ATHEROSCLEROSIS AND ARTERIOSCLEROSIS
DEFINITION • Chronic inflammatory disease of blood vessels that is of large arteries characterised by formation of fibro-fatty plaques called atheroma. • Hardening of arteries - Arteriosclerosis • It is a modern life style disease and is a major cause of • CVD • MI • Stroke & Aortic disease • death & disability
AETIOLOGY and EPIDEMIOLOGY • Refer to pages 173 – 177 and draw up your summary of the main factors involved: • Aetiology • Risk factors
Interrelationship Between Atherosclerosis and Insulin Resistance Insulin Resistance Hyper-insulinemia Hypertri-glyceridemia Small,denseLDL Hypercoag-ulability Hypertension Obesity Diabetes LowHDL Atherosclerosis
Morphologic types: Fatty dotsFatty Atheroma PlaquesComplicated
Stages of Atheroma - Aorta Stage VI III II
COMPLICATIONS OF CEREBRAL ATHEROSCLEROSIS(Bone 2004) • Cerebral atherosclerosis can lead to vascular dementia, which is the second commonest cause of dementia (after Alzheimer's). However, cerebral atherosclerosis can occur without any cognitive impairment • There could be subtle psychological deficits such as • slower rate of mental processing • impaired attention and concentration
Carotid Artery Atherosclerosis and snoring • 110 volounteers participated in an observational cohort study to investigate if snoring is independently related to the risk of developing carotid atherosclerotic plaque. (Lee,SA, Amis,TC, Byth,K et al (2008) Heavy snoring as a cause of carotid artery atherosclerosis, Sleep, vol.31, iss.9, pp.1207-13) • The theory is that exposure to chronic snoring vibrations may cause carotid artery endothelial damage and contribute to the development of carotid artery atherosclerosis.
In a sleep laboratory, snorers and nonsnorers underwent overnight polysomnography (to quantify snoring) and ultrasound of the carotid and femoral arteries (to quantify atherosclerosis). • The prevalence of carotid atherosclerosis was 20% with mild snoring, 32% with moderate snoring and 64% with heavy snoring. • After adjustment for known atherosclerosis risk factors (age, male sex, smoking history and hypertension) heavy snoring was found to be significantly associated with carotid atherosclerosis.
TREATMENT PROTOCOL • Lipid / cholesterol lowering herbs • Cynara scolymus (page 182/3) • Artichoke dietary supplementation seems to positively modulate endothelial function in hypercholesterolemia, with endothelial dysfunction representing the first stage of atherosclerotic disease. (Lunatteli, G., Marchesi,S., Lambardini,R., Roscini,AR., Trinca,F., Gemelli,F., Vaudo,G., Mannarino,E. 2004, `Artichoke juice improves endothelial function in hyperlipemia’, Life Sciences, vol.76, no.7, pp.775-82)
Allium sativum (page 181/2) • This clinical trial, aimed at evaluating the effect of raw garlic consumption on human blood biochemical factors in hyperlipidemic individuals, was conducted on 30 volunteers with hypercholesterolemia who were asked to consume 5g raw garlic twice a day for 42 days. After 42 days the mean blood total cholesterol, triglycerides, and FBS were reduced significantly, but HDL-C was increased significantly. Following 42 days of no garlic consumption total cholesterol, triglycerides and FBS were significantly increased and HDL-C decreased. (Mahmoodi,M., Idslami,MR., AsadiKAram,GR., Khaksari,M., SahebghadamLitfi,A., Haiizadeh,MR., Mirzaee,MR. 2006, `Study of the effects of raw garlic consumption on the level of lipids and other blood biochemical factors in hyperlipidemic individuals’, Pakistan Journal of Pharmaceutical Sciences, vol.19, no.4, pp.294-8)
Camellia Sinensis • Has been shown to be significantly associated with reduced serum cholesterol and triglycerides and increased HDL(Bone 2004) • It has been demonstrated that the plasma triglyceride, cholesterol, and LDL-cholesterol of rats have been significantly reduced by feedings of oolong, black, and green tea leaves to the animals. The data indicated showed this occurs because of the fatty acid synthase gene suppression by tea polyphenols. (Lin,JK & Lin-Shiau,SY. 2006, `Mechanisms of hypolipidemic and anti-obesity effects of tea and tea polyphenols’, Molecular Nutrition and Food Research, vol.50, no.2, pp.211-17)
Salvia miltiorrhiza • Hepatoprotective • Cardioprotective • Has an effect on lipid breakdown • Gymnema sylvestre • Found to reduce cholesterol in clinical trials on diabetes (Bone 2004)
Improve circulation and prevent ischaemia • Ginkgo biloba • Zanthoxylum americanum • Salvia miltiorrhiza • Rosemarinus officinalis
Antioxidant and vasoprotective herbs • Vaccinium macrocarpon The free radical scavenging activity of cranberry’s flavonol glycosides have found to be superior to Vitamin E. Yan et al (2004) in vitro work identifies the berry’s ability to inhibit low-density lipoprotein oxidation. In human trials, 500mLs of cranberry was favoured over blueberry juice when a significant increase in antioxidant plasma levels was shown after 60-120 minutes of ingestion, attributed to the ascorbic acid content in cranberry, which is absent in blueberry. (Yan. Xiaojun, Murphy. Brian T, Hammond. Gerald B, Vinson. Joe A and Neto. Catherine C. 2002, ‘Antioxidant Activities and Antitumor Screening of Extracts from Cranberry Fruit)
Vaccinium myrtillus • Cratageus oxycantha • Curcuma longa • Camellia sinensis • Ginkgo biloba • Ginkgo flavonoids were shown to play a major role in the anti-oxidation of human plasma low density lipoproteins (LDL) in in vitro research. (Huang,P., Li,J., Zhang,S., Wang,H. 2004, `Comparison study on inhibitory effect of extracts from leaves of Ginkgo biloba L. on the oxidation of human low density lipoproteins’, Journal of Chinese Medicinal Material, vol.27, no.9, pp.654-6)
Ginkgo biloba extract • Has been reported to have antioxidant properties, to modify vasomotor function, to reduce adhesion of blood cells to endothelium, to inhibit activation of platelets and smooth muscle cells, and to alter signal transduction. In addition, potential benefits in CVD, in particular arterial and venous insufficiency and in the prevention of thrombosis has been shown. (Zhou,W., Chai,H., Lin,PH., Lumsden,AB., Yao,Q., Chen,C. 2004, `Clinical use and molecular mechanisms of action of extract of Ginkgo biloba leaves in cardiovascular diseases’ Cardiovascular Drug Reviews, vol.22, no.4, pp.309-19)
Cardiotonic and cardioprotective • Cratageus • Salvia miltiorrhiza • Coleus forskohlii
Cratageus oxycantha • A meta-analysis by Pittler, Schmidt and Ernst identified 13 randomised, double blind, placebo-controlled studies that investigated the effects of hawthorn extract for chronic heart failure. In all studies the hawthorn used was standardised to 18.75% Oligomeric procyanidins and the daily dose ranged from 160mg to 1800mg. (Braun, L. 2005, ‘Hawthorn’, The Journal of Complementary Medicine, vol.4, no.4, pp.69-71)
Eight of those studies covering a population of 632 people showed a significant increase in the maximal workload in patients receiving hawthorn extract compared to placebo. • Six of the studies suggested a significant beneficial reduction in blood pressure and heart rate. • Clinical symptoms such as dyspnoea and fatigue improved significantly with hawthorn treatment and it was well tolerated.
Braun, L. 2005, ‘Hawthorn’, The Journal of Complementary Medicine, vol.4, no.4, pp.69-71 • In addition to treating congestive heart failure, hawthorn is also used to treat arrhythmias, angina and hypertension. It is mainly in vitro and in vivo studies which provide the evidence to support these uses. • One human study compared the hypotensive effects of low dose hawthorn extract (500mg) and magnesium supplements individually and in combination, to placebo. It found that hawthorn reduced the resting diastolic BP at week 10 compared with the other groups. As well, there was a reduction in anxiety observed with the hawthorn treatment.
Braun, L. 2005, ‘Hawthorn’, The Journal of Complementary Medicine, vol.4, no.4, pp.69-71 • Animal models have shown hawthorn to have lipid-lowering properties and may reduce lipid deposits in the liver and aorta. • According to in vitro tests, hawthorn exerts antioxidant and anti-inflammatory activity, which relates to its flavonoid and proanthocyanidin content. Both of these properties may contribute to its beneficial effects in cardiovascular disease
Hawthorn exhibits collagen-stabilising activity that is used clinically to strengthen connective tissue, decrease capillary fragility and prevent collagen destruction in the joints. • As well, antiviral activity has been demonstrated in vitro with the flavonoids and proanthocyanidins acting against herpes simplex virus.
Treat the cardiovascular risk factors • Ginkgo biloba • Can compensate for the deficits associated with cerebral ischaemia (Bone 2004) • Vinca minor • Improves cerebral blood flow • Cratageus oxycantha • Salvia miltiorrhiza • Impaired peripheral and cerebrovascular circulation • Ischaemic heart disease
Boost cognitive function • Ginkgo biloba • Bacopamonniera • Vinca minor • Schisandradecandra • Peonia • Paeoniflorin, isolated from the extract of Paeonialactiflora, showed a lowering effect on cholesterol level in experimentally-induced hyperlipidemic rats. Paeoniflorin showed a significantly lowering effect of total cholesterol, LDL and triglyceride levels (Yang,HO., Ko,WK., Kim,JY., Ro,HS. 2004, `Paeoniflorin: an antihyperlipidemic agent from Paeonialactiflora’ Fitoterapia, vol.75, no.1, pp.45-9)
Now using the information on pages 178-186, as a group, put together your: • Detailed summary of the treatment aims (that is, greatly expand on the short version at the bottom of page 178). • A treatment protocol chart for a client with classic atherosclerosis and dyslipidaemia + priorities + therapeutic actions +long list of herbs • What dietary and lifestyle modifications will you be making for the 1st, 2nd, and 3rd visits. • Your final herb and supplement treatment.
May affect 5-10% of the general population. • Women account for over 75% of reported cases • As many as 20-25% of young women have some form of this disorder • In women onset typically occurs between the ages of 15-40. • Men usually develop Raynaud's later in life than women
Raynaud's phenomenon appears to be more common in people who live in colder climates. However, people with the disorder who live in milder climates may have more attacks during periods of colder weather. • Workers that subject their hands to unusual wear-and-tear are particularly at risk. These people would include typists, pianists, and those who use vibrating machinery such as pneumatic drills, chain saws and even vacuum cleaners. Workers who operate vibrating tools can develop a type of Raynaud's phenomenon called vibration-induced white finger.
Raynaud's phenomenon is a disorder that affects the blood vessels in the fingers, toes, ears, and nose. • It is characterized by episodic attacks, called vasospastic attacks, that cause the blood vessels in the digits (fingers and toes) to constrict. • Raynaud's can occur on its own, or it can be secondary to another condition such as scleroderma or lupus.
When a person is exposed to cold, the body's normal response is to slow the loss of heat and preserve its core temperature. To maintain this temperature, the blood vessels that control blood flow to the skin surface move blood from arteries near the surface to veins deeper in the body. For people who have Raynaud's, this normal body response is intensified by the sudden spasmodic contractions of the small blood vessels (arterioles) that supply blood to the fingers and toes. The arteries of the fingers and toes may also collapse. As a result, the blood supply to the extremities is greatly decreased, causing a reaction that includes skin discoloration and other changes.
Once the attack begins, a person may experience three phases of skin colour changes (white, blue, and red) in the fingers or toes. The order of the changes of colour is not the same for all people, and not everyone has all three colours. • Pallor (whiteness) may occur in response to spasm of the arterioles and the resulting collapse of the digital arteries.
Cyanosis (blueness) may appear because the fingers or toes are not getting enough oxygen-rich blood. The fingers or toes may also feel cold and numb. • Finally, as the arterioles dilate (relax) and blood returns to the digits, rubor (redness) may occur. • As the attack ends, throbbing and tingling may occur in the fingers and toes. An attack can last from less than a minute to several hours.
There are two categories of Raynaud’s syndrome: • Primary Raynaud’s • Is idiopathic and not associated with another illness • Most people who have Raynaud's have the primary form (the milder version) • Several researchers who studied people who appeared to have primary Raynaud's phenomenon over long periods of time found that less than 9 percent of these people developed a secondary disease.
Although secondary Raynaud'sphenomenon is less common than the primary form, it is often a more complex and serious disorder. Secondary means that patients have an underlying disease or condition that causes Raynaud's phenomenon.
Connective tissue diseases are the most common cause of secondary Raynaud's phenomenon. • Some of these diseases reduce blood flow to the digits by causing blood vessel walls to thicken and the vessels to constrict too easily. • Raynaud's phenomenon is seen in approximately 85 to 95 percent of patients with scleroderma and mixed connective tissue disease, and it is present in about one-third of patients with systemic lupus erythematosus.
Raynaud's phenomenon also can occur in patients who have other connective tissue diseases, including Sjögren's syndrome, dermatomyositis, and polymyositis.
Possible causes of secondary Raynaud's phenomenon, other than connective tissue diseases, are • carpal tunnel syndrome • obstructive arterial disease (blood vessel disease) • Some drugs, including • beta-blockers • ergotamine preparations (used for migraine headaches) • certain agents used in cancer chemotherapy • drugs that cause vasoconstriction (such as some over-the-counter cold medications and narcotics) • are linked to Raynaud's phenomenon
People with secondary Raynaud's phenomenon often experience associated medical problems. • The more serious problems are skin ulcers or gangrene (tissue death) in the fingers or toes. • Painful ulcers and gangrene are fairly common and can be difficult to treat. • As well, a person may experience heartburn or difficulty in swallowing. These two problems are caused by weakness in the muscle of the oesophagus that can occur in people with connective tissue diseases. • The nicotine in cigarettes causes the skin temperature to drop, which may lead to an attack.
Many doctors encourage patients who have Raynaud's phenomenon, particularly the primary form, to exercise regularly. Most people find that exercise • promotes overall well-being • increases energy level • helps control weight • promotes restful sleep • Control stress • Because stress and emotional upsets may trigger an attack, particularly for people who have primary Raynaud's phenomenon, learning to recognize and avoid stressful situations may help control the number of attacks.
DURING AN ATTACK • Take action during an attack--An attack should not be ignored. Its length and severity can be lessened by a few simple actions. • The first and most important action is to warm the hands or feet. Running warm water over the fingers or toes or soaking them in a bowl of warm water will warm them. • Taking time to relax will further help to end the attack. • People with Raynaud's phenomenon should also be aware that air conditioning can trigger attacks. Turning down the air conditioning or wearing a jumper may help prevent attacks.
TREATMENT PROTOCOL • Peripheral vasodilating / vasoprotective herbs • Crataegusoxycantha • Coronary and peripheral vasodilator having a beneficial effect on improving circulation to the extremeties.(Heinrich et al 2004) • Salvia miltiorrhiza • Viburnum opulus • Coleus forskolii • Tiliaeuropea • Vacciniummyrtillus • Improves blood circulation in conditions involving venous insufficiency (Heinrich et al 2004) • Vitisvinifera
Circulatory stimulants that will deal with any ischaemic changes that are occurring • Ginkgo biloba • Salvia miltiorrhiza • Vinca minor