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«1. Introduction The treatment of angina pectoris as an important symptom of coronary artery disease is usually focused on restoring the balance ...»

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Alternative Non-Medical, Non-Surgical

Therapies for the Treatment of Angina Pectoris

Maryam Esmaeilzadeh, Bahieh Moradi and Nasim Naderi

Tehran University of Medical Sciences,

Shaheed Rajaei Cardiovascular Medical and Research Center


1. Introduction

The treatment of angina pectoris as an important symptom of coronary artery disease is

usually focused on restoring the balance between myocardial oxygen demand and supply

by administration of drugs interfering in heart rate, preload, afterload, and coronary vascular tone. For non responders to drug therapy or for those with jeopardized myocardium, revascularization procedures such as coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA) are at hand.

However, these therapies cannot stop the disease process and, at longer terms, angina may recur. It is not always possible to revascularize all the patients who do not sufficiently react to medical treatment. In these group patients alternative therapies are more effective. A major difference between alternative therapies versus traditional therapies is that alternative therapy tends to look at the entire patient rather than simply treating a disorder as traditional treatments do. Some kinds of these therapies are applicable in all patients with coronary artery disease irrespective of their symptoms and the other ones would be considered in patients with refractory angina who are not suitable for revascularization.

2. General alternative therapy These therapies are applicable in all patients with coronary artery disease whether they are symptomatic or not.

2.1 Heart healthy lifestyle 2.1.1 Goals Preventing heart disease, living heart healthy, and overcoming stress-related heart illness requires more than just a physical approach to heart problems. Whether or not patients had an interventional angioplasty or bypass surgery, it's obvious that some changes in lifestyle will need to be made. To continue living a normal active life, one needs to begin making heart healthy lifestyle changes that include eating a heart healthy diet. Maintaining a healthy diet and lifestyle offers the greatest potential of all known approaches for reducing the risk for CVD in the general public. Specific goals are to consume an overall healthy diet;

www.intechopen.com 160 Angina Pectoris aim for a healthy body weight; recommended levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglycerides; normal blood pressure; normal blood glucose level; be physically active and avoid use of and exposure to tobacco products.

Consume a Healthy Diet:

An emphasis on whole diet should be done to ensure nutrient adequacy and energy balance.

Hence, rather than focusing on a single nutrient or food, individuals should aim to improve their whole or overall diet. (1) The American Heart Association has provided dietary recommendations and recommendations for an overall healthy lifestyle to the American public with the goal of reducing risk for cardiovascular diseases. (1)

Achievement or maintaining an ideal body weight:

A healthy body weight is currently defined as a body mass index (BMI) of 18.5 to 24.9 kg/m2. Overweight is a BMI between 25 and 29.9 kg/m2, and obesity is a BMI 30 kg/m2.

Achieving and maintaining a healthy weight throughout life is particularly difficult and are critical factors in reducing CVD risk in the general public. Great emphasis should be put on prevention of weight gain (2), because achievement and maintenance of weight loss, although certainly possible, require more difficult behavioral changes ie, greater calorie reduction and more physical activity, than prevention of weight gain in the first place.

Prevention of excess weight gain:

Prevention of excess weight gain relies on the maintenance of energy balance, whereby energy intake equals energy consumption over the long term.(1, 2) This means maintaining a relatively stable weight across life stages. A positive imbalance will increase energy storage, deposited as body fat and observed as weight gain. Although the concept is seemingly simple, the physiological systems that regulate body weight through energy intake and consumption mechanisms are complex, interactive, homeostatic, and still poorly understood. Furthermore, the components of energy balance are not weighed easily or with adequate precision to be practical as a guide to help individuals maintain energy balance. In theory, a small persistent energy imbalance of 50 kcal per day could result in a 5-lb weight gain in 1 year, provided that all other things being equal. (2)

Treatment of obesity:

Although prevention and treatment of obesity both depends on the same principles of energy balance, the application of the principles is completely different. For treatment of obesity, a large reduction in calorie intake of about 500 to 1000 kcal per day, along with increased physical activity, can result in a loss of approximately 8- 10% of body weight over the relatively short period of about 6 months. Although the types of low-calorie diets that best promote weight loss are the subject of current investigations, behaviors for weight loss focused on caloric reduction such as decreasing overall food intake, reducing portion sizes, substituting lower-calorie for higher calorie foods, and increasing physical activity. Weight loss is best achieved by participation in a behavioral program using self-monitoring, goalsetting, and problem-solving techniques. Motivation levels may be high for appearance reasons or if adverse health consequences and quality of life impairments associated with obesity are readily perceived.(2) However, because weight regain after weight loss is common, motivations and strategies to maintain weight may differ largely from those initiating weight loss.(2) www.intechopen.com Alternative Non-Medical, Non-Surgical Therapies for the Treatment of Angina Pectoris

A diet rich in vegetables and fruits:

Most vegetables and fruits are rich in nutrients, low in calories, and high in fiber. Diets high in fiber, especially from cereal sources, substantially reduce the risk of coronary heart disease. Short-term randomized trials have shown that diets rich in vegetables and fruits not only provide micronutrient, macronutrient, and fiber requirements, but also lower BP and improve other CVD risk factors. Vegetables and fruits that are deeply colored, for example, spinach, carrots, peaches and berries, ought to be emphasized because they tend to be higher in micronutrient contents compared to other vegetables and fruits such as potatoes and corn. Equally important is the method of preparation which includes techniques preserving nutrient and fiber content without adding unnecessary calories, saturated or trans fat, sugar, and salt.(1)

2.2 Supplements It is ideal to get the body nutritional needs in foods.When that is not enough, a registered dietitian may also start a series of supplements to make up for nutrients not getting through the diet. Some of the more popular supplements for both healthy and those at risk for coronary artery disease include antioxidants such as vitamins C and E, B-complex, omega-3 fish oil and coenzyme Q10. The American Heart Association recommends 2-4 grams of Omega-3 per day for anyone with high triglycerides and at least 1 gram per day for anyone with documented coronary heart disease. (1) According to the results of many clinical trials performed to clear the role of dietary supplements in the prevention and /or slowing the progression of cardiovascular diseases, the long-term effects of most dietary supplements other than for vitamins and minerals are not known, so these agents should be prescribed under professional supervision of physician or a registered dietitian.

Essential Fatty Acids Omega-3 and Flaxseed oil Flaxseed oil comes from the seeds of the flax plant (Linum usitatissimum, L.) which contains both omega-3 and omega-6 fatty acids, which are vital for health. They are composed of essential fatty acid alpha-linolenic acid (ALA), which the body turns into eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), the omega-3 fatty acids found in fish oil. Some researchers argue that flaxseed oil might have some of the same usefulness as fish oil, but the body is not very efficient at converting ALA into EPA and DHA, however, the benefits of ALA, EPA, and DHA are not necessarily the same. The human body is not able to make its own omega-3 fatty acids, so it is important that they are part of everyone’s dietary intake. (3) The consumption of 2 servings (8 ounces) per week of fish high in EPA and DHA can result in a reduction of risk of mortality and morbidity from coronary artery disease. In addition to providing EPA and DHA, regular fish consumption may facilitate the displacement of other foods higher in saturated and trans fatty acids from the diet, such as fatty meats and full-fat dairy products.(1) Omega-3 fatty acids seem to have a small, dose-dependent, hypotensive effect, the extent of which seems to be dependent on the degree of hypertension.(4) In a meta-analysis, Morris et al found a significant reduction in blood pressure of ≤ 3.4/ 2.0 mmHg in studies with hypertensive subjects who consumed

5.6 g/d of omega-3 fatty acids.(4) Likewise, Appel et al found that blood pressure was decreased ≤ 5.5/ 3.5 mmHg in trials of untreated hypertensives given 3 g/d of omega-3 fatty acids. DHA seems to be more effective than EPA in lowering blood pressure. (4) Getting a www.intechopen.com 162 Angina Pectoris good balance of omega 3 and 6 fatty acids in the diet is important which are examples of polyunsaturated fatty acids (PUFAs). Omega 3 fatty acids help reduce inflammation, while most omega 6 fatty acids tend to contribute to inflammation. A healthy diet should consist of roughly 2 to 4 times fewer omega 6 fatty acids than omega 3 fatty acids. Some species of fish may contain significant levels of methylmercury, polychlorinated biphenyls (PCBs), dioxins, and other environmental contaminants which is a potential concern for using them.(1,4) Subgroups of the population, primarily children and pregnant women are advised by the FDA to avoid eating those fish with the potential for the highest level of mercury contamination. Eating up to 12 ounces (2 average meals) per week of a variety of fish and shellfish that are lower in mercury is also recommended. (1) The American Heart Association recommends inclusion of omega 3 fatty acids in patients with stable CAD because of evidence from randomized controlled trials. The recommended daily dose in patients with stable coronary artery disease is 1 gram of eicosapentaenoic acid/docosahexaenoic acid (EPA/DHA) by capsule supplement, the equivalent amount in alpha-linolenic acid (LNA) from vegetable source, or by eating daily fatty fish(1). Since maintaining daily fish meals can be difficult, capsule supplements may be preferred although there is no uniformity of EPA/DHA content or purity.

Niacin Niacin (nicotinic acid) is a B vitamin that has been used in high doses (1.0–4.5 grams per day) as a treatment for hyperlipidemia which is associated with increased risk of CAD.

Niacin reduces cholesterol and TG levels, and increases the concentration of high-density lipoprotein (HDL). (5) It is also effective at modulating blood lipids, but side effects sometimes dampen enthusiasm for therapy. Although side effects are dose-related, few studies have determined an optimal dose of nicotinic acid that alters lipid levels with the fewest side effects. Martin-Jadraque et al. (6) found improvement in blood lipid levels in 75% of subjects who tolerated low-dose nicotinic acid therapy. Nicotinic acid may also be useful in combination drug therapy for prevention of CAD if higher doses cannot be tolerated. Use of a lower dose should still be beneficial for producing a moderate rise in HDL levels. Women seem to have a greater LDL response to niacin, but experience more side effects at higher dosages. (7) Long-term treatment with nicotinic acid (4 g/day for 6 weeks) not only corrects serum lipoprotein abnormalities, but also reduces the fibrinogen concentration in plasma and stimulates fibrinolysis. (8) Although most medications used to treat dyslipidemias will raise HDL levels modestly; however, niacin appears to have the greatest potential to do so, increasing HDL up to 30%. (9) Vitamin C A widely publicized study showed that men who took 800 mg daily of vitamin C lived about 6 years longer than those consuming of 60 mg per day. (10) A study of elderly subjects; being supplemented by vitamin C and vitamin E to subjects using no vitamin supplements showed that use of vitamin E alone reduced death from myocardial infarction (MI) by 63% and overall mortality by 34%. When the vitamin C and E were used together, overall mortality was reduced by 42%. (11) A proper supply of nutrients will allow the cellular damage to vascular walls to be repaired properly and prevent further cracks and lesions. The results of a clinical studies, published in the Journal of Applied Nutrition (12), determine the effect of a nutritional supplement program, consisting of vitamin C therapy, on the natural progression of coronary artery www.intechopen.com Alternative Non-Medical, Non-Surgical Therapies for the Treatment of Angina Pectoris disease. The study used Ultrafast Computed Tomography to document the level of coronary artery disease and the sample of patients composed of people with early and advanced stages of the disease. During the course of the 12-month study, the rate of coronary artery calcification decreased in all patients by an average of 15%. In the subset of early stage patients, the progression of calcification was stopped completely. In some cases, calcification was actually reversed, including a case of the disappearance of all calcification deposits.

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