American College of Cardiology

Mr. Miller was a model patient and complied with Dr. Olshansky's advice. Conventional therapy, dietary modification, and the prescribed exercise regimen in combination were not completely effective. Mr. Miller felt he experienced little improvement—in terms of quality of life (he continued to experience syncope) and his cholesterol level remained high.

Dr. Olshansky then suggested "alternative" therapies, each designed as a complement to the "standard" medical treatments. To combat high cholesterol, Mr. Miller began taking soy protein; for the neurocardiogenic syncope, Dr. Olshansky recommended St. John's wort. A regimen of antioxidants and vitamins also was suggested.

Mr. Miller's cholesterol levels dropped to an acceptable level and, for the first time in nine years, there was regression of carotid atherosclerosis seen on carotid Dopplers. The syncope stopped. Mr. Miller was a happy patient, felt substantially better, and developed new faith in the medical profession.

Even physicians who are skeptical about complementary medicine—sometimes called "alternative" or "integrative" medicine—should educate themselves about these therapies. As the number of patients using complementary medicine skyrockets, so do the chances of cardiovascular complications, adverse interactions between standard and complementary remedies, and hard feelings between enthusiastic patients and doubting physicians.

A Growing Trend
That patients are enthusiastic is undeniable. According to a study by David M. Eisenberg, MD, an internist at Boston's Beth Israel Deaconess Medical Center, the percentage of Americans using at least one form of complementary medicine jumped from 34 percent in 1990 to 42 percent in 1997. In fact, visits to complementary practitioners actually outnumbered visits to primary care physicians. Consumers are so devoted to complementary medicine that they spent an estimated $27 billion out of pocket for such services in 1997, about the same as their out-of-pocket expenditures for physicians' services. Dr. Eisenberg's survey was published in the Nov. 11, 1998, issue of the Journal of the American Medical Association, a special issue devoted entirely to alternative medicine.

Dr. Eisenberg's statistics alarm many cardiovascular specialists, but they shouldn't, said Louis Evan Teichholz, MD, who directs a new complementary medicine program at Hackensack University Medical Center. After all, he points out, William Withering, MD, first got the idea to use digitalis for treating heart failure from a country woman's herbal tea.

As that fact suggests, distinguishing between complementary and standard medicine often depends on time and place. In Europe, for instance, physicians routinely prescribe St. John's wort and other herbal remedies. Opinions also change over time. Although a cardiologist who recommended folic acid and vitamin E might have been laughed at five or 10 years ago, said Dr. Teichholz, use of these nutritional supplements is fast becoming mainstream.

"What seemed crazy years ago sometimes becomes conventional," said Dr. Teichholz. "The key is for everyone to keep an open mind and evaluate the available scientific data."

Cardiovascular Effects
No matter how physicians feel about complementary medicine, they need to know about it. At the most basic level, physicians should know enough to be able to review efficacy data with patients and warn them of potential dangers. Herbal remedies, for example, are not regulated by the Food and Drug Administration, and dosage and purity levels can vary dramatically. Some preparations may even be contaminated with arsenic and other heavy metals.

"At a minimum, what patients are using could be ineffective," said C. Noel Bairey Merz, MD, chair of the ACC Prevention of Cardiovascular Disease Committee and director of Cedars-Sinai Medical Center's Preventive Cardiac Center. "At a maximum, it could be unsafe."

Cardiovascular specialists need to be especially wary. Some complementary therapies can actually cause heart problems. Ma huang, a natural form of ephedrine used for weight loss and energy enhancement, can cause stroke, myocardial infarction, supraventricular tachycardia, and even sudden death. Herbs are not the only complementary treatments with the potential to cause problems. A blood-cleansing technique called chelation, which adherents claim as an angina cure, has also killed some patients.

Complementary approaches can also affect test results. Patients who use Siberian ginseng to boost their energy levels, for instance, may show falsely elevated digoxin levels. Those false readings can lead physicians to make incorrect treatment decisions.

Drug interactions are another potential minefield. According to Dr. Eisenberg's study, 18 percent of patients using prescription medications in 1997 were also taking herbal remedies or high doses of vitamins. A recent study of heart failure patients found that 44 percent were using herbs, high-dose vitamins, or other supplements. One in three did not bother to tell their physicians, and less than a quarter knew whether adverse interactions were possible.

Such lack of communication can prove fatal. Gingko, reputedly a memory enhancer, can also inhibit clotting and intensify the effect of anticoagulants, for example. Other commonly used herbs, such as ginger, garlic, and ginseng, may have a similar effect. The American Society of Anesthesiologists is so concerned about gingko, St. John's wort, and other herbs that it recently warned consumers to discontinue their use two or three weeks before surgery. Possible interactions between herbs and anesthetics include unintentional deepening of the anesthetic effect, blood pressure problems, and bleeding.

Physicians who are not knowledgeable about complementary medicine may inadvertently put more than their patients' health at risk, however. Ignorance about herbs and other popular therapies can also damage physicians' relationships with patients, warned Dr. Olshansky.

"Patients often know more about these therapies than doctors do," he explained, adding that patients' interest often transforms them from passive recipients of therapy to newly empowered partners in their own health care. "If a patient comes in and says he's taking flaxseed to lower his cholesterol and his physician doesn't know anything about flaxseed, the physician loses credibility in the patient's eyes."

The Future?
Faced with an increasingly polarized debate, the American College of Cardiology (ACC) is actively encouraging cardiovascular practitioners to learn the basics about complementary medicine.

"Educational programs and products need to provide information to our members about this new area," said Rick A. Nishimura, MD, of the Mayo Clinic, chair of the ACC Educational Programs Committee. The College's 48th Annual Scientific Session in New Orleans included sessions on complementary approaches, and the topic has been suggested for a future Bethesda Conference. On a local level, some of the ACC's local and regional chapters are following suit. The New Jersey Chapter of the ACC, for instance, will devote its upcoming scientific session to complementary medicine.

Younger cardiovascular specialists may find such information incorporated into their training. "In the next few years, what I call 'extended' medicine will probably become a reality in most of the institutions with training programs," said ACC Training Director Committee Chair Valentin Fuster, MD, PhD, of Mt. Sinai Medical School. Sixty-four percent of American medical schools now offer courses in complementary medicine.

Some medical centers are developing more than just individual courses on this new brand of medicine. The University of Arizona, for example, with grant funding from the National Institutes of Health (NIH) and the directorship of Andrew Weil, MD, has launched an integrative medicine program; and other universities, including Duke and Stanford, are considering developing similar programs.

"The patients are really leading the way in this area," explained Joseph S. Alpert, MD, who is head of the Department of Medicine at the University of Arizona. "Professional skepticism has prevailed in alternative medicine, mainly because this area simply isn't regulated the way traditional medicine is. The goal of this training program is to bring order to chaos."

Meanwhile, many cardiovascular specialists are already incorporating complementary therapies into their practices as adjuncts to more traditional approaches. Patients are often more open to approaches they perceive as more natural, say practitioners, and even ineffective therapies can benefit patients, thanks to the placebo effect.

Drawing on the preliminary evidence, these cardiovascular specialists are prescribing garlic in the hope of reducing cholesterol, urging patients to use meditation to lower blood pressure, recommending yoga as a way of managing congestive heart failure symptoms, referring patients to acupuncturists for pain relief, and adding counseling and relaxation training to rehabilitation efforts. In preliminary studies, these strategies that have been found to reduce post–myocardial infarction deaths by 41 percent.

Some cardiovascular surgeons are also exploring complementary approaches. Take Mehmet C. Oz, MD, author of Healing From the Heart: A Leading Heart Surgeon Explores the Power of Complementary Medicine. As medical director of Columbia-Presbyterian Medical Center's Complementary Care Center, he invites patients to try techniques such as aromatherapy, music therapy, nutritional modification, massage, reflexology, yoga, and therapeutic touch.

"The main reason for cardiovascular specialists to get involved in complementary medicine is not to advocate for it but to evaluate it," emphasized Dr. Oz, who has found, for example, that patients using self-hypnosis are less depressed, fatigued, and tense after cardiac surgery. "When a patient tells you about something you didn't learn in medical school, you automatically assume it's not real. That's not really fair."

Like Dr. Oz, other researchers are beginning to subject complementary medicine to rigorous scientific analysis to clarify its efficacy and safety. The pace is slow, said William W. Parmley, MD, editor in chief of the Journal of the American College of Cardiology (JACC). Although JACC recently published the results of a negative trial on a substance called coenzyme Q10, manuscript submissions on alternative therapies are still rare.

"The problem with the literature in this area is that it is very anecdotal," said Dr. Parmley, adding that most complementary practitioners simply cannot afford to pour millions into researching the effectiveness of their over-the-counter products and services. Others point to methodological difficulties, such as the challenge of creating appropriate controls or blinded conditions for therapies such as acupuncture or massage. Still others point to patients' reluctance to discuss their use of complementary approaches with their physicians, who then attribute treatment successes or failures to their own traditional methods. "Because there are rarely, if ever, any large clinical trials with complementary approaches," Dr. Parmley said, "it is difficult to evaluate whether these approaches are effective."

The National Center for Complementary and Alternative Medicine (NCCAM) at the NIH is now working to fill that research void. Originally established as the Office of Alternative Medicine in 1992, the congressionally mandated office has since been upgraded into a center and seen its annual budget soar from a paltry $2 million in 1993 to its current level of $50 million. The center's first request for grant applications generated the largest response in the NIH's history.

In addition to conducting and supporting research and training, the center also disseminates information about complementary medicine via the NCCAM Clearinghouse. Aimed at both physicians and their patients, the clearinghouse offers a toll-free hotline, fact sheets, and other resources. For more information, call 888-644-6226 or visit the NCCAM Web site at http://nccam.nih.gov.

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