Stephen Devries Integrative cardiology recognizes the central role of nutrition and lifestyle for prevention and treatment of heart disease, combined with diverse, scientifically validated modalities of healing—all within the framework of guideline-based conventional cardiology care. Most importantly, integrative cardiology is not an alternative system for heart health but instead emphasizes a comprehensive approach that is inclusive of all useful healing modalities. Integrative medicine should be distinguished from complementary and alternative medicine (CAM)—a term narrower in scope with variable scientific underpinning. CAM typically refers to healing modalities generally not part of conventional medicine, including but not limited to the use of supplements and herbs, massage, acupuncture, and mind-body approaches such as meditation, biofeedback, healing touch, and Reiki. Integrative medicine operates within the context of conventional medicine but selectively incorporates the most useful and scientifically valid of CAM approaches to achieve the best possible outcomes. In addition to prevention and treatment of physical disease states, the goals of an integrative medicine approach encompass spiritual and emotional well-being. Current approaches to cardiovascular care emphasize expert application of pharmacologic and procedural-based therapies. Even though enormous gains have been realized in modern cardiac care, some important gaps remain. For example, despite a wealth of evidence detailing the potency of nutrition as a therapeutic tool in cardiology, relatively little attention is directed to diet in most medical encounters (see Chapter 46). Similarly, research has confirmed the potent influence of mind-body interactions on heart health, yet the role of emotions is not typically emphasized in conventional care (see Chapter 86). Cardiologists, like most physicians, receive relatively little formal training in certain areas, including nutrition, scientific assessment of supplements, and mind-body interactions. An integrative cardiology approach holds that health is optimized by the application of all useful healing modalities. Incorporation of an integrative approach to cardiology can enhance the efficacy of conventional medical interventions for prevention and treatment of cardiovascular disease—with the added benefit of reduced health care costs because of the emphasis on low-cost nutrition and lifestyle interventions. In the United States, an estimated 15 million individuals use some form of complementary and alternative therapy at an annual cost of almost $30 billion.1 Patient expenditure for CAM services in the United States is comparable to out-of-pocket patient expenses for conventional medical services and prescription drugs. Of note, health care professionals are more likely to use complementary and alternative therapies than the general public is (76% versus 63%, P < 0.001).2 The use of CAM treatments is particularly widespread among cardiology patients. A survey of the cardiology outpatient practice of a tertiary care center showed that 82% of cardiology patients used complementary and alternative therapies.3 Among these patients, 44% used CAM for the treatment of cardiac symptoms. The most frequently used CAM modalities were dietary supplements (75%), chiropractic (32%), massage (19%), and relaxation techniques (13%).3 The CAM therapies most commonly used specifically for the treatment of cardiac symptoms were related to mind-body interactions and included relaxation techniques, stress management, meditation, and guided imagery. Of note, only 14% of patients who use CAM therapies discussed their choice with a physician.3 Patients often cite low expectation for physician knowledge of CAM and fear of ridicule as the reasons for not disclosing their use of CAM to physicians. One of the primary motivations for patients to seek integrative care is a desire for extended face-to-face time with their practitioner.4 Clinicians who provide longer visits are often viewed as more empathetic—a perspective with therapeutic implications. There is evidence that patients’ perception of their physician’s level of empathy is related to medical outcome, independent of disease variables.5 Another frequent driver for those seeking integrative care is the perceived enhanced sensitivity of integrative practitioners to patients’ personal preferences and philosophy regarding their health care.4 Many patients seeking integrative medicine practitioners do so because they wish to minimize their use of prescription medication—or at least delay the need for prescription medication until nutrition and lifestyle measures have been maximized and shown to be inadequate. Patients’ reluctance to take prescription medicine is reflected in data showing that as many as 50% of patients stop taking statin therapy within the first year of treatment.6 An integrative approach emphasizes the role of nutrition in both prevention and treatment. Although nutrition is included in all guidelines for cardiovascular care, conventional cardiology practice does not consistently emphasize nutritional recommendations. Moreover, a recent study revealed that physician time spent in counseling patients regarding nutrition is declining—especially for diabetic patients.7 Current Accreditation Council for Graduate Medical Education guidelines, which consist of 32 pages of specific criteria for accreditation of cardiovascular training programs, include no requirement that nutrition be incorporated in the curriculum.8 Lack of adequate attention to nutrition results in lost opportunities for preservation of heart health, especially given data supporting a greater than 70% reduction in cardiovascular events by adoption of a Mediterranean-style diet.9 In addition to the clear therapeutic benefits of optimal nutrition, emphasizing the role of nutrition facilitates patient empowerment and engagement. Exercise is a component of almost all recommendations in cardiology but plays a more central role in an integrative cardiology approach. Focused attention on exercise is well justified in light of data demonstrating benefit from physical activity on symptoms and prognosis of almost every cardiac disorder ranging from hypertension and dyslipidemia to ischemic heart disease and congestive heart failure. For this reason, exercise, together with nutrition and stress management, forms the foundation of integrative cardiology—to which appropriate medication and procedures are added. The existence of a strong connection between mind and heart health is intuitive but not consistently addressed in conventional cardiology encounters. Nevertheless, the nature of the mind-heart interaction has been well elucidated and includes hormonal input mediated through the central and autonomic nervous systems. A classic manifestation of the mind-heart interaction is takotsubo cardiomyopathy, a severe, acute-onset cardiomyopathy that is often triggered by an emotional stress response (see Chapter 65). The integrative practitioner uses a wide range of options for stress management. In addition to the psychological resources commonly used in conventional medicine, including behavioral therapy and antidepressant and anxiolytic medication, a wide variety of approaches may be considered in an integrative framework. Additional modalities for stress management include meditation, breathing exercises, biofeedback, massage, yoga, tai chi, and “energy” therapies such as healing touch and Reiki. Healing touch and Reiki require special explanation because they are probably less familiar to most cardiologists. These modalities are based on the assumption of an “energy field” surrounding the body that can be manipulated by light touch and hand motions over the body focused on presumed energy centers. Some of the largest health care institutions in the United States have used such strategies as aids for stress reduction during recovering from cardiac surgery. Acupuncture has been shown to be effective in modulating sympathetic input to vascular beds in both experimental and clinical studies. Clinical studies of acupuncture have shown potential for use as an adjunct in the treatment of hypertension, palpitations, and congestive heart failure. Moreover, acupuncture can be an effective modality for reduction of emotional stress, an exacerbating factor in all cardiovascular disorders. In a survey of more than 1000 cardiology outpatients, 75% reported the use of some form of supplement or herbal products.3 The most common over-the-counter products include multivitamins (53%), fish oil (45%), vitamin C (36%), vitamin E (29%), fiber (27%), folic acid (18%), coenzyme Q10 (CoQ10) (12%), and garlic (12%).3 Many of these products are taken at the patient’s own direction or on the recommendation of nonphysician health care providers. Some products that were initially prescribed predominantly by alternative health providers, such as fish oil and plant stanols, have been well studied and are now often recommended in conventional cardiology practice. Cardiologists may not be aware of the vast and growing body of science surrounding the use of supplements. If for no other reason, knowledge of supplements is important so that clinicians can identify potential adverse reactions, as well as appreciate possible interactions with prescription medication. In selected cases, clinicians may choose to consider prescribing a supplement or herbal product, either as adjunctive treatment of patients receiving prescription medication or as an option for patients unable to tolerate prescription medication because of adverse reactions. Fortunately, several excellent resources are available to help clinicians learn about the science of supplements, including those offered by the National Institutes of Health (NIH) Office of Dietary Supplements (http://ods.od.nih.gov), NIH National Center for Complementary and Alternative Medicine (http://nccam.nih.gov), and a service of the U.S. National Library of Medicine, MedlinePlus (http://www.nlm.nih.gov/medlineplus/druginfo/herb_All.html). Independent private groups that provide detailed scientific assessments of supplements include the Natural Medicines Database (http://naturaldatabase.therapeuticresearch.com) and the Natural Standard (http://www.naturalstandard.com). These Internet-based resources are extensively referenced to help guide clinical evaluation of the pharmacologic properties of supplements. Apart from questions about the potential for clinical benefit from supplements, there is legitimate concern regarding the consistency of supplement content and absence of contamination. According to the U.S. Dietary Supplement Health and Education Act, the manufacturer is responsible for the accuracy of all information on the product label. Supplement manufacturers are required to follow Dietary Supplement Current Good Manufacturing Practices for quality control and to submit a list of adverse events to the U.S. Food and Drug Administration (http://www.fda.gov/food/dietarysupplements). As an added assessment tool, certain supplements have been analyzed and certified by independent nonprofit groups that evaluate manufacturing procedures and product strength and purity, including the U.S. Pharmacopeial Convention (http://www.usp.org) and the National Sanitation Foundation (http://www.nsf.org). Another source of information for clinicians wishing to evaluate the quality of individual brands of supplements is Consumer Lab (http://www.ConsumerLab.com), an independent group that performs laboratory analyses on a variety of brands of common supplements and reports on dosage and purity. Nutrition is the cornerstone of an integrative approach for both prevention and treatment of cardiovascular disease (see Chapter 46). A whole-diet approach is preferred over attention to individual nutrients. One of the best studied dietary approaches in cardiology is the Mediterranean-style diet—a relatively simple diet plan that includes increased intake of vegetables and fruit, preference for whole grains over refined, reduced red meat and increased fish consumption, and predominant use of olive and canola oil. The Mediterranean diet has been shown in the Lyon Diet Heart Study, a secondary prevention trial, to reduce risk for a cardiovascular event by 72% in comparison to controls.9 Adherence to a Mediterranean-style diet has been tested in diverse settings, including the United States, where the NIH-AARP study showed a reduction in both cardiovascular and cancer mortality rates in an observational study.15 TABLE 48-1 Most Useful Integrative Strategies for Prevention of Coronary Disease Nutritional choices are associated with substantial mortality benefit in those already being treated with optimal medical therapy. In an analysis of more than 31,000 patients from two secondary prevention trials, those with the healthiest diet had a 35% lower cardiovascular mortality rate than did individuals consuming the least healthy diet. Even in the subset of patients being treated with combination medical therapy, including aspirin, beta blockers, and a statin, a healthier diet was associated with a 23% reduction in cardiovascular events.10 The Dietary Approaches to Stop Hypertension (DASH) diet, although initially conceived as an adjunct for treatment of hypertension (see Chapters 43 and 44), is similar to the Mediterranean diet with the exception of no specific recommendation for the preferred type of vegetable oil. In an observational study of more than 88,000 participants in the Nurses’ Health Study, those with the strongest adherence to a DASH diet had an adjusted 24% reduction in coronary events and an 18% lower risk for stroke than did those with low adherence.16 A very consistent finding in nutritional studies is the strong cardiovascular benefit of high intake of vegetables and fruit. Dark green leafy vegetables, including spinach and kale, are especially cardioprotective, probably in part because of their high folate concentration.17 Interestingly, the folic acid in supplements has not been demonstrated to reduce cardiovascular risk. The reason for this discordance is unclear but may be related to the fact that supplements are typically in the form of folic acid whereas food contains reduced forms of folate. For the folic acid found in supplements to be bioactive, it must first be metabolized by a process that can become overloaded when high doses of supplements are consumed, thereby resulting in a buildup of potentially harmful circulating free folic acid.18 The role of exercise in the prevention and treatment of cardiovascular disease cannot be overemphasized (see Chapter 47). Most cardiovascular risk factors are improved through a combination of aerobic exercise, resistance training, and stretching. A dose-response relationship between exercise and cardiovascular benefit has been established, with a 14% reduction in risk for coronary heart disease noted with as little as 30 minutes of walking daily.11 Interestingly, blood pressure reduction was found to be even greater when exercise was divided into three 10-minute walks versus a single 30-minute session daily.19 Nontraditional forms of exercise have also shown remarkable cardiovascular benefit, including tai chi, an ancient Chinese martial art form characterized by gentle, flowing movements often experienced as calming and meditative.20 A clear association has been observed between emotional state and heart health (see Chapter 86). Identification of an increased tendency toward hostility was associated with a doubling of risk for ischemic heart disease over a 10-year period.21 A moderate or high level of perceived stress before myocardial infarction was associated with a 42% increase in 2-year mortality risk.22 Stress can induce ischemia by triggering both epicardial and microvascular vasoconstriction. In addition, stress leads to autonomic dysregulation and an outpouring of circulating catecholamines with potentially serious consequences, including takotsubo cardiomyopathy, or stress-related heart failure. The range of reported antecedent stressors to this potentially fatal condition is broad, including the death of a parent, a surprise birthday party, fear of a medical procedure, and public speaking. Emotional factors identified early in life can predict those more likely to suffer cardiac events much later. Increased anxiety by 20 years of age was an independent predictor of future cardiac events, with more than a twofold increased risk for myocardial infarction over a 37-year follow-up.23 Conversely, individuals with the most optimistic outlook appear to have some degree of cardioprotection when compared with their more pessimistic peers, with a 22% reduction in cardiac events over a 10-year follow-up.24 The potency of mind-body interventions is exemplified by a study of 201 patients following myocardial infarction, in whom a regular practice of meditation combined with optimal medical therapy resulted in a 48% reduction in major cardiovascular events in comparison to those treated with medical therapy alone.12 Blood pressure was significantly reduced in the meditation group, a finding common to many mind-body intervention studies, including biofeedback, breathing exercises, and tai chi. The benefits of a comprehensive lifestyle intervention program, including nutritional changes (plant-based diet with 10% of calories from fat), exercise, and stress management, have been demonstrated in a study of 1152 individuals with coronary disease from 22 locations enrolled in the Multisite Cardiac Lifestyle Intervention Program. At 12 weeks into the program, 74% of those with angina at baseline were asymptomatic. Among the remainder with persistent angina, 9% improved from limiting to mild angina.13 Supplement use is common in the treatment of dyslipidemia (see Chapters 41 and 42). Supplements may be used by patients who refuse prescription statins because of fear of adverse reactions, as well as by those with a history of statin intolerance. The frequency of adverse reactions to prescription statins, particularly muscle-related symptoms, is not commonly recognized but appears to be as high as 10% of all statin users.25 Supplements with established efficacy in the treatment of dyslipidemia include psyllium, niacin, stanols/sterols, red yeast rice, and fish oil. Psyllium is rich in soluble fiber, a component known to reduce absorption of cholesterol from the gastrointestinal tract. Psyllium at a dose of 10 g/day can reduce low-density lipoprotein cholesterol (LDL-C) by 7%.26
Integrative Approaches to the Management of Patients with Heart Disease
Integrative Cardiology: Overview
Definition
Rationale
Use
Elements of an Integrative Approach in Cardiology
Extended Face-to-Face Time with the Physician
Patient Preference Sensitive
Nutrition Emphasis
Exercise
Mind-Heart Interactions
Healing Touch and Reiki
Acupuncture
Supplements
Prevention of Coronary Artery Disease (Table 48-1)
Nutrition
Nutrition
Mediterranean diet led to a 72% reduction in cardiac events9; healthiest diet linked to a 35% reduction in cardiovascular mortality10
Exercise
Walking 30 min 5 days/wk reduces risk for coronary heart disease by 14%11
Meditation
Twice-daily meditation reduced cardiovascular events by 48%12
Comprehensive lifestyle intervention
The combination of a low-fat, plant-based diet, exercise, and stress management led 74% of patients with angina to become asymptomatic13
Red yeast rice
Red yeast rice resulted in a >20% reduction in LDL-C and was often tolerated in patients with previous statin-related myalgias14
Exercise
Mind-Heart Interactions
Meditation
Multifaceted Lifestyle Intervention
Supplements for Dyslipidemia
Psyllium
Integrative Approaches to the Management of Patients with Heart Disease
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