ACC NEWS
President’s page: complementary and alternative medicine: ignore at doctors’ and patients’ peril
Douglas P. Zipes, MD, FACC
Reprint requests and correspondence: Douglas P. Zipes, MD, FACC, Indiana University School of Medicine, Krannert Institute of Cardiology, 1111 W. 10th Street, Indianapolis, Indiana 46202
One day last year, I was examining a long-time patient whom I’ll call Mrs. Smith. She was diagnosed with atrial fibrillation about 10 years previously, and throughout the course of her treatment we’ve become friends, often chatting about our grandchildren. We both have grandsons who play Little League baseball. On this particular visit, she complained about increasing fatigue and asked whether the beta-blocker dose might be reduced. She felt that her household duties took longer to finish, and she had to stop often to regain her strength. As we discussed the pros and cons of a dose reduction, she said, "I think the herbal supplements I’ve begun taking are helping prevent the fibrillation, so maybe you can decrease the beta-blocker. I haven’t had any episodes of palpitations since I started to take them. One of my friends learned from something she found on the Internet that they give you more energy, and I’ve been taking them since the last time I saw you."
I was startled and immediately concerned about the possibility of drug interactions, particularly with her warfarin. I  asked her whether she had been taking the drugs I had prescribed, but I chided myself for not asking whether she had taken any  drugs since her last visit, even though I knew I was the only doctor she saw.
It turned out that she was taking some sort of a multivitamin preparation and a garlic supplement. I took the opportunity to tell her that there are many complementary and alternative therapies available over the counter these days and, while some may have great potential, others can be harmful and most haven’t been well tested. Whether or not the supplements were affecting the atrial fibrillation was questionable, but maybe they were helping, if for no other reason than she believed they would. But I was worried about their impact on her warfarin. I suggested that she could continue taking the medications I had prescribed as well as the supplements she chose, but we agreed to monitor her condition, particularly the level of anticoagulation, extra carefully. We also agreed that she would take no other medications, regardless of the type, without consulting me first.
Mrs. Smith’s offhand remark that she was supplementing my prescriptions with a self-prescribed remedy elicited a number of reactions in me. First was outright alarm—was her health, even her life, in danger due to some unregulated drug being touted on the Internet? Next, a little resentment—didn’t she trust my judgment? Why hadn’t she at least asked me if the supplements would work for her? Finally, I had a healthy dose of skepticism.
The 18th-century physician William Withering may have had some doubts, too, when he was presented with a folk remedy used to treat dropsy, the condition we now call congestive heart failure (1). But he didn’t scoff; instead, he identified foxglove as the mixture’s active ingredient, conducted a large-scale study to determine optimal dosing, and published An Account of the Foxglove and Some of Its Medical Uses in 1785. Digitalis—the drug made from foxglove seeds and leaves—at one point became one of the most widely prescribed cardiac medicines in the world.
Today, we physicians should remember Dr. Withering’s story as more and more of our patients, like Mrs. Smith, turn to preventive and therapeutic resources beyond the mainstream of Western medicine. Many of our patients are searching for alternative medicine—practices used instead of conventional medical care; they are also exploring complementary medicine—practices used alongside conventional care; and they are using integrative or blended medicine—what proponents see as the best of both worlds (2). This broad range of practices has come to be known by the acronym "CAM," but the term "blended medicine" seems particularly apt. It was suggested by Earl Bakken, who has founded an integrative healing hospital—the North Hawaii Community Hospital on the Big Island of Hawaii—based on a blend of high tech and high touch. Whatever we call it, like Dr. Withering, we must keep an open mind about our patients’ unconventional practices. By doing so, we will protect our patients’ health and perhaps improve it.
Just how many patients are using CAM is subject to debate. In a 1998 study published in the Journal of the American Medical Association (JAMA), Eisenberg et al. (3) reported that the percentage of Americans using at least one kind of alternative therapy jumped from 34% in 1990 to 42% in 1997. Chronic conditions, such as back pain, headaches, anxiety, and depression, were the most frequent complaints of those using alternative therapies.
By extrapolating the findings of their telephone surveys to the U.S. population as a whole, Eisenberg and colleagues (3) estimated a 43% increase in visits to CAM practitioners. If those extrapolations are correct, then visits to alternative medicine practitioners outnumbered visits to primary care physicians in 1997, and out-of-pocket expenditures for such therapies were comparable to out-of-pocket expenditures for physician services. A 1999 JAMA (4) article suggested that the number of Americans using unconventional therapies may actually be much smaller than Eisenberg et al.’s (3) estimates. Drawing on data from 16,068 adults participating in the 1996 Medical Expenditure Panel Survey, Druss and Rosenheck (4) estimated that only 2% of Americans used unconventional therapies exclusively and 7% combined both conventional and unconventional approaches.
However, a recent report from the Macy Foundation (5) suggested that at least half of the U.S. population is using at least one form of CAM. The authors estimated that Americans visit CAM practitioners 600 million times annually—that’s more often than they see their primary care physicians.
No matter which study is right, it’s clear that a sizable number of Americans are turning to medical practices beyond conventional medicine. Herbal remedies, in particular, have become big business. While still growing at a rate of 20% to 30%, this industry is already amassing $10 billion a year (5). And even physicians who doubt the effectiveness of such practices need to know about them. On the positive side, these therapies may have real potential.
For example, some cardiologists are already urging their patients to use meditation to lower their blood pressure (6). Others are suggesting that patients try yoga as a way of managing congestive heart failure symptoms or acupuncture to relieve pain. Still others are prescribing soy or garlic for patients’ high cholesterol or St. John’s wort for neurocardiogenic syncopy. Some cardiovascular surgeons are becoming interested, too. Oz (7) found that patients who practice self-hypnosis suffer less depression, fatigue, and tension following heart surgery.
But there is a downside, too. Complementary medicine can be dangerous because most drugs have not been tested in any sort of a scientific fashion; and, if they are called a "dietary supplement," then the Food and Drug Administration does not monitor them. This means that a bottle of herbal medicine may contain the substances in the amount stated on the label, but it may not. While it is likely that most untested herbal remedies are harmless, examples of adverse responses abound. Patients who use a natural form of ephedrine called ma huang to lose weight and boost their energy levels are at risk for stroke, myocardial infarction, supraventricular tachycardia, and even sudden death (6). Patients can unknowingly consume preparations contaminated with arsenic, lead, or other toxins. Or they can delay their visit to a physician and lose precious time in the diagnosis and treatment of an illness (8).
There are other, more subtle dangers. Some complementary treatments can affect test results. A study published in the Canadian Medical Association Journal (9) in 1996, for example, suggested that herbal preparations containing Siberian ginseng can cause falsely elevated results on digoxin tests. Such inaccurate results can in turn lead physicians to base treatment decisions on inaccurate data, thereby placing the patient at risk.
Drug interactions are another potential problem. According to Eisenberg et al.’s (3) 1997 survey, 18% of patients taking prescription medication were also taking herbal remedies or high doses of vitamins. In a study presented at the American College of Cardiology (ACC) Annual Scientific Session in 1999, Hermann et al. (10) found that 44% of heart failure patients also used herbs, high-dose vitamins, or other supplements. They also found that, like Mrs. Smith, one in three didn’t share that information with their physicians. And, I suspect, a lot of physicians like me don’t routinely ask their patients whether they are "complementing" their prescriptions. On the one hand, it’s simply not on many physicians’ radar screens; on the other hand, we have so little time with our patients that we rarely get to talk, to find out if our patients are searching for more than we are offering them in the examination room.
That lack of communication can have deadly results. In a study published in the Archives of Internal Medicine in 1998, Miller (11) noted that garlic, ginkgo, ginger, and ginseng can inhibit clotting and thus should not be used with blood thinners such as aspirin, heparin, or warfarin. Likewise, the American Society of Anesthesiologists was so alarmed by the potential interactions between such popular supplements as St. John’s wort and gingko and anesthetic drugs used during surgery that it issued a warning to consumers in 1999 (12). Following reports that such supplements could deepen the effect of anesthesia or cause blood pressure or bleeding problems, the Society now recommends that patients stop using herbal remedies at least two to three weeks before undergoing surgery.
Physicians suspicious or ignorant of complementary medicine can inadvertently put their patients at risk. When patients are silent about using complementary therapies, perhaps fearing derision, the physician–patient relationship is damaged. And, even worse, such physicians might offend or scare off complementary medicine adherents who may be in dire need of the conventional treatment only physicians can provide.
But, in these scenarios, we also miss an opportunity to enhance our own credibility and improve rapport with our patients. That’s part of the appeal of CAM: Its practitioners give their patients time, something we physicians seem to have in very short supply. The average CAM practitioner spends 30 min in a session; we physicians have only about 7 min to share with each patient (5). In addition to giving patients a chance to talk about what’s on their minds, being open and able to discuss complementary therapies with patients helps transform them from passive recipients of care to true partners in care.
That relates to another of CAM’s attributes, which is a holistic approach. Complementary and alternative medicine practitioners acknowledge the crucial roles of the body and the mind in health. Complementary and alternative medicine tends to focus on staying well, not treating illness, and stresses the role of self-care (5). Like Mrs. Smith, many patients want to be involved in their own care. They want to be empowered to make decisions that affect their health, and they want to believe in the outcomes. That’s part of the reason that, at the very least, we physicians should review efficacy data with our patients, warn them of any potential dangers, and make them intimate participants in the decision to take—or not take—certain remedies.
We physician researchers acknowledge the role of the "placebo effect" in clinical trials and other studies. But CAM practitioners often take it one step further. Instead of merely acknowledging that the placebo can influence results, they believe in the power of this effect to help patients feel better and even get well. The power of the mind as a tool for healing is an extraordinary but elusive attribute, often unsupported by conventional scientific data. But anecdotes attest to extraordinary things the mind appears to mediate from time to time—help a mother wrench open a car door to pull her child from danger, walk on hot coals without burning one’s feet (performed by my wife and me many years ago), or bend a spoon into modern art aided by the power of thought (Fig. 1). These are the inexplicable events the human brain can help perform; no less miraculous may be the inner peace that comes with yoga or meditation or the benefits that seem to accompany sipping tea or undergoing acupuncture. We don’t understand why these approaches may work, and some defy biologic mechanisms that we have been taught must underlie acceptable medical practices; but we must resist the temptation to discard all of them out of hand merely because we don’t understand them. Experience one of them personally, and you become a believer.
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Figure 1 The power of thought can help bend spoons into modern art. It may be able to help make people well, too.
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Of course, there’s still a great need for research in this area. The National Center for Complementary and Alternative Medicine (NCCAM) at the National Institutes of Health is already working to fill that void. Originally established as the Office of Alternative Medicine in 1992, the center now has a budget of $90 million (13). That’s 45 times the budget the office had when it opened, a sure sign of growing interest in this area.
American College of Cardiology members are also doing their part to help distinguish between snake oil and useful remedies. At this year’s Annual Scientific Session in Orlando, Florida, for instance, a special symposium called "Alternatives and Complementary Practices in Cardiovascular Disease" explored the latest research on nontraditional approaches to medicine. Presenters reviewed the evidence about the effectiveness of therapies, examined coenzyme Q and other supplements, described potential adverse effects and drug interactions, and reviewed clinical trials.
The time has come not only for us to acknowledge the potential of some forms of CAM but also for physicians and CAM practitioners to learn from each other. It is time for forums like a recent one sponsored by the Macy Foundation, which brought together practitioners from both worlds, and a June 2000 workshop titled "Complementary and Alternative Medicine in Cardiovascular, Lung, and Blood Research," which was sponsored by the National Heart, Lung, and Blood Institute and the NCCAM (14). The latter workshop drew nearly 100 attendees and resulted in recommendations for standardizing the formulation of botanical products and CAM procedures and studying the safety and efficacy of such treatments in clinical trials. Both physicians and CAM practitioners share a common mission—to help people get well, to help them feel healthy, and to prevent disease in the first place. Complementary and alternative medicine practitioners are gradually accepting that they need controlled studies to demonstrate the effectiveness of their treatments, and physicians are opening their minds to the potential benefit of these unproven therapies. If these groups put their minds together, the result could be the best of both worlds for our patients.
Note: Physicians can learn more about CAM by calling the NCCAM clearinghouse (888-644-6226) or visiting http://nccam.nih.gov/nccam/fcp/clearinghouse. The ACC is offering an extramural program, called The First Conference on the Integration of Complementary Medicine in a Traditional Cardiology Practice, which will explore the pros and cons of numerous CAM treatments. Dr. John H.K. Vogel will direct the October 18–20, 2001, conference in Santa Barbara, California. For more information, call the ACC Resource Center at 800-253-4636, ext. 694.
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References
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- National Institute of General Medical Sciences. Medicines by design: the biological revolution in pharmacology. Undated. Available at www.nigms.nih.gov/news/science_ed/medbydes.html.
- Seidman BF. Medicine wars: will alternative and mainstream medicine ever be friends? Skeptical Inquirer. 2001;:28–35
- Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997. JAMA. 1998;280:1569–1575[Abstract/Free Full Text]
- Druss BG, Rosenheck RA. Association between use of unconventional therapies and conventional medical services. JAMA. 1999;282:651–656[Abstract/Free Full Text]
- Josiah Macy, Jr., Foundation. Chairman’s summary: Education of Health Professionals in Complementary/Alternative Medicine, February 2001. Available from the Foundation, 44 E. 64th St., New York, NY 10021.
- Clay R. Love it or loathe it: physicians need to know about complementary medicine. Cardiology 1999:September;1.
- Oz M. Healing from the Heart: A Leading Surgeon Combines Eastern and Western Traditions to Create the Medicine of the Future. New York: Dutton; 1999.
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- Hermann DD, Kuiper JJ, Shabetai R, et al. Herbal, megavitamin and nutritional supplement (naturoceutical) use is very common in heart failure patient populations. (abstr)J Am Coll Cardiol. 1999;33(Suppl):201A
- Miller LG. Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med. 1998;158:2200–2211[Abstract/Free Full Text]
- Nagourney E. A warning not to mix surgery and herbs. New York Times. July 6, 1999:D-5.
- Dreifus C. Separating remedies from snake oil. New York Times. April 3, 2001:D-5.
- Lin MC, Nahin R, Gershwin ME, Longhurst JC, Wu KK. State of complementary and alternative medicine in cardiovascular, lung, and blood research: executive summary of a workshop. Circulation. 2001;103:2038–2041[Abstract/Free Full Text]
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