CAM a special challenge for cardiac care

Many heart patients seek alternative therapies

A study published this spring and follow-up work yet to be released underscore an as- yet unmet challenge presented by many heart patients: An extraordinarily high percentage of these patients turn to CAM (complimentary alternative medicine) therapies in addition to their prescribed meds, often to their detriment.

In a study whose results were released March 19, 2003, at the American College of Cardiology’s 51st Annual Scientific Session, researchers at the University of Michigan in Ann Arbor found that, while earlier research showed that nearly half of all Americans use alternative treatments, a full 74% of the heart patients surveyed reported using some sort of CAM therapy. The study involved 145 patients who had been hospitalized for heart attack or angina within the past six months.

"If you look in the literature, herbal therapies are used more for chronic illnesses like arthritis, and coronary artery disease is a chronic illness; it’s not something you can cure," notes Eva Kline-Rogers, RN, MS, an acute care nurse practitioner in interventional cardiology at the University of Michigan Medical Center.

Kline-Rogers coordinated the study under the Michigan Cardiovascular Outcomes Research and Reporting Program. "When somebody has coronary artery disease, they may believe that since some traditional meds will help but will never cure, why not try some herbal remedies?"

In addition, she says, since all of these patients were recently in the hospital and were made aware they had a syndrome that was fairly severe, they might be more likely to look at alternative meds as the way to go.

More worrisome than the reasons these patients tried CAM are the possible health effects. Many heart patients are prescribed aspirin, Coumadin (warfarin), or Plavix (clopidogrel) to thin their blood, prevent clotting, and reduce their risk of heart attack, stroke, or other problems. But dietary supplements such as ginkgo biloba, ginseng, garlic, vitamin E, fish oil, or coenzyme Q10 also cause blood-thinning effects, and doses aren’t carefully studied like those for medicines. The potential total anticlotting effect, or other possible interactions, are what worry experts.

It was those concerns that led the research team into further study, this time with 177 patients.

"When coronary syndrome patients are released from the hospital, they are sent home on a minimal dose of aspirin, which can cause some bleeding," she notes. "When they have had an intervention like a stent, they are often put on another med, like Plavix. A small percentage of them are sent home on warfarin, which we do know causes bleeding as a side effect.

"Our thought was that if we send our patients out on these meds and 50% of them take supplements that also cause bleeding, are we also having bleeding problems?" she continues. "We wanted to know what prescription drugs they were taking, and if they were using any other supplements known to cause bleeding, were they indeed having more bleeding?"

(Editor’s note: While the first study showed that 74% of the patients were using CAM, when the patients who only used multivitamins and prayer were subtracted, 60% of all patients were found to use at least one remaining CAM technique.)

While none of the findings have been published, an abstract has been submitted, says Kline-Rogers. "We found bleeding was fairly common — about 25%," she reports. "Most of it was fairly minor, like nose bleeds or easy bruising, but the percentage was fairly high. We also looked at whether any supplements jumped out as a cause of bleeding. The only thing we found that increased the incidence of bleeding was consumption of green tea. In our literature search, we found there is some biological evidence to support this."

The team worked with Sara Warber, MD, co-director of the University’s CAM center, who helped them design the surveys and look in the most appropriate directions.

"One thing we found, as a side point in the first study, was that those therapies that have some proven scientific benefit, like folic acid and fish oil, were not used as frequently as, for example, vitamin E, which in several studies has been shown to have no cardiovascular benefit," Kline-Rogers notes.

All of this underscores the need for more and better information — for patients and for health care providers, Kline-Rogers asserts. What are the responsibilities of hospitals, and their quality professionals, in this area?

"My thoughts are that first, everything the patient is taking needs to be assessed on admission," she recommends. "And you need to specifically ask the patient if they take green tea or other teas, as well as other supplements. The health care provider needs to be aware of what is beneficial and what is not. The nurse needs to be able to counsel people appropriately.

"For example, one recent paper indicated that vitamin E in some patients blocks the effects of cholesterol meds trying to raise HDL. Also, you must caution patients about to go home to let their primary care provider or cardiologist know what [CAM] they’re taking," Kline-Rogers adds.

One long-term solution is to integrate more herbal medicine into the curricula at medical schools, which currently is happening across the country, she says. "Certainly, for practicing physicians and nurses, inservices and updates would be a good idea."

It also would be extremely helpful, says Kline-Rogers, for staff to have a written guide. "And it must be continually updated."

Need More Information?

For more information, contact:

• Eva Kline-Rogers, RN, MS, Acute Care Nurse Practitioner, Interventional Cardiology, University of Michigan Medical Center, Ann Arbor. E-mail: evakline@umich.edu.