Title A Study of Cardiovascular Diseases in Ayurveda with special emphasis on the role of Ayurveda as a complementary medicine in selected Cardiovascular Diseases. A research project completed as a partial requirement for the qualification of the Diploma of Ayurvedic Medicine 2007 John Vorstermans Supervisor: Dr Vijayendra Srinivasa Murthy, BAMS. M.S. Head of Faculty Ayurveda Wellpark College of Natural Therapies. 6 Francis Street, Grey Lynn Auckland Wellpark College Of Natural Therapies P.O. Box 78-229, 6 Francis Street, Grey Lynn, Auckland Phone: 0-9-360 0560 Fax: 0-9-376 4307 Email: firstname.lastname@example.org Certificate This is to certify that John Vorstermans has successfully completed a research project/paper on the topic; A Study of Cardiovascular Diseases in Ayurveda with special emphasis to the role of Ayurveda as a complementary medicine in selected Cardiovascular Diseases, towards the partial fulfilment of the a Diploma of Ayurvedic Medicine. Date ............................................ Supervisor..................................... Place .......................................... Principle: ...................................... A Study of Cardiovascular Disease in Ayurveda John Vorstermans Table of Contents 1. Acknowledgement........................................................................................................4 2. Introduction..................................................................................................................5 3. Aims and objectives......................................................................................................8 4. Materials and Methods.................................................................................................9 5. An Overview of Ayurveda.........................................................................................10 6. Literature Review.......................................................................................................29 6.1 Cardiovascular Disease statistics.....................................................................29 6.1.2 History of Cardiovascular Disease .............................................................31 6.2 Cardiovascular Disease.........................................................................................33 6.2.1 Overview.......................................................................................................33 6.3 Development of Cardiovascular Disease........................................................45 6.3.1 The medical model........................................................................................45 6.3.2 Ayurveda model..........................................................................................47 6.4 Risk Factors........................................................................................................55 6.4.5 Medical Pathophysiology of Cardiovascular Disease..................................63 6.4.6 Ayurvedic Pathogenesis (Samprapti) .........................................................64 6.5 Clinical Manifestation.....................................................................................69 6.5.1 Symptomatology - Western Medical ..........................................................69 6.5.2 Symptomatology - Ayurveda ......................................................................69 6.6 Treatment.............................................................................................................71 6.6.1 Medical Treatment.......................................................................................71 6.6.2 Ayurvedic Treatment...................................................................................75 6.6.3 Medical Drugs..............................................................................................81 6.7 Correlation between Ayurveda and Modern Medicine...................................89 6.8 Classifying Ayurvedic Herbs on Modern Pathology......................................91 6.9 Research on Ayurvedic Herbs.........................................................................93 6.10 Details of Ayurvedic Herbs under research.................................................103 6.11 Drug Interactions.........................................................................................129 7. Discussion .................................................................................................................134 8. Conclusion.................................................................................................................139 9. Recommendation for Further Study..........................................................................141 Illustrations index......................................................................................................142 Table index.................................................................................................................142 Abbreviations..............................................................................................................143 Glossary of Sanskrit Terms........................................................................................144 Bibliography...............................................................................................................147 Page 3 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 1. Acknowledgement I would like to acknowledge the staff and tutors at Wellpark College for their dedication, attention and perseverance over the last three years in facilitating my journey and understanding of Ayurvedic Medicine, with an emphasis on the use of Ayurveda as a complementary medicine alongside today's modern medical systems. I especially wish to acknowledge the dedication and skills of Dr Vijayendra Srinivasa Murthy, who has proved himself a very skilled learning facilitator. His depth of understanding of both Ayurveda and the modern medical systems have been invaluable throughout the course and his dedication and understanding of both classical and modern Ayurveda have added an extra depth to the learning experience. It has been a privilege to spend time with a tutor who lives and practises the principles that he teaches. I would wish to acknowledge further outstanding tutors, Barbara Cook and Thomas Mueller who have given much of their time in sharing their individual expertise and knowledge of Ayurveda. All this would not have been possible without the patient understanding and support of my partner, Margarita Sisam to whom my heartfelt thanks goes to. Page 4 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 2. Introduction This research paper focuses on a literary review of both the modern and Ayurvedic approaches to cardiovascular disease. We will look at how each modality views, diagnoses and treats some common cardiovascular diseases and finally discuss the commonalities and differences of approach. Is it possible to effectively use both from a complementary perspective? Modern medicine is comparatively new in its approach to Cardiovascular Disease, having built up its understanding over the last 200 years in comparison to Ayurveda, which dates back over 5,000 years. James Le Fanu in The Rise & Fall or Modern Medicine says; “The history of modern medicine starts sometime in the 1830s when a few courageous physicians acknowledged that virtually everything they did – bleeding, purging, prescribing complicated diets – was useless. The distinguished medical commentator Lewis Thomas elaborates: Gradually over succeeding decades the traditional therapeutic ritual of medicine was given up... [to be replaced by] meticulous, objective, even cool observations of sick people. Accurate diagnosis became the central purpose and justification for medicine and as the methods improved, accurate prognosis also became possible, so that patients and their families could be told not only the name of the illness but also, with some reliability, how it was most likely to turn out. By the time this century had begun, it was becoming generally accepted as the principle responsibility of the physicians.i” Modern medicine, as we know it today grew in prominence through several important landmark events over the last 80 years, such as the discovery of Penicillin in 1941 and Cortisone in 1949. From the demands for the manufacture of these drugs grew the 2. Introduction Page 5 A Study of Cardiovascular Disease in Ayurveda John Vorstermans pharmaceutical industry, which over the course of the last century grew to became a large and powerful industry, focusing much of its work on the the development and supply of a constant stream of new drugs for use in modern medicine. By the 1960s over seventy new drugs were being introduced every year but by the 1970s that had reduced to less that 20 a year due to the introduction of legislation requiring much stricter means for testing drugs, due in some part to the serious side-effects of some drugs after being released to the public. In the 1990 drug companies began to focus their attention on techniques for screening millions of chemical compounds for their biological activity, hoping to identify the lead components that might have the sort of genuine therapeutic effect that could form the basis of new drugs. Ayurveda is a system that has been in use now for 5,000 years and through this time has developed its own tried, tested and unique approach to health and disease. Like modern medicine it has a well developed and accurate diagnosis and prognosis framework for the helping the sick. Ayurvedic medicine has also formed its own medicines based on herbs, which date back to its inception. These medicines have proven to be effective in helping people with mild and chronic diseases over this time. Over the last 2,000 years further medicines have been developed in Ayurveda using herbs, minerals and metals, some of which are considered controversial by modern medicine today, although they have a long proven record of success when used by indigenous Ayurvedic practitioners in their place of origin. Ayurveda recognises the person as a whole composite being and treats the person on the level of physical body, emotions and mind, all being integrated aspects, which are involved in the pathology of a disease. Its focus is on treating the cause rather than just the symptoms. The symptoms however, from and Ayurvedic perspective, give a good insight into the the underlying cause. 2. Introduction Page 6 A Study of Cardiovascular Disease in Ayurveda John Vorstermans This paper explores aspects of both the Modern and Ayurvedic approaches to selected cardiovascular diseases. It will explore both systems of health and healing and where they are most useful for the well-being of the patient. In general it appears that Modern Medicine is suited well to deal with acute cardiovascular conditions while ayurveda is more suited to deal with cardiovascular disease in its earlier stages, benefiting from its unique understanding of the pathology of these diseases from an Ayurvedic perspective. Page 7 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 3. Aims and objectives. The aim of this literature review is to compare side by side the approach of Modern Medicine with that of Ayurveda with regard to cardiovascular disease and to discuss the approach of each science to the development and treatment of the disease. The objective is to: Study medical research completed in both modalities. Study the treatment methods of each approach. Look at the methods of how both approach the various Cardiovascular Diseases. Look at similarities in both approaches. Research the differences in each approach to Cardiovascular Disease. Analyse and present possibilities for use of Ayurveda as a complementary medicine in selected Cardiovascular Diseases. 3. Aims and objectives. Page 8 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 4. Materials and Methods. This is a literature review on Cardiovascular Disease from a Modern Medical and Ayurvedic perspective comparing and contrasting both approaches to Cardiovascular Disease. Sources: 1. Charaka Samhita translated by R.K. Sharma and V Bhagwan Dash 2. Heart Disorders & Their care in Ayurveda by Prof. Ajay Kumar Sharma 3. Cardiology in Ayurveda by Dr V.B. Athavale 4. Ayurvedic Management for Heart Diseases by Dr J.L. Sastry and Dr. K. Nistewar. 5. Understanding Pathology by Sue E. Huether & Katheryn L. McCance 6. Merck Manual, eighteenth edition Methods: Included in the study are a review of Cardiovascular Disease as relates primarily to the heart. Included is an outline of the Ayurvedic and Modern Medical framework of CVD with particular focus on Arteriosclerosis, Coronary Artery Disease, Cardiomyopathy, Aneurysm, Pericardial disease, Heart Failure, High Blood Pressure, Peripheral arterial disease and Angina. Not included are Cardiovascular tests, Arrhythmias, Valvular disorders, endocarditus, diseases of the Aorta and its branches, venous and lymphatic disorders and cardiac tumours, although some references to these may be made as passing comments. 4. Materials and Methods. Page 9 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 5. An Overview of Ayurveda This overview is provided to give some background understand of how Ayurveda looks at the human being and thereby create a meaningful context for the discussion later in the paper. 5.1 Brief History Ayurveda dates back around 5,000 years and is widely considered to be the oldest form of health care in the world. It is believed by many scholars that knowledge of Ayurveda spread out from India and influenced the ancient Chinese system of medicine, Unani medicine, and the humoral medicine practised by Hippocrates of Greece. It is for this reason that Ayurveda is often referred to as the "Mother of all healing." The knowledge of Ayurveda is believed to be of Divine origin, being communicated to the saints and sages of India who received its wisdom through deep meditation. Ayurvedic knowledge was thereafter passed down orally through the generations and then written down in the Vedas, the sacred texts of India believed to be the oldest writings in the world. Written in Sanskrit, the Vedas cover a vast number of subjects from grammar to health care. The Vedas were written approximately 2500 BC or earlier. Current knowledge about Ayurveda is mostly drawn from relatively later writings, primarily the Charaka Samhita (approximately 1500 BC), the Ashtang Hrdyam (approximately 500 AD), and the Sushrut Samhita (300 - 400 AD). These three classics describe the basic principles and theories from which Ayurveda has evolved. They also contain vast clinical information on the management of a multitude of diseases expanded upon by later writings and research. The Charaka Samhita is a monumental work comprising 120 chapters grouped into 5. An Overview of Ayurveda Page 10 A Study of Cardiovascular Disease in Ayurveda John Vorstermans eight sections. 1. Sutra ('Aphorism') Sthana. Thirty chapters on Ayurveda's origin, general principles, philosophy and theories. 2. Nidana ('Diagnosis') Sthana. Eight chapters on the cause and symptoms of disease. 3. Vimana ('Measure') Sthana. Eight chapters on many subjects, including physiology, methodology and medical ethics. 4. Sharira ('Body') Sthana. Eight chapters on anatomy and embryology and on metaphysiocs and ethics. 5. Indriya ('Sense organ') Sthana. Twelve chapters on prognosis. 6. Chikitsa ('Treatment') Sthana. Thirty chapters on therapeutics. 7. Kalpa ('Preparation') Sthana. Twelve chapters on pharmacy 8. Siddhi ('Success') Sthana. Twelve chapters on purification therapy. 5.2 Luminaries of Ayurveda Ayurveda has a long history and through this time has been influenced by many great personages, some going back so far in time that little evidence exists of them but the writing they left while others a better know. 5.2.1 Mythological Personages The more mythological personages are seen today as the gods of Indian. Such as: Brahma: Believed to have been the creator of the Universe and also the fountain- head of all knowledge. It is believed that the great Veda were propounded by him as well as the science of Ayurveda which was first taught of Prajapathi Daksha who passed this on to 5. An Overview of Ayurveda Page 11 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Aswinis who in turn passed the knowledge onto Indra, then to sage Bharadawja, then onto Punarvasu Atreya, then Agnivesha and so on. Prajapathi Daksha: He learned Ayurveda from Brahma and passed on his knowledge to the two Aswins. Not much reference is available either in general Sanskrit literature or Ayurveda literature as to his contribution to the science of Ayurveda except as the preceptor of Aswins. Aswinikumaras: The twin deities still remain as an enigma to scholorship both ancient and modern. Rigveda describes that Nasatya and Dasra, the twin sons of Vivaswat (sun) came to be known as Aswinikumaras. During the time of the Rigveda they were considered as celestial physicians coming down to earth whenever propitiated by faithful men to cure their ills. They performed many wonderful feats including restoring youth, providing artificial limbs, substituting organs in the body. Both Charaka and Sushruta samhitas mention many of their wonderful feats. Dhanwantari: Is a great celebrity in the field of Ayurveda about whom many different views are found in ancient Indian literature. According to the Ramayana and Mahabharata, Dhanwantari is one of the products of churning the milky ocean. He came out of the ocean proficient in Ayurveda. There are also other stories of Dhawantaris beginings but he is recognised as one of the first god physicians in the three worlds and has been considered by some an incarnation of the great god Vishnu. 5.2.2 Semi-historical personages Some of the Semi-historical personages of note are: Bharadhwaja: or Bharadhwaja Vagineya in full, belong to the linage of Atharvangirasa who was the propounder of Atharvaveda. Bhardhwaja, in the course of time 5. An Overview of Ayurveda Page 12 A Study of Cardiovascular Disease in Ayurveda John Vorstermans acquired great fame and became a Rishi. His name stands out in the Rigveda and Artharvaveda as well as in the Ramayana and Mahabharata. He is credited with two great achievements, having brought the heat of the sun to the earth for the benefit of living beings and also the science of healing. Having learnt the science of healing from Indra, he imparted it to other sages systematically lying the firm foundations of logical concepts. Vasista: one among the saptarrishis, he learnt Ayurveda from Bharadhwaja. He is credited with two great treatises, on on law (Vaishtadharma shastra) and another on medicine (Vaishta samhita). The later is quoted by Trimalla Bhatta in his yoga-tarangini but is not available today. Agastya: His name appears in the Tigveda as the author of several hymns. He also learnt Ayurveda from Bharadwaja. In his latter life he crossed the Vindhya mountains and settled in south India. There are of course many others such as Graga, the author of Graga samhita, a treatise on medicine. Narada, the author of Narada samhita on music and Dhatulaksana on Ayurveda dealing with pulse reading. Chyavana, the author of Jeevadana, a treatise on Ayurveda. Vyasa or Krishna Dwaipayana Vyasa in full reputed to be the author of Mahabarata and Brahmasutra and founder of the Mimamsa school of philosophy. He is quoted as the medical author by Arunadata. Markandeya, the author of Markeandeya Purana and a treatise on medicine – Nadi Prakasha dealing with the science of pulse. Sanatkumara, composed the Sanathakumara samhita which is part of Pancharatragama dealing with treatment of eye diseases. Shounaka who wrote a treatise, Shoundaka lanta of poisons and evil of inauspicious elements. Kanda, how wrote Kanada samhita, a treatise on Ayurveda; only one section of this 5. An Overview of Ayurveda Page 13 A Study of Cardiovascular Disease in Ayurveda John Vorstermans work is now available. Atri: Was another great sage, a composer of hymns and one of the saptarishas, During the time of Sri Rama he was living in Chitrakoota mountains in South India. He is the father of Punarvasu Atreya and Dattatreya. He is said to have written Atri samhita, a treatise on medicine which is found quoted by later medical authors. Dattatreya: the son of Atri is said to be an incarnation of Vishnu and worshipped as such even today. A treatise on diagnosis and treatment of diseases embodying the teaching of Dattatreya by the name of Daditawanidhi is available today with commentary by Telugu. Punarvasu Atreya: the son of sage Atri was well versed in many sciences, mature in philosophy and a teacher of the science of medicine, especially Kayachikitsa. Charaka samhita, the book par-excellence on Kayachikitsa identifies itself as the teaching of Atreya. Agnivesha: The illustrious pupil of Punarvasu Atreya composed a treatise embodying the teachings of his preceptor. It is believed that he was the author of Agnivesha tanta which is not available today; the Nadi pariksha which contains 150 versus on the study of the pulse; Agni nidana giving a few important symptoms to almost every disease under Kayachilitsa. Further authors are Bhela who wrote a treatise on medicine called Bheda samhita which parts of are still available and is said to be comparible to the Charaka Samhita. Divodasa: was the king of Kashi. He was a great scholar of that time and was proficient in Ayurveda. He is the founder of Salya Chikitsa, the school of surgery. Some scholars believed he lived around 8th cent B.C. Sushruta: was the son of of Viswamitra and learnt the science of medicine from Divodasa. The Sushruta Samhita that is extant now is shown by scholars to be not the 5. An Overview of Ayurveda Page 14 A Study of Cardiovascular Disease in Ayurveda John Vorstermans original treatise written by Sushruta but a revised and redacted version of it. 5.2.3 Historical Personages Bhikshu Atreya: (7th Century B.C.) The reputed teacher of Jivaka the famous physician of the Buddha. Jeevaka: (6th Century B.C.) was the well known physician of Buddha. He studied medicine for seven years at the famous University of Takshashila from the reknowned physician by name Bhikshu Athreya. It is said he affected wonderful cures in dropsy, eye diseases, tumours, swelling glands and even performed cranial operations. Charaka: Agnivesha Samhita written by Agnivesha embodying the teaching of Punarvasu Atreya is now available not in its original name but in the name of its redactor the celebrated Charaka. It is not sure if Charaka was a person or a school to which he belonged or a title given to someone. Thus it could be a name of several personages. Some say Charaka and Patanjali, the grammarian are identical, that Charaka was the court physician of king Kanishka. Pantanjali: In ancient Indian literature we come across this revered name as the author of 1) Mahabhasya – a commentary on Vyakarana sutra of Panini; 2) the Yoga Sutras, the aphorisms of the Yoga school of philosophy; 3)Loha Sastra, a treatise on metallurgy and 4) as the redactor or commentator of Charaka Samhita. It is uncertain of the identity of Pantanjali as there are a number of individuals by this name. Nagarjuna: is the name referring to three great scientists of India. 1) the Buddhist monk Nagarjuna who was also an alchemist; 2) Siddha Nagarjuna, the metallurgist and 3) Bhadanta Nagarjuna, (1st Century A.D.) the author of Rasavaiseshika Sutra, which deals with one of the fundamental theories in Ayurveda, the six tastes. 5. An Overview of Ayurveda Page 15 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Palakapya: (1st or 2nd Century A.D.) A notable name in veterinary medicine in ancient India. He produced the Palakapya Samhita or Hastuayurveda, a large work on elephants describing in detail their diseases and treatment both medical and surgical. Vagbhata: author of Asthanga Sangraha, Asthanga Hridaya and Rasaratna Samuchaya. Little is known of author or dates, many authors with same name. Bhattara Harichandra (4th - 5th A.D.). Wrote a commentary on Charaka Samhita called Charaka Nyasa which is the earliest known commentary on this treatise. No longer available in full. Madhavakara: (8th Century A.D.) wrote the famous book Rugvinischata known today as Madhavanidana. It was a first attempt to produce books from a subject perspective. 5.3 Recent History Before Ayurveda began its recent growth in the West, it went through a period of decline in India when Western medical education became dominant during the era of British rule. Ayurveda became a second-class option used primarily by traditional spiritual practitioners and the poor. After India gained its independence in 1947, Ayurveda gained ground and new schools began to be established. More than five hundred Ayurvedic companies and hospitals have opened in the last ten years, and several hundred schools have been established. Although Ayurveda remains a secondary system of health care in India, the trend toward complementary care is emerging, and Western and Ayurvedic physicians often work side by side. Interest in Ayurveda in the West began in the mid 1970's as Ayurvedic teachers from India began visiting the United States, Europe and later New Zealand. By sharing their 5. An Overview of Ayurveda Page 16 A Study of Cardiovascular Disease in Ayurveda John Vorstermans knowledge they have inspired a vast movement toward body-mind-spirit medicine. Today Ayurvedic colleges are opening throughout Europe, Australia, New Zealand and the United States. 5.4 An Overview of Ayurvedic Anatomy and Physiology The Western allopathic medicine is based on a medical model of the human being. It considers only the physical body and treats the mind as a physical entity. Ayurveda looks at the human body as being an integral part of nature and is based on the theory of biological humors and body energies. This helps it to get to the root of the problem rather than simply addressing the symptoms. A fundamental aim of Ayurveda is to prevent illnesses by timely adherence to a natural way of life that falls within the bounds of a person's nature. Ayurveda is a science of self-understanding. By understanding our own unique nature or constitution we can begin to understand how we interact with our environment and thus make choices that will lead us toward greater health. Ayurveda defines disease as the natural end result of living out of harmony with our original constitution (prakruti). Therefore, the Ayurvedic approach is very individualised, since the path to good health is different for each person, depending upon their unique constitution or prakruti. Many factors, both internal and external, can disturb our delicate balance, which brings about changes in our original constitution that may lead to disorders and disease. Some of these factors include emotional and physical stresses, improper food combinations and choices, physical trauma, or seasonal and weather changes. Once we understand how these factors affect us on a constitutional level, we can take appropriate actions to nullify or minimise their effects and eliminate the causes of imbalance. 5. An Overview of Ayurveda Page 17 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Ayurveda looks at the human from the following perspective: 5.5 Doshas (Bodily Humors) According to Ayurveda the functional aspects of the body are determined by three biological humors, called doshas - Vata, Pitta and Kapha. They co-ordinate, control and direct all the biological functions of human body and therefore are considered extremely important. This knowledge plays a crucial role in the diagnosis and treatment in Ayurveda. Vata Dosha Vata Dosha is associated with motions, transportation and electromagnetic activities. Vata signifies the kinetic energy of the body. In different proportions, these qualities appear in human beings. The Vata nature notably has these attributes: • Cold • Quick • Dry • Rough • Light • Subtle • Mobile • Hard Pitta Dosha Pitta Dosha is associated with the transformations in the body. Pitta represents the fire principle. It deals with the chemical changes taking place in a body including consumption and conversion. It controls digestion of food and is responsible for emotions. The Pitta nature notably has these attributes: • Hot • Sharp • Moist • Sour • Light • Flowing • Liquid • Slightly Oily Kapha Dosha 5. An Overview of Ayurveda Page 18 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Kapha follows the principle of water and earth. This Dosha signifies the potential energy of the body. Depending on the anatomy and body function, five types of Kapha Doshas have been identified. The Kapha nature notably has these attributes: • Heavy • Sweet • Steady • Soft • Oily • Cold • Slow • Slimy All these Doshas are connected with life. Each of them has different significance and a different quality. A perfect balance of these three Doshas are important in maintaining a healthy life. 5.6 Sub-Doshas As well as the above doshas, Ayurveda divides each dosha into a further five sub- doshas, each of which has a special function in relation to the main dosha. Vata Vata governs all movement in the mind and body. It controls such things as blood flow, elimination of wastes, breathing and the movement of thoughts across the mind. Since Pitta and Kapha cannot move without it, Vata is considered the leader of the three Ayurvedic principles in the body. These are the sub-categories or sub-doshas under Vata – • Prana Vata: The senses, creative thinking, reasoning, enthusiasm, leader of all 15 categories of Vata, Pitta and Kapha • Vyana Vata: Blood flow, heart rhythm, perspiration, sense of touch 5. An Overview of Ayurveda Page 19 A Study of Cardiovascular Disease in Ayurveda John Vorstermans • Udana Vata: Quality of voice, memory, movement of thoughts • Samana Vata; Movement of food through digestive tract • Apana Vata: Elimination of wastes, sexual function, menstrual cycle Pitta Pitta governs bodily functions concerned with heat and metabolism, and directs all biochemical reactions and the process of energy exchange. For example, Pitta controls how we digest foods, how we metabolize our sensory perceptions, and how we discriminate between right and wrong. Pitta governs the important digestive "Agnis" or fires of the body. Pitta dosha is further divided into the following sub-doshas – • Pachaka Pitta: Digestion, assimilation, metabolism for healthy nutrients and tissues • Ranjaka Pitta: Healthy, toxin-free blood • Alochaka Pitta: Functioning of the eyes • Bhrajaka Pitta: Healthy glow of the skin • Sadhaka Pitta: Desire, drive, decisiveness, spirituality Kapha Kapha governs the structure and cohesion of the organism. It is responsible for biological strength, natural tissue resistance, and proper body structure. It also governs lubrication in the mind and body. It controls weight, growth, lubrication for the joints and lungs, and formation of all the seven tissues – nutritive fluids, blood, muscles, fat, bones, marrow and reproductive tissues. These are the sub-doshas of Kapha – 5. An Overview of Ayurveda Page 20 A Study of Cardiovascular Disease in Ayurveda John Vorstermans • Kledaka Kapha: Moisture of the stomach lining for good digestion • Avalambaka Kapha: Protects the heart, strong muscles, healthy lungs • Sleshaka Kapha: Lubrication of the joints, soft and supple skin • Tarpaka Kapha: Moisture for nose, mouth, eyes and brain • Bhodaka Kapha: Sense of taste, which is essential for good digestion • 5.7 Dhatus (Tissues) According to the basic fundamentals of Ayurveda, our body is composed of four basic factors - Dosha, Dhatu, Mala and Agni. The root of the word "Dhatu" is "Dha", which means "foundation". The function of Dhatu is to support the body by providing basic nutrition. It helps in the growth, as well as maintenance of the structure of the mind. Dhatus provide nourishment to tissues. According to Ayurveda, there are seven Dhatus in our body. They are • Rasa - plasma • Rakta - blood • Mamsa - muscle • Meda - fat tissues • Asthi - bone • Majja - marrow • Shukra - semen 5. An Overview of Ayurveda Page 21 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Each Dhatu is developed from the previous Dhatu, and then transformed to another. In this way, the Dhatus form a chain system in our body. Any disturbance in the equilibrium of these Dhatus causes disease. Significance of Dhatu Dhatus are the foundation for growth and existence. They exist in multiple forms. Different body parts as well as organs are made of Dhatus. It is important to note that as they form a chain system in our body this points to one thing - if the first tissue is not formed properly, it will in turn affect the other tissues. The formation and maintenance of each of these Dhatus, and their perfect balance is very important for our health. 5.8 Srotases (Bodily Channels) Srotases or channels are present in all living things. These srotases carry food, minerals, water, air and thoughts. A block in a srotases is the beginning of diseases. Only three srotases or channels are recognized by modern medical science – they are the anna vaha srotas (the digestive system), rakta vaha srotas (circulatory system) and the prana vaha srotas (respiratory system). Charaka Samhita, lists thirteen srotases in his book. Three srotases for food, air and water, seven srotases associated with dhatus, and three srotases for excretion. Presently there are sixteen srotases identified. The first three srotases are: Prana vaha srotas carries breath Anna vaha srotas carries solid and liquid food Udaka vaha srotas carries water in the body 5. An Overview of Ayurveda Page 22 A Study of Cardiovascular Disease in Ayurveda John Vorstermans The seven srotases associated with dhatus are: Rasa vaha srotas carries plasma and lymphatic liquid Rakta vaha srotas carries blood – circulatory system Mamsa vaha srotas carries nutrients to and from muscle tissue Meda vaha srotas supplies fat to adipose tissues Asthi vaha srotas supplies nutrients to bones Majja vaha srotas supplies nutrients to bone marrow, the nervous system and the brain. Shukra vaha srotas supplies nutrients to sexual organs and carries reproductive cells and liquids. The three srotases associated with malas (excretion) are: Purisha vaha srotas carries feces Mutra vaha srotas carries urine Sveda vaha srotas carries sweat The three additional srotases that are not described in Charaka Samhita are: Two women-only srotases are: Artava vaha srotas carries menstrual fluids Stanya vaha srotas carries breast milk One srotas associated with mind is: Mano vaha srotas carrying thoughts and wisdom 5.9 Mala (Waste products) The waste products of the body are called Malas. The metabolic activities going on in the body will result in the excretory by-products. They are known as Malas because their main characteristic is to detoxify. It is necessary to remove these waste products in order to 5. An Overview of Ayurveda Page 23 A Study of Cardiovascular Disease in Ayurveda John Vorstermans maintain a healthy body. The main excretory products of the body are also known as. Dushyas These can cause an imbalance in the doshas and can cause diseases. There are three main types of Malas. • Purisha (Stool) • Mutra (Urine) • Sweda (Sweat) The essence of the ingested food will nourish the tissues. The waste products formed out of the food should be removed at appropriate intervals. This is essential in maintaining proper health. 5.10 Agni (Digestive Fire) The meaning of Agni is fire. Ayurveda calls the biological fire Agni. The metabolic activities as well as the digestive activities of the body take place with the help of Agni. The various enzymes present in the body can be considered as aspects of Agni. The main functions of Agni are to: • Take the essence of nourishment from food. • Help in carrying out the metabolic reactions of the body. • Help the immune system by destroying harmful organisms and toxins. The digestive power and immune system depends on the proper functioning of Agni. So the balance of Agni with the other factors is important for a fit and healthy body. Ayurveda classifies Agni into thirteen forms of which the most important is Jatharagni. The main function of Jatharagni is to take part in the digestion process and 5. An Overview of Ayurveda Page 24 A Study of Cardiovascular Disease in Ayurveda John Vorstermans separate nutrients from waste products. To maintain fitness we have to understand the key factors in maintaining the balance of the Agni in the human body. When Agni is healthy there will be good digestion, proper elimination of waste products, excellent circulation of nutrition and proper tissue formation. Thus the person remains in a state of good mental and physical health. 5.11 Prakriti Unlike other medicinal systems, Ayurveda treats the individual as a whole. During the diagnosis and treatment, Ayurveda tradition gives particular emphasis to the condition of body as well as mind. Prakriti and Vikriti By Prakriti, Ayurveda means the individual constitution of the human body. A state of disease occurs whenever there is a deviation from the normal physical or mental constitution of a human being. This is often called a Vikriti. During diagnosis, Ayurveda examines the Prakriti first. Then it examines the diseased state or Vikriti. Ayurveda is interested in the individual, not only the disease. The Individual Constitution Ayurveda believes that the constitution of a humanbeing is genetic in origin. It is determined at the time of conjugation of the male seed (sperm) and female egg (ovum). The resulting embryo then carries the individual constitution of the parents. According to Vedic wisdom, every material object in this universe is composed of five elements called Pancha Mahabhutas (ether, air, fire, water, earth). But for the 5. An Overview of Ayurveda Page 25 A Study of Cardiovascular Disease in Ayurveda John Vorstermans functioning of living beings, Ayurveda identifies Tri Doshas (Tri = three) for body constitution and Tri Gunas responsible for mental constitution. Ayurveda treats these doshas as the manifestation of five elements in the human body. Tri Doshas • Vata • Pitta • Kapha Tri Gunas • Satva • Rajas • Tamas Different individuals will have different combinations of these doshas and therefore, each individual will have a unique Prakriti. 5.12 Restoring Balance An individual may have a natural predominance of one or more doshas. These doshas need not be present in equal proportion in an individual to ensure balance, but they need to be functioning in harmony with each other. According to Ayurveda, disorders stem from an excess of a dosha or a shortage of a dosha, whereas maintaining balance of the doshas results in good health. For example, when Pitta is in balance in an individual, digestion is normal, but an aggravated Pitta can result in ulcers and acid indigestion. Over time, the natural balance of the doshas in an individual can be disturbed by a 5. An Overview of Ayurveda Page 26 A Study of Cardiovascular Disease in Ayurveda John Vorstermans number of factors, such as improper diet, poor digestion, high day-to-day stress levels and environmental pollution and chemicals. The Ayurvedic approach to health is all about restoring this natural balance, through dietary and lifestyle recommendations as well as herbal formulations. The goal is not to treat surface symptoms, but the underlying imbalance, thus creating long-term health and a strong immune system. 5. An Overview of Ayurveda Page 27 A Study of Cardiovascular Disease in Ayurveda John Vorstermans The Human Body is made up of 5 Elements Time Direction Mind Soul 3 Qualities Sattva i.e. Rajas i.e. Tamas i.e. Knowledge & Force & Ego Inertia & Positivism Negativity Dosha Dhatu Mala Humour Tissues Excretory Material 3 in number 7 in number 3 in number Purusha Mutra Sweda Stools Urine Sweat Vata dosha Pitta dosha Kapha dosha Agency of Agency of Agency of Propulsion Conversion Cohesion Rasa Rakta Mamsa Meda Asthi Majja Shukra Lymph RBCs Muscle Fat Bone Bone Semen Plasma (for keeping Tissue Tissue (for support Marrow & Ovum (for life (for (for keeping of body) Brain, (for nourishment) force) covering the body Nerves reproduction of body & slimy) (for filling up & enjoyment) other the space tissues) specifically in deep bone tissue) Table 1 The Human Body 5. An Overview of Ayurveda Page 28 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6. Literature Review. 6.1 Cardiovascular Disease statistics. More than half of the deaths in the USA and New Zealand are due to coronary Cardiovascular Disease or “hardening of the arteries” resulting in heart attacks and what is called SCD, or sudden cardiac death (discussed in more detail below). Another almost 20% is from stroke. The third most common cause of death, congestive heart failure (pump failure) has a number of causes, but in 75% of the cases it is a consequence of extensive heart damage following a heart attack. Thus nearly 80% of deaths from cardiovascular disease come from diseases that take years to become clinically apparent and are caused by the development of atherosclerotic plaque in the heart and its arteries (coronary arteries) or in the arteries that supply blood to the brain. What is the frequency of cardiovascular diseases related to age and gender? The prevalence (frequency) of cardiovascular (CV) diseases in the US is shown in the figure below. As you can see, CV diseases are generally uncommon in the very young and the statistics generally begin around age 20. The frequency increases dramatically with age. In men, the prevalence is only about 6% at age 20 Figure 1a - Prevalence of CV Diseases in Men and Women 20 years of age and older–source AHA and increases to 80% by age 75. In women the prevalence is about 5% at age 20 and increases also to 80% by age 75. However, there are distinct prevalence of CV Diseases in Men and differences between men and women in the years. The frequency in women remains generally lower than in men until 6. Literature Review. Page 29 A Study of Cardiovascular Disease in Ayurveda John Vorstermans around age 50 (the timing of the onset of menopause) and then accelerate to equal that of men. Between the ages of 25 and 55, the prevalence of CV disease in women, which is mainly Cardiovascular Disease related, is roughly ten years behind that of men of the same age. Coronary Cardiovascular Disease rates in women after menopause are 2-3 times those of women the same age before menopause. Cardiovascular Disease and general atherosclerotic disease (the most common causes of CV disease deaths) increases in frequency as we get older. Symptomatic atherosclerotic disease takes years to develop, although data in heart transplant donors (who died mostly from accidents or suicide) have shown that 25% of teenagers already have developed some atherosclerotic plaque in their coronary arteries. This year an estimated 700,000 Americans will have a initial heart attack. About 500,000 will have a recurrent heart attack. The lifetime risk of developing coronary Cardiovascular Disease after age 40 is 49% for men and 32% for women. Coronary Cardiovascular Disease caused more than 1 of every 5 deaths in the United States in 2001. Coronary Cardiovascular Disease is the leading cause of premature, permanent disability in the US labour force, accounting for 19% of disability allowances by the Social Security Administration. Depending on their age and clinical outcome, people who survive a first heart attack have a risk of hospitalization or death that is 1.5 to 15 times higher than that of the general population. Within 6 years of a first heart attack: • 18% of men and 35% of women will have a second heart attack • 7% of men and 6% of women will experience sudden cardiac death • 22% of men and 46% of women will be disabled with heart failure • 8% of men and 11% of women will have a stroke 6. Literature Review. Page 30 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Cardiovascular disease in New Zealand [Mortality] Ischaemic heart disease was the second leading cause of death after cancer in 2002, with 6287 deaths. Males accounted for 53.0 percent of these deaths, but the male age- standardised rate was almost twice the female rate in 2002. Ischaemic heart disease was the second leading cause of death after cancer in 2003, with 6196 deaths. Males accounted for 52.3 percent of these deaths. In 2002, the calculated Māori male age-standardised rate of death from ischaemic heart disease was 97 percent higher than the non-Māori male rate, and the calculated Māori female rate was 92 percent higher than the non-Māori female rate. In 2003, the calculated Māori male age-standardised rate of death from ischaemic heart disease was 120 percent higher than the non-Māori male rate, and the calculated Māori female rate was 84 percent higher than the non-Māori female rate. 6.1.2 History of Cardiovascular Disease Cardiovascular disease is an established chronic disease for the population of developed and developing countries. Chronic diseases are illnesses that are prolonged, do not resolve spontaneously, and are rarely cured completely. Cardiovascular disease refers to variety of diseases and conditions affecting the heart and blood vessels. The major cardiovascular diseases are coronary Cardiovascular Disease (CHD), myocardial infarction (MI), stroke and congestive heart failure (CHF). Cardiovascular diseases are preventable. This disease causes a significant burden in mortality, morbidity, and health care cost. Despite the gradual decline in cardiovascular death rates over the last few decades, these diseases are and will remain the number one cause of death in industrialized countries. 6. Literature Review. Page 31 A Study of Cardiovascular Disease in Ayurveda John Vorstermans In this region, 48.6 percent of deaths were caused by cardiovascular disease in the year 2000 (WHO1, 2002). By 2020, 46.4 percent deaths are expected to be attributable to CVD in this region. Moreover, CVD will soon become the main cause of death and disability in the developing world as well; by 2020, a third (33.8 percent) of all deaths are expected to be due to CVD (WHO, 2002). In the year 2000, 16.7 million people died from CVD, accounting for 30.3 percent of all deaths worldwide; more than half of these deaths were in developing countries (WHO, 2001). Not only is cardiovascular disease a considerable health burden (e.g. high morbidity and high mortality), it causes also a significant health care cost (i.e. economic burden), which will continue to grow as the population ages. The ongoing economic and technological developments taking place in the developing countries will in all likelihood cause the pattern seen in developed world to be repeated. The epidemic of cardiovascular disease is expected initially to emerge in those who are wealthy and subsequently to spread to those who are less wealthy. Likewise, when the epidemic starts to slow, this will first become apparent among the affluent, with the disease continuing to have a high prevalence in those who live in poverty. The burden of CVD, although already high in developed world, is therefore expected to increase on a global scale as the developing countries start to contribute significantly to this (WHO, 2002). The presence of rising CVD underscores the imperative need to develop effective and appropriate prevention policies.ii 1 WHO = World Health Organisation 6. Literature Review. Page 32 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.2 Cardiovascular Disease. 6.2.1 Overview Cardiovascular disease is a term used to describe a large range of diseases that affect the heart or blood vessels. There are various diseases considered as cardiovascular disease includes coronary artery disease, heart attack, heart failure, high blood pressure and stroke. The term "cardiovascular disease" is often used interchangeably with “heart disease” because both terms refer to diseases of the heart or arteries. Whatever name is used — cardiovascular disease or heart disease – it is clear that diseases of the heart and blood vessels are serious problems. Cardiovascular disease is the No. 1 worldwide killer of men and women, as mention previously under “Cardiovascular Disease Statistics” 6.2.2 Cardiovascular Disease from a Medical Perspective Cardiovascular disease refers to many different types of heart or blood vessel problems. It is used most often to describe damage caused to the heart or blood vessels by atherosclerosis. This is a disease that affects the arteries. Arteries are blood vessels that carry oxygen and nutrients from your heart to the rest of the body. Healthy arteries are flexible, strong and elastic. Over time, however, too much pressure in the arteries can make the walls thick and stiff — sometimes restricting blood flow to the organs and tissues. This process is called arteriosclerosis, or hardening of the arteries, and atherosclerosis is the most common form of this disorder. 6. Literature Review. Page 33 A Study of Cardiovascular Disease in Ayurveda John Vorstermans The ultimately causes of atherosclerosis are an unhealthy diet (lots of saturated fats), lack of exercise, being overweight and smoking. All of these are major risk factors for developing atherosclerosis and, in turn, cardiovascular disease. Some forms of cardiovascular disease are not caused by atherosclerosis. Those forms include diseases such as congenital Cardiovascular Disease, heart valve diseases, heart infections or disease of the heart muscle called cardiomyopathy. Causative Theory There are two main theories about why atherosclerosis develops: 1. High levels of cholesterol in the blood injure the artery's lining, causing an inflammatory reaction and enabling cholesterol and other fatty materials to accumulate there. 2. Repeated injury to the artery's wall may occur through various mechanisms involving the immune system or through direct toxicity. In both cases, there are changes that can lead to the formation of atheromas. The two theories are probably interrelated and are not mutually exclusive. ”Infection may have a role in the development of atherosclerosis. The infection may be due to bacteria (Chlamydia pneumoniae, which can cause pneumonia, or Helicobacter pylori, which can contribute to stomach ulcers) or to a virus (as yet unidentified). Infection may Figure 1 – Formation of atheromas in arteries. 6. Literature Review. Page 34 A Study of Cardiovascular Disease in Ayurveda John Vorstermans damage the lining of the artery's wall, enabling atherosclerosis to begin..iii 6.2.3 Cardiovascular Disease from an Ayurvedic Perspective. Ayurveda classifies Cardiovascular Disease under the following: Adibalapravrutta: Hereditary Cardiovascular Disease e.g. metabolic diseases Janmabalapravrutta: Congenital Cardiovascular Disease Doshabala pravrutta: Vata, Pitta, Kapha, Sannipatika Sanghatabalapravrutta: (a) Traumatic. (b) Poisoning Kalabalapravrutta: Environmental or seasonal Upasargaja: Infectious diseases e.g. Endocarditis, Myocarditis, Pericarditis Swabhavabalakruta: Natural diseases e.g. ageing, death Adhyatmika: Psychological factors leading to Cardiovascular Disease or hypertension Daivabalakruta: Idoipathic, bad luck due to bad deeds of previous lives. Table 2 - Ayurveda Cardiovascular Disease. The diseases of each organ are classified and treated according to the tissue (dhatu) and dosha affected. For example, embryologically, endocardium is derived from Rasa and Rakta dhatus. Myocardium is derived from muscular tissue (Mamsa) and pericardium is derived from fatty (Meda) and connective tissue. Each of these three layers of the heart can be affected by one or all of the doshas. Looking at the endocardium, if it is a Vata disorder then this will lead to valvular 6. Literature Review. Page 35 A Study of Cardiovascular Disease in Ayurveda John Vorstermans affections like aortic and mitral stenosis and regurgitation. If Pitta is effected then we would include bacterial endocarditis and if Kapha the endocardial fibroelastosis. It would be treated by strengthening Rasa and Rakta and restoring the balance to the Doshas involved. For diseases of the myocardium, if they involved Vata then we would see atrophy or fibrosis of the heart muscle which would result in dilation of the heart. If Pitta is involved then we would see myocarditis and with Kapha, hypertrophy of heart muscle as well as for example, glycogen storage diseases. The treatment in these cases would look at strengthening the muscular tissue (Mamsa) and treating the affected Doshas. For diseases affecting the coronary arteries; if a Vata disorder, it gives rise to angina pectoris, if Pitta then specific or non-specific arteritis, and Kapha to atherosclerosis changes. For each of the above classifications of Cardiovascular Disease Ayurveda has a different treatment approach. 6.2.4 Types of cardiovascular disease The cardiovascular system consists of the heart and all blood vessels throughout the body. Diseases ranging from aneurysms to valve disease are types of cardiovascular disease. A person may be born with some types of cardiovascular disease (congenital) or acquire others later on, usually from a lifetime of unhealthy habits, such as smoking, which can damage the arteries and cause atherosclerosis. Some specific terms used to describe the various forms of cardiovascular disease are: 6. Literature Review. Page 36 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Coronary artery disease. This is a common form of cardiovascular disease. Coronary artery diseases are diseases of the arteries that supply the heart muscle with blood. Sometimes known as CAD, coronary artery disease is the leading cause of heart attacks. It generally means that blood flow through the coronary arteries has become obstructed, reducing blood flow to the heart muscle. The most common cause of such obstructions is a condition called atherosclerosis, a largely preventable type of vascular disease. Coronary artery disease and the resulting reduced blood flow to the heart muscle can lead to other heart problems, such as chest pain (angina) and heart attack (myocardial infarction). Ayurveda views atherosclerosis according to the symptoms. Degeneration of the blood vessels is caused by increased Vata in the blood vessels, which make them hard, thin, dry and rough. Deposits of lipids and calcium represents deposition of Kapha (water & earth element) in the degenerated vessels resulting in irregular thickening of blood vessels. Ayurveda therefore concludes that this disease is caused by an increase of Vata and vitiation of Kapha in the blood vessels. Figure 2 – Coronary Artery Disease causing heart attack Heart attack. A heart attack (see Figure 2) is an injury to the heart muscle caused by a loss of blood supply. The medical term for heart attack is "myocardial infarction," often abbreviated MI. A heart attack usually occurs when a blood clot blocks the flow of blood through a coronary 6. Literature Review. Page 37 A Study of Cardiovascular Disease in Ayurveda John Vorstermans artery — a blood vessel that feeds blood to a part of the heart muscle. Interrupted blood flow to your heart can damage or destroy a part of the heart muscle. Cardiomyopathy Cardiomyopathy means diseases of the heart muscle. Some types of cardiomyopathy are genetic, while others occur for reasons that are less well understood. Types of cardiomyopathy include ischemic, which is caused by loss of heart muscle from reduced coronary blood flow; dilated, which means the heart chambers are enlarged; hypertrophic, which means the heart muscle is thickened; and idiopathic, which means the cause is unknown. One of the most common types of cardiomyopathy is Figure 3 . Cardiomyopathy idiopathic dilated cardiomyopathy — an enlarged heart without a known cause. Ayurveda would look at this as being associated with a pathology of Mamsa dhatu and a blockage, caused by toxins in the Mamsa Vaha srotas. Congenital heart disease. Congenital heart disease refers to a form of heart disease that develops before birth (congenital). Congenital heart disease is a broad term and includes a wide range of diseases and conditions. These diseases can affect the formation of the heart muscle or its chambers or valves. They include such conditions as narrowing of a section of the aorta (coarctation) or holes in the heart (atrial or ventricular septal defect). Some congenital heart defects may be apparent at birth, while others may not be detected until later in life. 6. Literature Review. Page 38 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Aneurysm. An aneurysm is a bulge or weakness in a blood vessel (artery or vein) wall. Aneurysms usually get bigger over time. Because of that, they have the potential to rupture and cause life-threatening bleeding. Aneurysms can occur in arteries in any location in your body. The most common sites include the abdominal aorta and the Figure 4 Aneursyms arteries at the base of the brain. Ayurveda classifies aneurysm as gulma and understands that this is caused by weakness of muscular tissue (Mamsa) and an increase in Vata. Valvular heart diseases. These are diseases of the heart valves. Four valves within your heart keep blood flowing in the right direction. Valves may be damaged by a variety of conditions leading to narrowing (stenosis), leaking (regurgitation or insufficiency) or improper closing (prolapse). You may be born with valvular disease, or the valves may be damaged by such conditions as rheumatic fever, infections (infectious endocarditis), connective tissue disorders, and certain medications or radiation treatments for cancer. Pericardial diseases. These are diseases of the sac that encases the heart (pericardium). Pericardial disorders include inflammation (pericarditis), fluid accumulation (pericardial effusion) and 6. Literature Review. Page 39 A Study of Cardiovascular Disease in Ayurveda John Vorstermans stiffness (constrictive pericarditis). These can occur alone or together. The causes of pericardial disease vary, as do the problems they may lead to. For instance, pericarditis can occur after a heart attack and, as a result, lead to pericardial effusion or chest pain. Figure 5 Pericardial effusion From and Ayurvedic perspective the inflammation (pericarditis) is associated with Pitta, while fluid fluid accumulation (pericardial effusion) with Kapha and stiffness (constrictive pericarditis) with Vata. Heart failure. Heart failure, often called congestive heart failure, is a condition in which the heart can't pump enough blood to meet the needs of your body's organs and tissues. It doesn't mean your heart has failed and can't pump blood at all. With this less effective pumping, vital organs don't get Figure 6 Congestive Heart Failure enough blood, causing such signs and symptoms as shortness of breath, fluid retention and fatigue. "Congestive" heart failure is technically reserved for situations in which heart failure has led to fluid buildup in the body. Not all heart failure is congestive, but the terms are often used interchangeably. Heart failure may develop suddenly or over many years. It may occur as a result of other cardiovascular conditions that have damaged or weakened the heart, such as coronary artery disease or cardiomyopathy. Ayurveda recognises that a mild disturbance in the balance of Vata, Pitta and 6. Literature Review. Page 40 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Kapha in the heat muscle results in the impairment of the cardiac function, which is usually compensated by augmenting the heart rate and increasing the force of ventricular contraction. Marked disturbance in the balanced state of Vata, Pitta and Kapha in the heart muscle give rise to uncompensated heart failure. High blood pressure. High blood pressure (hypertension) is the excessive force of blood pumping through your blood vessels. It's perhaps the most common form of cardiovascular disease in the Western world, affecting about one in four Americans. Although potentially life-threatening, it's one of the most preventable and treatable types of cardiovascular disease. High blood pressure also causes many other types of cardiovascular disease, such as stroke and Figure 7 Blood Pressure heart failure. Ayurveda has no corresponding condition in the ancient texts, rather the varying symptoms are described in various sections. P.V. Sharma suggests that Rakta Vata is possibly the most appropriate ayurvedic equivalent. The cause is generally due to a low agni which causes toxins (ama) along with increased Kapha and deposits of fat like substances in the blood vessels in the body resulting an disturbance of Vyana Vata in Rasa and Raktavaha srotas which triggers hypertension. Stroke. A stroke occurs when blood flow to the brain is interrupted (ischemic stroke) or when 6. Literature Review. Page 41 A Study of Cardiovascular Disease in Ayurveda John Vorstermans a blood vessel in the brain ruptures (hemorrhagic stroke). Both can cause the death of brain cells in the affected areas. Stroke is also considered a neurological disorder because of the many complications it causes. Other forms of cardiovascular disease, such as high blood pressure, increase your risk of stroke. Peripheral arterial disease and claudication. You may be more familiar with the term "claudication" — which usually refers to pain in your legs during exercise — than you are the term "peripheral arterial disease." Strictly speaking, claudication is a symptom of peripheral arterial disease. However, claudication is often referred to as a disease itself. Peripheral arterial disease is a disorder in which the arteries supplying blood to your limbs — usually your legs — become narrowed or blocked. When this happens, your legs receive less blood than they need to keep up with demand. Claudication may then develop. Figure 8 Peripheral arterial disease When the obstruction is mild, you may have such symptoms as pain in your legs only during strenuous exercise. As the disease progresses and arteries become more obstructed, you may have pain or cramping in your legs even at rest. Arrhythmias. Heart rhythm problems (arrhythmias) occur when the electrical impulses in your heart that coordinate your heartbeats don't function properly, causing your heart to beat too fast, too slow or irregularly. Other forms of cardiovascular disease can cause arrhythmias. 6. Literature Review. Page 42 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Stable Angina Also known as Angina pectoris is chest pain caused by myocardial ischemia. It usually last from 3 to 5 minutes and if the blood flow is restored no permanent change or damage results. It is usually experienced by chest discomfort ranging from a sensation of heaviness or pressure to moderately severe pain. Discomfort may radiate to the neck, lower jaw, left arm and left shoulder, or occasionally to the back or down the right arm. Discomfort is commonly mistaken for indigestion. Stable angina is caused by gradual luminal narrowing and hardening of the arterial walls, so that affected vessels cannot dilate in response to increased myocardial demand associated with physical exertion or emotional stress. Prinzmetal angina. Prinzmetal angina is chest pain attributed to transient ischemia of the myocardium that occurs unpredictably and almost exclusively at rest. Pain is caused by vasospasm of one or more major coronary arteries with or without associated atherosclerosis. The pain often occurs at nigh during rapid eye-movement sleep and may have a cyclic pattern of occurrence. The angina may occur from hyperactivity of the sympathetic nervous system, increases calcium flux in arterial smooth muscle or impaired production or release of prostaglandin or thromboxane. Silent Ischemia. Myocardial ischemia often does not cause detectable symptoms such as angina. Ischemia can be totally asymptomatic which is referred to as silent ischemia. People who do not experience angina often have silent episodes of myocardial ischemia. Mental Stress induced Ischemia. 6. Literature Review. Page 43 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Recent study has suggested that an artery is occluded in some individuals during mental stress. Rozansky documented myocardial ischemia by radionuclide angiography (RNA) during mental stress, the majority of cases (83%) were silent. These observations confirmed in similar studies, suggest that the increases in blood pressure induced by mental stress and the increase in myocardial oxygen demand play a role in the pathophysiology of mental stress-induced myocardial ischemia.iv Chronic stress has been linked to a hypercoagulable state that may contribute to acute ischemic events. Stress management has been associated with a significant reduction in CAD events in men. Hypertension. Hypertensive Cardiovascular Disease is generally 1. Left ventricular hypertrophy in the absence of other cariovascular pathology and 2. A history of hypertension. Hypertension strongly predisposes to atherosclerosis and so most patients with elevated blood pressure have significant coronary atherosclerosis. The vascular disease increases peripheral resistance and viscosity in the arteries. The heart then must maintain a normal cardiac output against this increased peripheral resistance and can accomplish this only by hypertrophy of myofibres causing cardiac enlargement Evaluation This is generally done by taking a complete history, including risk factors, a physical examination, laboratory tests. Judicious use of x-ray, electrocardiography, ultrasonography, nuclear scanning and angiography may be necessary to identify affected vessels, particularly coronary vessels. 6. Literature Review. Page 44 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.3 Development of Cardiovascular Disease 6.3.1 The medical model. The factors that cause Cardiovascular Disease are classified into modifiable and nonmodifiable. The nonmodifiable risk factors refer to variables that cannot be altered by persons wishing to decrease their risk of cardiovascular disease. Examples of this are genetic polymorphisms. Numerous types of genetic susceptibilities to CAD have been identified in individuals with a family history of Cardiovascular Disease. Modern medicine looks at several factors which contribute to Cardiovascular Disease. Arteriosclerosis This is a chronic disease of the arterial system resulting in the abnormal thickening of and hardening of the walls of the blood vessels. Smooth muscle cells and collagen fibres migrate into the tunica intima, causing stiffness and thickening, which gradually narrow the arterial lumen. It is believed that changes in the lipid, cholesterol and phospholipid metabolism within the tunica intima also contribute to arteriosclerosis. Atherosclerosis Atherosclerosis is a form of arteriosclerosis is which soft deposits of intra arterial fat and fibrin on the vessels walls of medium to large arteries harden over time. Atherosclerosis is the most common vascular disease, being the main cause of death in approximately 50% to 60% of people in the developed world. The word Atherosclerosis is derived from the Greek athere (porridge) and scleros (hardness). 6. Literature Review. Page 45 A Study of Cardiovascular Disease in Ayurveda John Vorstermans It is the main cause of ischaemic coronary Cardiovascular Disease, carotid artery stenosis by occlusion or thromboembolism. In turn, this can cause ischaemia in the cerebral arteries, presenting either as transient ischaemic attack or cerebral infarction. Abdominal aortic atherosclerotic aneurysm, where the main artery in the abdomen becomes abnormally wide with a thin wall, can burst. Peripheral vascular disease (PVD), which causes intermittent claudication or gangrene of the extremities, pain in the legs when walking, can be relieved by Figure 9 Atherosclerosis rest. Heart attack and stroke are very loose terms. "Heart attack" most commonly indicates myocardial infarction. It is sometimes used to denote dysrythmia. Coronary thrombosis is typically due to plaque rupture. In this process, the atherosclerotic lesion (abnormal area of artery) has a thin fibrous lining that is more mechanically weak, has increased macrophage cells, and has reduced vascular smooth muscle cells (which normally make collagen). In plaque rupture, the plaque inflammation erodes the fibrous lining (fibrous cap) to the point where it breaks apart (possibly under added hemodynamic stresses), releasing necrotic debris containing tissue factor in the lipid necrotic core into contact with blood. This stimulates clotting that blocks off the artery (occlusive thrombus). Unless reopened by drugs or percutaneous coronary intervention the blocked artery causes the heart muscle to die of lack of nutrients and oxygen. This is termed a myocardial infarction. 6. Literature Review. Page 46 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.3.2 Ayurveda model Heart Tissue The heart is a muscle (mamsa dhatu). It derives its nutrients from Rasa, its oxygen from Rakta and its vital energy from Ojas. The movements of the heart are controlled by Vyana Vata (autonomic nervous system). Sadhaka Pitta represents the intracellular enzymes in the cells of the heart, which helps it to digest and utilise the nutrients and oxygen. Avalambaka Kapha represents the intracellular and interstitial fluid of the heart and chest. Any of these eight basic elements, that is, Rasa, Rakta, Mamsa (muscular tissue), Ojas, Prana Vata, Vyana Vata, Sadhaka Pitta and Avalambaka Kapha, when affected can disturb the function of the heart and cause Cardiovascular Disease. Rasa and the Heart It is important to maintain and protect the volume and composition of Rasa, the body fluids, at all times. Any disturbance in Rasa can impair the movement of essential nutrients to our bodies cells and organs. This will then affect all our tissues (dhatus), Rakta (blood), Mamsa (muscle), Meda (fat), Asthi (bone), Majja (nervous tissue), Shukra (reproductive tissue), Ojas (vital fluid) which in turn will effect our sense organs and mind. Any effect to the channel that carries Rasa (Rasa Vaha Srotas) will cause imbalance in Rasa. Rasa can be vitiated (rasa-dusthi), increased (rasa-vruddhi) or decreased (rasa- kshaya) Vitiation of Rasa is generally caused by eating too much heavy, fatty or cold food or by excessive thinking or worry. It gives rise to anorexia, inability to appreciate taste, nausea, 6. Literature Review. Page 47 A Study of Cardiovascular Disease in Ayurveda John Vorstermans weak digestive power, body ache, drowsiness, fever, malnutrition, premature hair greying, baldness, impotence. This can lead to hypercholesterolemia and heart attack. However and increase in rasa – body fluids which can be indicated by excess salivation, nausea, regurgitation, weak digestive power, heaviness, coldness of body, excess sleep, pallor, cough and breathlessness. This can lead to hypertension and congestive cardiac failure. This leads to kapha cardiovascular disease. A decrease in rasa – body fluids. This manifests as thirst, weak digestive power, malnutrition, exhaustion, inability to bear loud noises, headache, sluggish moments, giddiness, tremors and cardiac pain. Symptoms can be dehydration and shock and can precipitate coronary thrombosis. Rakta and the Heart In general, to vitiation of Rakta, occurs by intake of excessive fermented, hot, fatty foods and drinks and by working in hot environments or in the heat of the Sun. Signs that Rakta (blood vessels) are affected are generally - a dark bluish or purplish colouration of the skin, pallor, fever, burning, increase in blood volume, contraction of blood vessels, congested eyes and bleeding. This is often associated with hypertension and bleeding disorders due to capillary fragility. A vitiated Rakta (dusthi) gives rise to bleeding disorders, splenomegaly, cyanosis, pallor, gout and various skin diseases. Deficiency in coagulation factors gives rise to bleeding disorders, and hemoglobin decrease can indirectly affect heart conditions. However an increase (vruddhi) in blood volume also leads to bleeding tendency, red discolouration of skin eyes and urine. The veins appear full and give rise to skin disorders and vatarakta. This can lead to hypertension and congestive heart failure. If there is a decrease (kshaya) in the number of red blood cells which leads to anemia, malnutrition, weak digestive power, 6. Literature Review. Page 48 A Study of Cardiovascular Disease in Ayurveda John Vorstermans exertional breathlessness, desire for cold and sour food and drinks, dry and pale skin and symptoms of diminished blood. Acute blood loss can result in shock and chronic anemia can give rise to heart failure. Mamsa and the Heart The heart as a muscular tissue is affected by weakness of mamsa dhatu in the body. Weakness is caused by sleeping during the day and eating excess heavy foods which when absorbed retain fluid in the body. Mamsa-dusthi or vitiation can lead to atrophy of the muscle tissue or tumours of the muscles and oedema. Others effects are Myocarditis or inflammation of the heart muscle, hypertrophy of the heart. These can all lead to poor contraction of the heart and heart failure. Ojas and the Heart Ojas is the essence of the vital fluid, which supplies energy to the different tissues in the body. Its nature is heavy, cold, soft, smooth, sweet, stable, sticky and unctuous. It contains the energy for the body and mind to function well. It gives good complexion and voice. The heart is the main site of Ojas and pumps it throughout the body along with Rasa. An increase in ojas, which in turn gives strength and energy to all the organs of the body, including the heart. Ojas disorders, such as vitiation show up in psychological factors such as anger, sorrow, worry and physical factors such as hunger, injury, exertion or excessive travelling. A decrease can lead to weakness, discolouration of skin, exhaustion, emaciation, fear, constant worry, improper function of sense and motor organs, fainting, delirium, unconsciousness and ultimately death. 6. Literature Review. Page 49 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Doshas and the Heart. The subdoshas that are most applicable to the heart and its proper function are: Prana vata which on a practical level is responsible for supply of oxygen and respiration as well as for some of the functional component of the nervous system. In thrombosis or blockage of any of the coronary arteries the supply of oxygen and therefore Prana Vata is affected. Prana vata disorders are generally caused by excess breath retention or excessive exercise, hunger and wasting of body tissues. The symptoms are dyspnoea, tachypnoea, slow respiration, noisy breathing, cough, hiccup, difficulty in exhaling, clouding of one's consciousness or sense organs, intellect and mind and eventually death. Vyana Vata is responsible for all voluntary and involuntary movements on the body. It controls contraction, relaxation and rhythmicity of the heart, movement of the valves within the heart. A disturbance here can lead to feeble or forceful contraction of the heart or any disturbance to its rhythm such as extrasystoles, heart block, auricular and ventricular fibrillation. Also valvular disorders like stenosis and regurgitation. Any spasms of the coronary artery by abnormal Vyana Vata leads to angina attacks. Sadhaka Pitta represents the enzymes in the heart. It is also responsible for intercellular digestion of nutrients brought by the coronary arteries. Proper action of the heart and indirectly circulation and intelligence are dependent on sadhaka pitta. Disorders lead to weak action of heart and ultimately heart failure. Avalambaka Kapha represents interstitial fluid in the heart, lungs and mediastinum, namely pericardial and pleural fluid as well as the fluid in the cavity of the chest. Avalambaka Kapha provides the necessary lubrication and strength to the heart for its continuous work, as 6. Literature Review. Page 50 A Study of Cardiovascular Disease in Ayurveda John Vorstermans well as preventing friction between the cells and between the heart and mediastinum. When its function is abnormal it will impair the action of the heart and can lead to pericardial effusion, pleural effusion and pulmonary oedema. Srotas and the Heart. It is interesting to note that “Charaka's concept in that Pranavaha srotas is comparable to pulmonary circulation including the circulation of visceral organs and Rasavaha srotas is comparable to systemic circulation. The former entity includes blood (Rasa and Rakta) circulating between Hridaya [heart] and Maha Srotas [the GIT]. Under Maha Srotas the following visceral organs are involved viz., Hepatic circulation (Amashaya-Agniashaya-Pakvashaya-Unduka), Renal Circulation (Mutrashaya), Splenic circulation (Rudhirashaya), Coronary circulation (Hridya) and pulmonary circulation (Phupphusa). Charaka's view on Rasavaha srotas reflects: capillary, cutaneous circulation and skeletal muscle circulation”v Mind and Emotions of the Heart In Ayurveda the mind, the way we think and our intentions play a very important role in our constitution. The mind is classified as being sattvic (light, intelligent), Rajasic (energetic, focused) or Tamasic (sluggish, grounded). The mind affects the ability of the heart. Heart is affected in intellectual pursuits and in emotional upheavals like rage, sorrow, pleasure, pain, fear, anxiety, depression or excitement. That is why heart is considered to be the seat of mind and intellect. Stress is an experience of imbalance. Whether it is brought on by a physical event or by an emotion, stress occurs when a person is unable to receive information into the mind/body system in a balanced way. 6. Literature Review. Page 51 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Many of life's stresses, though hardly dramatic when viewed as separate incidents, nonetheless take their toll on us as they are repeated over and over again. We constantly find ourselves under stress, be it at work due to irritating work problems or when we are at odds with the ones we that matter most to us. Our bodies can handle high levels of stress for short periods of time, but we are not made to endure ongoing stresses for long periods of time. Doing this harms the heart in both its emotional and physical aspects. Under normal conditions, the cells in our body are hard at work nourishing themselves, defending themselves and repairing damage. However when we are under stress these cells actually stop this process of renewal as they are called on to perform other activities to meet the demands of the situation. Each cell contains an intelligence which can heal and reverse disease and harm, so it is important that we do all we can to ensure that stress does not hinder the basic functioning of the body. Emotions can be associated with the three Doshas in Ayurveda, having different effects on the cardiovascular system. Below is a summary of how emotions and stress affect each of the doshas: Vata dosha is characterised by sudden change and unpredictability. Although Vata imbalance is associated with several forms of heart problems including palpitations and arrhythmias, it is generally less significant in coronary Cardiovascular Disease than Pitta and Kapha imbalances. Symptoms of Vata related Cardiovascular Diseases include shortness of breath, dry cough and fainting. Insomnia, unhealthy diet and an inability to relax are common Vata behaviours that can exacerbate the problems. Pitta dosha. Anger is a hot emotion. The face turns red when someone is angry and 6. Literature Review. Page 52 A Study of Cardiovascular Disease in Ayurveda John Vorstermans perspiration may suddenly start as if there was high fever. Since Pitta dosha is associated with fire and heat, Ayurveda describes chronic anger and hostility as arising primarily from a Pitta imbalance. Moreover, since coronary Cardiovascular Disease arises out of an irritation or inflammation of the arterial walls, CHD can be understood as a Pitta related illness. In general when Pitta accumulates to excess many of its negative qualities manifest. Perfectionism, compulsive behaviour, impatience and hostile judgements of others are characteristic. There is a need to assert total mastery over oneself, over other people, and over the world in general. Since that level of complete control is impossible to achieve, a sense of frustration builds up, which expresses itself in the generalised hostility characteristic of Pitta imbalances. This can significantly raise the risk of coronary Cardiovascular Disease. Kapha dominant people are naturally slow and easygoing. Unlike Pittas, they are not particularly attached to tight schedules and planned routines in their everyday lives. They tend to be tolerant and forgiving, and they will put up with unpleasantness for long periods before becoming angry. The general slowness of their nature, however, means that Kapha are retentive individuals. They require long periods of time to process an experience, whether it's a heavy meal or a perceived insult. High blood cholesterol is a common Kapha related problem, both because Kaphas tend to eat rich foods and because their systems are slow to metabolise the residues of such a diet. This same sluggishness can express itself in the emotional lives of Kapha types as well. They may hold on to hurts, betrayals and disappointments; this can create toxic feelings of hostility just as undigested foods can give rise to toxins in the body. Dealing with emotions. From an Ayurvedic perspective negative emotions can literally be deadly. There are 6. Literature Review. Page 53 A Study of Cardiovascular Disease in Ayurveda John Vorstermans many ways to prevent them from taking root in our consciousness. The seven steps below are a guideline to help the system metabolise and release emotional toxins. 1. Identify the emotion. What are you really feeling? Is it anger, sadness, hurt, betrayal or some other toxic emotion? 2. Be mindful of the physical sensation in your body. Negative feelings express themselves not only as thoughts but as actual pain in the body. It may be a headache, muscle stiffness, or chest pains that prefigure a heart attack. 3. Take responsibility for what you're experiencing and recognise that you have a choice in the matter. You can't always control the circumstances of your life, but you can always control your responses. 4. Express your feelings in private. You may want to do this through writing, or even out loud. Do you believe that someone has injured or offended you? If so, imagine that you are speaking directly to that person. What would you say to convey exactly how you feel? What would you write in a letter to that person? 5. Let go of the emotion through some personal ritual. Physical exercise is often useful for this, especially when combined with the Ayurvedic breathing techniques. 6. Share what you're feeling with another person, but don't undertake this until you feel calm and composed. You should be able to share your feelings without ascribing blame to anyone and without looking for pity. 7. Celebrate and rejuvenate! Reward yourself for taking control of the situation in ways that are best for physical and emotional health. 6. Literature Review. Page 54 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.4 Risk Factors 6.4.1 Risk factors from a medical perspective. The major modifiable atherosclerotic risk factors include smoking, hypertension, hyperlipidaemia, diabetes and obesity. Obesity is a mild independent risk factor and very common, and contributes to development of hypertension, hyperlipidaemia and diabetes. Established adult risk factors Unmodifiable traits that predict risk Age Sex Race Behaviours that Alcohol Psychological affect risk Smoking Diet Exercise consumption factors Physiological Hypercholester conditions Hypertension Obesity Diabetes olemia increasing risk Cardiovascular CHD MI Stroke CHF Death endpoints Source: Stolley and Lasky, (1995) Table 3 Adult Risk Factors 6.4.2 Major Risk Factors High Blood Pressure (Hypertension). High blood pressure increases the risk of cardiovascular disease, heart attack, and stroke. Though other risk factors can lead to high blood pressure, you can have it without having other risk factors. If obese, smoking, or there is high blood cholesterol levels along with high blood pressure, the risk of cardiovascular disease or stroke greatly increases. Blood pressure can vary with activity and with age, but a healthy adult who is resting 6. Literature Review. Page 55 A Study of Cardiovascular Disease in Ayurveda John Vorstermans generally has a systolic pressure reading between 120 and 130 and a diastolic pressure reading between 80 and 90 (or below). High Blood Cholesterol. One of the major risk factors for cardiovascular disease is high blood cholesterol. Cholesterol, a fat-like substance carried in your blood, is found in all of the body's cells. The liver produces all of the cholesterol which the body needs to form cell membranes and to make certain hormones. Extra cholesterol enters the body when food is eaten, that comes from animals (meats, eggs, and dairy products). Although the cholesterol found in Figure 10 Cholesterol foods is blamed for raising blood cholesterol, the main culprit is the saturated fat in food. Foods rich in saturated fat include butter fat in milk products, fat from red meat, and tropical oils such as coconut oil. There are two major types of cholesterol found in the blood: low-density lipoprotein (LDL) cholesterol, sometimes referred to as 'bad' cholesterol, and high-density lipoprotein (HDL) cholesterol, or 'good' cholesterol. Low density lipoprotein (LDL) cholesterol is called 'bad' because it is a major contributor to the development of atherosclerosis - the sticky plaques that can form inside blood vessels and contribute to problems like stroke. High density lipoprotein (HDL) is 'good' because it helps remove cholesterol from these developing plaques, taking it back to the liver to be excreted from the body in 6. Literature Review. Page 56 A Study of Cardiovascular Disease in Ayurveda John Vorstermans bile. Levels of HDL in the body can be raised for example by things like exercise, and lowered by smoking. What is a 'normal' cholesterol level? There is no simple answer to this question - we still don't know exactly how much of each type of cholesterol is 'good' for us. The National Heart Foundation and The Cardiac Society of Australia and New Zealand give the following target levels: Total cholesterol < 4.0 mmol/L LDL-cholesterol < 2.5 mmol/L HDL-cholesterol > 1.0 mmol/L These numbers indicate a level to aim for in patients with other risk factors for coronary Cardiovascular Disease, such as a family history of the disease, or diabetes mellitus. In people with no other risk factors, safe levels may be slightly higher. In general, though, it is healthier to have low levels of LDL-cholesterol and high levels of HDL-cholesterol. Diabetes. Heart problems are the leading cause of death among people with diabetes, especially in the case of adult-onset or Type II diabetes (also known as non- insulin-dependent diabetes). Certain racial and ethnic groups (African Americans, Hispanics, Asian and Pacific Islanders, and Native Americans) have a greater risk of developing diabetes. The American Figure 11 Diabetes – glucose build-up Heart Association estimates that 65% of patients with diabetes die of some form of cardiovascular disease. 6. Literature Review. Page 57 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Obesity and Overweight. Extra weight is thought to lead to increased total cholesterol levels, high blood pressure, and an increased risk of coronary artery disease. Obesity increases the chances of developing other Table 4 Graph of Risk Factors for CVD risk factors for cardiovascular disease, especially high blood pressure, high blood cholesterol, and diabetes. Many doctors now measure obesity in terms of body mass index (BMI), which is a formula of kilograms divided by height in metres squared (BMI =W [kg]/H [m2]). According to the National Heart, Lung, and Blood Institute (NHLBI), being overweight is defined as having a BMI over 25. Those with a number over 30 are considered obese. Smoking. Most people know that cigarette and tobacco smoking increases the risk of lung cancer, but fewer realize that it also greatly increases the risk of cardiovascular disease and peripheral vascular disease (disease in the vessels that supply blood to the arms and legs). According to the American Heart Association, more than 400,000 Americans die each year of smoking-related illnesses. Many of these deaths are because of the effects of smoking on the heart and blood vessels. Research has shown that smoking increases heart rate, tightens major arteries, and can create irregularities in the timing of heartbeats, all of which make the heart work harder. Smoking also raises blood pressure, which increases the risk of stroke in people who already 6. Literature Review. Page 58 A Study of Cardiovascular Disease in Ayurveda John Vorstermans have high blood pressure. Although nicotine is the main active agent in cigarette smoke, other chemicals and compounds like tar and carbon monoxide are also harmful to the heart in a variety of ways. These chemicals lead to the buildup of fatty plaque in the arteries, possibly by injuring the vessel walls. And they also affect cholesterol and levels of fibrinogen, which is a blood-clotting material. This increases the risk of a blood clot that can lead to a heart attack. Physical Inactivity. People who are not active have a greater risk of heart attack than do people who exercise regularly. Exercise burns calories, helps to control cholesterol levels and diabetes, and may lower blood pressure. Exercise also strengthens the heart muscle and makes the arteries more flexible. Those who actively burn 500 to 3500 calories per week, either at work or through exercise, can expect to live longer than people who do not exercise. Even moderate-intensity exercise is helpful if done regularly. Gender. Overall, men have a higher risk of heart attack than women. But the difference narrows after women reach menopause. After the age of 65, the risk of cardiovascular disease is about the same between the sexes when other risk factors are similar. Heredity. Cardiovascular disease tends to run in families. For example, if parents or siblings had a heart or circulatory problem before age 55, this then creates a greater risk for cardiovascular disease than someone who does not have that family history. Risk factors (including high blood pressure, diabetes, and obesity) may also be passed from one generation to another. 6. Literature Review. Page 59 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Race. Researchers have found that some forms of cardiovascular disease are more common among certain racial and ethnic groups. For example, studies have shown that African Americans have more severe high blood pressure and a greater risk of cardiovascular disease than whites. The bulk of cardiovascular research for minorities has focused on African Americans and Hispanics, with the white population used as a comparison. Risk factors for cardiovascular disease in other minority groups are still being studied. In New Zealand it has been shown that Maori have a greater risk of cardiovascular disease also. Age. Older age is a risk factor for cardiovascular disease. In fact, about 4 of every 5 deaths due to cardiovascular disease occur in people older than 65. As we age, our hearts tend to not work as well. The heart's walls may thicken, arteries may stiffen and harden, and the heart is less able to pump blood to the muscles of the body. Because of these changes, the risk of developing cardiovascular disease increases with age. Because of their sex hormones, women are usually protected from cardiovascular disease until menopause, and then their risk increases. Women 65 and older have about the same risk of cardiovascular disease as men of the same age. 6.4.3 Contributing Risk Factors Stress. Stress is considered a contributing risk factor for cardiovascular disease because little is known about its effects. The effects of emotional stress, behaviour habits, and socioeconomic status on the risk of cardiovascular disease and heart attack have not been proven. That is because we all deal with stress differently: how much and in what way stress 6. Literature Review. Page 60 A Study of Cardiovascular Disease in Ayurveda John Vorstermans affects us can vary from person to person. Researchers have identified several reasons why stress may affect the heart. Stressful situations raise the heart rate and blood pressure, increasing the the heart's need for oxygen. This need for oxygen can bring on angina pectoris, or chest pain, in people who already have cardiovascular disease. During times of stress, the nervous system releases extra hormones (usually adrenaline). These hormones raise blood pressure, which can injure the lining of the arteries. When the arteries heal, the walls may harden or thicken, making is easier for plaque to build up. Stress also increases the amount of blood clotting factors that circulate in the blood, and makes it more likely that a clot will form. Clots may then block an artery narrowed by plaque and cause a heart attack. Stress may also contribute to other risk factors. For example, people who are stressed may overeat for comfort, start smoking, or smoke more than they normally would. Sex hormones. Sex hormones appear to play a role in cardiovascular disease. Among women younger than 40, cardiovascular disease is rare. But between the ages 40 and 65, around the time when most women go through menopause, the chances that a woman will have a heart attack greatly increase. From 65 onward, women make up about half of all heart attack victims. Birth control pills. Early types of birth control pills contained high levels of estrogen and progestin, and taking these pills increased the chances of cardiovascular disease and stroke, especially in women older than 35 who smoked. However birth control pills today contain much lower doses of hormones. Birth control pills are considered safe for women younger than 35, who 6. Literature Review. Page 61 A Study of Cardiovascular Disease in Ayurveda John Vorstermans do not smoke or have high blood pressure. If smoking or have other risk factors, birth control pills will increase the risk of cardiovascular disease and blood clots, especially if older than 35. According to the American Heart Association, women who take birth control pills should have yearly check- ups to test blood pressure, triglyceride and glucose levels. Alcohol. Studies have shown that the risk of cardiovascular disease in people who drink moderate amounts of alcohol is lower than in nondrinkers. Experts say that moderate intake is an average of one to two drinks per day for men and one drink per day for women. One drink is defined as 1 fluid ounce (fl oz) or 30 ml of 80-proof spirits (such as bourbon, Scotch, vodka, gin, etc), 30 ml of 100-proof spirits, 120 ml of wine, or 360 ml of beer. However drinking more than a moderate amount of alcohol can cause heart-related problems such as high blood pressure, stroke, irregular heartbeats, and cardiomyopathy (disease of the heart muscle). And the average drink has between 100 and 200 calories. Calories from alcohol often add fat to the body, which may increase the risk of cardiovascular disease. It is not recommended that nondrinkers start using alcohol or that drinkers increase the amount that they drink. 6. Literature Review. Page 62 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.4.4 Ayurvedic Aetiology of Cardiovascular Disease Aetiology of Heart Diseases (from Cardiology in Ayurveda by Dr V.B. Athavale) Aetiological factors Vata Pitta Kapha Tridosha Krumi 1. Psychological Fear, sorrow, worry and Anger, worry & tension, Carefree state, Worry, tension, tension. vexation laziness. excessive study 2. Diet – Calories Low calorie diet Low calorie diet Diet excess, high Combination of the Excess of sesame seeds, calorie diet, high fat causes leading to Vatam milk and jaggery. diet i.e. heavy diet. Pitta and Kapha (a) Fat Low fat diet, dry diet. (b) Taste Excess of bitter, pungent, Excess sour, pungent Excess of sweet, sour Eating food like salt astringent food and salty food. and salty food or which retains fluid in excess of food with body. retains fluids in body. ( c ) Temperature of drinks & food Excess of cold beverages Excess of hot beverages Excess of cold + and food and food. beverages and food (d) Dietetic incompatibilities e.g. vegetables + milk e.g. fish + milk e.g. banana + milk + (e) Indigestion Excess fermented food Ama promoting food Diet to which one is not used to 3. Activity Over exertion or over Over exertion or over No work at all, excess Abnormal or excessive work, excessive travelling work in sun or hot sleep. activity immediately climate after food. 4. Sexual intercourse In excess In excess 5. Suppression of natural urges like Leads to Vata heart urination, defecation, yawning, sneezing disease etc. holding the breath during inspiration and expiration 6. Alcohol in excess Leads to Pitta hear disease 7. Microbial infection& parasitic + + + + + infestations 8. Iatrogenic (a) Toxic effects of drugs + + + + + (b) Improper management of disease + + + + ( c) Abnormal or excessive use of emetics, ++ + purgatives or enemas 9. Traumatic heart lesion ++ 10. Complication of other diseases + + + + + Table 5 Ayurvedic Aetiological of Cardiovascular Disease 6.4.5 Medical Pathophysiology of Cardiovascular Disease Inflammation plays an important role in mediating all the steps in the initiation and progression of atherogenesis. Atherosclerosis begins with the injury of the endothelial cells that line artery walls. The injured endothelial cells become inflamed and cannot make normal amounts of antithrombic and vasodilating cytokines.. Inflamed endothelial cells express adhesion molecules that bind macrophages and other inflammatory and immune cells. The macrophages adhere to the injured endothelium 6. Literature Review. Page 63 A Study of Cardiovascular Disease in Ayurveda John Vorstermans and release enzymes and toxic oxygen radicals that further injure the vessel wall and result in oxidation of low-density lipoprotein (LDL). Oxidized LDL is engulfed by macrophages, which then penetrate into the intima of the vessel. When they accumulate in significant amounts they form lesions called fatty streak. Once formed these fatty streaks produce more toxic oxygen radicals and cause immunologic and inflammatory changes resulting in progressive damage to the vessel of the walls. It is currently though the treatment to lower LDL, that this process may be reversed. As this process happens, smooth muscle cells proliferate, producing collagen and migrate over the fatty streak forming a fibrous plaque. This results in narrowing of the blood vessel lumen and reduces blood flow to distal tissue. As the plaque continues to develop, continued inflammation leads to instability of the plaque and can result in ulceration and rupture, resulting in platelet adherence to the lesion. Platelet adherence to the plaque can initiate the coagulation cascade and result in rapid thrombus formation with complete vessel occlusion causing tissue ischemia and infarction. To prevent this process antiplatelet medications such as aspirin are used. 6.4.6 Ayurvedic Pathogenesis (Samprapti) Cardiovascular Disease from an Ayurvedic perspective can be classified into: 1. Causes which directly act on the heart. 2. Causes which are important for maintaining physiological functions of the heart. 3. Cardiovascular Disease as a complication of other diseases. These would be classified as being imbalances of 1) Vata, 2) Pitta, 3) Kapha, 4) Tridoshas (all three doshas), or 5) Parasites, viruses, worms, bacteria (Krumi). 6. Literature Review. Page 64 A Study of Cardiovascular Disease in Ayurveda John Vorstermans The aetiological factors are generally classified as psychological factors, diet, activity, excessive sexual indulgence, suppression of natural urges, alcohol in excess, bacteria, viruses, worms and other toxins, iatrogenic, causes effects of drugs, improper management of disease, abnormal or excess use of emetics, purgatives or enemas, trauma to the heart, complications of other diseases. These will cause abnormal increase or decrease in Vata, Pitta and Kapha and in turn Rasa which enters the heart and gives rise the Cardiovascular Disease. The various factors which lead to the different types of Cardiovascular Disease are listed in Table 5. In summary, the eight basic elements that maintain the integrity of the cellular structure and functions of the heart are, Rasa, Rakta, Mamsa, Ojas, Prana vata, Vyana vata, Sadhaka pitta and Avalambaka kapha. In Ayurveda the pathogenesis provides insights into the development of the disease process, showing in detail how the doshas when aggravated by certain aetiological factors effect the dhatus and srotas of the body, eventually manifesting in disease. Ayurveda describes the following types of pathogenesis of cardiac disease. Derangement of Rasa Dhatu The following can be seen as the interpretation of the Samprapti of Cardiovascular Disease. 1. Vitiation of Doshas 2. Accumulation of Vitiated Doshas and Vitiated Rasa Dhatu in the heart. 3. Development of Obstruction in the heart and impairment of physiological function of the heart. Thus, due to the impairment of nutrition of the cardiac muscle (by Rasa) the outcome is some 6. Literature Review. Page 65 A Study of Cardiovascular Disease in Ayurveda John Vorstermans sort of Cardiovascular Disease. Organic changes. Organic changes in the structure of the heart by the formation of nodules lead to the distortion of normal structure of the heart. This may result in a build-up of fluid. Various pathogenic organism are likely to grow in this area, which may cause obstruction in the cardiac region. Thus the development of Krimi Cardiovascular Disease which results in growths/tumours in parts of the heart. These can continue to grow, along with the krimi which can eventually attack the entire heart causing severe pain and may lead to death. Role of Vitiated Doshas Doshas become vitiated by the continual cycle of incorrect lifestyle and diet (Nidana). In Cardiovascular Disease, the aspects of Doshas that are vitiated are Prana Vata, Vyana Vata, Sadhaka Pitta, Avalambaka Kapha. In the early stage of the Nidana Kapha is in Amashaya (duodenum), Pitta in Grahani and Vata in Pakwashaya (colon). In the later stages the vitiated doshas vitiate the Hridayastha (heart). Ama (toxins created by undigested food) causes blockages in places in the body where they have a predisposition to settle in. Ama is produced by Agnimandhya - a decrease in the digestive fire or metabolism, which is the cause of leaving food undigested. creating toxins. The ama, if left to continue to grow will eventually, exploit whatever weakness there is in the body. First it manifests in the G.I.T. and hollow organs, in the particular part where Dosha which are vitiated lives. However as the Ama increases it will start to move into the bodily tissues (dhatus), first entering into Rasa and then eventually into Rakta etc. When it has entered Rasa, it will affect the organ that is the seat of Rasa, the heart and eventually weaken the sub-doshas of Prana Vata, Vyana Vata, Sadhaka Pitta, Avalambaka Kapha, 6. Literature Review. Page 66 A Study of Cardiovascular Disease in Ayurveda John Vorstermans and Ojas. The reason the heart is affected in some people rather than everyone, although Cardiovascular Disease is very common these days, is because there is an inherent weakness at this level. Such weakness (Khaivaigunaya) will attract Ama and block this major channel in the body. Development Once the condition reaches stage III (sthana Sansharaya) the symptoms of Cardiovascular Disease appear clinically. (See Figure 12). During this process the deformities in the Rasavaha Srotas are well established and there is an excess flow (atipravritti) or growth (granthi) established in the heart region which will cause the dosha or dhatu to increase or decrease. If the proper treatment of Cardiovascular Disease (Hridroga) is not followed and the causative factors are continued the doshas in the heart become more and more vitiated along with the development of various complications. This condition is called “Bheda Avastha”. In this condition the circulation of Rasa- Figure 12 Samprapti Heart Disease Rakta may be affected and is also called “Marma- Upaghata”. 6. Literature Review. Page 67 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Figure 13. Diagramtic representation of Samprapti of Hrdroga 6. Literature Review. Page 68 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.5 Clinical Manifestation 6.5.1 Symptomatology - Western Medical Initial signs and symptoms come from inadequate perfusion of tissue because of the obstruction of the vessels that supply them. Initially partial obstruction may lead to ischemic events when exercising or under stress. As the lesion causes increasing obstruction the result can be thrombosis. One of the most common manifestations is coronary artery disease caused by atherosclerosis being the major cause for myocardial ischemia. Atherosclerotic obstruction of the vessels supplying the brain is the major cause of stroke. Chronic coronary obstruction causes reoccurring predictable chest pain referred to as stable angina. Abnormal vasospasm of the coronary vessels result in unpredictable chest pain called Prinzmetal angina. Myocardial ischemia that does not cause detectable symptoms is called silent ischemia. 6.5.2 Symptomatology - Ayurveda The symptoms differ and give an indication of what type of Cardiovascular Disease we are looking at. Vata symptoms are severe pain, convulsions, stiffness in the chest, feeling of emptiness in the chest, pricking pain, dry feeling inside the chest, edema, sudden attacks, aversion to loud sounds, breathlessness, insomnia and twitching pain. Malnutrition of the organs, particularly in old age, make the tissue of the heart dry, tense, shrunken, shortened, rough and hard. Irritability, exhaustion or inability to cope with 6. Literature Review. Page 69 A Study of Cardiovascular Disease in Ayurveda John Vorstermans emergency demands cause spastic contractions or rapidity of contraction and produce pain and fatigue in a short time-frame and depletion of body fluids may all provoke Vata. Pitta symptoms include heart burn, persistent bitter taste, sour and bitter belching or burping, tiredness, thirst, partial or complete loss of consciousness, excessive sweating, fever, yellowish colouration, frightened, restless, darkness before the eyes, vertigo, vomiting, dryness of mouth, and severe burning sensation. Inflammatory changes leading to tissue destruction and attendant with high fever. Kapha symptoms include numbness or heaviness in the heart, drowsiness, anorexia, nausea, fever, cough, feelings of a stone in the heart, excessive sleep, laziness, persistent sweet taste, vomiting, and chest pain. Increase in size and shape making the heart heavy, sluggish and flabby due to deposits of fat (meda) or hypertrophy (mamsa). Drying and density of Rasa dhatu produces obstruction and prevents free movement. Thickening and hardening of the arteries will occur. Tridosha symptoms will be a combination of the above. Krimi (parasite) symptoms include pain like pricking needles, tearing pain, severe pain, itching, darkness before the eyes, nausea, wasting, scissoring pain in the heart, anorexia, edema, fever, syncope, dyspnoea. 6. Literature Review. Page 70 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.6 Treatment 6.6.1 Medical Treatment The primary goal of treatment is to restore adequate blood flow to the aeffected tissue. If the ischema is acute then intervention is specific according to the area effected. When the situation is not considered serious then the focus is on management or removal of the cause to prevent lesions progressing. This would include exercise, smoking cessation and control of hypertension and diabetes where appropriate while reducing LDL cholesterol by diet or medications or both. Treatment of cardiovascular disease depends on the specific form of the disease in each patient, but effective treatment always includes preventive lifestyle changes. Medications, such as blood pressure reducing medications, aspirin and the statin cholesterol- lowering drugs may be helpful. In some circumstances, surgery or angioplasty may be warranted to reopen, repair, or replace damaged blood vessels. Treatment for Cardiovascular disease varies depending on the practitioner. However common treatments are listed below: Aerobic Exercise Regular exercise strengthens muscles and keeps them flexible, helping to maintain mobility. Not only does exercise improve the ability to perform usual physical tasks, it can also help to control weight and improve the sense of well being. Aerobic exercise should last for at least 30+ minutes, make use of large muscles groups and increase the heart rate, without a large increase in blood pressure. Examples of aerobic exercise include walking, swimming, bicycling and light aerobics. Cardiac patients should avoid weight training, running and sports like squash and tennis without first getting medical advice. Gym and 6. Literature Review. Page 71 A Study of Cardiovascular Disease in Ayurveda John Vorstermans aerobics classes should only be done with an instructor who is trained in treating heart patients. Angioplasty The aim of angioplasty is to push the plaque (Figure 14) against the artery wall. With such, the artery is dilated and bigger - giving more room for the blood to flow through the previously narrowed artery. This improved flow of blood reduces the risk of heart attack and sudden death due to Cardiovascular Diseases. Generally, this procedure lasts 1 to 2 hours in the respective cardiac centres in hospitals or other medical centres. The procedure itself involves inserting a balloon-tipped pipe (a catheter) into the femoral artery in the groin or upper thigh. The Figure 14 Angioplasty catheter is then passed into the artery all the way towards the heart. There may be some minor discomfort during the process. A video monitor is used to guide the process. Once the catheter reaches the designated area, a coronary angiogram will be done. This means an x-ray of the coronary arteries will be taken to locate and measure the narrowing of arteries. The catheter will be inserted further into the exact location of the narrowing, and then the balloon at the tip of the catheter will be inflated. The time period for inflation can last from seconds to several minutes. During this period because there is no blood flow to the heart muscle, the patient may feel the same type of chest pain as they feel in Figure 15 Stent angina. Multiple inflations of the balloon may be 6. Literature Review. Page 72 A Study of Cardiovascular Disease in Ayurveda John Vorstermans needed in the same area. After the inflation, further coronary angiograms will be done to assess the narrowing of the artery. Following angioplasty, usually a stent will be implanted at the site of narrowing. A stent is a small wire-mesh tube. It acts as a scaffolding tube that supports the weakened artery. This is important to reduce the chances where the dilated artery may become narrowed again (known as restenosis) after angioplasty. Finally, the catheter will be taken out . Complications One of the complications of angioplasty is sudden closure of the affected vessel. Sudden closure of the artery can lead to a heart attack and also sudden death. If this occurs, emergency heart surgery may be needed. However, the risk is rare, and it is reduced further by inserting a stent during angioplasty. Other risk include blood clots forming after the procedure. However by giving medications such as aspirin and clopidogrel (a drug used to prevent clotting) in combination, the risk is significantly reduced. Another risk of the procedure would be narrowing of the artery at the same site after angioplasty (known as restenosis). Although the insertion of stents during angioplasty has reduced this risk, this is still a relatively common occurrence. Some minor complications include local collection of blood at the catheter insertion site (haematoma) or local infection. These are usually benign but can be dangerous if they are widespread. Coronary Artery Bypass Grafting CABG CABG surgery involves using a vessel from the leg, wrist or inner chest to attach to 6. Literature Review. Page 73 A Study of Cardiovascular Disease in Ayurveda John Vorstermans the coronary vessels on the outside of the heart. Much like a detour on the road, this allows blood to get to the remainder of the heart muscle by bypassing the blockage. Usually an incision is made down the centre of the chest and an open operation performed. CABG surgery is one of three different treatment modalities for coronary artery disease. The decision for surgery is largely based on the symptoms and severity of disease. Studies have shown that the following patients benefit from CABG surgery over the alternative treatment options: • Patients with persistent symptoms of angina despite medical therapy or who cannot tolerate medical therapy. This group of patients is the most common indication. • Patients with disease of the left main Figure 16 CABG coronary artery. The left coronary artery supplies most of the heart muscle including the main pumping chamber, the left ventricle. Blockage of this vessel can have severe consequences. • Patients with triple vessel disease, meaning that 3 big vessels (the left anterior descending, right coronary and circumflex arteries) have blockages from atherosclerotic plaques. The left ventricle also has reduced contractile function. • Patients with two vessel disease, one of which includes the left anterior descending near its origin. If this important vessel is blocked close to its beginning, a large area of heart muscle will not get sufficient blood supply. 6. Literature Review. Page 74 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.6.2 Ayurvedic Treatment. Treatment of Cardiovascular disease. The Ayurvedic approach is generally focused on prevention rather than cure. So it is a matter of looking at the predisposing factors. The predisposing factors for Cardiovascular Disease are similar to those of other Ayurvedic pathologies, such as in diabetes (prameha), obesity (medaroga) and rhematoid arthritis (Amavata). These are lifestyle factors such as overeating, lack of exercise, stress. If one is already suffering from a cardiovascular disease, then curative measures are necessary and the aim is to treat the underlying cause. For this Ayurveda uses herbs with have an agreeable action on the heart (hyridya) , give strength and stamina (bala) and are have a regenerative effect on the tissue (rasayana). Generally the treatment is considered under two headings, namely curative (shodana) and palliative (Shamana) types of treatment. 220.127.116.11 Shodana Treatment (Curative) The aim of this treatment is to remove the vitiated or aggravated dosha from the body. The treatment is quite different depending on the dosha involved. Vata Cardiovascular Disease i. Vamana (Emesis) is normally contraindicated in Vata Cardiovascular Disease. However if Kapha dosha is also present and the patient is strong, he should be administered medicated oil or ghee followed by Vamana herbs consisting of dashamula decoction, Ghrita (medicated ghee) and lavana (salt). ii. Tila Taila (oil) medicated with Vata alleviating drugs should be used for administrating Basti Therapy (Enema) in adequate quantity. 6. Literature Review. Page 75 A Study of Cardiovascular Disease in Ayurveda John Vorstermans iii. Normal Swedana (Fomentation) over the Cardiac region should be avoided. But during the stage of pain and feeling of constriction in the chest, local Mrudu Sweda with luke warm medicated oil massage over the chest may help in relieving the symptoms. Pitta Cardiovascular Disease i. Vamana (emesis) with mixture of Katphala, Yastimadu, Honey, Sugar, Jaggery and water is indicated in strong patients with Kapha constitution. ii. Cold application and cold shower. iii. Virecana (purgation) • Mixture of grapes, sugar, honey, Parusaka is very effective purgative preparation. • Paste of Yastimadhu and Kutaki should be taken with sugar and water. • Haritakyadi Churna – dried black grapes and Haritaki powder should be mixed with sugar and taken with luke warm water. iv. Basti Therapy. If the patient is constipated, Basti with Tila Oil medicated with honey and liquorice should be administered. Kapha Cardiovascular Disease i. Vamana with Vaca or Nimba kwartha. ii. Oral administration of Kashaya prepared with Madanadi gana or Mustadi gana or Triphala. iii. Virecana (purgation) by administering ghee prepared with Shyama and Trivrit kalka. 6. Literature Review. Page 76 A Study of Cardiovascular Disease in Ayurveda John Vorstermans iv. Basti with Bala taila shall be performed after taking all the necessary precautions. v. Sneha (oleation), Swedana (sweating) and Vamana are to be conducted at first and afterwards. Kaphahara (kapha pacifying) procedure are to be adopted. vi. Fasting. Tridosha Depending on the predominant dosha, the respective lines of treatment as mentioned under different doshas above may be performed. Krimi (parasites) i. Snehana followed by diet of meat soup or cured meat for three days. ii. Afterwards virechana should be done. iii. Herbs of Dhanyamla along with Sugandha dravya, Saindhava lavana, Jiraka, sugar, Vidanga may be given. iv. Meal consisting of Yavaana and Vidanga curna is also prescribed. Note: Vamana is generally contraindicated in Cardiovascular Disease due to morbid doshas as well as in Cardiovascular Diseases due to krimi. However Vamana in the early stages of Cardiovascular Disease if the patient is strong if permitted. However vamana is contraindicated in serious cardiac illness. 18.104.22.168 Shamana Treatment (Palliative) Different herbs are used for the different types of pathology. The following suggestions are from the classical references. 6. Literature Review. Page 77 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Vata Cardiovascular Disease. i. A decoction made from Puskaramula, Nimba, Shunti, Kharjura, Haritaki and Vaca. ii. Patient should drink oil boiled with Panca Lavana (five salts) iii. Pippalyadi powder 2 – 6 gm iv. Haritaki powder 5 – 10 gm v. Panchakoladi decoction 20 – 40 ml vi. Punarnavadi Oil 5 – 10 ml Pitta Cardiovascular Disease i. Arjuna milk decoction 24-50 ml ii. Hrid pousthika powder 5 – 10 ml iii. Arjuna bark powder 5 – 10 gm Kapha Cardiovascular Disease i. After Vamana, powder of Trivrit, Bala, Rasna, Shunti, Haritaki, Pushkaramula, Ela and Pippalimula. ii. Trivrtadi powder 3 - 6 gm iii. Suksmela powder 3 – 6 gm Krimi Cardiovascular Disease i. Diet of rice, meat, curd and tila to be given for three days after shodhana. The diet attracts the worms and helps in releasing the hold of the worms on the gastro intestinal tract (GIT). ii. Ajamoda, cumin seeds, Palasa seeds, and krimigha herbs. 6. Literature Review. Page 78 A Study of Cardiovascular Disease in Ayurveda John Vorstermans iii. Vidanga powder + gomutra 2 – 4 gms iv. Vidanga + kustha + gomutra powder There are numerous herbs that are effective in treatment of Hrdrogas in Ayurveda. Some of these are listed below. 1. Powders (Churnas) 1. Amaladi 10. Narayana 2. Arjuna 11. Narayanadi 3. Ashwagandha 12. Navayasa 4. Dadima 13. Patadi 5. Hingupancaka 14. Pushkaramula 6. Hinguvadi 15. Satyadi 7. Kakubhadi 16. Talisadi 8. Kustha 17. Yavanyadi 9. Karoiiradu 2. Decoctions 1. Dashamula 6. Nagara 2. Dashamula + Saindhava 7. Nagaradi 3. Dhauakadi 8. Puskarahvadi 4. Lasuna Ksherapaka 9. Yavakshara 5. Madha Darvyadi 3. Alkalis (Kasara) 1. Pippalyadi 3. Trayamanadi 2. Ksara gutika 4. Triphaladi 6. Literature Review. Page 79 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 4. Medicated Ghee (Ghritas) 1. Arjuna 7. Pippalyadi 2. Amritaprasa 8. Souvarcaladi 3. Balad 9. Trayamanadi 4. Brhat satavari 10. Vallabhaka 5. Dadimadi 11. Vasa 6. Mahatiktaka 12. Yastyadi 6. Oil (Tailas) 1. Bilva kshara 3. Satapaka madhuparni 2. Punarnavadi 7. Fermented products 1. Abhayasrista 6. Mulasava 2. Arjunarista 7. Phalasava 3. Dhatryarista 8. Punarnavadyarista 4. Kanakarista 9. Sarkarasava 5. Madhwarista 8. Avalehyas 1. Agastya Haritaki 3. Danti Haritaki 2. Citrakadi lehya 4. Pippalyadi lehya 6. Literature Review. Page 80 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.6.3 Medical Drugs 22.214.171.124 Dual inhibition Dual inhibition' describes a type of drug therapy that uses both Statins and Ezetimibe to lower cholesterol. Together, these drugs seem to be more effective at helping to reduce cholesterol than just one drug alone. How it works. The first drug, the Statin, reduces the amount of LDL-cholesterol that is made in the liver, and also increases the amount of cholesterol that the liver 'clears out' of the blood as it passes through. The second drug, Ezetimibe, acts by reducing the amount of cholesterol absorbed from the intestines. This means that less cholesterol is taken into the body, and so less can make its way into the bloodstream. With both of these drugs working together, there is less cholesterol being taken into the body, less cholesterol being made in the liver, and more cholesterol being 'filtered' out of the blood. Overall, blood levels of LDL-cholesterol are lowered. Why use it? Dual inhibition therapy may be useful when one drug alone is not effective in lowering LDL-cholesterol. For example, most of the effect of a Statin occurs at the recommended starting dose; doubling the dose after that will only produce an additional benefit of 6%. Ezetimibe acts differently to a Statin, so adding the two together can have a more beneficial effect on cholesterol levels than simply increasing the dose of the Statin. 6. Literature Review. Page 81 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Side-effects. Ezetimibe is a generally safe drug and is well tolerated by most people. It may produce some mild side effects, including headache and diarrhoea. It rarely interacts with other drugs to cause adverse reactions. Statins have a few important side effects. Common problems include headache, nausea and vomiting, constipation, diarrhoea, or rash. A more serious but rare side effect is called rhabdomyolysis, where breakdown of muscle cells occurs, resulting in muscle pain and weakness. Another important side effect which may be caused by both ezetimibe and statins is changes in liver function. This means that dual inhibition therapy may not be safe to use in people who have a liver problem such as liver failure or cirrhosis. Dual inhibition therapy, where ezetimibe is combined with a statin, has been demonstrated in a number of trials to be well tolerated. Side effects are minimal, almost similar to those of statin treatment alone. 126.96.36.199 Fibrates Fibrates are derivatives of fibric acid which are particularly suited to reducing the triglyceride levels of lipid in the blood. They also have the effect of increasing HDL cholesterol ('good cholesterol') in the blood. Common examples of fibrates include gemfibrozil, fenofibrate and clofibrate. Fibrates lower triglyceride levels by two methods: • by reducing production of triglycerides in the liver; and • by increasing the rate at which triglycerides are removed from the bloodstream. 6. Literature Review. Page 82 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Fibrates have been shown to reduce triglyceride levels by 35-50 percent in patients with high lipid levels. Additionally, fibrates (and in particular the drug gemfibrozil) have been shown to increase good HDL cholesterol levels by up to 15-25 percent. The effect of fibrates on LDL-cholesterol levels is not always the same in every patient. In most people, fibrates will lower LDL-C levels slightly. In some people, though, and particularly in people with a type of hypercholesterolaemia called 'type I hyperlipoproteinaemia', fibrates may actually raise LDL-C levels slightly. Side effects of fibrates may include: • gastrointestinal symptoms: dyspepsia (indigestion), abdominal pain or diarrhoea • allergic reactions • fever or chills • generalised body aches and pains One serious but rare side effect of fibrate therapy is called rhabdomyolysis, where breakdown of muscle cells occurs, resulting in muscle pain, weakness, and even death. The risk of this occurring is greater when kidney function is impaired or when fibrates are combined with statins. Potential drug interactions associated with fibrates may include: •Interactions with other lipid lowering drugs such as statins. •Interactions with the blood thinning drug warfarin. 188.8.131.52 LDL (Low-Density Lipoprotein) Cholesterol Lowering LDL-cholesterol lowering drugs are commonly prescribed to people with high levels of LDL (low-density lipoprotein) cholesterol. 6. Literature Review. Page 83 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Previous research has demonstrated that lowering LDL cholesterol reduces the progression of Cardiovascular Disease and death rate. However, the optimal method of lowering LDL cholesterol as well as the target levels were once unknown until the results of several trials provide some clues. Why lower LDL-cholesterol? Lowering LDL-cholesterol levels in the blood can have a number of positive effects for health, including: • Reducing the number and extent of sticky cholesterol plaques on artery walls; • Stopping existing plaques from rupturing, which can cause problems with formation of blood clots; • Decreasing the risk of developing problems such as heart attack and stroke. How can the level of LDL-cholesterol be lowered? Other than drugs, there are a number of lifestyle changes that can be made to help lower LDL cholesterol levels. These include: • Healthy Eating: a low-fat, high fibre diet, avoid greasy foods and eating more vegetables, can drastically improve cardiac health. More details and help with regards to diet, can be obtained from a general practitioner. • Fish Oil and Fish: Consumption of fish twice a week helps to lower cholesterol levels. This can also enhance the effects of medication. • Plant Sterols: These can be found in some margarines and help reduce the absorption of cholesterol. • Stop Smoking: stopping smoking is vital to cardiac health as well as overall well- being. It is strongly encouraged that all patients quit smoking, and there are various 6. Literature Review. Page 84 A Study of Cardiovascular Disease in Ayurveda John Vorstermans methods for helping with this that can be advised by a GP. • Physical Activity: Moderate to intense physical activity of at least 30 minutes should be undertaken on most, if not all, days. • Weight Reduction: While this should come from improved diet and exercise, weight reduction plays an important role in the reduction of LDL cholesterol levels. • Alcohol: Alcohol should be drunk in moderation, especially if there is a high level of triglycerides. • Salt: Reduction in salt intake has been shown to lower hypertension and thus reduce general cardiovascular risk. Sometimes, though, these lifestyle changes are not enough, so a cholesterol-lowering drug is prescribed to help lower your cholesterol levels. The most commonly used type of cholesterol-lowering drugs are called 'statins' (sometimes also known as HMG CoA reductase inhibitors). Other drugs used include fibric acid derivatives, bile acid sequestrants, cholesterol absorption inhibitors, and nicotinic acid. These drugs differ in terms of the way they act and the degree and type of cholesterol lowering they can each produce. What is the evidence for using these treatments to lower LDL-cholesterol? Many trials have been conducted to look at the benefits for patients of taking cholesterol-lowering medications. Some of the results are summarised below: • The Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI 22) trial in Boston compared a high-dose statin treatment to a low-dose statin treatment. The higher dose provided greater protection against death, heart attack, chest pain requiring hospital admission and stroke; and also improved outcomes over two years among patients with acute Cardiovascular 6. Literature Review. Page 85 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Disease. • Another group of researchers from the United States also showed in their trial, the Treating of New Targets (TNT) trial, that intensive lipid-lowering treatment provides more significant clinical benefit compared to a lower dose of statin drug. • The Heart Protection Study in the UK showed that lowering LDL cholesterol from below 3 mmol/L to below 2 mmol/L reduces risk of Cardiovascular Disease by about 25%. Overall, the results of these trials suggest that intensive therapy to lower LDL cholesterol levels is beneficial in treatment of both acute and stable Cardiovascular Disease. They also suggest that high-risk patients may benefit from more extensive lowering of LDL- cholesterol than was once thought necessary. 184.108.40.206 Cardiovascular Drugs Broadly, the drugs for the treatment of Cardiovascular Disease may be classified as follows: 1. Anti-arrhythmic drugs. (a) Membrane stabilising agents • Quinidine and similar agents • Lignocain, phenytoin and similar agents (b) Sympathetic agents: beta-blockers ( c) Drugs prolonging action potential: amiodarone (d) Calcium flux antagonists: verapamil 2. Beta – Adrenergic Blocking drugs. 3. Digitalis and allied cardiac glycosides 6. Literature Review. Page 86 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 4. Inotropic agents 5. Hypotensive agents 6. Vasodilators and other agents used in Angina Pactoris 7. Diuretics 8. Anticoagulants 9. Management of hyperlipidmias 220.127.116.11 Statins Statins are a type of lipid-lowering drug in common use in New Zealand Statins are a type of lipid-lowering drug that are used to lower LDL- and total cholesterol levels in the blood. Statins work by blocking the action of an enzyme called HMG-CoA reductase, which is the enzyme that controls the rate of cholesterol production in the body. By doing this, the availability of cholesterol is reduced. Statins also increase production of the receptor for 'bad' LDL-cholesterol, which helps clear LDL-cholesterol from the circulation; and help liver cells take up more LDL cholesterol from the blood as it passes through. The resulting effect is a reduction of total cholesterol, LDL cholesterol and triglyceride fats. A small increase in high-density lipoprotein cholesterol (HDL-C), the 'good' cholesterol, is also produced. How effective are statins? Statins can reduce the level of LDL-cholesterol in the blood by 30 to 63 per cent. Atorvastatin in particular has a strong effect on LDL-cholesterol. 6. Literature Review. Page 87 A Study of Cardiovascular Disease in Ayurveda John Vorstermans In terms of the action on high-density lipoprotein (HDL) cholesterol, simvastatin has been reported to be effective in increasing the level. Atorvastatin is also effective for the reduction of triglyceride levels. The strength of this effect increases with the dose of the drugs taken. Many studies have confirmed the safety and efficacy of statin therapy in reducing overall mortality from cardiovascular disease. There are guidelines currently recommending their use in virtually all patients at high risk of coronary Cardiovascular Disease. Are statins safe? Statins are considered one of the safest classes of lipid-lowering drugs. They are well tolerated in the short term. Common side-effects include headache, nausea and vomiting, constipation, diarrhoea, or rash. Muscle pain and break down of muscle tissue may also occur, but this is uncommon with statin therapy alone. Patients at increased risk of developing muscle problem associated with statin therapy are those with kidney failure, thyroid problems and liver disease. Patients started on statins should report muscle ache or weakness that have recently developed. Liver function abnormality may also occur. Liver problems are dependent on the dose used and mainly occur in the first three months of treatment. Drugs used in this treatment: • Vytorin (Ezetimibe/ Simvastatin) • Lipitor (Atorvastatin calcium) • Pravachol (Pravastatin sodium) • Zocor (Simvastatin) 6. Literature Review. Page 88 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.7 Correlation between Ayurveda and Modern Medicine Exact correlation between Ayurveda and the modern medical system is not so easy as they both look at cardiovascular disease so differently. However a reasonable comparison can be done as follows: Vata Cardiovascular Disease Valvular Cardiovascular Disease Cardiac arrhythmias Angina pectoris Constrictive pericarditis Aneurysm and dilation of heart and aorta Pitta Cardiovascular Disease Myocardial infarction Endocarditis including valvulitis Myocarditis and pericarditis of all varieties. Kapha Cardiovascular Disease Metabolic disorders like glycogen storage of heart, tumours of the heart. Krimi Cardiovascular Disease This type of Cardiovascular Disease is due to parasite, viral or bacterial infections. There are several Cardiovascular Diseases caused by macro and micro-organisms such as: (i) Infective Endocarditis may result from infection by different micro-organisms and by fungi. (ii) Acute infection by trypanosoma cruzi will terminate in myocardial infarction within 20 to 30 days. Chronic form is characterised by disturbed cardiac rhythm (heart block and 6. Literature Review. Page 89 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Adams syndrome). This is because of T. cruzi, which resides in the heart muscle during its infestation in the body. (iii) Toxoplasma gondii – its pseudocyst in muscle fibre of the heart will cause Myocarditis. (iv) Hydatid cyst of the heart may be caused by Echinococcus granulosus infestation. 6. Literature Review. Page 90 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.8 Classifying Ayurvedic Herbs on Modern Pathology Ayurveda has its own unique way of classifying herbs, according to taste (sweet, sour, salty, astringent, pungent and bitter), post digestive taste, action on the doshas and each herb is also classified with it recognised actions which have been observed over the centuries. However, we can also classify them under modern perspectives based on the Ayurvedic understanding of the herbs as below. 1. Cardiac Stimulants. 1. Brahmi (Bacopa monniera) 2. Kaka nasa (Asclepia surassavica) 3. Kokilasksa (Asterecantha longifolia) 4. Pasana bhedi (Berginia ligulata) 2. Cardia depressants; antihypertensives & diuretics 1. Nimba (Azadirachta indica) 2. Punarnava (Boerhavia diffusa) 3. Vaca (Acorus calamus) 3. Antianginal & hypocholesterolemic 1. Ajamoda (Carum copticum) 2. Haritaki (Terminalia chebula) 3. Guggulu (Commiphora mukul) 4. Kustha (Saussurea lappa) 5. Lashuna (Allium sativum) 6. Puskaramula (Inula racemosa) 4. Antiatherogenic 1. Amragandhi Haridra (Curcuma amada) 2. Guggulu (Commiphora mukul) 6. Literature Review. Page 91 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 5. Antihypertensive & antiatherogenic 1. Haridra (Curcuma longa) 6. Hypolipidemic & hypoglycemic 1. Kapikacchu (Mucuna prurience) 2. Marica (Piper nigrum) 7. Hypolipidemic, hypoglycemic & antihypertensive 1. Bijaka (Pterocarpus marsupium) 8. Antihypertensive & hypoglycaemic 1. Jimutaka (Luffa echinata) 2. Kadali (Musa paradisciaca) 3. Shati (Hedychium spicatum 4. Tulasi (Ocimum sanctum) 9. Antihypertensive, hypoglycaemic & diuretic 1. Apamara (Achyranthis aspera) 2. Sahacara (Barkerua cristata) 10. Diuretics 1. Kasamarda (Cassia oxidentalis) 2. Parusaka (Grewia hirsuta) 3. Punarnava (Boerhavia diffusa) 4. Sahacara (Barleria prionitis) 11. Antihypertensives 1. Aswaghanda (Withania somniferia) 2. Arula (Ailanthus excelsa) 3. Bhringaraja (Eclipta alba) 4. Durva (Cynodon dactylon) 5. Nagakesara (Mesua ferrea) 6. Palandu (Allium cepa) 7. Sigru (Moringa pterigosperma) 6. Literature Review. Page 92 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.9 Research on Ayurvedic Herbs It is difficult to find valid scientific research on Ayurvedic herbs, not because it has not been done but rather that it is not so easy obtain of research done in India outside India without the necessary contacts. However below is a summary of some of the research that has been done with some of the more common herbs used in cardiovascular disease. Some of these studies are on animals, which of course does not mean that they will have the same effect on humans. Ajamoda (Apium graveolens). (1) Carum copticum is usually added to foods and used in the kitchen. In the experimental studies seed powder was feed to normal albino rabbits for four weeks and hypocholesterolemic, hypotriglyceremic and hypophosopholipidemic effects were observed. [I JMR, Vol. 83, Jan 1986] (2) Essential oil and total oils caused marked fall in BP in cats. [Mukharejee et al,. 1967] Arka (Calotropis procera) (1) The aqueous extract and alcoholic extracts (0.2 ml and 0.2 ml / 100g body weight) caused slight depression followed by stimulation of the rate and force of myocardial contraction of isolated frog's heart and marked vasoconstriction in blood vessels of frog and hind limbs of the rat. Both the extracts showed persistent rise in BP of dogs which could not be altered by any sympathetic drug. The aqueous extract had a mild diuretic effect in male albino rats [Derasari & Shah 1965] 6. Literature Review. Page 93 A Study of Cardiovascular Disease in Ayurveda John Vorstermans (2) The crude latex of C. procera and its protein fraction were found to possess high fibrinolytic activity and anti-coagulant activity both in rabbit and human plasma [Srivastava et al., 1962] (3) Calotropin (from C. procera) showed digitalis-like action on the heart, but its action was not cumulative and was less harmful [Bull. Fac. Pharm. Cairo Univ. 1971, 10, 1] Arjuna (Terminalia arjuna) (1) An experimental study was carried out in 50 dogs by ligating coronary artery and Arjuna (Terminalis arjuna) decoction was administered. 25 dogs were taken as treatment group and 25 dogs were kept as control group. At the end of the study histopathological evaluation was done which revealed that Arjuna significantly regenerated the cardiac tissue in the infarcted area. After carrying out coronary angiographs in dogs treated with Arjuna it was noticed that new coronary vessels developed [Gupta L. P.; “Studies on cardiac muscle regeneration under the influence of certain indigenous drugs” IMS BHU, Varanasi, Ph.D. theses, 1972] (2) It was observed that Arjuna (T. arjuna) significantly decreased the elevated cholesterol and increased the levels of HDHL. cholesterol. It was also noted that the prostaglandin levels which were low have been increased and high levels of catecholamines were brough down by the administration of the drug besides relief from symptoms like pain, palpitation etc. [Dwivedi S., 1986] (3) Diet-induced hyperlipidemic rabbits were given 50% ethanolic extract of T. Arjuna. The extract effectively reduced the TCL, LDL & TG levels. The extract did not show any adverse effect on liver and renal function and haematological parameters [Ram A. et al; “Hypocholesteroaemic effects of Terminal arjuna tree bark” J. of Ethnopharmacol., 55 6. Literature Review. Page 94 A Study of Cardiovascular Disease in Ayurveda John Vorstermans (3): p. 265-269, 1997] (4) Efficacy of Terminalia arjuna in chronic stable angina: a double-blind, placebo- controlled, crossover study comparing Terminalia arjuna with isosorbide mononitrate.2 Fifty-eight males with chronic stable angina (NYHA class II-III) with evidence of provocable ischemia on treadmill exercise test received Terminalia arjuna (500 mg 8 hourly), isosorbide mononitrate (40 mg/daily) or a matching placebo for one week each, separated by a wash-out period of at least three days in a randomized, double- blind, crossover design. They then underwent clinical treadmill tests showing significant decrease in the frequency of angina. CONCLUSIONS: Terminalia arjuna bark extract, 500 mg 8 hourly, given to patients with stable angina with provocable ischemia on treadmill exercise, led to improvement in clinical and treadmill exercise parameters as compared to placebo therapy. The test was only done on men and it was also only a short term test. It would have been more interesting to see a longer term test over 3 months to 1 year and then see results. There were no other tests performed in this case so no clear evidence on what is happening internally. (5) ARJUNA by Ray Sahelian, M.D. (natural health database).3 Several studies here. Casuarinin from the Bark of Terminalia arjuna Induces Apoptosis and Cell Cycle Arrest in Human Breast Adenocarcinoma MCF-7 Cells. Terminalia arjuna (Roxb.) protects rabbit heart against ischemic-reperfusion injury: role of antioxidant enzymes and heat shock protein. Terminalia arjuna reverses impaired endothelial function in chronic smokers. 2 http://www.findarticles.com/p/articles/mi_m0FDN/is_4_7/ai_91155410#continue 3 http://www.raysahelian.com/arjuna.html 6. Literature Review. Page 95 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Cardioprotective effect of the alcoholic extract of Terminalia arjuna bark in an in vivo model of myocardial ischemic reperfusion injury. Possible mechanisms of hypotension produced 70% alcoholic extract of Terminalia arjuna in anaesthetized dogs. • Antioxidant and hypocholesterolaemic effects of Terminalia arjuna tree-bark powder: a randomised placebo-controlled trial. These results come from a website selling Arjuna so they are likely to pick results that promote their products. Most of the studies were done with extracts of aspects of Arjuna or were compared with other drugs or Vitamines. None of the tests were long term however there does appear to be postive results in using Arjuna for its hypocholesterolaemic effect. (6) Dravyaguna Vijnana by Dr J.L.N. Sastry4 gives references to 12 studies done on the effects of Arjuna mainly on dogs or other animals. The result show Arjuna has good results in effecting “T wave changes”, as a cardiotonic, a significant result in regenerating cardiac tissue and development of new coronary vessels. It is also shown to decrease elevated cholesterol and increase HDL cholesterol in rats shows antidiabetic activity, diuretic and hypotensive and anti-acne properties. No side effects or adverse effects on the plasma, liver, heart or adipose tissue in hyperlipaemic rats. The results look positive in these cases and and verify the Ayurvedic actions of Arjuna. While some of the tests were done on humans it would be worth while doing some longer term tests 4 Dravyaguna Vijnana Vol II by Dr J.L.N. Sastry published by Chaukhambha Orientalia, Second Edition 2005, Page 496 6. Literature Review. Page 96 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Amalaki (Emblica officinale) (1) The dried powder pulp of Emblica officinalis fruit showed significant reduction in serum cholesterol and atherosclerosis in cholesterol fed rabbits [Thakur and Mandal 1984] (2) Phyllemblin, isolated from ethanolic extract of fruit pulp increased the amplitude of cardiac contraction and heart rate transiently [Khurana et al., 1970] (3) The hypertensive activity of E. officinalis is also reported [Dwivedi S. et al., 1994 (4) The anti-atherosclerotic and hypocholesterolarmic effects are also documented [Mand J. K. 1991; Bordia A. et al., 1985] (5) Hypo-lipidemic and anti-atherosclerotic activity – Five groups of rabbits were studied for 16 weeks to determine the effect of emblica fruit and vit. c (6 mg/kg) on cholesterol- induced hypercholesterolaemia and atherosclerosis. Both reduced the serum cholesterol. [Thakur & Mandal, 1984] (6) Amla juice and pulp (25 mg/kg/day) have prevented developmental atheroma both in aorta and coronary artery. [Bordia et al., 1985] (7) Amla fed to rabbits showed hypolipidemic and anti-atherosclerotic activity [Mand et al., 1991] (8) Hepatoprotective activity – Dry powdered pulp of fruits (1.0g/kg) reduced the levels of serum, aortic and hepatic cholesterol significantly in rabbits [Thakur, 1995]. Haridra (Curcuma longa) (1) Curcumin (7.5 mg/kg) caused a sharp but transient fall in BP which was not blocked 6. Literature Review. Page 97 A Study of Cardiovascular Disease in Ayurveda John Vorstermans by atropine, anti histamines or beta-blockers. On isolated heart from guinea pig, Curcumin revealed a depressant effect (Sinha et al. 1972) (2) The extract of turmeric has significantly reduced the serum TCL, TG, HDL and LDL lipoproteoms by administering 1gm b.i.d., for 15, 30 and 60 days respectively. [Deshpande U.R. et al; “Effect of turmeric extract on lipid profile (A-22)”. Int Seminar on Free Radicals Medicated Diseases. Fac of Ayu., IMS, BHU, Varanasi. 2-4 Sept 1966] (3) The alcoholic and ether-soluble extracts showed hypocholesterolemic effect [Pachauri & Mukherjee, 1970] (4) Hypolipdaemic activity of C. longa (50% ethenol) extract was studied in hyper lipidemic rabbits. The increased cholesterol levels were brought to normal by administration of C. longa. Similarly, phospholipids and triglyceride levels were also reduced. [Purohit & Daradka, 1999] (5) Oral administration of curcumin to rats caused a significant reversal in lipid peroxidation, brain lipids and produced enhancement of glutathione, a non-enzymatic anti-oxidant in ethanol intoxicated rats, revealing the anti-oxidative and hypolipidaemic action of curcumin responsible for its protective role against ethanol-induced brain injury. [Rajakrishnan et al., 1999] Haritaki (Terminalia chebula) (1) Terminalia chebula fruit powder showed reduction in serum lipid levels without reduction in body weight [CCRIM, Annual report 74-75] (2) Various extracts prepared from the fruit rind of T-chebula have shown cardiotonic activity when tested on normal as well as hypodynamic isolated frog hearts. The extracts increased the force of contraction and cardiac output without altering the heart rate 6. Literature Review. Page 98 A Study of Cardiovascular Disease in Ayurveda John Vorstermans [Reddy et al., 1990] (3) Bala Haritaki is found to be effective in reducing the levels of total lipids, serum TG, serum cholesterol, LDL, and VLDL significantly. On the other hand level HDL is increased significantly [Sood & Sharma, 2000] Lashunadi Guggulu (1) Lashunadi guggulu, a combination of 2 medicinal plants, Allium Sativum (lashuna), Inula racemosa (pushkaramula), and oleoresin of Commiphora mukul (guggulu) is a ration of 1:1:1 was evaluatied clinically for its efficacy in patients with chronic stable angina. The drug was chosen for the study on the basis of textual references in Ayurveda and previous research work carried out during the last 4 decades. 20 patients of chronic stable angina entered the randomized single blind type trial. Efficacy was assessed using objective end points. Ten patients completed all phases of study. After 2 months treatment with the drug, there was a marked improvement in precordial pain, dyspnoea and fatigue in all patients. Under computerised Tread Mill Test there were statistically significant increases (P<0.01) in mean exercise time, serum cholesterol and serum triglyceride levels were reduced from high and moderate significant levels. [Dr. Awasthi A.K. Haridwar. Published Journal of International Medical Research, West Sussex, UK] (2) Anti-atherosclerotic activity – Effect of gum-guggulu was observed on serum cholesterol, fibrinolytic activity and platelet adhesive index in healthy individuals (group 1) and in patients of CAD (group II) for a period of 30 days. Serum fibrinolytic activity improved by 22% and 19% at the end of 24 hrs, where as after 30 days it was 40% and 20% in group I & II respectively. Platelet adhesive index showed 22% and 19% after 30 days in group I and II respectively. Serum cholestrol did not decrease significantly 6. Literature Review. Page 99 A Study of Cardiovascular Disease in Ayurveda John Vorstermans [Bordia & Chuttanu, 1979] (3) Crude guggulu was reported to posses highly encouraging hypolipemic activity in rabbits [Satyavati, 1966] (4) Crude drug as well as its two fractions (alcohol soluble and alcohol insoluble) were found to cause a significant fall in serum cholesterol and serum turbidity with a concomitant increase in the coagulation time and prothrombin time. The alcohol insoluble fraction was slightly more potent in this respect than alcohol-soluble fraction as well as crude guggulu [Sastri, 1967; Tripathi et al., 1968] Lashuna (Rasona) (Allium sativum) (1) Allium sativum and A.ascalonium have shown significant anticoagulant and fibrinolytic activities by virtue of increasing whole blood coagulation time, prothrombin time and fibrinolytic activity. In addition, A.ascaonicum also possesses significant hypocholesterolemic properties [JRIM, Vol. IX, No 4] (2) Daily intake of a single piece of Garlic helps to control hypertension and prevents thickening of heart & arteries. Reversal of fat-induced decrease in plasma fibrinolytic activity and coagulation time in normal subjects as well as in patients of IHD following garlic therapy [Arocra et. al. 1984] (3) A.sativum extract – diallyl disulfide and diallyl propyl disulfide effectively reduces the total cholesterol and triglycerides (Gupta N.K.; “Possible mechanisms underlying the hypolipidemic action of garlic in irradiation (A-25)”. Int. Seminar on Free Radicals Medicated Diseases. Fac of Auy., IMS, BHU, Varansasi 2-4 Sept. 1996.) (4) Blood cholesterol level was significantly decreased in all human subjects after two 6. Literature Review. Page 100 A Study of Cardiovascular Disease in Ayurveda John Vorstermans months of ingestion of garlic [Ind. J. Physiol. Pharmaeol. 1979, 23, 1979] (5) Platelet adhesion to polycarbonate film surface was decreased by 0.05-0.5 ml garlic oil/ml of platelet-rich plasma; thus extract inhibited platelet aggregation [Theanb. Res. 1985, 37, 489\ Shankhapuspi (Convolulus pluricaulis) (1) The alcoholic extract of whole plant depressed the amphibian and mammalian myocardium [Boveju & Singla, 1996] Clinical studies were conducted on 25 cases of arterial hypertension with the decoction of the drug, a gradual fall in BP along with relief in the symprom was observed [Chaturvedi et al., 1966] (2) The alcoholic extract of whole plant depressed amphibian and mammalian myocardium. The extract had a spasmolytic activity on the smooth muscle [Barbar & Sharma, 1965] (3) The expressed juice of the plant caused a fall in the arterial blood pressure of anaesthetized dogs. In larger doses it produced a transient inhibitory effect on both force and rate of contraction of the heart [Chaturvedi et al., 1966] Vaca (Acorus calamus) (1) Cardiac depressant activity was observed both with ascarone and beta-ascarone. Both showed moderate degree of hypotensive action in anaesthetized dogs [Sharma & Dandiya, 1962] (2) Administration of Vaca (1.5 to 3 gms/day in divided doses) for 3 months found effective in chest pain, dyspnoea on effort, reduction of body weight, improvement in 6. Literature Review. Page 101 A Study of Cardiovascular Disease in Ayurveda John Vorstermans ECG changes etc. (3) Vaca (acorus calamus) administered in a dose of 1.5 to 3gm per day in divided doses for 3 months decreases serum TCL, TG, HDL & LDL. 6. Literature Review. Page 102 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.10 Details of Ayurvedic Herbs under research. Sanskrit Name: Ajamoda English Name: Celery Botanical Apium graveolens Name: Synonyms: Family: Apiaceae Gana: Description: It is native to Europe and now naturalized and occurring wild in the foothills of the northwestern Himalayas and the outlying hills of Punjab, Himachal Pradesh and Uttar Pradesh. It is largely cultivated in Punjab, Haryana and Uttar Pradesh. It is an erect, annual or biennial herb. The roots are numerous, succulent and well developed. The stem branches are angular or fistular, conspicuously jointed. The leaves are oblong to obovate, pinnate or trifoliolate. The leaflets are ovate to sub-orbicular and 3-lobed. The flowers are white or greenish white and very small. The fruit (commonly called seed) is a schizocarp consisting of two mericarps, sub-orbicular to ellipsoid, greyish brown to brown with pale ridges, aromatic and slightly bitter. Principle Constituents: Rasa: Katu (pungent), Tikta (bitter) Guna: Laghu (light), Ruksha (dry) Virya: Usna (heating) Vipaka: Katu (pungent) Prabhava: Parts used: Seeds Dosage: 5-7 gms powder Dosha Karma: KaphaVata hara, Pitta Kara Actions and Indications: Anulomana (expels downward) Pachana (digests ama) 6. Literature Review. Page 103 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Deepana (appetizer) Swasa (relieves asthma) Important Actions: Vidahi, Kaphavataji, Deepana, Rucikrt, Krimijit, Sulaghna Indications: Celery seeds are credited with stimulant and carminative properties and are prescribed as nervine, sedative and tonic. They are prescribed as a decoction or as a liquid extract. The fatty oil from the seeds is used in many medicinal preparations as an antispasmodic and nerve stimulant. The roots are credited with diuretic property. Srotas: Precautions: No adverse effect was reported on use of this plant as medicine in recommended doses. Usage: External: Internal: Circulatory system: Digestive system: Flatulence, borborygmus, intestinal cramps. Low agni is stimulated by the pungent volatile oils Nervous System: Spasms, cramps, tension. Obstructed vata is moved by reducing tension throughout the whole nervous system- the constriction is eased and a normal flow ensues. Also benefits heart pain from nervous constriction.4 As an anti-spasmodic with an affinity for the lower abdomen it can help ease the pain of dysmenorrhea and menstrual cramps. Respiratory system: Asthma, bronchitis, cough, sinus congestion. It actively helps to dilate the bronchioles by preventing spasm in the airways. Excess kapha is 'digested' Reproductive system: Skin: Urinary system: Specific herb for kidney and bladder discomfort from cold. The vegetable 'stalk' heals the urinary system afflicted with problems from heat- irritation, cystitis etc. Temperature: Eyes: Important Yogas: (combinations) Preparations: Ajamodarka, Ajamododadi churna 6. Literature Review. Page 104 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Arka English Name: Madar Botanical Calotropis procera Name: Synonyms: Alarka, Bhanu, Bhaskara, ravi, Surya pushpaka Kshiraparni, Mandara Family: Asclepiadaceae Gana: Bhedhaniya (Ch), Vamanopaga (Ch), Svedopaga (Ch) Adhobhagahara (Sh), Arkadi (Sh). Description: Tall shrub up to 2-4 metres in height, yellow – white bark. Leaves: sessile, elliptic, oblong, thick, clothed beneath and above with cotton. Flowers: purplish, white, dilated at the base, pedicles longer than the flowers, covered with cotton wool, buds are ovoid. Roots: Curved, woody, light – greyish white yellow, covered with think bark. Varieties: Two types distinguished by the colour of the flower; Calotropis gigantea – Shveta Arka, white flowers. Calotropis procera – Rakta Arka, red flowers. Principle Constituents: A yellow bitter resin; a black acid resin; Madaralbum, a crystalline colourless substance; Madarfluavil, an amber coloured viscid substance; and caoutchouc, and a peculiar principle which gelatinizes on being heated, called Mudarine. Lewin found a neutral principle, Calatripin, a very active poison of the digitalis type. In India the author's husband experimented with it for paper-making, the inner bark yielding a fibre stronger than Russian hemp. The acrid juice hardens into a substace like gutta-percha. It has long been used in India for abortive and suicidal purposes. Mudar root- bark is very largely used there as a treatment for elephantiasis and leprosy, and is effective in cases of chronic eczema. Rasa: Katu (pungent). Tikta (bitter) Guna: Laghu (light), Ruksha (dry), Tikshna (sharp) Virya: Ushna (hot) Vipaka: Katu (pungent) Pabhava: Parts used: Root bark, latex, flowers Dosage: Root bark churna 1-2 gm, Flowers 1-2 gm, Latex 1/8th – ¼ gm, 6. Literature Review. Page 105 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Leaves 2-4 gm Dosha Karma: Vata hara (white variety), Pitta hara (red variety), Kapha hara (red & white) Actions and Indications: Bhedana-virecanopaga-recana Rakta Pitta Shamaka (pacifies rakta pitta (laxative) disorders) Deepana-pacana (stimulates Raktashodhaka (blood purifier) agni) Vamanopaga-vamaka (emetic) Jvaraghana (anti-pyretic) Vedanasthapana (pain killer) Hridya (heart tonic) Visaghna (anti poison) Kaphaghana (kapha pacifying) Kusthaghna (skin conditions) Important Actions: Indications: Gall stones, kidney stones, constipation, liver and spleen enlargement, eczema, skin disorders, boils, asthma, cough, cold, fever, ear ache, haemorrhoids, eye disorders, parasitic conditions – worms. Srotas: Pranavaha, Annavaha, Rasavaha, Raktavaha, majjavaha, Purishavaha Dhatus: Rasa, Rakta, Majja Organs: Liver, spleen, heart. Precautions: High toxic properties. Not wise to use for internal use and may be not for external. It is a strong irritant to skin. Not available in NZ Usage: External: As it is analgesic, antinflammatory, vranashodana, auto- dermatosis, anti microbial, it is used in elephantitis and rheumatoid arthritis. Conditions in which there is inflammation and pain, leaves are heated and bound on the affected area, oil made up of the juice is also used for massage. Oil used in otalgia, deafness. Leaf powder helps wounds heal faster. Brush on teeth for toothache. Internal: Circulatory system: Root bark is a cardiac stimulant, purifies blood and is antiinflammatory. Flowers of red variety is used in haemorrhagic disorders. Root bark is use in cardiac debility, filaria, chancroid ulcers and many other blood diseases. Digestive system: It is an emetic, increases appetite, digestive, cholagogue, purgative, anthelmintic. It causes irritation of stomach by stimulating vomiting centre in the brain and thus causes emesis. In anorexia, its latex is used. Respiratory system: Expectorant and anti asthmatic. Therefore root bark and flowers are used in kaphavata kasa and asthma. Alkaline extract of flowers is useful in many disorders. Skin: As it is a diphoretic, antidermatotic, therefore is used in 6. Literature Review. Page 106 A Study of Cardiovascular Disease in Ayurveda John Vorstermans dermatosis. It is very potent remedy for scabies. Temperature: Febrifuge, also effective in typhoid. Important Yogas: (combinations) Preparations: Arka Lavana, Arka Taila, Arka Kshara 6. Literature Review. Page 107 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Arjuna, Kakubha, Pārtha, Vīravrksa, Nadisarja, Indradru, dhavala English Name: Arjuna Botanical Name: Terminalia arjuna W. & A. Family: Combretaceae Gana: Kasayaskandha [ch] - astringent Udardaprasamana [ch] - relieving rashes Nyagrodhadi [sh] Salasaradi [sh] Rasa: Kashaya (astringent) [Vatakara, Pittahara and Kapahara] Guna: Laghu (light) [Vatakara, Pittakara and Kapahara] Ruksha (dry) [Vatakara, Pittahara and Kapahara] Virya: Shita (cooling) [Vatakara, Pittahara and Kapakara] Vipaka: Katu (pungent) [Vatakara, Pittakara and Kapahara] Prabjave: Hridya Karma: From the properties of rasa, guna, virya and vipaka the action of Arjuna has the following effects on doshas: Vatakara, Pittahara and Kapahara, Dosha Karma: Kapha hara Pitta hara Parts used: Bark Dosage: Bark - Powder 1-3 gms,; 10-30 grains. Juice 10-15 gms. Decoction 50 – 100 ml. Actions and Indications: Ashogna (piles) Raktaprasadana (good for the blood) Balya (building) Rasayana (tonic) Hridya (heart tonic) Sandhaniya (joining) Kaphaghana (Kapha pacifying) Shothahara (swelling) Jvaraghna (antifever) Stambhaka (stopping) Medohara (fat reducing) Tvacya (skin disorders) Mutrasangrahaniya (anti-diuretic) Visaghna (anti-poison) Vranaropana (wounds) Important Actions: Cardiac tonic, cardiac stimulant, blood disorders, 6. Literature Review. Page 108 A Study of Cardiovascular Disease in Ayurveda John Vorstermans swelling, bleeding, anemia. Srotas: Pranavaha, Rasavaha, Raktavaha, Medavaha Dhatus: rasa, rakta, meda, Organs: heart, circulatory, respiratory Precautions: Due to it's vatakara quality it could cause constipation so need to be taken with herbs that will prevent this. Usage: External: It helps in wound healing and joining by astringent property. It is haemostatic. The bark paste can be applied to wounds, ulcers and especially used in promoting the union of fractures. Internal: Circulatory system: Cardiac tonic, giving strength to cardiac muscles, improving cardiac function and rhythm. It reduces cardiac rate. It increases the peripheral resistance by constricting capillaries which leads to rise in blood pressure. It enhances blood quality. Prevents accumulation of fluids thereby reduces oedema. Digestive system: Its astringent property reduces motility and being a haemostatic it controls bleeding in dysentery and haemorrhoids. Respiratory system: Astringent properties useful in purulent and tuberculous cough and in haemoptysis. Reduces heartburn and cough. Reproductive system: Prevents early ejaculation of semen. Useful in menorrhagia and leucorrhoea. Urinary system: Useful in diabetes from astringent properties and gonorrhoea, by reducing urinary discharge and relieving burning and pain during micturition. Skin: Useful in skin diseases with prurits. Temperature: It is febrifuge. In chronic fever it not only helps as antipyretic but also acts a general tonic. Important Yogas: (combinations) Preparations: Kakubhadhi, Curna, Arjunasrista, Parthadyarista, Arjunatvak, Arjunaghrta 6. Literature Review. Page 109 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Amalaki English Name: Emblic myrobalan Botanical Emblica officinalis Name: Synonyms: Dhatri; the nurse, because it nurses the people and protects them against disease. Amalaki. Family: Euphorbiaceae Gana: Triphala Parushakadi Kustaghna - Anti dermatitus, reduces skin inflammation Virecanopago – Adjunts to purgation, usually laxative in nature. Kāsahara - stop cough; anti-trussive Jvarahara - febrifuge; relieves fevers Praja-sthapana – Promotes reproduction; cure sterility. Vaya-sthapana – Promotes longevity; rejuvenation, counters the aging process. Description: Tree and Bark: small medium sized tree, 8-18 metres in height, with thin light grey bark that exfoliates in small thin irregular flakes. Leaves: Simple, very many sub sessile, closely set along the branches, light green. Flowers: Greenish yellow, unisexual, flowers in autumn, Fruits: Ovary three celled, globose fruit, fleshy, pale yellow, six striations with seeds. Principle Constituents: Rich in Vitamin C, Gallic Acid, Tannic Acid, Glucoses, Albumin, Cellulose and minerals like Calcium. Rasa: Pancha (five) Rasa; Amla (sour) predominant, Madhura (sweet), Katu (pungent), Tikta (bitter), Kashaya (astringent) Guna: Laghu (light), Ruksha (dry), Shita (cold) Virya: Shita (cooling) Vipaka: Madhura (sweet) Pabhava: Parts used: Fruits Dosage: Powder 3-6 gms daily Dosha Karma: Tridosaghna, Specifically Pitta pacifying. 6. Literature Review. Page 110 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Actions and Indications: Anulomana (causing downwards movement of apana) Balya (strength tonic) Dahaprashamana ( anti burning) Deepana (kindles digestion) Hridya (heart tonic) Jivaniya (life giving) Jwaraghna (anti pyretic) Kandughna (anti pruritic – anti itching) Keshya ( hair tonic) Kushthaghna (skin conditions) Mutrala (diuretic) Sarvadoshahara (kills all diseases) Stambhana (stopping) Rakta Pitta Shamaka (pacifies rakta pitta disorders) Rakta prasadaka (builds good quality Rakta Stambhaka (to stop bleeding) blood) Rasayana (rejuvenative) Rochana (enhances taste) Sandhaniya (help to heal, joining of bones, wounds etc). Shukrakara (increases sperm) Shula prashamana ( reduces abdominal pain) Tvachya (skin disorders) Vayasthapana (promoting longevity) Vrishya and Vijikara (building good shukra & sexual tonic) Important Actions: Rejuvenative, general tonic, aphrodisiac, cardiac tonic, laxative. antipyretic – refrigerant, anti-inflammatory, haemostatic, Indications: mental disorders, weakness of the liver or spleen, hepatitis, anaemia, bleeding disorders, gout, gastritis, cardiac disorders, asthma, bronchitis, skin diseases, constipation, haemorrhoids, fever, diabetes, general weakness, eye disorders, male infertility, lack of libido, premature greying or hair loss, peptic ulcers, inflammation, leucorrhoea, general debility and tissue deficiency. Srotas: Annavaha, Ambuvaha, Rasavaha, Raktavaha, Majjavaha, Shukravaha, Purishavaha, Mutravaha Dhatus: Rasa, Rakta, Shukra, increases ojas – works on all levels of the dhatus as a rejuvenative. Organs: Brain, heart, liver, pancreas. Precautions: Acute diarrhea, dysentery Usage: External: Netra vikara, Keshavika – hair wash, Kushtha.Tvakrog – skin 6. Literature Review. Page 111 A Study of Cardiovascular Disease in Ayurveda John Vorstermans disorders. Internal: - strengthens the nervous system, bone marrow and sense organs. Digestive system: it improves taste and appetite, curative, antacid, biliousness, Small doses cause constipation while large doses is laxative. Circulatory system: Cardiac tonic, complexion enhancer. Respiratory system: Reduces cough. Reproductive system: Aphrodisiac tonic and haemostatic Urinary system: Useful in diabetes though it is a diuretic. Skin: Useful in skin diseases. Temperature: Antipyretic, refrigerant. Manoroga – brain diorders, Indriya daurbalya – weakness of the senses. Netra vikara – eye sight problems Udara roga – ascities; stems from liver disorders. Arsha – piles Grahi – constipation Yakruti vikara – liver/spleen disorders Aruchi – loss of taste, anorexia Agnimandya – low digestive fire Amla pitta – gastritis Gulma – tumor in the abdomen Hridroga – heart disorder Pandu – anemia Rakta pitta – bleeding disorders Chardi – vomiting Atisara - diarrhoea Kasa – cough Svasa – asthma Rajayakshma Kshaya – TB Koch's all tissues affected mainly respiratory tract. Prameha – diabetes Pradara – leuccorrhea & menorrhea Mutrakruchra – dysuria Jirna Jvara – chronic fevers Important Yogas: (combinations) Preparations: Triphala, Chyavanaprasha, Brahma Rasayana, Dhatriloha, Dhatri Avaleha (jam) 6. Literature Review. Page 112 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Haridra English Name: Turmeric Botanical Curcuma longa Name: Synonyms: Rajani, Nisha, Ratri, Ksanada, Dosa Family: Gana: Description: Turmeric is native to India. It is found today cultivated in India and other parts of south-east Asia. The medicinal part of the plant is the dried and cooked rhizome. Principle Constituents: Essential oil, resin, an alkaloid, curcumin--the yellow coloring matter, turmeric oil or turmerol. (oil has no phenols, aldehydes or ketones), caproic acid, cqleric acid, sesquiterpene hydrocarbons maily zingiberene. Fe Rasa: Tikta (bitter), Katu (pungent) Guna: Ruksha (dry) Virya: Ushna (heating) Vipaka: Katu (pungent) Prabhava: Antibacterial, regulates blood sugar Parts used: Root Dosage: 1.5 to 3 grams Dosha Karma: VataKaphahara Pittakara Actions and Indications: Krimighna (destroys parasites) Pramehana (anti-diabetic) Kustaghna (skin conditions) Varnya (complextion) Vishaghna (anti-poison) Important Actions: Visavikira, Kustha (skin), Vrana, Twakroga, Prameha (diabetes), Pandu (anemia), Sitapitta. Indications: chronic strep, hemorrhoids, diabetes, anemia, non healing ulcer, bronchitis, asthma, thin blood, HIV,conjunctivitis inflammation, 6. Literature Review. Page 113 A Study of Cardiovascular Disease in Ayurveda John Vorstermans fungus, bacterial infection, hemorrhoids, cold, cough, wounds, sinus congestion, strep throat, pharyngitis, tonsillitis, lump in breast(not fibrocytic), diabetes, cat scratches, non-healing wounds, anemia bronchitis, bronchial asthma, inflammed piles, hoarseness of voice, traumatic arthritis, dermatitis, eczema, psoriasis, sore muscles, Srotas: Precautions: Turmeric should not be used during pregnancy due to its reported antifertilty effects. It is also contraindicated for those with diagnosed gall bladder disease. Usage: Turmeric specifically affects the digestive, respiratory, and circulatory systems. Its actions are: carminative, alterative, stimulant, antibacterial, and vulnerary. It has proven useful in conditions of: indigestion, sore throat, cough, skin conditions, poor circulation, amenorrhea, diabetes, arthritis, anemia, and in wound and bruise healing. Turmeric should be used cautiously in acute jaundice, hepatitis, and in pregnancy. It is prepared as an infusion, decoction, milk decoction, or by taking it in powder form of 250mg to 1 gram. Turmeric is an excellent natural antibiotic, while at the same time it strengthens digestion and helps improve intestinal flora. As such it is a good antibacterial for those chronically weak or ill. It not only purifies the blood, but also warms it and stimulates formation of new blood tissue. Turmeric gives the energy of the Divine Mother and grants prosperity. It is effective for cleansing the chakras (nadi-shodhana), purifying the channels of the subtle body. It helps stretch the ligaments and is, therefore, good for the practice of hatha yoga. Turmeric promotes proper metabolism in the body, correcting both excesses and deficiencies. It aids in the digestion of protein. Externally, it can be used with honey for sprains, strains, bruises or itching. It is tonic to the skin, for which purposes it can be taken internally as a milk decoction.” Important Yogas: (combinations) Preparations: Haridra Khanda 6. Literature Review. Page 114 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Haritaki Pathya, abhaya, (popular names), amrut, haimavati, siva English Name: Myrobalans; Chebulic myrobalan. Botanical Name: Terminalia chebula Synonyms: Family: Combretaceae Gana: [Triphala, Amalakyadi, Parushak, Trivrutt,] Prajasthapana, Jwaraghna, Kusthanghna, Kasaghna, Arshoghna Description: A large tree up to 30 meters high with hard and bulky bark. Leaves – 10 – 30cm in length and pointed with 6-8 pairs of veins. Interior aspects of leaves show two small nodules near its attachment to the stalk. Flowers – short stalks, white or yellow and strong smell. Fruits – 3-6 cm long green and become yellowish-brown on ripening. Seeds oval and hard and on breaking the shell of the seed, an oval shape pulp is obtained. Principle Constituents: Fruit containsup to 30% tannin, chebulinic acid and it also contains gallic acid, resin etc. Rasa: Kasahaya (astringent), Madhura (sweet), Amla (sour), Tikta (bitter), Katu (pungent) Guna: Laghu (light), Ruksha (dry) Virya: Ushna (heating), Vipaka: Madhura (sweet) Prabhava: Parts used: Fruit Dosage: Fruit (greater) 3-6gm laxative, 1gm for alterative. Dosha Karma: Tridosha Actions and Indications: Anulomana (expels downwards) Mutrala (mild diuretic action) Balya (strengthens nerves) Pachana (digests ama) Deepana (appetizer) Prajastapana (helps in conception) Jwaraghna (anti-pyretic) Rasayana (rejuvinitive tonic) Kaphagna (pacifies kapha, reduces Shotahara (anti-inflammatory) ama) Yakrututtejaka (good for liver, 6. Literature Review. Page 115 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Krimighna (destroys parsites – mild) hepatitis) Medya (supports actions of brahmi) Vedanesthapana ( good for pain) Mrudurechana (mild laxative) Vrishya (removes ama from shukra) Important Actions: A preventative and curative herb. Antioxidant and amapachana Indications: Agnimandya, Ajirna – indigestion 3 types = ajirna K type / vidagdha P type/ vistabdha V type, Shula, Anaha – gaseous disorders, Chardi, Krumi, Hrahani, Arsha, Vatarakta, Amavata, Rakta vikara, kasa, Shwasa, Pratishyaya – cold, Hikka, Pharyngitis, Prameha, Mutraghata – obstruction, Dysuria, Kustha, Visarpa, Jwara, Vishama jwara – typhoid, Jirnajwara – chronic fever, Nerves weakness, Uterine waekness, Shweta pradara – leucorrhea, Vata vyadhi, Shotha, Netravikara, Mukha roga, Fileriasis, Medo roga, Raktapitta, granthi – excess glands and tumours. Therapeutic Uses: Very commonly used herb, rasayana - rejuvenative medicine and used on number of disorders. Fruit is expectorant, de-worming, stambhana effect on GIT. Churna decoction are used in Asthma, sore throat, thirst, vomiting, eye diseases, urinary calculi, ascits, tumors, bleeding piles, typhoid, leucoderma, gout, anemia and bhrama – dizziness. Unripe fruit for diarrheoa and dysentry and ripe is purgative, tonic, carminative, good on paralysis and brain disorders. For Vata Vyadhis. Grandusha and local application on bleeding and ulcerative conditions of the gums. Smoke / cigarettes of fruit powder for asthma conditions. Fruit is kept in water over night and this water is used for eye wash as is very cooling. For piles – ½ tsp. K less, V more. Use Daily. For Gout – Triphala or Haritaki will drop Uric acid levels. Srotas: All srotas Precautions: Important Yogas: (combinations) Preparations: Abhayamodaka, arishta, vati, vyaghri haritaki, pathyadi churna, haritaki khanda, amru haritaki, pathyadi kwatah, haritkaydi rasayana, churna, lepa Haritaki rasayana: Anupana: rainy season saindha -salt. Autumn – sugar. Winter: shunti. Spring: honey. Summar guda – jaggery. For: vata dosha anupana ghruta. Pitta dosha: sugar. Kapha dosha Lavana. Gandharva Haritaki 1:1 Castor oil & Haritaki, stir 10 min on low heat. Use as powder, in 6. Literature Review. Page 116 A Study of Cardiovascular Disease in Ayurveda John Vorstermans capsule or vati. 2 capsules for therapeutic use before going to bed. 6. Literature Review. Page 117 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Guggulu English Name: Gum, Guggul, Indian Bedellium Botanical Name: Commiphora mukul Synonyms: Guggul, Deodhoop, Mahishaha, Palankash, Kashi, Kumbha, Deveshta Family: Burseraceae Gana: Vedanasthapan (Ch), Eladi (Sh) Description: Tree is 1.5-1.3 mtrs high, young parts are glandular, branches are knotty and crooked, usually ending in sharp spines. Leaves – 1-3 foliate, ovate and serrate, toothed in the upper part. Flowers fascicles 3-5, triangular long as tube. Ovary oblong ovoid attenuated into the style. Drupes red when ripe, 6-8 mm in diameter, acute and readily splitting into two. Flowering and fruiting – after rainy season up to autumn. Distribution – Rajasthan, Gujarat, Mysor, warm regions of India. Varieties – are based on colour and accordingly they are used on humans or for animals. Mahissraka black in colour used for human body. Mahinila blue in colour for veterinary use. Kumuda and Padme red colour one also for Veterinary use. Kanaka is yellow for human body use. In market you get two types, kana and Bhaina Guggul. Principle Constituents: Contains volatile oil, resinous gum and bitter principle Rasa: Kashaya (astringent), Katu (pungent), Tikta (bitter) Madhura (sweet) Guna: Lagu (light), Tikshna (sharp), Snigdha (unctuous), Pichilla (sticky), Sukshma (fine), Sara (mobile) Virya: Ushna (hot) Vipaka: Katu (pungent) Prabhava: Tridoshahara Parts used: Gum resin Dosage: 1-2 gms Dosha Karma: Tridoshahara Actions and Indications: Arshoghna (relieves piles) Rasayana (Rejuvenative) 6. Literature Review. Page 118 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Ati Lekhana (excessively scraping) Sandhanakara (promotes fracture Balya (Strengthening tonic) healing) Deepana (Appetizer) Shotahara (anti-inflammatory) Krumighna (destroys parasites) Swarya (good for the voice) Kustaghna (Skin conditions) Vatahara (Vata pacifying) Medahara (Fat reducing) Vranaropana (Wound healing) Important Actions: Hypolipidic, hypocholestremia, obesity and weight loss, chronic skin conditions, helps in rheumatoid arthritis. Most important for obesity, arthritis and skin conditions. Good for ama & vata. Indications: Amavata Arsha Bhahgna (fractures) Gandamala (goitre) Granthi (tumors) Kustha (skin) Medoroga (obesity) Sandhivata ( fractures & connective tissue) Shota (inflamation) Vata vyadhi Srotas: Asthivaha Precautions: It is mentioned that guggul is very useful, still one has to be careful about injudicious use of it. The dosage should be adequate. Misuse of guggul leads to pathological changes in liver and lungs while excessive dose causes vertigo, dryness of mouth, impotency, loss of weight and dryness of skin. Guggul should not be used in patients with the above complaints. Usage: External: Anti inflammatory, analgesic, cleaning of wounds and healing due to antibacterial action. Paste of guggul is locally applied in rheumatoid arthritis, cervical lymphadenitis, skin diseases, piles etc. It reduces foul smell and wound swelling. Its vapours are useful as deodorant and disinfectant in the house. Gargling is useful in pyorrhoea and dental disorders. Internal: Circulatory system: Cardiac tonic. Increases haemoglobin and leucocyte count and enhances blood quality. It helps in oedema, lymphadenitis, glandular enlargement and filaria when given for a long period. Digestive system: Appetizer by pungent and bitter; laxative by snigdha picchila, sara and tikshna; liver stimulant, antihaemorrhoidal and anthelminitc by bitter and ushna gunas. Thus useful for loss of appetite, constipation, liver diseases, piles and worms. In stomatitis guggul kept in the mouth helps in wound healing. Nervous System: Vatashamak, analgesic, nervine tonic, so 6. Literature Review. Page 119 A Study of Cardiovascular Disease in Ayurveda John Vorstermans guggul us useful ineuralgia, rheumatoid arthritis, sciatica, facial paralysis, hemiplegia, and gout. Great for vata disorders. Respiratory system: Expectorant being snigdha and picchila. Deodorant, anthelmintic. Useful in chronic cough and chronic asthma, Preparation of guggul + pippali + honey + ghee is useful in kapha disorders. Reproductive system: Increases sexual power and acts as an emmenogogue, It is also useful in oligospermia, impotency, dysmenorrhoea, leucorrhoea, and other gynaecological diseases. Skin: Effective in dermatoses, enhances complexion, and useful in many skin diseases. Important Yogas: (combinations) Preparations: Yogaraj Guggul, Mahayogaraj Guggul, Chandraprabhavati – obesity scraping, Arogyavardhini, Triphala Guggul. 6. Literature Review. Page 120 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Pushkaramula Pushkara, Haimavati, Shwetavacha, Kashmir, Kushthabheda, Kashari, Shwasari, Shoolahara, Sugandhika English Name: Botanical Inula racemosa Name: Synonyms: Padmapatra (leaves similar to lotus leaves) Kashmari Family: Compositae Gana: Swasahara, Hikkanigrahana (Ch) Description: A stout herb up to 1.5 meters tall with grooved stem. Leaves are feathery, top is rough, coriaceous densely hairy beneath. Toothed, radical leaves, long stalked, elliptic-lanceolate, cauline at the base. Flowers yellow in racemes, heads involucral with recurved triangular tips. Principle Constituents: Sesquiterpene lactones, alantolactone, isoalantolactone, inunal isoalloaltolactone and essential oil. Rasa: Tikta (bitter), Katu (pungent) Guna: Laghu (light), Tikshna (sharp) Virya: Ushna (heating) Vipaka: Katu (pungent) Prabhava: Parts used: Roots Dosage: Powder 1-3 gms Dosha Karma: Kaphahara Vatahara Actions and Indications: Hyridya (heart tonic) Panduhara (anaemia) Kasahara (relieves coughs) Parshwashilahara (relieves chest pain) Jwaraghna (anti pyretic) Shotahara (anti-inflammatory) Medohara (good for reducing fat) Swasahara (relieves asthma) Mutrajanana (diuretic) Vajikarana (aphrodisiac) Important Actions: Good for the respiratory conditions, the heart – angina. Good for cardiac failure. 6. Literature Review. Page 121 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Indications: Kasa, Swasa, Anemia, Especially in Vata and Kapha predominant jwara, Angina pectoris, Cardio protective, Hypertension. Srotas: Annavaha, raktavaha Precautions: Usage: External: It is an antifungal, it cures pus formation, swelling and pain. It's powder is sprinkled over tuberculosis ulcers or its paste if applied, It is used in painful swelling. Local application of paste is effective in lateral chest pain by which swelling and pain are relieved. Internal: Circulatory system: Digestive system: Used in anorexia indigestion and flatulence. Nervous System: Stimulates the brain and nervous system, hence is useful in cerebral impairment and vata disorders. Respiratory system: It clears the airways and alleviates cough, dyspnoea and hiccough. It is effective in chronic cough, hiccups, dyspnoea and pleurisy. In these diseases it alleviates the dosha by killing bacteria and relieves fever and pain. Reproductive system: Useful in amenorrhoea and dysmenorrhoea. Also a good aphrodisiac. Skin: Urinary system: Stimulates the kidneys and increases urine formation Important Yogas: (combinations) Preparations: Pushkaramuladi churna (All listed indications), Pushkaramulasava (all listed indications, especially in respiratory conditions. 6. Literature Review. Page 122 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Rasona Lashuna English Name: Garlic Botanical Name: Allium Sativum Synonyms: Ugragandha, Yavunesta, Lashuna Family: Liliaceae Description: A bulbous variety of plant. It is 30-60 cms in height. Its stem is tender. Leaves are flat, thin and long. Inflorescence arises from the centre of the plant and bears flowers right at the top. Bulb white, pinkish with 5 to 12 buds in it. Cold weather is the season for flowering and fruits. Varities: Two 1) Rason and 2) Maharason. The bulb of Maharason is larger. Another (third) variety – garlic with a single bud. The single bud variety is used extensively in medical pharmacopoeia. Principle Constituents: Volatile oil, whote liquid, albumin, sugar, jelly like substance. The volatile oil which is yellow in colour contains organic sulphur. Rasa: Madhura (sweet), Lavana (salty), Katu (pungent), Tikta (bitter), Kashaya (astringnet) Guna: Snigdha (unctuous), Tikshna (sharp), Picchilla (slimy), Guru (heavy), Sara (mobile) Virya: Ushna (heating) Vipaka: Katu (pungent) Prabhava: Parts used: Bulb, oil Dosage: Paste 3-6 gms; oil 1-2 drops Dosha Karma: VataKapha hara Actions and Indications: Anulomana (expels Rasayana (rejuvenative) downwards) Sandhaniya (promotes fracture healing) Artavajamama (amenogouge) Shotahara (anti inflammatory) Deepana (digestive) Shukrala (increases shukra) Hridya (heart tonic) Sulaprashamana (pacifies abdominal pain) Kaphagna (reduces kapha) Swedanjana (promotes sweating) Krimighna (destroys parasites) Uttejaka (liver stimulant) Kustaghna (skin conditions) Vataaghna (reduces vata) Mutrajanana (diuretic) Vedanasthapana (removed pain) Pachana (digests ama) Vishaghna (anti poison) 6. Literature Review. Page 123 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Raktapittajanana (pacifies Yakrituttejaka (Liver regulator) rakta pitta disorders) Important Actions: Indications: Vata vyadi, Shula, Ajirna, Vibandha, Gulma, Hrdroga Heart), Swasa (asthma), Kasa (cough), Asthibhagna, Rajayaksma, Shota (inflammation), Krmi (parasite) Precautions: Being tikshna and ushna it is contraindicated in pregnancy and those with pitta prakruti because it aggravates pitta. Usage: External: It is an anti inflammatory, pain killer and removes toxicity. In childhood cough, a necklace of garlic buds is worn. Garlic paste is used for swelling in rheumatoid arthritis, paralysis, sciatica, facial palsy and pain in the ribs. Juice is also used. Garlic juice is used in skin disorders like eczema. Swelling due to insect bites almost disappear on rubbing garlic juice or oil of garlic. A bud of garlic, inserted in the ear also relieves pain. It the uvula is elongated, juice of garlic brings it to normal. Internal: Circulatory system: Oedema due to cardiac disorders is decreased by garlic. Digestive system: In digestion, low appetite, pain, constipation, worm infestation, piles, all diseases of vata and kapha, garlic is useful. Flatulence caused by food like rice can be avoided easily if cooked in garlic water. Nervous System: Used in paralysis, arthritis, sciatica and weak memory. Garlic juice is given internally in diminished vision. Respiratory system: It decreases cough. Milk boiled with garlic reduces chronic cough, asthma, tuberculosis and hoarseness of voice. The volatile oil kills Mycobacterium tuberculi. Healing properties are therapeutic to inflammation patches in lungs. Cough is demulcified by buds of garlic. In a persistent cough, a garland of garlic buds is put around the neck. In diseases of Vata and Kapha, garlic oil is rubbed on the chest. Reproductive system: It stimulates the production of semen. Thus it is of much use in paucity (weakness) of semen. Being a regulator of menstrual function it is useful in dysmenorrhoea. Skin: As it contains organic sulphur is is very effective in skin diseases, pruritus and eczema etc. Urinary system: Is used in urinary disorders. Temperature: Useful in fevers. In fevers with rigours, garlic oil should be used for massage before fever rises. It is used as a preventative medicine in enteric fever, diphtheria etc. Important Yogas: (combinations) Preparations: Rasonvati, Rasonpinda, Rasonashtaka, Lasunadighrita, Rasona siddha taila 6. Literature Review. Page 124 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Shankhapushpi English Name: Botanical Name: Convolvulus pluricaulis Synonyms: Kshirpushpi, Kusum, Supushpa, Medhya, Malavinashini, Shoolaghna, Smrutihita, Varnavilasini Family: Convolvulaceae Gana: Description: A creeper, convula, perennial with many branches. Stem is slightly quadrangular. Leaves are thin, long, with three veins, without stalk and ciliated. The flowers are shell shaped, white. The fruits are small at the top or near the branches. Root is like a rope, a finger thickness, 15-30 cm long, whitish or greenish. Principle Constituents: Contains sedative ad tranquilliser Rasa: Kashaya (astringent), Katu (pungent), Tikta (bitter) Guna: Snigdha (unctuous) Virya: Shita (cooling) Vipaka: Madhur (sweet) Prabhava: Medhya Parts used: Whole plant Dosage: Decoction 20 – 30 ml Powder 3-6 gms Cold infusion 12 – 50 ml Dosha Karma: Tridoshahara Actions and Indications: Anulomana (expels downward) Medhya (brain tonic) Hridya (heart tonic) Mutrala (diuretic) Kapha nissaraka (liquifies kapha) Prajasthapana (infertility treatment) Keshya (hair tonic) Rakta stambhana (stops bleeding) Kustaghna (skin conditions) Rasayana (rejuvenative) 6. Literature Review. Page 125 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Vrsya (improves sperm count) Important Actions: Intellect promoting rasayana. Used in insanity, insomnia, epilepsy and other mental disorders. Used in mental and psychosomatic diseases. Indications: Brain tonic, memory promoter, anti stress, hypertensive. abdominal diseases, flatulence, dyspepsia, loss of gasteric power, gulma, piles, heart diseases, raktapitta, cough, dysuria, gonorrhoea, seminal disorders, uterine disorders, blood impurities, kustha, skin diseases, fever. Srotas: Manavaha Precautions: Usage: External: Kusthaghna and hair tonic. It is used in the form of a paste in skin diseases and siddha oil for hair growth. Internal: Circulatory system: Cardiotonic, haemostatic. Useful in heart disease, haemopysis, hematemesis and hypertension. Digestive system: Improves appetite. digestion and peristalsis. Great for loss of appetite, flatulence and other Vata conditions of the bowel. Its peristaltic action helps to eliminate intestinal toxins and constipation. Nervous System: Brain tonic, shamaka, sedative and therefore it is used in epilepsy, insomnia and giddiness. In schizophrenia, it reduces the sensitivity of attacks because of its prabhava. Fresh juice 2-4 tolas overcomes schizophrenia by clearing the bowel. Respiratory system: An optimum expectorant. Used in cough caused by vatapitta and hoarseness of voice. Reproductive system: Good aphrodisiac. Used in defective sperm conditions, uterine debility, abortions and cervical incompetence. Skin: Good blood purifying action so good for skin conditions. Urinary system: Temperature: Eyes: Important Yogas: (combinations) Preparations: Shankhapushpi syrup, Amrutadi rasayan. Shankhapushpipanaka, Medhya kasaya, Shankhapusphi ghrita 6. Literature Review. Page 126 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Sanskrit Name: Vaca English Name: Sweet flag Botanical Acorus calamus Name: Synonyms: Vacha (helps improve speech), Ugragandha (strong odor), Shadgrantha (rhizome having six nodules), Golomi (like hairy cow) Family: Araceae Gana: Virechana, Lekhaniya, Arshoghna, Tripthighna, Asthapanopaga, Shitaprashamana, Samjnasthapana, Shirovirechana (Ch), Pippalyadi, Vachadi, Mustadi, Urdhvabhagahara (Su) Description: A grass like, aromatic, rhizome forming, perennial that can grow up to 2 metres high. This species inhabits perpetually wet areas like the edges of streams and around ponds and lakes, in ditches and areas of seepage. The plants have long creeping roots that spread out just below the surface of the soil. These roots spread horizontally and can grow to almost 2 metres in length. Native to most Northern Latitude countries around the world. Calamus can often be found growing close to the sites of Indian villages. Fruit – turbinate prismatic, top pyramidal. Seeds oblong, micropyle often fimbricate, albumen fleshy, embryo axile. Principle Constituents: Monoterpene hydrocarbons, sequestrine ketones, (trans or alpha) Asarpne (2,4,5-trimethoxy-1-propenylbenzene), and Beta-asarone (cis-isomer) contained in the roots essential oils. The American variety has consistently tested free of the carcinogenic Beta-asarone. The Asian varieties do contain varying amounts of Beta-asarone, and cause a more sedate feeling when ingested. Rasa: Katu (pungent), Tikta (bitter) Guna: Laghu (light, Tikshna (sharp) Virya: Ushna (heating) Vipaka: Katu (pungent) Prabhava: Medhya (brain tonic) Parts used: Roots, Rhizome 6. Literature Review. Page 127 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Dosage: Powder 125-500 mg 3 or 4 times daily. 1 tsp with honey to improve voice. Dosha Karma: Kapha hara, Vata hara Actions and Indications: Arshoghna (relieves piles) Sajnasthapana (restores consciousness) Kantya (good for the throat) Shotahara (anti inflammatory) Krimighna (destroys parasites) Swedajanana (promotes sweAting) Kustaghna (skin conditions) Vamaka (emetic) Lekaniya (removes excess ama) Vatahara (pacifies vata conditions) Medhya (brain tonic) Vedanasthapana (removes pain) Important Actions: Indications: In large quantities causes vomiting. It is used in vamana therapy. Good for throat infections, for improving speech, useful in diseases of the mouth, good for health of gums (gargle with water). Apasmara (epilepsy) Srotas: annavaha, astivaha, raktavaha, manovaha, majjavaha, medovaha Precautions: The unpeeled, dried rhizome was listed in the U.S. Pharmacopoeia until 1916 and in the National Formulary until 1950, for medicinal use in humans. Calamus has been banned by the FDA as a food additive within the last few years. Massive doses given to lab rats over extended time periods has proven to be carcinogenic. FDA studies have shown that only calamus native to India contains the carcinogen Beta-asarone. The North American variety contains only Asarone. Important Yogas: (combinations) Preparations: Saraswatha churna (as a Medhya), Medhyarasayana (as Medhya) 6. Literature Review. Page 128 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.11 Drug Interactions. Drug interactions are something that must be taken into account when treating Cardiovascular Disease, especially drug to drug interactions and drug to herb interactions. 6.11.1 Drug to Drug interactions. There are major drug-drug interactions with almost all drugs, it paying to check each drug carefully before they are used in combination with any other drug, including over-the- counter drugs. Adverse drug reactions, however, frequently go unnoticed or are misdiagnosed in older people for the following reasons: • Drug reactions sometimes mimic signs or symptoms of disease (e.g., dementia). • Symptoms of a drug reaction are thought to be caused by an existing medical condition or the onset of a new health problem. • Physical reactions to medication, such as fatigue, falling, or weight loss, may be mistakenly labelled as "normal" aging. There are many physical signs that may be attributed to an adverse drug reaction. These include: • fatigue • constipation or diarrhea • confusion • incontinence • frequent falls • depression • weakness or tremors 6. Literature Review. Page 129 A Study of Cardiovascular Disease in Ayurveda John Vorstermans • excess drowsiness or dizziness • agitation or anxiety • decreased sexual behavior Polypharmacy -- which is generally defined as the use of at least three prescription drugs at the same time -- is on the rise in the U.S. for a variety of reasons, among them direct-to-consumer advertising and the mind-set that every ailment has a remedy in the form of a pill. When a person is taking several concomitant drugs, there is a higher risk of suffering an adverse drug reaction. Some examples of how prescription drugs can interact with each other follow: • Mixing antidiabetic medication (e.g., oral hypoglycemics) and beta blockers (e.g., Inderal) can result the decreased response of the antidiabetic drug and increased frequency and severity of low blood sugar episodes. . • Mixing antihypertensive medication (e.g., Reserpine, Aldoril, Combipres) and digitalis (e.g., Lanoxin) can result in abnormal heart rhythms. • Mixing anticoagulants (e.g., Coumadin, Warfarin) and sleeping pills (e.g., Nembutal, Amytal, Seconal) can result in decreased effectiveness of the anticoagulant medication. In addition to prescription drugs interacting with each other, over-the-counter drugs can also interact with prescription drugs. Some examples of this type of drug interaction include: • Aspirin can significantly increase the effect of blood thinning drugs (anticoagulants), thus increasing the risk of excessive bleeding. • Antacids can cause blood-thinning drugs (anticoagulants) to be absorbed too slowly. 6. Literature Review. Page 130 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Antacids can interfere with drug absorption of antibiotics (i.e., tetracycline), thereby reducing the effectiveness of the drug in fighting infection. • Antihistamines, often used for allergies and colds, can increase the sedative effects of barbiturates, tranquilizers, and some prescription pain relievers. • Decongestants in cold and cough medications can interact with diuretics or "water" pills to aggravate high blood pressure. • Iron supplements taken with antibiotics can reduce or stop the ability of the antibiotics to fight infection. (The chemicals in the supplement and the antibiotic bind together in the stomach, instead of being absorbed into the bloodstream.) • Salt substitutes can interact with "water" pills or blood pressure medication to increase blood potassium levels. This can result in symptoms of nausea, vomiting, muscle cramp diarrhea, muscle weakness, and cardiac arrest. These are just a few of the many interactions that can occur when multiple drugs are taken together. Accordingly, it is very important that a patient check with their prescribing doctor(s) and dispensing pharmacist(s) to make sure that the combination of drugs prescribed to them does not have the potential to interact so as to cause them to suffer an adverse drug reaction. Cardiovascular drugs such as Quinidine have over 80 interactions with other drugs interaction and minor interactions with a over a further 120 drugs. Atorvastatin, Liptor and Zocor each have over 140 major interactions with other drugs, over 250 moderate interactions and a similar amount of minor interactions with other drugs. Pravachol has less major interactions with other drugs, around 20 but has excess of 200 moderate interactions. There are 60 other drugs known to interact with ezetimibe. There are 381 other drugs known to interact with simvastatin. 6. Literature Review. Page 131 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 6.11.2 Drug to Herb Interactions Drug to herb interactions are not so common as drug to drug interactions. Listed in the table below are some possible contraindication and interactions but much of these is theoretical so have not as yet been conclusively proven. Table 6 Herbal reference chart Herb/plant Complementary Effect with Theoretical Cautions / Theoretical Interactive Drug Therapy Contraindications / Drug/Drug category Adverse Effects Ashwaghandha Acts as a radio sensitizer Contraindicated in pregnancy Benzoidiazepines (Withania somnifera) when administered with and lactation (may be an anxiolytics radiation therapy, with heat abortifacient). Used in Cyclophosphamide reportedly enhancing these narcotics analgesics. Use Narcotic analgesic effects with caution on individuals on benzodiazeppines Brahmi (Bacopa None known Use with Caution in None known monnieria) individuals taking medications for seizure disorders or Alzheimer's disease Lashuna - garlic Reported to increase the May cause GI distress in Amphotericin B (Allium sativam) fungicidal, amphotercin B, sensitive individuals. Anticoagulents against Cryptococcus Use with caution if history of Antihypertensives neofomans bleeding or hemostatic Antiplatelet agents disorders. Asprin and asprin Discontinue use prior to containing products dental or surgical Hypoglycemic agents procedures. May alter Insulin glucose regulation. NSAIDs Non-nucleoside reverse transcriptase inhibitors Protease inhibitors Squinavir Ginger (Zingber May decrease nausea May be contraindicated in Anticoagulants officinalis) associated with radiation individuals with active Antiplatelet agents and chemotherapy. bleeding. Asprin and asprin Decreases gastric emptying Use with caution with history containing products delays associated with of bleeding or hemostatic Cardiac glycosides cisplatin. disorders. Chemotherapy agents Discontinue use prior to Cispatin dental or surgical NSAIDs procedures. Guggulu None known Use with caution in Anticoagulant (Commiphora mukul) pregnancy and lactation due Antihypertensives to thyroid-stimulating Antiplatelet agents properties. Asprin May be contraindicated in Beta blockers individuals with a history of (especially propranolol) bleeding or hemostatic Calcium channel disorders. blockers (especially Discontinue prior to dental or ditiazem) surgical procedures. NSAIDs Adverse effects may include Thyroid agents GI upset 6. Literature Review. Page 132 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Generally there are no known interaction between Ayurvedic Herbs and Drugs when Ayurvedic herbs are taken in their recommended dosage. It is important to recognise the actions of the herbs used alongside the actions of the drugs, and if ever mixing the two then it must be done with the consent of the patient, and the doctor so that the effects can be monitored. 6. Literature Review. Page 133 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 7. Discussion Cardiovascular Disease, as can been seen under Cardiovascular Disease Statistics on Page 29-30, is a major concern with 48.6 percent of death in 2000, according to the World Health Organisation (WHO). It is predicted that by 2020 46.4 percent will die of Cardiovascular disease (CVD). It is thus clear that this is a major concern through the world. In New Zealand the statistics are slightly higher at around 53%, however the native Māori rate of death is an average of 94 percent higher that non-Māori in 2002 which is increasing annually. Modern medicine as outlines under Causative Theory of Cardiovascular Disease is based around atherosclerosis and its development. This theory postulated that: 1. High levels of cholesterol in the blood injure the artery's lining, causing an inflammation reaction and enabling cholesterol and other fatty materials to accumulate there 2. Repeated injury to the artery wall may occur through various mechanisms involving the immune system or through direct toxicity. In both cases there are changes which can lead to the formation of atheromas and eventual reduced or blocked blood flow to the muscles of the heart. Ayurveda recognises that cardiovascular disease is a disease associated with hereditary factors, aging, lifestyle. CVD can be caused by changes to blood circulation (rasa and rakta); however Ayurveda views the causative factors behind the disorder quite differently due to its perception of the body. Apart from an inherent weakness, today's lifestyle and diet are the main causes of Cardiovascular Disease, in agreement with modern medical research. 7. Discussion Page 134 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Ayurvedic medicine recognises the modern medical causative theory as symptomatic of Cardiovascular Disease. Both modalities understand similar causative factors relating to lifestyle and diet as has been mentioned throughout the paper, although Ayurveda is more specific with its approach to different foods and lifestyles affecting the make up of individual Doshas differently, therefore the causative factors may be somewhat different for individuals with differing Doshas. Ayurveda is therefore better placed to give advice and guidance to patients in the early developmental stages of CVD and could work well to complement modern medical practitioners in this area. In the modern medical system, there has been very good and thorough scientific understanding of the various CVDs under discussion as can be seen in Types of Cardiovascular Disease. Each seems a complex pathology. For example, modern medicine understands that arteriosclerosis is part of the general pathology of Cardiovascular Disease, associated with the repair of the artery walls due to damage to the walls, which eventually leads to, for example, hardening of the arteries, constriction of arterial pathways or stroke, as shown in the section on Development of Cardiovacular Disease. Ayurveda classifies Cardiovascular Disease into various types as shown in the Table 2. Ayurveda's understanding of the development of Cardiovascular Disease is also more specific. The Ayurveda model associates the various diseases with toxic build-up in the various bodily channels, such as in Rasa (plasma and lymph), Rakta (RBC and the liver), Mamsa (muscles), Majja (Nerves as in irregular heart beat), the energy in the body (Ojas in the heart) and the effect these toxins have on the energy in the various Ayurvedic Sub- doshas. This includes looking at the tissue (dhatu) involved, the state of the dosha, the symptoms, and thereby is able understand what the underlying cause is, as outlined in the Ayurvedic Model and Ayurvedic Samprapti, and lastly, but most importantly the mind and 7. Discussion Page 135 A Study of Cardiovascular Disease in Ayurveda John Vorstermans emotions. Thus with hardening of the arteries there is a aggravation of Vata, with inflammation that of Pitta and with arteriosclerosis an increase in Kapha. Understanding this, at an early stage allows specific Ayurvdic dietary advice and lifestyle changes to be very specific. This allows the Ayurvedic practitioner to target specifically the tissue and other factors which are the underlying cause. As seen under the Ayurvedic Treatment section, Ayurveda has various methods of helping to reduce the effect of the Doshas and Ama (toxins) within individuals effectively if treated before the pathology becomes acute. In its treatment principles as outlined under Shamana and Shodana it is clear that the Ayurvedic approach is to remove the toxicity in the dhatu (tissue) or srotas (channel) involved and then to support the cleansing process with herbs and diet appropriate to the condition. This differs to the medical approach, which focuses largely on reducing the cholesterol in the blood stream or its production in the liver through the use of the various drugs as outlined under the section on Treatment. Not all drugs work with all people and these drugs do have side effects and may cause damage to the liver, while Ayurvedic medicines have no known side effects or cause damage to the liver. Thus, while medical drugs are important in acute cases of CVD, in cases which have not yet reached this stage it is clear that Ayurveda de-detoxification and herbal medicines may prove useful as a complimentary therapy and medicine in these cases. An important part of any Ayurveda treatment is to remove the blockages we find within our bodily channels. For Cardiovascular diseases the approach is to: 1. Ensure lifestyle and diet factors are put into place. 2. Reduce stress and help patient to process psychological issues. 7. Discussion Page 136 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 3. Clear channels of toxins (ama). 4. Provide rejuvenative support for the weakened tissues and channels. So in cardiovascular disease we need to clear the toxins from Plasma (Rasa), blood vessels (Rakta) and if necessary support the muscles (mamsa) and the Sub-doshas Prana Vata, Vyana Vata, Sadhaka Pitta, Avalambaka Kapha specifically. Depending on the patient's condition a curative or palliative approach would be used. It is clearly seen in this paper that Ayurveda is in a good position for first line of help in dealing with people with a genetic predisposition to CVD and in early stage if management of the risk factors involved. Ayurveda is also in a unique position, with its detailed understand of diet and lifestyle for each individual persons prakruti, it is able to produce a lifestyle and diet plans which will work to prevent to formation of toxins within the body and thereby prevent the pathology of CVD and if toxins have begun to be formed, to be able to help the patient remove the toxins. Modern medicine tends to take a more invasive approach to treatment, especially when there are signs of blockages with the use of angioplasty and stents or by-pass surgery, while Ayurveda's approach is non-invasive, treating the condition through a variety of approaches from Panchakarma, body therapies and herbal formulas to help clear any blockages before they become acute. Ayurvedic herbs have a well established history of use today. There is a lot of valid scientific research taking place showing the positive actions of these herbs. While modern medicine looks for the active constituents in herbs to find its usefulness, Ayurveda sees the herbs as a whole, and understands the actions of each herb are unique and cannot be isolated through chemical analyses alone. 7. Discussion Page 137 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Ayurvedic herbs are generally well understood in the industry, from the long established tradition and usage of the herbs, dating back to the Charaka Samhita and other early texts. However we are beginning to see scientific research taking place to validate the tradition usage of these herbs. Some of the results of this can be seen in the section under Research on Ayurvedic Herbs. While more research is needed it is clear that the current research supports some of the traditional usage as shown in the section Research on Ayurvedic Herbs and the following section of Details of Ayurvedic Herbs under research, which details the traditional usage of these herbs according to Ayurvedic texts. Modern medical drugs are especially noted for there adverse interaction with other drugs as seen in drug to drug reactions. The older we get and the more drugs we take the risk of adverse effects becomes higher. Drug to herbs reactions are in general minimal however the table 6 does show some theoretical interactions however there seems to be little scientific research to actually prove these. Ayurvedic herbs used alone or in combination have few if any side effects and are therefore a viable alternative in many cases, although it is necessary to note that some herbs may have similar effects to some drugs, so when taken together the effects do need to be watched or supervised by a doctor. 7. Discussion Page 138 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 8. Conclusion. While Ayurveda is popular in India and there is some work between Ayurveda practitioners and Medical doctors, in New Zealand, Ayurveda is still in its early days of establishment. With the growth of alternative and complementary medicines in New Zealand it would seem there is good scope to see Ayurveda move to a front line of support for people with early and non-acute health problems. Modern medicine and Ayurvedic Medicine, two health modalities working under differing scientific frameworks, each have their unique and similar approaches in dealing with Cardiovascular Disease as is clearly presented in this paper. Today the Modern Medical framework is used to treat acute Cardiovascular Disease, and along with pharmaceuticals it aims to help to prevent its onset. Our modern medical system is well placed to deal with CVD in acute stages with such treatments as angioplasty, angiograms, and coronary artery bypass grafting, and in the diagnosis of CVD using modern equipment, Ayurveda on the other hand, as shown in this paper, while perhaps not having the mechanisms to treat acute Cardiovascular Disease is well placed to manage those at risk, and help in occurrences of chronic Cardiovascular Disease. The main benefit of Ayurveda as a complementary practice is in the early stages of chronic manifestation of cardiovascular disease. The Ayurveda approach may make a significant difference to any developmental cardiovascular disease. Ayurveda's view of the human body give it the skills to help people bring themselves back into balance, before the pathology goes to the third level of manifestation (as shown in Figure 12). Once it goes to the third stage (called Bhedha in Ayurveda) then the best help is by a modern medical practitioner. There is scope for working alongside modern medical practitioners and patients, 8. Conclusion. Page 139 A Study of Cardiovascular Disease in Ayurveda John Vorstermans especially with those patients who have an adverse reaction to medical drugs, have liver problems or are generally adverse to taking drugs. Ayurveda can act as a good complementary approach. 8. Conclusion. Page 140 A Study of Cardiovascular Disease in Ayurveda John Vorstermans 9. Recommendation for Further Study. While Ayurvedic herbs are popular in India there are issues in New Zealand with obtaining fresh pure and organic herbs for effective use by patients. New Zealand has many of its own plants and herbs which also need proper research in the hope that these plants over time will be able to replace Indian imports. There is also further quality research required to satisfy both the public and the scientific community that Ayurvedic herbs are indeed safe and effective as indicated. This paper goes part way in outlining the use of Ayurveda in CVD but further study in these areas, in New Zealand would be recommended along with some valid clinical trials to validate the effect of these herbs in comparison with medical drugs. There is a great deal of research done in India on Ayurveda herbs, which is not at present easy to get hold of outside India. I would recommend that some work is done at making this research available. Further research is required on drug to herb reaction and also into the use of Ayurvedic minerals along with herbs. 9. Recommendation for Further Study. Page 141 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Illustrations index Figure 1a Prevalence of CVD in Med and Women P.29 Figure 1 Formation of atheromas in arteries P.34 Figure 2 Coronary artery disease causing heart attack P.37 Figure 3 Cardiomyopathy P.38 Figure 4 Aneurysms P.39 Figure 5 Pericardial effusion P.40 Figure 6 Congestive heart failure P.40 Figure 7 Blood Pressure P.41 Figure 8 Peripheral arterial disease P.42 Figure 9 Atherosclerosis P.46 Figure 10 Cholesterol P.56 Figure 11 Diabetes – glucose build-up P.57 Figure 12 Samprapti of Heart Disease P.67 Figure 13 Diagrammatic representation of Samprapti of Hrdroga P.68 Figure 14 Angioplasty P.72 Figure 15 Stent P.72 Figure 16 Coronary artery bypass grafting P.74 Table index Table 1 The Human body P 28 Table 2 Ayurveda Heart Diseases P 35 Table 3 Adult risk factors P 55 Table 4 Graph of risk factors of CVF P 58 Table 5 Ayurvedic Aetiology of Heart Disease P 63 Table 6 Herbal reference chart P 132 Illustrations index Page 142 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Abbreviations BMI Body Mass index CABG Coronary Artery Bypass Grafting CHD Coronary Heart Disease CHF Congestive Heart Failure CHF Congestive Heart Failure CV Cardiovascular CVD Cardiovascular Disease GIT Gastro Intestinal Tract GP General Practitioner HDL High density Lipoprotein LDL Low density Lipoprotein MI Myocardial infarction NHLBI National Heart, Lung, and Blood Institute PVD Peripheral vascular disease SCD Sudden Cardiac Death TNT Treating of New Targets WHO World Trade Organisation Abbreviations Page 143 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Glossary of Sanskrit Terms Sanskrit Word Meaning Adhyatmika Psychological factors leading to Cardiovascular Disease or hypertension Adibalapracrutta Hereditary Cardiovascular Disease e.g. metabolic diseases Agni Digest fire – ability to digest and assimilate food, emotions, thoughts. Agnimandhya a decreases the digestive fire or metabolism Alochaka Pitta Functioning of the eyes Ama Toxins created by undigested food Amashaya Duodenum Amavata Rheumatoid arthritis Anna vaha srothas the digestive system Apana Vata Elimination of wastes, sexual function, menstrual cycle Artava vaha srotas carry menstrual fluids Asthi vaha srotas supplies nutrients to bones Asti Bone tissue Atipravriti Excess flow Avalambaka Kapha Protects the heart, strong muscles, healthy lungs Bala Strength and Stamina Basti Enema Bhodaka Kapha Sense of taste, which is essential for good digestion Bhrajaka Pitta Healthy glow of the skin Daivabalakruta Idoipathic, bad luck due to bad deeds of previous lives. Dhatus The seven bodily tissues, Rasa, Rakta, Mamsa, Meda, Majja, Asti, Sukra, Bodily humors. Composed of the elements of either, air (Vata); fire and Dosha water. (Pitta); water and earth (Kapha). Dosha Karma Action of the Dosha (hara reduced, kara increases) Doshabala pravrutta Vata, Pitta, Kapha, Sannipatika Dravya Medicines/Herbs Dushyas Main excretory products of the body Dusthi Vitiated Ghee Clairified butter Ghrita Medicated ghee Granthi Growth such as tumour Guna Quality Hridya Heart Glossary of Sanskrit Terms Page 144 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Janmabalapravrutta Congenital Cardiovascular Disease Takes part in the digestion process and separate nutrients from waste Jatharagni products Kalabalapravrutta Environmental or seasonal Kapha Dosha made of the element water and earth Khaivaigunya Inherent weakness Kledaka Kaph Moisture of the stomach lining for good digestion Krimi Viruses, parasites, worms Kshaya Decreased Lavana Salt Majja Nervous system Majja vaha srotas nutrients to bone marrow, nervous system and the brain. Mala Waste products of the body. Mamsa Muscular system Mamsa vaha srotas carries nutrients to muscles and wastes from muscle tissue Mano vaha srotas carrying thoughts, and wisdom Meda Bodily fat – adipose tissue Meda (medha) vaha srotas supplies fat to adipose tissues Medaroga Obesity Mrudu Mild Mutra Urine Mutra vaha srotas carries urine Nidana Incorrect lifestyle and diet Ojas Essence relating to vitality and immunity Pachaka Pitta Digestion, assimilation, metabolism for healthy nutrients and tissues Pakvashya Colon Pancha Mahabhutas Five elements - ether, air, fire, water, earth Pitta Dosha made of the elements of Fire and Water Prabhava Special action The individuals constitution as given at birth which should remain the Prakruti same throughout life. prameha Diabetes prana vaha srotas respiratory system Prana Vata The senses, creative thinking, reasoning, enthusiasm, leader of all 15 categories of Vata, Pitta and Kapha Purisha Stool – waste products Purisha vaha srotas carries feces Rajas Force and ego Rakta Red blood cells Rakta vaha srotas carries blood – circulatory system Ranjaka Pitta Healthy, toxin-free blood Glossary of Sanskrit Terms Page 145 A Study of Cardiovascular Disease in Ayurveda John Vorstermans Rasa Blood plasma or fluid. Rasa vaha srotas carries plasma and lymphatic liquid Rasayana Rejuvenating effect Sadhaka Pitta Desire, drive, decisiveness, spirituality Samana Vata Movement of food through digestive tract Samprapti Pathogenesis Sanghatabalapravrutta (a) Traumatic. (b) Poisoning Sattva Knowledge and Positivism Shamana Palliative treatment Shodana Curative treatment Shukra Reproductive tissue Sleshaka Kapha Lubrication of the joints, soft and supple skin Snehana Oliation Srotases Bodily channels that transport food, minerals, water, air and thought through the body Stanya vaha srotas carry breast milk sthana Sansharaya Third stage of disease Sukra vaha srotas supplies nutrients to sexual organs and carry Sveda vaha srotas carries sweat Swabhavabalakruta Natural diseases e.g. ageing, death Sweda Sweat, perspiration Swedana Fomentation Taila Oil Tamas Inertia and negativity Tarpaka Kapha Moisture for nose, mouth, eyes and brain Tri Three Tridosha All three doshas Udaka vaha srotas carry water in the body Udana Vata Quality of voice, memory, movements of thought Upasargaja Infectious diseases e.g. Endocarditis, Myocarditis, Pericarditis Vamana Emesis Vata Dosha made of ether and air physical, mental constitution of the The deviation from the normal Vikriti individual – away from their Prakruti Vipaka Post digestive taste Virechana Purgation Virya Active principle – potency Vruddhi Increased Blood flow, heart rhythm, perspiration, sense of touch, autonomic Vyana Vata nervous system. 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