Paul Saunders, ND, PhD.

TORONTO—A number of common herbs have cardiovascular benefits, and optimal use of these botanicals to prevent or reverse cardiovascular disease depends on knowing which are best for short term use, and which are appropriate for long term maintenance therapy, said Paul Saunders, ND, PhD, at the annual meeting of the American Holistic Medical Association.

Dr. Saunders is a clinical instructor at the Canadian College of Naturopathic Medicine, and author of the widely hailed book, Herbs: Every Day Reference for Health Professionals, published by the Canadian Pharmacy Association (www.cdnpharm.ca or 1-613-523-7877). He provided practical tips for getting the most out of botanical approaches to treating dyslipidemia, hypertension, and other cardiovascular risk factors.

Photos courtesy of William Coupon.

Garlic (Allium sativum): There is ample evidence that if taken consistently at high enough doses, garlic can reduce total cholesterol, LDL, VLDL, and triglyceride levels, while also reducing platelet aggregation and increasing glutathione levels—all of which are associated with a lower CVD risk profile.

Dr. Saunders also noted that there is preliminary evidence from animal studies that daily intake of garlic can prevent the complexing of LDL and calcium, thus reducing atherosclerotic plaque buildup. This correlates with clinical observations in women that at high doses, garlic supplementation increases carotid and aortic elasticity.

Obtaining benefits from garlic requires consistent, long-term use—at least 6 months—at an allicin dose of 900–1,200 mg daily. Garlic loving patients can get there if they eat roughly 4 grams per day (the equivalent of 2 cloves), but for many, supplements are the way to go. Standardized liquid extracts should be dosed in the range of 2–5 mL per day, depending on their allicin concentration.

Macerated garlic in capsule or pill form should be dosed according to the package instructions. Dr. Saunders said the bulk of research with standardized garlic supplements has been done on two products: Kwai® and Kyolic®.

Generally, garlic is very safe for long-term daily use. However, it can increase INRs, so patients on coumadin or other anticoagulants need to be careful. It can also interfere with uptake of iodine if the two are taken simultaneously. It may not be the best option for patients with thyroid deficiencies.

Despite the marketing claims, Dr. Saunders insisted that if a garlic preparation doesn’t stink, it probably doesn’t work. “If it is deodorized and doesn’t have any taste, it is probably not going to be too therapeutic.”

Capsicum (Capsicum annuum): Capsicum, aka Cayenne, is one of the strongest, least expensive short-term vasodilators in the plant kingdom. It is also an anticoagulant, and alters release of substance P, causing an overall reduction in sensation of pain. Like garlic, it can be used everyday, provided the patient is not at increased risk for bleeding. However, a little bit goes a long way. “A sprinkle on food is all you need.”

Patients on ACE inhibitors, especially first-generation ACE inhibitors, should probably avoid cayenne, as it tends to exacerbate the cough typically associated with these drugs. Because it is a vasodilator, it can increase absorption of many drugs, which can be good or bad, depending on other metabolic factors and the desired therapeutic outcome. The point is to be aware of this phenomenon.

Dr. Saunders added, however, that there are no data to support claims that use of cayenne increases the risk of bleeding in normal individuals.

Guggul (Commiphora mukul): Guggul, a resin in the myrrh family that is a mainstay in Indian Ayurvedic medicine for controlling body weight, contains a host of heart friendly compounds. It contains steroid compounds called guggulsterones, which can reduce triglyceride synthesis while also increasing HDL. Dr. Saunders noted that it is particularly useful in patients who are hypothyroid.

Compounds within guggul modulate specific enzyme systems within the liver that are different from the HMG coA reductase system that is blocked by statin drugs. They inhibit cholesterol production through different pathways than the statin drugs. Guggul supplementation also appears to reduce inflammation within the myocardium after infarction, making it a good option for post-infarction therapy.

Guggul is pretty fast-acting: some patients experience significant drops in cholesterol within two weeks. Obtaining therapeutic benefit from guggul depends on dosing high enough, said Dr. Saunders. The typical starting dose is in the range of 500 mg/d for capsulized powdered guggul resin. In published trials showing total cholesterol reductions of 25% and triglyceride drops of 30%, the doses were as high as 15 g per day. “A lot of times, people don’t give sufficient quantities.”

Hawthorn (Crataegus monogyna): “I see a lot of hypertension, and Hawthorn is the first thing I think about,” said Dr. Saunders, who uses the herb in combination with magnesium supplements. Standardized extracts of Hawthorn berries, leaves or flowers have been well studied in Europe. The German Commission E granted a positive assessment to flower and leaf preparations, and many European cardiologists use these routinely. There is a 2,300-patient study underway assessing the efficacy of moderate doses of Hawthorn (450 mg per day) in combination with magnesium.

In addition to lowering blood pressure, this herb can also reduce hyperlipidemia by stimulating metabolic pathways involved in cholesterol degradation. While the exact antihypertensive mechanism has not been identified, Hawthorn is a vasodilator. It also reduces vascular permeability, thus reducing edema.

“There is a lot of research in congestive heart failure in which Hawthorn extracts have proven equal to drug in NYHA Class I and II CHF.” He added that a study of Hawthorn in Class III CHF is underway.

While there are a number of standardized liquid extracts of Hawthorn on the market, Dr. Saunders said he’s had the most success with the so-called “solid” extracts—viscous, molasses-like concentrates. Several professional-level nutraceutical companies, including Thorne Research, Pure Encapsulations, and Metabolic Maintenance, are marketing solid extracts of Hawthorn in the US.

Dr. Saunders instructs patients to take a quarter teaspoon of the solid extract beginning thrice daily, and then tapering off to twice or even once daily when blood pressures drop to normal ranges. “It takes four to six weeks to see some effects,” he said, adding that, “I’m very impressed with this herb.”

Reviewing the global literature on Hawthorn, he said there are no known interactions, no adverse reactions, and no data to support the claims that it interferes with digoxin. However, one must be careful in patients already on beta blockers, as this herb tends to synergize with beta-blockers, thus increasing the risk of bradycardia. “I do use it to wean patients off beta blockers,” he said, noting that these drugs tend to cause fatigue and loss of libido, which does not happen with Hawthorn.

Rauwolfia (Rauwolfia vomitoria): “This is one of my favorite herbs for hypertension,” said Dr. Saunders of the plant that gave the medical world the drug reserpine. But this is only one of more than 50 indole alkaloids contained within this plant. Others lower heart rate by decreasing catecholamine production. One of the great things about it is it is very fast-acting. “You’ll see effects within days to two weeks.”

Dr. Saunders uses a standardized tincture of Rauwolfia, beginning with 15–20 drops, thrice daily for several weeks. In many cases, the dose can be reduced to 10 drops per day. Rauwolfia acts so quickly that there is some danger that patients can drop into hypotensive ranges, so it is important to tell patients not to overdo it. This herb has the added benefit of being mildly anxiolytic and slightly sedative, properties valued by Mahatma Gandhi, who used to regularly drink Rauwolfia tea as a calmative. This herb works very well in combination with Motherwort (see below).

Rauwolfia is a short-term antihypertensive. It should not be used ad infinitum. For many patients, Dr. Saunders begins with Rauwolfia for several weeks, until the pressures are within normal range. Then, he switches them over to Hawthorn for long-term maintenance. “Rauwolfia will deal with serious hypertension, while Hawthorn is generally for more mild hypertension.”

The major downsides to Rauwolfia are its taste, which is strong and bothersome to some patients. It can aggravate peptic ulcers and other GI problems. It can enhance the effect of beta-blockers or sympathomimetic drugs, and its effects are attenuated by tricyclic antidepressants.

Patients should be cautioned against drinking alcohol while taking this herb, as the two can combine to greatly increase impairment. Animal studies indicate that it is teratogenic, so it should not be given to pregnant or lactating women. But for hypertensive patients not already on a lot of medications, a course of Rauwolfia followed by Hawthorn is a good place to start.

Motherwort (Leonurus cardiaca): A member of the mint family, this herb increases peripheral blood flow, induces normal peristalsis in smooth muscles, and has an overall muscle relaxant effect.

While not terribly effective as a primary treatment for hypertension, it does have antihypertensive effects, and Dr. Saunders has found it works well in combination with Rauwolfia in the initial stage of hypertension management. He has also found it useful for slightly hypertensive menopausal women who have a lot of anxiety or insomnia.

Ginkgo (Ginkgo biloba): Most commonly thought of as an herb to improve memory and cognitive function, Ginkgo also reduces platelet aggregation and thrombus formation, and increases erythrocyte flow through capillaries. It is also an excellent antioxidant. Dr. Saunders noted that in experimental ischemic stroke models, Ginkgo reduced free radical damage following reperfusion.

Ginkgo received considerable media hype for its alleged ability to slow the progression of dementia. Dr. Saunders said there is something to the claim, provided treatment is started at the earliest stages. “Once dementia is advanced, [Ginkgo] will not help to reverse it. But if there’s a patient with a family history, and he or she is right at the age when the problems begin, you can start Ginkgo and try to delay progression.”

In most of the published clinical trials on Ginkgo, the doses were in the range of 100–240 mg/d, using extracts standardized to 24% glycosides and 6% terpinoids.

Ginkgo is a potent antiplatelet agent, and it has potential for interaction with warfarin or other anticoagulant medications. Though actual cases of bleeding problems are fairly rare, it is something to watch out for. “Self treatment with Ginkgo in patients on coumadin is a bad idea.” He added that the main problem he sees in patients taking this herb is headache. They tend to be frontal or vertex type, and are usually short-lived. But for some patients, it proves too bothersome to tolerate.

Olive Oil: Relatively inexpensive, easily obtainable, and very tasty, olive oil is good everyday cardiovascular medicine, as Mediterranean peoples have known for centuries. It is an excellent source of monounsaturated fats, which are extremely heart-healthy. Dr. Saunders advises his patients to use as much extra virgin, cold-pressed olive oil as they want. “Up to 30% of total calories per day,” he said.

THE REDUX: Common culinary herbs like garlic, capsicum (cayenne) and olive oil have many heart healthy properties, and they can be used almost ad infinitum. In fact, they must be used consistently to obtain benefits. Rauwolfia and Hawthorn are two of the most potent anti-hypertensive herbs available, and in some cases, they can be used in place of medications. Rauwolfia is excellent for rapid pressure reductions, but it is best for short-term use in initial pressure control. Hawthorn, preferably in “solid” extract form, is better for long-term maintenance. In some cases, one can achieve initial control with Rauwolfia, and then switch to Hawthorn for ongoing control.