TREATMENT OF CARDIOVASCULAR DISEASES WITH CHINESE HERBS
Congestive Heart Failure and Other Cardiovascular Disorders of Aging
In the practice of modern medicine, it is recognized that high blood pressure, atherosclerosis, easy blood clotting, and heart enlargement can lead to catastrophic events such as heart attack and stroke, which are the principal causes of death in persons over 40 years of age. Therefore, a major campaign has been launched to get all adults in this age range tested for cardiovascular disease risk factors and to have them treated by drug therapies when there is increased risk. As a result of such efforts, millions of adults are taking one or more of the drugs to lower blood pressure, lower cholesterol, and/or to reduce platelet aggregation. The prescribed regimen must be adjusted for individual needs by modulating the drug dosage and selecting from a collection of possible drugs to yield the desired response while keeping serious side effects to a minimum. Among the side effects commonly reported are fatigue and lowered libido from some antihypertensive drugs and liver damage from cholesterol reducers. Anticoagulant therapies carry the risk of bleeding episodes and cause considerable worry about interactions with drugs, herbs, vitamins, and even ordinary foods. In addition to regular use of the drugs, patients with elevated risk are also asked to participate in a program of cardiovascular preventive health care including a lower fat diet and increased exercise.
Once a person has been started on a drug therapy, it becomes more difficult to recommend an herb therapy that might also be of assistance largely because of fears that the herbs will interact with the drugs, disturbing the careful balance that has been attained. Further, there are concerns that too little is known about the herb actions, so that doctors and patients wonder whether or not the herbs might do more harm than good. In evaluations of drug innovations, the calcium channel blockers that had been recommended as an improvement on earlier therapies turned out to be no better overall, and actually appeared to increase risk of heart attacks (18). The possibility that herbs might do little, or might even worsen certain outcomes, can be raised. Still, a growing collection of promising research reports about herbs leads many people to seek out appropriate supplements.
While the use of herbs may be contraindicated or limited when an elderly patient is taking multiple drugs, there are many others who are being tested for cardiovascular risk factors while still relatively young and healthy: that is, when herb therapy might be a reasonable option, at least to try before starting a drug regimen. In addition, some drug therapies, especially single agents used to lower single risk factors, might be augmented with herbs without imposing a significant new risk if the herbs are selected carefully. As an example, a single blood-pressure lowering drug might be augmented with herb therapy so long as regular monitoring of blood pressure shows that it remains under control. While a potent anticoagulant such as Warfarin (coumadin) is thought to be subject to significant herb-drug interactions (including herbs such as salvia, ginseng, and tang-kuei), low dose aspirin (85 mg/day) used as an anticoagulant may be better suited to mixing with herbs. After all, low dose aspirin is little different from administering willow bark or meadowsweet (herbs that contain aspirin-like active ingredients) in an herbal formulation.
Following is a brief overview of a few key herbs used for cardiovascular diseases associated with aging. The purpose of this article is not to provide extensive details of the treatment methods, but to illustrate the tendency of modern Chinese clinical reports to refer repeatedly to certain herbs that contain a relatively limited range of active components. The dominant herbs are qi tonics, of which the ones relied upon most consistently are ginseng and astragalus. A few years ago, Chinese doctors and researchers had focused on treating cardiovascular disease by the method of clearing phlegm-obstruction of the orifices. This method is slowly being downplayed in favor of the tonic preparations and use of mild blood vitalizing herbs, notably salvia. The change is timely, as many of the ingredients that were used in the orifice opening therapies have since been deemed toxic or endangered (see Appendix 1 for an example).
There are two groups of non-toxic constituents frequently found in herbs employed for cardiovascular diseases: flavonoids and triterpenes. These substances can be ingested in quantities of several hundred milligrams per day and appear to be safe for long-term administration. They are present in some foods and in numerous herbs that are considered non-toxic.
Flavonoids are the main active components of two herbs widely used and promoted in Europe for improving circulation: gingko leaf (see: Ginkgo) and crataegus, commonly called hawthorn fruit (17). Both these herbs are used in China, though their application to treatment of cardiovascular disease is relatively new. In traditional Chinese medicine, the ginkgo tree was primarily used as a source of ginkgo nuts, which are used for the treatment of asthma; crataegus is primarily used in traditional Chinese medicine for aiding digestion.
Flavonoids are also the active ingredients associated with cardiovascular benefits in red grapes, soybeans, and green tea (which contains polyphenols, a condensed flavonoid). In China, considerable research has been carried out with pueraria flavonoids for cardiovascular health (see: Pueraria flavonoids). There is growing evidence that regular ingestion of flavonoids can reduce the incidence of cardiovascular disease, perhaps by reducing blood pressure, blood coagulation, and blood fats
Triterpenes are the main active components of ginseng, which has been promoted as an aid to treatment of cardiovascular diseases in modern times; traditionally, it was used mainly in formulas to benefit digestion. Triterpenes have also been identified as an active ingredient in the popular new herbs from China, gynostemma and rhodiola, as well as in ganoderma, a rare herb famous in ancient times that was reintroduced after cultivation methods were developed. All three of these herbs have been the subject of research related to potential beneficial cardiovascular effects. The ginseng saponins (triterpene glycosides) are believed to be the primary active components in Shengmai San (Pulse Generating Powder) used in China for recovery from heart attacks (see: Shengmai San). The triterpenes lower blood lipids and enhance oxygen utilization and may have cardiac protective effects, such as reducing free radical damage.
Several reports in Chinese medical journals detail evaluation of patients with coronary heart diseases who have been treated with Chinese herbs. In the following summary, the main purpose is to illustrate the herbs selected for treatment of patients, rather than to elaborate the claimed benefits of the treatment. Repeated reliance on certain herbs or on herbs with similar active components suggests that there is general agreement among Chinese physicians that these methods of therapy are useful.
In a review of the traditional Chinese medicine (TCM) approach to congestive heart failure, Liang Donghui and Zhang Min specified that one should pay attention to the following principles, paraphrased from their article (5):
They mentioned certain herbs and base formulas (to be modified as needed) that had been used in clinical trials, with the qi tonics astragalus, ginseng, and atractylodes being most prominent, and supported by the blood vitalizers salvia, leonurus, red peony, curcuma, and notoginseng. Formulas mentioned included Zhen Wu Tang, a formula with atractylodes and aconite; Shengmai San, a formula with ginseng and ophiopogon; and Shen Fu Tang, comprised of ginseng and aconite. An example of the use of the herbs and modifications of the formulas is the anti-myocardial infarction mixture made with the qi tonics astragalus, codonopsis, and polygonatum (huangjing) and the blood vitalizers salvia, red peony, and curcuma (15). Additional herbs were described in the article as adjunctive agents, such as using alisma to alleviate edematous swelling due to heart failure) and aconite to treat coldness and to strengthen the heart contractions. For ginseng, either red ginseng or American ginseng might be selected, depending on the presentation of symptoms (e.g., use American ginseng when yin deficiency is present), while notoginseng is sometimes selected to combine qi tonic and blood vitalizing properties. All these ginseng plants have similar active components.
Shen Mai injection, a combination of ginseng and ophiopogon (similar to Shengmai San, but without schizandra) was used in treatment of congestive heart failure (8) and Shen Fu injection, the combination of ginseng and aconite, has been used in the treatment of heart damage due to viral myocarditis (16). The combination of ginseng, astragalus, and tang-kuei, called Yiqi Huoxue injection, has been used for coronary heart disease (7, 15). Ganoderma, which contains ganoderic acids that are similar in structure and effect to ginsenosides, has been used as a therapy for coronary heart disease and hyperlipemia (13). Ganoderma is also an ingredient, along with notoginseng and salvia, in a tranquilizing formula, Qingxin Anshen Fang, designed to treat coronary heart disease with premature beat (1). By contrast, a stimulating formula, Huo Dou Wan, was administered for treatment of sick sinus syndrome; the pill is made with astragalus, codonopsis, epimedium, curculigo, ma-huang, and salvia (4). The general approach is to use qi tonics supplemented by a few herbs that address constitutional factors (e.g., use aconite for yang deficiency; ophiopogon for yin deficiency; salvia or other herbs for blood stasis).
Zhu Boqing and his colleagues at the Huashen Hospital of the Shanghai Medical College explained a basis for primary reliance on qi tonics, even in patients with blood stasis syndrome (2). They had treated patients with chronic congestive heart failure of various causes with the combination of astragalus and codonopsis. This combination was considered cardiotonic and suitable for patients with both qi deficiency and blood stasis, the latter condition responding to qi tonics according to the traditional principle: "if the qi is set in motion through the use of the tonics, then the blood circulation will proceed normally." They recognized that it was common to use salvia to vitalize blood circulation, but considered that the qi tonics were the key to the therapy in these patients. The treatments were administered either as an intravenous drip (11) or an oral preparation; for oral administration, as would be suitable outside of China, the dosage of 10-15 grams of each herb. A course of therapy would be 2-4 weeks, which could then be repeated. Zhu Boqing wrote a follow-up report on Chinese herbs for various cardiac disorders in which he focused on the value of astragalus, codonopsis, salvia, and aconite, and concluded that (9):
Salvia can effectively improve myocardial ischemia and abnormal hemorrheological parameters in patients with coronary heart disease. Astragalus can significantly enhance cardiac systolic function in patients with heart failure. It also has a positive iontropic effect [increases cardiac contractility]. Astragalus and salvia exhibit a synergistic effect for the improvement of symptoms and cardiac performance, and hemorrheology in patients with heart failure of the qi deficiency and blood stasis type. Aconite can effectively improve sinus-node function and cardiac performance in asthenic patients with sick sinus syndrome, especially those of the yang deficiency type.
Codonopsis was not included in his summary, but was mentioned in combination with astragalus, as in his former study report. These key herbs have been used in a variety of combinations. Aconite with salvia was used in one study for treatment of heart failure, in which Zhen Wu Tang (an aconite-containing prescription) was combined with both salvia and carthamus; another study of heart failure was carried out with Zhen Wu Tang plus astragalus and cinnamon (10). The combination of astragalus and salvia (30 grams each, as a daily dose in decoction form) was another treatment administered for heart failure (3).
The essential herbs for treating cardiovascular diseases have all been reviewed in recent years. Thus, for example, a review of pharmacological studies of astragalus in relation to the cardiovascular system indicated that it had protective effects against myocardial ischemia and reperfusion injury, on free radical injury, on platelet sticking, and on myocardial viral infection (6). A review of ginseng (12) described the same benefits as those listed for astragalus, except for the effect against myocardial viral infection (the herb is, nonetheless, used to aid recovery from such infections). A review of ganoderma indicated that it could have a positive iontropic effect, and protect against myocaridal ischemia (13). Salvia is reported to facilitate circulation by improving capillary bed circulation, dilating peripheral blood vessels, reducing excessive platelet aggregation, inhibiting vascular smooth muscle cell proliferation, and having a positive iontropic effect (14).
There are two English language journals of Chinese medicine published in China that are distributed in the West: the Journal of Traditional Chinese Medicine and the Chinese Journal of Integrated Traditional and Western Medicine. In a recent issue of the latter journal (December 2000), there appeared a brief summary of the famous Chinese patent remedy Guanxin Suhe Wan (a similar summary had appeared earlier in the Journal of Traditional Chinese Medicine).
This formula was developed by the Shanghai Huashan Hospital and the Shanghai First Traditional Pharmaceutical Factory. It has appeared in the 1988 and 1995 editions of the Pharmacopoeia of the People's Republic of China. The formula is as follows:
(aka storax; suhexiang)
(synthetic; rengong bingpian)
(white sandalwood; baitanxiang)
(aristolochia root; qingmuxiang)
The herbs are powdered, mixed with honey, and made into pills, with 680 mg of herbs per pill; the weight of the finished pill is 900-1,000 mg, including the honey. The dosage is one pill each time, 1-3 times per day. The pill is chewed, sucked, and then swallowed. Its uses are: for treating coronary heat disease, angina pectoris, and stuffiness in the chest. It is contraindicated during pregnancy.
This formula is a simplification of a prescription of the Taiping Huimin Hejiju Fang (1110 A.D.) called Suhexiang Wan (Styrax Pills). That formula has 10 additional ingredients, including the now banned substances rhino horn and musk, the mercuric compound cinnabar, and a collection of aromatic and spicy herbs such as clove, aquilaria, and cyperus. Suhexiang Wan is still produced as a patent medicine in China, with all the original ingredients listed. In a modern book on patents (Zhongguo Jiben Chenyao, 1988), cinnabar is included in the formulation for Guanxin Suhe Wan as well.
Guanxin Suhe Wan has been produced by several factories; the article in the Chinese Journal of Integrated Traditional and Western Medicine mentions it as a product of factories in the following cities: Hebei, Shijiazhuang, Huhehot, Shenyang, Changchun, Harbin, Shanghai, Nanjing, Hebei, Jinan, Henan, Wuhan, Guangzhou, and Xian. Two products became commonly distributed in the U.S.: the Shanghai product in the form of pills (30 pills per bottle) and a Tianjin product in the form of capsules (40 capsules per bottle). According to the labeling of the Tianjin product, birthwort is replaced by oroxylum (muhudie), but this may be a labeling error.
Most of the patents that have arrived in the U.S. go to California and its numerous Chinese herb shops concentrated in Los Angeles and San Francisco. The U.S. FDA and the California FDA (the Food and Drug Branch of the Health Department), have numerous objections to the product. In addition to serious concerns about labeling that would indicate treatment of any disease condition (especially such a potentially dangerous one as cardiovascular disease marked by the symptom of angina pectoris), the California FDA considers two of the five ingredients to be toxic.
Borneol is listed by the California FDA as a cardiac toxin. Borneol occurs naturally in some approved herbal materials, such as cardamon seed, so this component (in its natural form) should be permissible in herbal products up to a certain level, not more than about 2%. In Guanxin Suhe Wan, borneol is present as 15% of the herbal formulation, and about 11% of the entire pill (when made as a honey pill) and it is synthetic borneol. All aristolochia materials are currently restricted for any use by the U.S. FDA, since they contain aristolochic acid, a carcinogenic agent that might cause renal failure with prolonged use. There are no indications for duration of use or any limitations on duration of use of this formula in any of the Chinese literature. In America, patients with angina pectoris and other coronary heart diseases are usually prescribed drugs that must be taken for life; thus, it would be reasonable for practitioners prescribing the herbs to consider long-term administration.
In a test evaluation of several patent formulas found in Chinese herb shops, the California FDA checked Guanxin Suhe Wan manufactured in Guangzhou. It was found to contain no mercury (a marker compound for cinnabar), but it had 74 ppm of arsenic, which is usually contributed by realgar. Currently, a major effort is being made in the U.S., and California in particular, to reduce exposure to arsenic by removing naturally-occurring arsenic from community water supplies.
The combination of borneol, aristolochic acid, and arsenic (in at least one of the versions), makes this product appear, from the FDA perspective, to be a deadly poison. Nowhere in the articles alluded to above is there any discussion or mention of toxicity or any cautions about use other than the contraindication during pregnancy. In Clinical Handbook of Chinese Prepared Medicines (1989), there is an additional contraindication which reads: "Do not use this formula if the coronary artery disease is caused by blood stasis, which will be indicated by such symptoms as fixed, stabbing, strong, sharp pain that is possibly worse at night, or heart palpitations, accompanied by a dark purple tongue and a deep and choppy pulse. In such cases, Dan Shen Pian is the formula of choice." Dan Shen Pian is reported to contain just salvia (danshen) and borneol. Although it is unclear why Guanxin Suhe Wan would be contraindicated in cases of blood stasis, the formula design is not aimed at treatment of blood stasis cases, but for regulating the flow of qi and resolving obstruction due to "turbid phlegm." The symptoms that would indicate use of the formula include stuffiness and numbness rather than sharp-stabbing pain.
Clearly, there is a complete divergence of views regarding this formula from the perspective of Chinese doctors versus that of the California FDA. The pharmacological effects of the formula, as described in the above-referenced journal article are: "improve the cardiovascular function; dilate coronary artery; increase the coronary blood flow; inhibit platelet aggregation and thrombosis; and promote the repairing of heart muscle necrosis." These are all highly desirable actions for persons suffering from chronic cardiovascular disease. However, from the FDA point of view, the product is a poisonous and carcinogenic preparation, which may be contaminated by toxic metals, labeled with illegal indications for use (because it is not a registered drug), and presenting a potential for adverse interactions with drugs, particularly if the pills effectively reduce platelet aggregation and, thereby, overemphasize the effect of anticoagulants commonly prescribed to these patients.