Complementary and Alternative Medicine and Cardiovascular DiseaseComplementary and Alternative Medicine and Cardiovascular Disease_An Evidence-Based Review_2013

8/12/2019 Complementary and Alternative Medicine and Cardiovascular DiseaseComplementary and Alternative Medicine an

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Hindawi Publishing CorporationEvidence-Based Complementary and Alternative MedicineVolume , Article ID ,pageshttp://dx.doi.org/.//

Review ArticleComplementary and Alternative Medicine andCardiovascular Disease: An Evidence-Based Review

Matthew J. Rabito1 and Alan David Kaye1,2

Department of Anesthesiology, Louisiana State University Health Sciences Center, School of Medicine, ulane Avenue,Room , New Orleans, LA , USA

Department of Pharmacology, Louisiana State University Health Sciences Center, School of Medicine, ulane Avenue,Room , New Orleans, LA , USA

Correspondence should be addressed to Alan David Kaye; [email protected]

Received December ; Accepted March

Academic Editor: abinda Ashaq

Copyright M. J. Rabito and A. D. Kaye. Tis is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

Complementary and alternative medicine (CAM) plays a signicant role in many aspects o healthcare worldwide, includingcardiovascular disease (CVD). Tis review describes some o the challenges o CAM in terms o scientic research. Biologically-based therapies, mind-body therapies, manipulative and body-based therapies, whole medical systems, and energy medicine arereviewed in detail with regard to cardiovascular risk actors and mediation or modulation o cardiovascular disease pathogenesis.

CAM use among patients with CVD is prevalent and in many instances provides positive and signicant effects, with biologically-based and mind-body therapies being the most commonly used treatment modalities. More rigorous research to determine theprecise physiologic effects and long-term benets on cardiovascular morbidity and mortality with CAM usage, as well as moreopenlines o communication between patients and physicians regarding CAM use, is essential when determining optimal treatmentplans.

1. Introduction

Te National Center or Complementary and AlternativeMedicine (NCCAM) denes complementary and alternativemedicine (CAM) as a group o diverse medical and health

care systems, practices, and products that are not generallyconsidered part o conventional medicine []. Complemen-tary medicine is used along with conventional medicine,whereas alternative medicine is used in place o conventionalmedicine. In the National Health Interview Survey(NHIS), approximately % o USA adults and % o chil-dren reported using CAM in the past months, and lietimeprevalence o CAM use in the United States and worldwidehas increased steadily since [,]. A systematic searcho the existing literature ound that the prevalence o CAMuse ranges between % and .% []. Te NHIS report alsonoted that ,, adults spent . billion out o pocketon CAM, constituting .% o total out-o-pocket health

care expenditures and approximately .% o total health careexpenditures [].

Te NHIS report demonstrated that the top vemost requently used CAM therapies (excluding prayer) werenatural products, such as sh oil/omega , glucosamine,

echinacea, and axseed (.%), deep breathing (.%),meditation (.%), chiropractic and osteopathic (.%), andmassage (.%), ollowed by yoga, diet-based therapies, pro-gressive relaxation, guided imagery, and homeopathic treat-ment []. Frass et al. report that the most used therapies arechiropractic manipulation, ollowed by phytotherapy/herbalmedicine, massage, and homeopathy []. Te conditions orwhich CAM is most requently used according to the NHIS include back pain, neck pain, joint pain, arthritis, andanxiety, while Frass et al. report the top ve conditions tobe back pain/neck problems, depression, insomnia/troublesleeping, severe headache/migraine, and stomach/intestinalillness [, ]. CAM use among adults is greatest among


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Evidence-Based Complementary and Alternative Medicine

women and those o middle age who are better educated andhave higher incomes [,].

Te scientic study o CAM poses several unique chal-lenges that must be taken into consideration in order toadequately produce and assess evidence-based data. Manyorms o CAM are elements o broader healing systems based

on unique theoretical constructs and systems o analysis,rather than stand-alone treatmentsisolating a particulartherapy (i.e., acupuncture) rom its broader discipline (i.e.,Chinese medicine) may notdo it justice. Tere is the potentialor disparity in disciplines: Chinese, Korean, and Japaneseacupuncture styles are different, and adjunct therapies suchas manual or electrical needle stimulation and use o herbalpreparations orally or through moxibustion add to thedisparity. Another potential conounder is that traditionaloutcome measures may not capture the ull effect o treat-ment, since many such therapies do not have well-recognizedand understood physiologic mechanisms o action (i.e., qior chi in Chinese medicine). Te placebo effect must alsobe considered. Because many o the popular CAM therapiesare in act physical methods (i.e., massage or acupuncture)o treatment, it is difficult to ormulate a placebo that isboth inert and indistinguishable rom the real treatment.Additionally, the lack o a uniorm denition o CAM andthe huge diversity o the different methods, therapies, anddogmas o CAM make the studies difficult to compare [].Enthusiasm, individuality, and the specic nature o thedoctor-patient relationships play a role. Finally, the qualityo these trials is requently lacking in that many have smallsample sizes and are not prospective, randomized, rigorouslyconducted, placebo-controlled studies, and they ofen havepoor methodological characteristics and high incidences obias.

Cardiovascular disease (CVD) is the leading cause omortality in the United States or both men and women[]. Approximately , people die o heart disease inthe United States every year, representing one in every ourdeaths []. Te most common orm o CVD is coronary heartdisease, which kills more than , people and costs theUnited States . billion each year []. Risk actors orCVD include hypertension, high LDL-cholesterol, smoking,diabetes, overweight and obesity, poor diet, physical inactiv-ity, and excessive alcohol use []. Despite growing interest inCAM or cardiovascular health, ew data are available regard-ing patterns o use o CAM or cardiovascular disease in theUnited States []. One study used the NHIS to analyze

data on CAM use among patients with CVD and ound that% o patients with CVD had used CAM (excluding prayer)in the previous months []. Herbal products (echinacea,garlic, ginseng, ginkgo biloba, and glucosamine) and mind-body therapies (deep-breathing exercises and meditation)were used by % and % o patients, respectively, andconstituted the most commonly used therapies []. Overall,CAM use in this patient population mirrored CAM use in thegeneral population, with the most common reasons or usebeing musculoskeletal complaints, anxiety/depression, andstress/emotional health and wellness []. According to thisstudy, ewer respondents (%) used CAM specically ortheir cardiovascular conditions (% or hypertension, % or

coronary disease, % or vascular insufficiency,


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versus placebo []. Tere is evidence that garlic is associatedwith blood pressure reductions in patients with elevatedsystolic blood pressures ( mm Hg systolic, mm Hgdiastolic), but not in normotensive patients []. However,there is insufficient evidence to determine whether garlicprovides a therapeutic advantage versus placebo in terms o

reducing the risk o cardiovascular morbidity and mortality[].Tere is some evidence that ginseng has a plethora o

cardiovascular benets, including cardioprotection, antihy-pertensiveeffects, and attenuation o myocardialhypertrophyand heart ailure []. However, a randomized, double-blind, placebo-controlled study demonstrated that Koreanred ginseng had no signicant effect on blood pressure, lipidprole, oxidized low density lipoprotein, asting blood glu-cose, or arterial stiffness in subjects with metabolic syndrome[]. A systematic review and meta-analysis also ailed todemonstrate superiority o redginseng over placebo in regardto effectiveness or type diabetes mellitus [].

Ginkgo biloba is purported to have cardioprotectiveeffects by several studies through its antioxidant, antiplatelet,antithrombotic, vasodilatory, and antihypertensive proper-ties []. A double-blind, placebo-controlled, randomizedclinical trial determined, however, that the herb does notreduce blood pressure or the incidence o hypertensionin elderly men and women []. Te trial also noted thatthere was no evidence that ginkgo biloba reduced totalor CVD mortality or CVD events; there were, however,more peripheral vascular disease events in the placebo arm,suggesting that the herb may reduce the risk o developingperipheral arterial disease [].

Hawthorn lea and ower extracts are advocated asan oral treatment option or patients with chronic heartailure; in act, the German Commission E approved the useo hawthorn extracts in patients with heart ailure gradedstage II []. Te results o a Cochrane review suggestthat there is a signicant benet in symptom control andphysiologic outcomes rom hawthorn extract as a treatmentadjunct or chronic heart ailure []. For the physiologicoutcome o maximal workload, treatment with hawthornextract was more benecial than placebo []. Hawthornextract increased exercise tolerance, benecially decreasedcardiac oxygen consumption, and improved symptoms suchas shortness o breath and atigue as compared with placebo[]. However, no data on relevant mortality and morbiditywere reported []. Te SPICE trial, a large, randomized,

placebo-controlled, double-blind study, specically lookedat morbidity and mortality as endpoints [,]. Te studyconcluded that the primary endpointsreductions in cardiacdeath, nonatal myocardial inarction, and hospitalizationdue to progressive heart ailurewere not achieved [].Te SPICE trial also ound that the deaths o a suddencardiac cause, deaths due to progressive heart ailure, andatal myocardial inarctions were all lower in the treatmentgroup; these gures, however, did not reach statistical signi-icance []. Finally, the study suggested that treatment withhawthorn may reduce sudden cardiac deaths specically inpatients with lef ventricular ejection ractions between %and % [].

A meta-analysis determined that overall, axseed sup-plementation was associated with a decrease in blood totaland LDL-cholesterol concentrations but did not signicantlyaffect HDL-cholesterol and triglycerides []. Te studyreported that whole axseed interventions resulted in signi-icant reductions in total and LDL-cholesterol, while axseed

oil did not []. Flaxseed contains a large amount o ber,and dietary soluble ber has been shown to have cholesterol-lowering effects []. Flaxseed is also a rich source odietary lignans. Puried lignans have been shown to reducecholesterol in animal studies, but human data are limited [].Importantly, the benecial effects o axseed were observedonly among those with relatively high initial cholesterolconcentrations and were more apparent in emales (partic-ularly postmenopausal emales) []. A multitude o othercardiovascular benets have been proposed or axseed dueto its high alpha-linolenic acid content [], but notenough reliable data are available to determine whetheraxseed is effective or heart disease in humans.

Antioxidants, which include anthocyanins, beta-carotene, catechins, coenzyme Q, avonoids, lipoic acid,lutein, lycopene, selenium, and vitamins C and E, haveshown promising results in laboratory and observationalstudies; however, systematic reviews o the literature andlarge, randomized, controlled trials have generally ound nobenecial effects o antioxidant supplements or primaryor secondary prevention. In act, vitamin A, beta-carotene,and vitamin E may actually increase mortality []. TePhysicians Health Study II concluded that neither vitaminE nor vitamin C reduced the risk o major cardiovascularevents (nonatal myocardial inarction, nonatal stroke, andCVD death) or had a signicant effect on total mortality [].Te Womens Health Study concluded that, overall, vitaminE did not reduce the risk o death or major cardiovascularevents (myocardial inarction, stroke, or death) in almost, healthy women; however, there was a signicant %reduction in the secondary endpoint o cardiovascular deathsand a signicant % reduction in major cardiovascularevents among a subgroup o women aged at least years[]. Te Womens Antioxidant Cardiovascular Study oundthat there were no overall effects o vitamins C, E, or beta-carotene on cardiovascular events among women at high riskor CVD []. Possible reasons or the disconnect betweenndings o laboratory and observational studies and resultso clinical trials, according to one article, may be that trialsare entirely too short to reverse the results o decades o

oxidative stress contributing to atherosclerosis or that theantioxidants selected or study were chosen or their easyavailability rather than proven efficacy (vitamin E) [].

Red yeast rice contains monacolin K, which has thesame chemical structure as lovastatin, an inhibitor o HMG-CoA reductase []. Monacolin K in substantial amountslowers blood levels o total cholesterol and LDL-cholesterol[]. One study reported, however, that there is marked

variability o monacolin levels in commercial red yeast riceproducts, and several products had elevated levels o citrinin,a potentially nephrotoxic mycotoxin []. Products with verylittle monacolin K may have little to no effect on bloodcholesterol levels. Although red yeast rice has been marketed


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to patients intolerant o statin drugs due to those drugsside effects, there have been case reports o myopathy andrhabdomyolysis associated with red yeast rice []. In ,the FDA ruled that a red yeast rice product that contained asubstantial amount o monacolin K was no longer a dietarysupplement but an unapproved new drug and that marketing

the product as a dietary supplement would be illegal [].Despite FDA action, some products tested as recently as have been ound to contain substantial amounts o monacolinK []. Consumers thereore have no way o knowing howmuch monacolin K is present in most red yeast rice productsor whether a particular product is sae, effective, or legal [].

Soy protein and isoavones (phytoestrogens) have gainedattention or their potential role in improving risk actorsor CVD []. An American Heart Association scienticadvisory concluded that isolated soy protein with isoavones,as compared with milk or other proteins, decreased LDL-cholesterol concentrations by an average amount o approx-imately % when about hal o the usual total daily proteinintake was soy protein []. No signicant effects on HDL-cholesterol, triglycerides, lipoproteins,or blood pressurewereevident []. Earlier research indicating that soy protein hasclinically important avorable effects has not been conrmedby the meager evidence rom clinical trials [].

L-carnitine is FDA approved or replacement therapy inprimary (i.e., inborn errors o metabolism) and secondary(i.e., secondary to hemodialysis) L-carnitine deciencies [].Many clinical trials have suggested acetyl-L-carnitine (ALC)and propionyl-L-carnitine (PLC), two naturally occurringcarnitine derivates, as potential strategies in the managemento peripheral arterial disease (PAD), heart and cerebralischemia, and congestive heart ailure []. Te benecialeffects o PLC on PAD, particularly in alleviating intermit-tent claudication, have been widely studied. It is generallyagreed upon that PLC is able to improve exercise tolerancein terms o increasing the maximum walking distance inpatients suffering rom intermittent claudication as well asto improve most measures o quality o lie (overall physicalactivity, pain while walking, and psychological activity) [].Te recent rans-Atlantic Inter-Society Consensus II updaterecommends the use o PLC in combination with physicaltraining to improve the symptoms associated with PAD [].However, it has recently been reported that the long-termadministration o PLC to patients with intermittent claudica-tion did not result in a statistically signicant improvementin peak treadmill perormance or quality o lie as compared

with exercise alone []. Te clinical effectiveness o L-carnitine in the treatment o other CVD entities is not wellestablished [].

Chelation therapy is used to rid the body o excess ortoxic metals (i.e., in lead poisoning). Some physicians andCAM practitioners have recommended EDA chelation asa treatment or coronary heart disease (CHD) []. Te bulko evidence supporting EDA chelation therapy is rom casereports and case series, and the available randomized clinicaltrials, although underpowered, have seen no signicant di-erence in direct or indirect measurements o disease severityand subjective measures o improvements []. Te NationalInstitutes o Health, including the National Heart, Lung, and

Blood Institute and NCCAM, sponsored the rial to AssessChelation Terapy (AC), the rst large-scale, multicenterstudy designed to determine the saety and efficacy o EDAchelation or patients with CHD []. Preliminary results othe trial were shared at the American Heart AssociationScientic Sessions on November , ; however, the results

will not be reported until they are published in the literature[].Te results o a systematic review indicate that supple-

ment use is common in cardiac patients (%%) and thatthe concomitant use o dietary supplements and prescriptionmedication also appears to be requent (%%) [].Tese results are important orseveral reasons. Not only is theevidence regarding the efficacy o these products generallyinconclusive or unavorable, but also there is signicantopportunity or danger in their use. Most patients believe thatthe government oversees the saety o CAM; however, theonly requirement is or the manuacturer to send a copy othe product label to the FDA []. A new dietary supplementmay be introduced and marketed rapidly despite containingnew, experimental, or unregulated herbal ingredients, andmany supplements contain ingredients or contaminants withadverse effects or interactions [].

Te general public regards biologically-based therapies assae, natural, and as having ewer side effects than conven-tional medications (%% o CAMusers) [, ].Telacko knowledge about herb-drug and herb-herb interactionsand herb adverse effects by patients and health care providersis also problematic. A recent review determined that car-diovascular patients consumed on average seven prescribedmedications and two herbal, vitamin, or mineral productsdaily []. One study identied potential herb-drug inter-actions among these patients []. For instance, garlic mayinteract with aspirin, clopidogrel, wararin, or heparinoidsto increase bleeding risk []. Gingko biloba can increasehypoglycemia when taken with antidiabetes drugs and mayincrease bleeding when taken with aspirin or wararin [].Ginseng also increases hypoglycemiawith antidiabetes drugs,leads to alsely increased levels o digoxin, and decreaseseffectiveness o wararin []. Hawthorn increases the effectso digoxin and increases coronary vasodilatory effects ocalcium channel blockers or nitrates []. Echinacea increasesQ interval when taken with amiodarone or ibutilide andincreases the risk o hepatotoxic effects with statins, brates,or niacin []. St. Johns wort decreases serum digoxin con-centration, increases activity o clopidogrel, decreases war-

arin effectiveness, decreases simvastatin effectiveness, anddecreases the effectiveness o class IA and III antiarrhythmics[]. Supplemental potassium was taken by % o patientsin one study, which can result in adverse outcomes whenused concomitantly with angiotensin converting enzymeinhibitors, aldosterone receptor antagonists, or angiotensinreceptor blockers [,]. One study demonstrated that %o the patients with a diagnosis o atrial brillation, CHF,or ischemic heart disease attending a cardiovascular clinicreported concomitant use o CAM and prescription drugs% took supplements that had potential interactions withwararin, amiodarone, sotalol, or digoxin []. Tere areinnumerable other interactions and side effects that must


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be taken into consideration when using biologically-basedtherapies.

.. Mind-Body Terapies. Te mind-body therapies (MB)include anthroposophical medicine, autogenic training,

bioeedback, bioresonance, cognitive-behavioral therapies,deep-breathing exercises, group support, hypnosis, imagery,meditation, prayer, relaxation, Qigong, tai chi, yoga, andshiatsu []. One review reported on the prevalence o MBusage, which ranged rom % to %, with deep breathingand meditation representing the most common therapies inthe category []. In contrast to the complex and controversialbody o research surrounding biologically-based therapies,there is a growing body o research suggesting that MB arerelatively sae and may have measurable benets or cardio-

vascular health []. Cardiac patients used MB most com-monly or stress, emotional health, and general wellnessindeed, this use is supported by an established body o

research on psychosocial support, stress management, andcoping skills in cardiac rehabilitation and the inuence ostress hormones, cortisol, and the hypothalamic-pituitary-adrenal (HPA) axis as mediators o cardiac risk []. Tus,the use o MB or this purpose has become more widelyaccepted []. In act, a systematic review suggested that MBwere cost-effective in patients with recent cardiac events andafer cardiac surgery [].

Relaxation techniques include practices such as progres-sive relaxation, guided imagery, bioeedback, sel-hypnosis,and deep-breathing exercises []. Te goal o these tech-niques is to consciously produce the bodys natural relaxationresponse, characterized by slower breathing, lower bloodpressure and oxygen consumption, and a eeling o calmand well-being []. A Cochrane review ound thatinterventions to promote relaxation were associated with asmall, but statistically signicant, reduction in both systolicblood pressure (. mm Hg) and diastolic blood pressure(. mm Hg) []. However, when relaxation was comparedwith sham therapy, the mean reductions in blood pressurewere smaller and not statistically signicant []. Te reviewnoted that in light o the poor methodological quality othe included studies, it is difficult to draw any denitiveconclusions regarding the efficacy o relaxation techniquesor primary hypertension or or reducing morbidity (myocar-dial inarctions and stroke) and mortality []. A double-blind, randomized trial comparing relaxation versus

liestyle modication ound that both groups had similarreductions in systolic blood pressure; however, signicantlymore participants in the relaxation response group elim-inated an antihypertensive medication while maintainingadequate blood pressure control []. Although more studiesare needed regarding the effect o relaxation on heart disease,one observational study did nd that combining relaxationresponse training with cardiac rehabilitation resulted insignicant reductions in blood pressure, decreases in bloodlipid levels, and increases in psychological unctioning [].

Meditation reers to a group o techniques such as mantrameditation, mindulness meditation, transcendental medi-tation, and Zen Buddhist meditation []. Tere is evidence

thatmeditation is associatedwith potentially benecial healtheffects. For instance, a meta-analysis ound that transcenden-tal meditation resulted in a reduction o . mm Hg in systolicblood pressure and . mm Hg in diastolic blood pressure[]. Another review article suggested that transcendentalmeditation may reduce blood pressure as well as other risk

actors or CVD such as cholesterol, oxidized lipids, andsmoking []. However, most clinical trials on meditationpractices are generally characterized by poor methodologicalquality with signicant threats to validity in every majorquality domain assessed []. Tus, uture research must bemore rigorous beore rm conclusions may be drawn.

Yoga has many different styles, some more physicallydemanding than others. In general, practicing yoga, as well asotherormso regular exercise,leads to several cardiovascularbenets. Yoga typically causes increased heart rate duringthe act, but ollowing prolonged training, a decrease occursin exercise-induced heart rate []. One study that lookedat the effects o yoga on heart rate and blood pressure inhealthy men ound that the men in the yoga group showedgreater decreases in heart rate and blood pressure and greateraerobic perormance afer months as compared to thecontrol group (exibility exercises and slow running) [].Numerous studies have also commented on positive ndingsregarding weight loss, control o blood glucose, controlo blood lipids, reduction in number o anginal episodesin patients with advanced coronary artery disease, andimproved general quality o lie []. Some research indicatesthat there may be a difference between yoga and exercise.Different levels o intensity o exercise have been shown toaffect the HPA axis response to acute stress differentlylow-intensity exercise lowers cortisol levels and sympatheticstimulation, while intense exercise raises cortisol levels andstimulates the sympathetic nervous system, raising levelso epinephrine and norepinephrine []. Exactly how thisinuences cardiovascular morbidity and mortality requiresurther research.

ai chi, sometimes reerred to as moving meditation,encompasses many styles, but all involve slow, relaxed,gentle movements []. A systematic review o the literaturedetermined that in o studies, reductions in bloodpressure ( mm Hg systolic, mm Hg diastolic) withtai chi were reported []. Another systematic review alsoconcluded that tai chi appears to have physiological andpsychosocial benets and appears to be sae and effective inpromoting balance control, exibility, and cardiovascular t-

ness in older populations with chronic conditions []. How-ever, limitations and biases exist in most studies analyzed;thus, drawing rm conclusions about the benets reportedis difficult []. A recent randomized clinical trial oundthat tai chi may improve quality o lie, mood, and exercisesel-efficacy in people with chronic heart ailure, despite theabsence o differential improvement in peak oxygen intakeand -minute walk test compared with education only [].Given that tai chi practice is sae and has good rates oadherence, it may represent an important complement tostandard medical care in the treatment o deconditionedpatients with systolic heart ailure []. Further research isneeded to explore these possibilities.


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.. Manipulative and Body-Based Terapies. Te manipula-tive and body-based therapies include acupressure, Alexan-der technique, Bowen technique, chiropractic manipula-tion, Feldenkrais method, massage, osteopathic manipula-tion, reexology, Rolng, rager bodywork, and ui na[].

Massage therapy encompasses many differenttechniques,such as Swedish massage, sports massage, deep tissue mas-sage, andtrigger point massage []. Our studyoundthat deeptissue massage resulted in a systolic blood pressure reductiono . mm Hg, diastolic pressure reduction o . mm Hg,mean arterial pressure reduction o mm Hg, and an averageheart rate reduction o . beats per minute directly afer themassage took place []. A review o the literature remarkedthat single treatment reductions in salivary cortisol and heartrate were consistently noted, but sustained reductions orthese measures were not supported in the literature []. Nochange was seen in urinary catecholamines at any point [].More research on the long-term effects o repeated messagesis necessary.

Spinal manipulation, as ound in chiropractic and osteo-pathic manipulation, has been reported to successully treathypertension []. A systematic literature review howeveround that there is a lack o low bias evidence to support theuse o spinal manipulation therapy to treat hypertension, asstatistically signicant decreases in blood pressure were notobserved in trials with low bias [].

.. Whole Medical Systems. Te whole medical systemsinclude acupuncture (as part o traditional Chinese med-icine), Ayurveda, homeopathy, and naturopathy [].

Acupuncture is a therapeutic modality anchored in tradi-tional Chinese medicine (which also includes Chinese herbalmedicine, moxibustion, cupping, Chinese massage, mind-body therapies such as Qigong and tai chi, and dietarytherapy) []. A systematic review and meta-analysis thatstatistically pooled sham-controlled trials out o studiesound that systolic blood pressure change was not statisticallysignicant ( mm Hg) and acupuncture only marginallyreduced diastolic blood pressure by mm Hg, but substantialheterogeneity was observed []. When given with antihyper-tensive medication, acupuncture signicantly reduced sys-tolic blood pressure ( mm Hg) and diastolic blood pressure( mm Hg) with no heterogeneity detected []. Given thepoor methodological quality and small sample sizes o most

acupuncture trials, the notion that acupuncture may lowerhigh blood pressure is inconclusive []. A systematic reviewand meta-analysis o randomized controlled trials oundthat acupuncture was associated with a signicant reductiono average body weight o . kg compared to control oliestyle and a signicant reduction o body weight o . kgcompared to placebo or sham treatment []. Again, giventhe poor methodological quality o the trials reviewed, itis difficult to say that the evidence is ully convincing [ ].Tere is also some evidence that acupuncture may help tocorrect various metabolic disorders such as hyperglycemiaand hyperlipidemia, but urther rigorous investigation in thisarea is warranted [].

Most rigorousclinical trials andsystematic analyses o theresearch on homeopathy have concluded that there is littleevidence to support it as an effective treatmentor any speciccondition[]. Tere are mixed results concerning the researchor the efficacy o naturopathy, and there is little scienticevidence currently available on the overall effectiveness o

this treatment system [].

.. Energy Medicine. Energy medicine includes healingtouch, light therapy, magnetic therapy, millimeter wavetherapy, Qigong, Reiki, and sound energy therapy []. Tiscategory is reportedly the least utilized and least studied othe CAM modalities [].

Te bioeld therapies o Reiki, therapeutic touch, andhealing touch are known as hand-mediated therapies andare used to reduce pain and anxiety and to promote healththrough the direction o healing energy []. Tere arereports describing changes in the physiological parameterso heart rate, skin temperature, muscle tone, and skin

conductance in response to bioeld therapies []. Mostreviews o the most commonly researched energy therapiesconclude that more research is needed, despite potentiallypromising ndings []. A review concluded thatstudies o bioeld therapies can only suggest efficacy inreducing anxiety, improving muscle relaxation, aiding instress reduction, relaxation, and sense o well-being, pro-moting wound healing, and reducing pain []. A randomized controlled study published in the Journal othe American College o Cardiology ound in a study oimmediate postacute coronary syndrome inpatients that reikisignicantly increased vagal activity as measured by high-requency heart rate variability compared with resting and

music control conditions, with a decrease in negative andan increase in positive emotional states []. Te magnitudeo the effect on heart rate variability seen was similar tothat o propranolol in the Beta Blocker Heart Attack rial[]. A randomized clinical trial measuring the efficacy ohealing touch in coronary artery bypass surgery recoveryound no signicant decrease in the use o pain medication,antiemetic medication, or incidence o atrial brillation;however, signicant differences were noted in anxiety scoresand length o stay, and all healing touch patients showeda greater decrease in anxiety scores when compared to the

visitor and control groups []. More rigorous research isneeded to determine the physiologic mechanisms and long-

term benets o these therapies.

3. Conclusion

CAM use among patients with CVD is prevalent, withbiologically-based and mind-body therapies being the mostcommonly used treatment modalities. Tis review illustratesthe necessity o both more rigorous research to determinethe precise physiologic effects and long-term benets oncardiovascular morbidity and mortality with CAM usage aswell as more open lines o communication between patientsand physicians regarding CAM use. Finally, it is hoped thatboth physicians and patients gain an appreciation o what


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the evidence does and does not say with respect to CAM useor CVD and take this into consideration when determiningoptimal treatment plans.

Disclosure

Te authors have no relationships with pharmaceutical com-panies or products to disclose, nor do they discuss off-labelor investigative products in this lesson.

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Complementary and Alternative Medicine and Cardiovascular DiseaseComplementary and Alternative Medicine and Cardiovascular Disease_An Evidence-Based Review_2013