered his “Top Ten” natural strategies for treating established CVD.
No. 10: Coenzyme Q10: “As soon as they’re diagnosed with CVD, I put ’em on CoQ10,” Dr. Sacher said. This compound is necessary for mitochondrial energy production, and is widely used by cardiologists in Japan. “They inject patients intravenously when they come out of bypass surgery, to increase myocardial contractility.” Though he has not used IV CoQ10, he has long experience giving it orally. “We looked at 30 patients with ejection fractions under 25%, and gave them 120 mg CoQ10, twice daily. The ejection fractions improved by 10–15%.” CoQ10 is also a potent antioxidant. The optimal dose is 100–120 mg, twice daily.
No. 9: Vitamin C: On a population basis, increased vitamin C intake correlates with reduced CAD mortality. Controlled studies have shown that high doses of vitamin C induce vascular smooth muscle relaxation by increasing endothelial nitric oxide production. Current recommendations are for 250–500 mg daily, but Dr. Sacher believes this is low. “I give at least 1,000 mg, twice daily. Vitamin C is essentially harmless, so it is better to err on the side of more.”
No. 8: Vitamin E: Though studies are conflicting as to whether vitamin E alone can reduce mortality, it is clearly an antioxidant and reduces platelet aggregation, so there’s a strong rationale for using it. The CHAOS study showed that 400–800 IU daily reduced the relative risk of cardiac events by 50% compared with placebo. However, the HOPE trial found no difference in cardiac events or cardiac deaths after five years of daily supplementation with 400 IU.
According to Dr. Sacher, the HOPE dose is too low. Many patients need 800 IU daily, and it is safe up to 1,000. There is still debate over the “optimal” form of vitamin E. Dr. Sacher prefers mixed tocopherols from natural sources, and chooses products that include tocotrienols. (See Related Article, Page 2.)
No. 7: Folic Acid & B Vitamins: Approximately 10–20% of the total risk for CAD can be attributed to elevated homocysteine, which is widely prevalent in the US. Homocysteine causes direct endothelial damage, promotes LDL oxidation, increases thromboxane production, and generates abnormalities in platelet function. In short, high homocysteine is bad news. Fortunately, it is easily reversible with 1–2 mg per day of folic acid and 1 mg of vitamin B12.
Reducing homocysteine has measurable effects. In one study, folate and B12 after angioplasty reduced restenosis by 25%. The recognized threshold for homocysteine elevation is 15–16 micromoles per liter. That’s probably too high, said Dr. Sacher. “I think the threshold should be 6–7. Even 10 is too high.”
No. 6: Omega-3 Fatty Acids: Two large-scale trials, DART and GISSI, show regular consumption of omega-3s from fish or fish-oil translates directly into reduced CV mortality. Even patients already on several heart medications will benefit from omega-3s. The GISSI data suggest that daily supplementation can save 20 lives per 100 post-MI patients, a larger therapeutic effect than that of HMG-CoA reductase inhibitors (statins).
“You can reduce arrhythmias with omega-3’s,” said Dr. Sacher. “If you reduce arachidonic acid and increase eicosapentaenoic acid (EPA), you will benefit your patients, and omega-3s are a great way to do this.” For CV patients, 3–4 grams daily is optimal. Women can take either flaxseed or fish oil, but the latter is preferable for men since flax oil may promote prostate cancer.
No. 5: The Mediterranean Diet: The case for a Mediterranean-style diet is practically ironclad. The Lyon Diet Heart Study was stopped after 27 months, owing to a 70% risk reduction among patients following the diet. In a nutshell, it involves increased consumption of olive oil, cold water fish, low glycemic index carbohydrates, ample fruit, vegetables, garlic, onions and nuts, and small amounts of red wine. Roughly, 20–25% of total dietary intake should be protein, 30–35% “healthy” fats, and 45–50% carbohydrates. Dr. Sacher also had high praise for the Ornish diet, which is nearly vegetarian and even more vigorous than the Mediterranean style diet.
No. 4: Recognize and Treat Depression: Depression after MI is a major predictor of 1-year mortality. Compared with non-depressed people, those with minor depression have a relative risk of 1.6. For major depression, it increases to 3.0. Roughly 50% of all post-MI patients have some form of depression, and 20% have major depression. “Immediately after MI, people feel glad they survived. A few months later, depression starts to creep in.”
The mechanisms by which depression contributes to mortality are unknown. But the clinical message is clear: follow patients closely for many months after MI, watch for depression, and treat it by any means necessary. Psychotherapy, mind–body interventions, nutrition and drug therapies all have their place.
No. 3: Mind–Body Training: Stress, anxiety and anger are all important emotional factors contributing to increased CVD risk. Any type of practice that helps reduce sympathetic nervous system drive, cortisol and catecholamine levels will be beneficial. Various forms of biofeedback, including heart rate variability monitoring, contemplative practices such as mindfulness meditation, yoga, stress management and self hypnosis are vital adjuncts.
No. 2: Develop Social Support: People who feel connected to a supportive, loving and nurturing community have lower morbidity and mortality rates. This holds for many different disorders, not just CVD. In short, love and loving engagement with others promotes health. Encourage patients to get involved with friends, family, and community in whatever ways feel comfortable to them.
No. 1: Nurture the Healing Relationship: Don’t underestimate your own impact as a physician. “A good relationship with your patients will keep them alive, even with ejection fractions of 10–15%,” said Dr. Sacher. “Once your patients know you care, and you really will go through the illness with them, they will start to listen to you. And you, as a doctor, will get a tremendous amount back from them.” In order to truly “be there” for your patients and provide a healthy role model, you must be committed to your own healing, health, and growth.
Dr. Sacher stressed that these “top ten” recommendations are on top of getting patients to exercise and lose weight. There are other options that are equally valid. Niacin supplementation, 250 mg twice daily, is particularly valuable in reducing lipoprotein (a) levels and shifting LDL to HDL, especially in diabetic patients. L-arginine has antioxidant effects and promotes vascular nitric oxide production.
