4 Cardiovascular Diseases – In heart failure, the heart is unable to maintain adequate circulation owing to a decrease in heart muscle function (cardiac output) resulting from cardiac myocyte death. The main causes are hypertension (see p. 138) with increased venous pressures or cardiac volumes, valvular defects, and ischemia due to sclerotic coronary artery disease (see p. 134). – The body attempts to compensate for the circulatory deficiency by stimulating mechanisms such as the sympathetic nervous system and by narrowing the blood vessels, resulting in a higher workload on the heart. Additional compensatory mechanisms lead to a further decrease in cardiac performance. – Effective treatment measures should be initiated as early as possible to prevent the progression of heart failure. – NYHA I: Symptoms do not occur during normal physical exercise. – NYHA II: Symptoms occur during more strenuous exercise. – NYHA III: Symptoms occur during light exercise. – NYHA IV: Symptoms occur even at rest. – Action: Procyanidins enhance the influx of calcium into cardiac muscle fibers while only moderately increasing the oxygen demand. These compounds widen the coronary arteries and other cardiac vessels, thereby extending the refractory time. This results in an antiarrhythmic effect. – Advantages of hawthorn • Effective and well-tolerated in the early stages of heart failure, especially in patients with age-related degenerative changes in the heart muscle. • With a high rate of acceptance by patients, hawthorn leaf and flower have only few side effects. • Since flavonoids do not reduce the afterload, hawthorn can also be used by patients with low blood pressure. • Hawthorn can be recommended for long-term use, and it combines well with cardiac glycosides, but may have a synergistic effect. This potential interaction should be watched. It may allow a reduction in medications like digoxin while maintaining the same overall therapeutic effect. – Dosage and administration: One oral dose, 2 to 3 times daily. Relatively large doses over time are needed for sufficient effects. A daily dose of ca. 900 mg hawthorn total extract is generally recommended. The herbal remedy takes around 4 weeks to become fully effective. – Action: The effects are comparable to those of the isolated substances digoxin and digitoxin, but the herbal preparations have secondary effects such as increased urinary excretion (squill) or frequency (lily-of-the-valley). – Advantages: The herbal preparations have a somewhat wider therapeutic range than the isolated substances, but their concentrations can extend into the toxic range. – Disadvantages: The absorption of the active compounds in the herbal preparations is generally poor and variable. Hence, their bioavailabilities and potencies are usually low. – Dosage and administration: One oral dose, 2 to 3 times daily. Individualized dose setting is required. – Advantages: The tolerance is said to be better than that of preparations containing digitaloid herbs alone. – Disadvantages: Their therapeutic range is smaller than that of pure hawthorn preparations, and their toxic effects are similar to those of digitaloid drugs. – The prevalence of coronary artery disease (CAD) is increasing in industrialized countries. This is certainly attributable to a general lack of physical exercise, increased consumption of fatty foods, and cigarette smoking, but is also due to the fact that people now live longer. – Despite intensive research, some risk factors of CAD are still unknown or untreatable. – In Germany, topical heart ointments containing aromatic herbs that increase local blood flow of cutivisceral reflex regions are thought to be beneficial in acute functional coronary artery spasms. – Flavonoids in hawthorn extract reduce wall tension in normal and sclerotic blood vessels. These chemicals are also presumed to stimulate beta-2 receptors and, thus, to widen coronary arteries and blood vessels in skeletal muscle. The usefulness of hawthorn in CAD is therefore arguable, but has not yet been confirmed in clinical studies. – The recommendations in this section are solely based on empirical experience. Clinical study data or controlled studies on most of these indications are not yet available. – Once CAD has become manifest, herbal measures should be restricted to adjunctive treatment only. – Antilipemic herbs: Garlic (see p. 70), artichoke (see p. 36). – Antithrombotic herbs: Garlic (see p. 70). – Antihypertensive herbs: Garlic (see p. 70). – The herbal treatments outlined here are purely prophylactic and adjunctive measures that can be recommended as home remedies. Clinical studies are available. – Action: Stimulate cutivisceral reflexes, blood flow and spasmolysis, thereby reducing CAD-related pain. – Dosage and administration: The preparations are applied to the left precordial region of the chest and rubbed into the skin as often as needed. – Dosage and administration: Dose is diluted oil or other balm applied several times daily or as needed for mild pain of angina. Apply twice daily to the left precordial region, or as needed when chest pain occurs. – Clinical value: Clinical studies have not been conducted. Large inter-individual differences in the effects of these remedies can be observed. – Steep 2 teaspoons of the herb in 150 mL of boiling water for 20 minutes. Sweeten lightly. This mild infusion should be used only for health-promoting benefits. – Hawthorn tincture (see p. 74): 2–4 mL several times a day. – Extract standardized to flavonoids and/or proanthocyanins: 1 to 2 capsules or tablets. – Dosage and administration: One dose, 2 to 3 times daily. – Clinical value: For low-potency treatment, hawthorn extracts that are not standardized have a smaller therapeutic range than the corresponding standardized commercial products. – Dosage and administration: 1 to 2 teaspoons per cup, 2 times daily. – Clinical value: For low-potency treatment. The extract is not standardized and has a smaller therapeutic range than commercial products. – Dosage and administration: 20 drops, 3 times a day. – Clinical value: This has proved to be a very useful remedy in elderly patients, who often develop Roemheld’s syndrome. – The diagnosis of functional heart disorder is a diagnosis of exclusion. The typical patient complains of heart palpitations. – The most common symptoms are “loud” heartbeat, cardiac arrhythmias, subjective feeling of unrest, diffuse left precordial, non-load-dependent pressure sensation, sudden shortness of breath, nervousness, anxiety, rapid fatigability, insomnia, lack of concentration, tendency to sweat heavily, symptoms of heart “agitation.” – The cardiac work-up usually does not reveal any abnormalities. If any changes are found, they are usually harmless extrasystoles or functional coronary spasms. – Action: • Hawthorn, see p. 74 ff. • Motherwort has mild negative chronotropic, antihypertensive, and calming effects. Its use is recommended only as an additive to other cardiac remedies or sedatives.
4.1 Heart Failure
Clinical Considerations
General comments
Prognosis: The overall prognosis for heart failure remains poor although the conventional treatments (diuretics, ACE inhibitors, beta blockers, AT1-blockers, digitalis) are effective.
Classification: According to the system of the New York Heart Association (NYHA), heart failure is divided into four clinical stages:
Clinical value of herbal medicine: Hawthorn and digitaloid herbs are used in NYHA I and II heart failure. The current knowledge does not support treatment of NYHA III and IV heart failure by herbal remedies.
Recommended Herbal Remedies
Flavonoid-containing Herbs
Hawthorn leaf and flower (Crataegie folium cum flore; see p. 74).
Digitaloid Herbs
Adonis (Adonidis herba; see p. 33), lily-of-the-valley (Convallariae herba; see p. 86), and squill root (Scillae bulbus; see p. 110).
All digitaloid preparations can be toxic (similar to the glycosides digoxin and digitoxin), producing symptoms such as nausea, vomiting, stomach complaints, diarrhea, and cardiac arrhythmias.
Combinations of Flavonoid and Digitaloid Herbs
4.2 Coronary Artery Disease
Clinical Considerations
General comments
Herbal treatment measures
Clinical value of herbal medicine
Herbal measures to help counteract risk factors
Clinical value of herbal medicine for risk factors of CAD
Recommended Herbal Remedies (Overview)
External Remedies
Aromatic plant medicaments such as camphor (Cinnamomic camphorae aetheroleum), rosemary leaf (Rosmarini folium; see p. 112), pine needles (Pini aetheroleum), eucalyptus leaf (Eucalypti folium; see p. 61), and menthol (Menthae aetheroleum).
Ointments containing camphor can cause skin irritation and inflammation and should not be applied to damaged skin.
Internal Remedies
Hawthorn (see p. 74).
Range of Applications
Acute Angina Pectoris
Hawthorn leaf and flower (see p. 74).
Prevention and Treatment of Early-stage CAD
Hawthorn leaf and flower (see p. 74).
Early-stage CAD with Mild Hypertension
Tea Rx: Crataegi flos; Crataegi folium; Visci albi, aa ad 100.0.
CAD with Gastrocardiac Symptom Complex (Roemheld’s Syndrome)
Tincture Rx: Ol. Carvi 5.0; Tinct. Convallariae, Tinct. Crataegi, Tinct. Carminativa, Spirit. Aetheris Nitrosi, ad 10.0.
Long-term Treatment of CAD
Hawthorn preparations (see p. 74), garlic (see p. 70).
4.3 Functional Heart Disorders
Clinical Considerations
General comments
Clinical value of herbal medicine: Herbal preparations can be helpful because no specific synthetic drugs or chemical remedies for functional heart disorders exist. Beta blockers are, in many cases, either contraindicated or not accepted by the patients.
Recommended Herbal Remedies (Overview)
External Remedies: See Coronary Artery Disease, p. 134.
Internal Remedies (nonglycoside drugs)
Hawthorn leaf and flower (Crataegi folium cum floribus; see p. 74), mother-wort herb (Leonuri cardiacae herba).
Internal Remedies (glycoside drugs)
Adonis (Adonidis herba, see p. 33) and lily-of-the-valley
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Tea infusion is not the best way to extract water-soluble compounds from hawthorn. Hawthorn tea therefore has only weak effects and can be recommended, at best, only for a health-promoting effect in the very early stages of cardiac insufficiency, or as a long-term preventative measure.
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