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- John H.K. Vogel, MD, MACC⁎ ()
- ↵⁎Santa Barbara Goleta Valley Cottage Hospital, 334 South Patterson Avenue, Santa Barbara, California 93111
In his letter to the editor regarding our document on “Integrating Complementary Medicine Into Cardiovascular Medicine” (1), Dr. Bartecchi states complementary medicine has no place in cardiovascular medicine. “No place for it?” This is not our choice in that more than a majority of patients already are using complementary and alternative medicine (CAM) therapy. In fact, over 50% of all Americans are seeking the help of an alternative health care practitioner, which in past years has represented over 600 million visits and nearly $40 billion. Consequently, our effort with this document was to put the emerging area of CAM treatment and investigation into focus in order to enable the physician to provide better patient care in a meaningful and safe manner. Whether the physician believes or does not believe in CAM, it is important that he or she is familiar with CAM so as to provide complete care to the patient and be aware of many good and bad interactions, such as with various supplements and herbs.
The “free ride” of CAM is a fact for most medical therapeutics—a minority of clinical practices are actually supported by class IA guidelines. Our intent is to stimulate more rigorous and informative research investigations of the safety and effectiveness of CAM therapies in cardiovascular care, with an emphasis on safety.
At the present time, chelation therapy is neither proven nor unproven, and there may be dangers. Clearly, this area deserves a careful randomized study now in progress (TACT) and sponsored by the National Institutes of Health (NIH) in order to resolve the role of chelation therapy.
Dr. Bartecchi criticizes acupuncture, stating that electro-acupuncture has wonderful placebo capabilities, and positive effects of acupuncture can be related to psychosomatic mechanisms—opinions that are not only not referenced but also unfounded. Clearly, all treatments in medicine, whether allopathic or integrative, have a placebo component that can contribute to as much as 30% to 40% of a clinical response. Our document provides evidence supporting a neurophysiologic basis for the influence of acupuncture in a number of diseased conditions including pain, nausea and vomiting, and certain cardiovascular conditions such as hypertension and myocardial ischemic symptoms, including angina pectoris. These studies support a role for the endogenous opioid system and other modulatory neurotransmitters that are activated by acupuncture and inhibit the action of excitatory neurotransmitters such as glutamate in regions of the brain concerned with cardiovascular regulation. These regions include the rostral-ventral-lateral medulla, the periaqueductal gray, and the arcuate nucleus, among others. Electro-acupuncture causes very similar effects to manual acupuncture as shown recently in the Journal of Applied Physiology.Instead of quoting reports published by the Scientific Review of Alternative Medicine, which, in fact, performs no independent scientific study of this emerging area of medicine, we would strongly encourage Dr. Bartecchi to review the high-quality scientific literature that has been published on the mechanisms by which acupuncture can regulate the cardiovascular system. Such studies are supported by the National Institutes of Health, the Heart, Lung, and Blood Institute, and have been published in journals such as Circulation; The American Journal of Physiology; The Journal of Applied Physiology; Neuroscience; Brain Research; and Autonomic Neuroscience: Basic & Clinical.
We appreciate the comments by Dr. Cheng regarding the Chinese herbal drug danshen. We were not able to include everything in our first document, but clearly it is important to understand that danshen may affect hemostasis, including inhibition of platelet aggregation, interference with extrinsic blood coagulation and antithrombin III-like activity, and promotion of fibrinolytic activities. Certainly patients receiving warfarin therapy may present with gross over-anticoagulation and bleeding complications with danshen, and because of these effects it should be avoided in patients taking warfarin or antiplatelet drugs.
In our report we made a strong effort to familiarize physicians with the actions of various herbs and supplements, not only in their benefits, but also the many dangers and interactions that can occur and with which the physician should be familiar. Unfortunately, various surveys have indicated that many patients do not share the information as to the herbs and supplements they are taking because they feel the physician is not interested. Consequently, because of this, various dangers, interactions, and consequences have occurred. It is important for the physician to inquire of patients about all medications they are taking, including herbs and supplements. See Appendix 5 in the document on www.acc.org.
In summary, as stated in our document, our purpose has been to familiarize cardiologists with widely employed complementary medical practices. For the most part, our document is neither an endorsement nor a recommendation of specific practices; rather, it is a resource for those practitioners wishing to learn about these techniques, and, thus, enable them to provide meaningful solid doctor–patient relationships with a commitment to the core mission of caring for patients on a physical, mental, and spiritual level.
Please note: Dr. Vogel has responded on behalf of the writing committee.
- American College of Cardiology Foundation
- Vogel J.H.,
- Bolling S.F.,
- Costello R.B.,
- et al.