Scientific Basis for Ayurvedic Therapies -34

Scientific Basis for

Ayurvedic Therapies 

edited by

Brahmasree Lakshmi Chandra Mishra

29.7.5.1 Treatment

Although the following methods are not practiced today, the descriptions below are given

to show how surgery was practiced thousands of years ago.57–60

Ayurveda mentions preoperative procedures (poorvakarma), main operative procedures

(pradhana karma), and post-operative procedures (pashchat karma). The procedure describes

piercing the globe at a particular position, specifically at the intersection of two thirds of

the limbal side and one third of the outer canthal side. This is where a thin rodlike

instrument (shalaka) is used to prick in such a way that it does not disturb other important

appendages of the eye or blood vessels of the eye; it reaches straight to the opaque lens

(drushtimani) and produces a typical sound when watery secretions of linganasha dosa

(liquified lenticular matter) come out. This is somewhat similar to the latest approach of

surgery, the phacoemulsification procedure. The procedure needs to be done in such a way

that the patient is able to see objects like fingers (anguli) and threads (tantu) clearly. The

eye is covered with a dressing of medicated ghee and is properly bandaged.

Ayurveda also describes the complications resulting from a surgery performed by an

inexperienced surgeon (e.g., breaking of the lens in several pieces or lens falling back into

vitreous chamber) and how to remedy them.

Ayurvedic ophthalmic surgeons currently follow all modern methods of treatment,

including conventional modern drugs for anesthesia. Surgeons also undertake procedures

like intraocular lens (IOL) implants as well for cataract.

29.7.6 Miscellaneous Eye Disorders (Drishtigat Vyadhi)

Ayurveda mentions 12 disorders of drishtigat vyadhi.56 Six types are linganasha and the other

six disorders include nakulandhya (eye looks like those of a cat under a flashlight). The pupil

gives a bright light suggestive of retinoblastoma of the eye or glioma of the retina. According

to Ayurveda and conventional medicine, it is an incurable disease. Enucleation of the

eyeball should be undertaken as soon as possible. In descriptions of patalgat dushti, equivalents

of vitreous degenerations, cobwebs, mosquitoes, refractive errors, diplopias, and

even clues towards retinal detachments are found. A certain description given by Vagbhatacharya

for timir specifically points to hypermetropia and myopia. In tritiya patalgat dushti,

references are indicative of conditions similar to retinal detachments.

29.8 Scientific Basis

An attempt is made here to review the existing scientific literature on Ayurvedic ophthalmology.

The references are taken from different sources such as research journals, postgraduate

theses, and Internet databases. Some references do not have details, but they are

cited only to show that there has been an interest.

29.8.1 Clinical Studies

29.8.1.1 Conjunctivitis

1. Neem eyedrops on viral conjunctivitis (netrabhishyanda by nimbapatra netrabindu)

—The drops were prepared in the department of the shalakyatantra. There were

30 patients of viral conjunctivitis who were treated for 3 weeks with sterilized

eyedrops prepared from the extract of leaves of Azadirrhacta indica. The improvement

was statistically significant.61

2. Ophthacare eyedrops (a herbal formulation manufactured by Himalaya Drug

Company) — An open multicentric clinical trial was conducted in patients suffering

from various ophthalmic disorders, namely conjunctivitis, conjunctival

xerosis (dry eye), acute dacryocystitis, and degenerative conditions (e.g., pterygium

and pinguecula), and in postoperative patients of cataract with Ophthacare.

The formula contains chemical ingredieents (details not available) from Carum

copticum, Terminalia belerica, Emblica officinalis, Curcuma longa, Ocimum sanctum,

Cinnamonum camphora, Rosa damascena, and meldespumapum. These herbs reportedly

possess anti-infective and anti-inflammatory properties.62

3. Second study on Ophthacare eyedrops — This was a comparative, double-blind,

multicentric-randomized, placebo-controlled clinical trial that included 157

patients suffering from different eye ailments: cataract dry eye syndrome, ocular

asthenia, refractive errors, and allergic conjunctivitis with a herbal eyedrop preparation

and placebo. In both dry eye syndrome and ocular asthenia, the herbal

eyedrop preparation was promising. In a few cataract patients, the vision seemed

to improve. No analysis of the data was given. In early myopia, it seems to correct

the refractive errors whereas in high myopic conditions it controlled the progressive

deteriorations. Subjective improvements were also noted with hypermetropia,

presbyopia, and astigmatism. Its healing capacity in allergic conjunctivitis was

certainly better than placebo. It had no short-term or long-term side effects and

is considered to be a useful drug in all conditions studied.63

29.8.2 Refractive Errors

Although there are no direct references available on refractive errors in ancient Ayurvedic

texts, some of the texts are indicative of refractive disorders. Available studies in this area

are described below.

1. Saptamrut loha and yashad bhasma on refractive errors — Although details of the

study are not available, the results were reported to be encouraging.64

2. Saptamrut loha, Yashtimadhu ghruta, Shatavari ghruta, Punarnavadi yoga, and Pathyadi

kwatha — The author of this chapter has treated many patients with refractive

disorders such as high myopia and high hypermetropia by using these formulas

with encouraging results at The Center of Ayurveda and Panchakarma Therapy,

Eye Care Clinic.

Some studies done at postgraduate institutes of Ayurveda in India by postgraduate

students and others on different eye disorders such as trachoma, pterygium, blephritis,

corneal ulcer, and retinal disorders are presented here.

29.8.2.1 Trachoma (Pothaki)

As per Ayurvedic texts,65 trachoma consists of multiple projections that are reddish on the

inner side of the lid (on palpebral conjunctiva).These symptoms are combined with profuse

eye discharge, pain, itching, and heaviness in eyes.

According to modern medicine, trachoma (granular conjunctivitis or granular eyelids)

is a specific contagious disease of the conjunctiva and cornea. It is chronic and characterized

by a subepithelial infiltration of the conjunctiva by a cellular granulation tissue, which

is responsible for the presence of the typical follicles or granulations.

29.8.2.2 Therapeutic Efficacy of Shobhanjana Eyedrops in Trachoma (Pothaki)

In one unpublished study,66 there were 30 patients with trachoma, where 22 patients in

the prefollicular stage of trachoma and 8 patients in the follicular stage of trachoma. All

patients were treated with the eyedrops for 8 weeks. There were 25 patients (85%) who

showed complete relief, 3 patients (10%) who have moderate relief, and 2 patients (5%)

who showed no relief.

29.8.2.3 Pterygium (Arma)

As per Ayurvedic texts,67 this is a disease of sclera (shwetamandala). It is a triangular growth

from either the inner or outer canthus heading toward the limbus. Ayurveda classifies it

into five types.

According to modern ophthalmology, pterygium is a threefold of conjunctiva. It occupies

the interpalpebral fissure extending from the inner or outer part of the bulbar conjunctiva

on the cornea, and the base spreads out and merges with the subconjunctival tissue.

In Ayurvedic texts, there is mention of both surgical and medical treatment of pterygium.

Thirty patients of Pterigyum were treated with Marichyadi yoga (containing marich [Piper

nigrum] and triturated with the juice of kesharaj [Eclipta alba]) for 4 weeks at one of the

institutes by a postgraduate student. Results were encouraging in 75% of the cases.68

29.8.2.4 Corneal Ulcer (Savarna Shukra)69

As per Ayurvedic texts, there is an ulceration of the cornea (krishnapatal) because of vitiated

increased pitta; it is circular in shape, with a little depression on the area of ulcer bed, and

it is surrounded by neovascularization. There is pain, redness, and overlacrimation of the

ulcer-affected eye. According to modern ophthalmology, the break of the continuous lining

of the epithelial line of the cornea is known as a corneal ulcer. There are various causes

attributed to the formation of the corneal ulcers.

Yashtimadhu ghruta (medicated ghee composed of amalki [Phyllanthus embelicus], haritaki

[Terminalia chebula], bhibhitaki [Terminalia belerica], musta [Cyperus rotandus], and haridra

[Curcuma longa]) was investigated in 30 patients with corneal ulcers by a postgraduate

student at one of the institutes. Significant healing activity was noted within 6 to 7 days

(p < 0.05).70

29.8.2.5 Blepharitis (Klinnavratma)

As per Ayurvedic texts,71 Blepharitis (klinnavartma) is explained as two types: simple

blepharitis (Pralinna vartma) and ulcerative blepharitis (aklinna vartma). In simple blepharitis

there is swelling of the lids, sticky blood-stained discharge from eyes, and pain and

itching of the eyelids. This is a kaphaja disorder. In ulcerative blepharitis, there are ulcerations

at the level of edges of the eyelids, which may lead to entropion if not treated

correctly. According to modern ophthalmology, blepharitis is a chronic inflammatory

condition of the margin of the eyelids. It occurs in two forms: nonulcerative (squamous

blepharitis) and ulcerative.

In one clinical study72 done at the institute by postgraduate students, rasanjanadi rasakriya

(ointment containing daruharidra [Berberis aristata] processed in goat’s milk) was used to

treat 30 patients with blephritis by external application. The ointment (anjan) showed

healing activity, reduced edema, discharge, itching, and pricking pain within the first

week. The results were significant (p < 0.05).

29.8.2.6 Retinal Disorders

29.8.2.6.1 Diabetic Retinopathy

Fifteen patients of diabetic retinopathy (a complication of diabetes mellitus) were given

Vasant kusumakar Rasa; the other 15 patients were given a placebo for a 12-week period.

There was a good improvement in, seven cases, no change observed in seven cases, and

deterioration in the condition observed in one case. One case of those seven cases improved.

This case initially had retinopathy and showed no evidence of the diabetic retinopathy, but

a complete cure was seen at the end of the study. Three cases showed marked improvement,

whereas two cases showed marginal improvement. There was no significant change noticed

in the biochemical parameters at the end of the therapy.73

29.8.2.6.2 Retinitis Pigmentosa

In an open prospective study74 on 15 cases of retinitis pigmentosa having less than 3 ft of

vision, 2 cases were screened with electroretinography and visual-evoked potential studies

in both pre- and posttherapy. The drugs used in the study were shatavaryadi ghrita, netryatarpaka

yoga, and mahatraiphal ghrita, along with certain herbal combinations of punarnava,

yashtimadhu, amalki, and other herbs. Treatment was given in either form, orally or locally.

Ghrita were used locally. All these preparations were prepared at the Center of Ayurveda

and Panchakarma Therapy, Eye Care Clinic. Nine patients completed the study, of which

four showed a marked improvement in the visual acuity, four showed moderate improvement,

and one patient showed no change.

29.8.3 Studies on Special Therapeutic Procedures

One of the Ayurvedic panchakarma therapies used in Ayurvedic ophthalmology is tarpana

(eye is kept in medicated ghee for a given predetermined period while keeping the patient

in a supine position). A preliminary study75 was conducted by the author of this chapter

on 25 healthy volunteers to assess this therapy’s safety profile. Certain parameters such

as IOP, temperature, pulse, respiration, blood pressure, and other common ocular symptoms

and signs were observed for possible adverse effects. No serious adverse effect were

noticed and no significant results were obtained.

29.8.4 Biological Studies

The anticonjunctival activity of the punarnava (Borehaavia diffusa) and neem (Azadirachta

indica) was assessed by preparing water extracts and testing them on the experimental

model of bacterial conjunctivitis in rats. The experimental study revealed that both extracts

as well as marketed gentamicin eyedrops showed statistically significant anticonjunctival

activity. Herbal extracts showed comparable effect with the established drug, Gentamycin.

76

29.8.5 Antimicrobial Activities of Herbs Used in the Treatment of Eye Disorders

A study of in vitro antibacterial activity of extracts from the plants T. chebula, E. alba, and

O. sanctum was carried out by disk diffusion technique. All showed activity against human

pathogenic Gram-positive and Gram-negative bacteria. The activity against salmonella

organisms was shown only by T. chebula; the action against shigella organisms was shown

by T. chebula and E. alha, but not by O. sanctum. The widest spectrum of antibacterial

activity was shown by T. chebula. It was also most potent. The antibacterial spectrum of

E. alba was between that of T. chebula and O. sanctum. The narrowest spectrum of antibacterial

activity was observed in O. sanctum.77

Eugenia aromatica (lavanga) (clove) has been studied for its antibacterial activity. Clove

oil inhibited tuberculosis at 1:80 dilution. Ethanol extracts of clove inhibited the growth

of C. botulinum. The extracts were also found to be effective against several Gram-positive

and Gram-negative microorganisms tested on agar media at 5000 ppm.78

The chloroform extract of Azadirachta indica (neem) oil has been found to be fungicidal

for common skin pathogens Trichphyton spp. The essential oil has shown antibacterial

activity against Staph. aureus, E. coli., S. pyogenes, etc. A. flavus and other fungi are also

susceptible to neem oil. Neem has known to have antiviral properties.

The volatile oil from the fruit of Piper nigrum (Maricha) showed antifungal activity.79 A

crystalline fraction obtained from bark of Symplocos racemosa Roxb. (Lodhra) is found to

inhibit the growth of staphylococci.80 Cold water extract of the fruit of Terminalia belerica

Roxb. (bibhitaka) was found to posses antibacterial activity.81 Curcuma longa (haridra) exhibits

antimicrobial activity; sodium curcuminate in a dilution of 1:1 million inhibited micrococcus

pyogenes.82

29.8.6 Anti-Inflammatory Activity of Herbs Used in the Treatment of Eye Disorders

The anti-inflammatory activity of various extracts of roots of Boerhaavia diffusa Linn. were

studied in carragenin-induced edema and formaldehyde-induced arthritis in albino rats.

Acetone extract showed most the potent anti-inflammatory effect.83

Commiphora mukul (Guggul) has been extensively studied for its anti-inflammatory effects.

The steroidal component of Fraction A of the petroleum ether extract has marked antiarthritic

effect comparable with that of hydrocortisone and more potent than phenyl-butazone.

84

Water extract of Curcuma lona Linn. (haridra) showed significant anti-inflammatory activity

in acute carrageenin-induced edema. Active principle curcumin showed anti-inflammatory

activity similar with cortisone and phenylbutazone in carrageenin-induced edema in

rats with an equivalent dose.85

Acknowledgments

I would like to thank Dr. Amita Manu, Dr. Ashish Mungantiwar, and Dr. Lakshmi Mishra

for their valuable help in developing this chapter. I also acknowledge all institutes, authors

of papers, and editors of various journals cited in this chapter.

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vyadhimen Yashtimadhu Ghrutka Prayogika adhyayana), M.D. thesis (Ayurveda), University of

Mumbai, India, 1997.

71. Padmawar, R., Netrarogavidnyana, 3rd ed., Shri Baidyanath Ayurved Bhavan Ltd., Nagpur,

India, 1989, p. 74.

72. Padvi, V., A clinical study of Rasanjanadi rasakriya on ulcerative blephritis (Rasanjanadi Rasakriya

ya Anjanacha Klinnavartma ya vyadhivara honara parinama eka adhyayana), M.D. thesis (Ayurveda),

University of Mumbai, India, 1999.

73. Tamboli, S., A Clinical Evaluation of Vasant Kusumakara Rasa in Prameha Upadrava with Special

Reference to Diabetic Neuropathy and Diabetic Retinopathy, M.D. thesis (Ayurveda), University

of Mumbai, India, 2001.

74. Phadke, A., A Clinical Evaluation of Cases of Retinitis Pigmentosa (R.P.) with the Management

of Ayurvedic Composite Therapy, paper presented at national conference of NIMA, Mumbai,

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76. Khadilkar, M., Phytochemical and Pharmacological Investigation of Water Extracts of Boerhaavia

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Usage), compiled by Bharatiya Vidya Bhavan’s S.P.A.R.C. Mumbai for Chemexcil, Basic Chemicals,

Pharmaceuticals and Cosmetics Export Promotion Council, Bombay, India, set up by

Ministry of Commerce, Government of India, 1992, p. 201.

80. Board of editors, Selected Medicinal Plants of India (A Monograph of Identity, Safety and Clinical

Usage), compiled by Bharatiya Vidya Bhavan’s S.P.A.R.C. Mumbai for Chemexcil, Basic Chemicals,

Pharmaceuticals and Cosmetics Export Promotion Council, Bombay, India, set up by

Ministry of Commerce, Government of India, 1992, p. 303.

81. Board of editors, Selected Medicinal Plants of India (A Monograph of Identity, Safety and Clinical

Usage), compiled by Bharatiya Vidya Bhavan’s S.P.A.R.C. Mumbai for Chemexcil, Basic Chemicals,

Pharmaceuticals and Cosmetics Export Promotion Council, Bombay, India, set up by

Ministry of Commerce, Government of India, 1992, p. 317.

82. Board of editors, Selected Medicinal Plants of India (A Monograph of Identity, Safety and Clinical

Usage), compiled by Bharatiya Vidya Bhavan’s S.P.A.R.C. Mumbai for Chemexcil, Basic Chemicals,

Pharmaceuticals and Cosmetics Export Promotion Council, Bombay, India, set up by

Ministry of Commerce, Government of India, 1992, p. 123.

83. Board of editors, Selected Medicinal Plants of India (A Monograph of Identity, Safety and Clinical

Usage), compiled by Bharatiya Vidya Bhavan’s S.P.A.R.C. Mumbai for Chemexcil, Basic Chemicals,

Pharmaceuticals and Cosmetics Export Promotion Council, Bombay, India, set up by

Ministry of Commerce, Government of India, 1992, p. 57.

84. Board of editors, Selected Medicinal Plants of India (A Monograph of Identity, Safety and Clinical

Usage), compiled by Bharatiya Vidya Bhavan’s S.P.A.R.C. Mumbai for Chemexcil, Basic Chemicals,

Pharmaceuticals and Cosmetics Export Promotion Council, Bombay, India, set up by

Ministry of Commerce, Government of India, 1992, p. 105.

85. Board of editors, Selected Medicinal Plants of India (A Monograph of Identity, Safety and Clinical

Usage), compiled by Bharatiya Vidya Bhavan’s S.P.A.R.C. Mumbai for Chemexcil, Basic Chemicals,

Pharmaceuticals and Cosmetics Export Promotion Council, Bombay, India, set up by

Ministry of Commerce, Government of India, 1992, p. 121.

Ischemic Heart Disease

Karunakaran Gauthaman and Lakshmi Chandra Mishra

CONTENTS

30.1 Introduction

Ischemic heart disease (IHD) is a leading cause of morbidity and mortality in the Western

world. Cardiovascular disease (CVD), particularly IHD, has become a worldwide health

problem affecting all economic groups of society and is responsible for 25% of all deaths

in the world. The mortality due to CVD ranges from 16 to 50% in the developing and

developed countries. Because 78% of all deaths in the world occur in the developing

countries, the absolute number of deaths is very high in these areas. Due to such high

incidence, IHD is now considered a modern epidemic.

1

Considering the huge burden of IHD management, there has been a continuous attempt

to develop drugs that will delay the development and halt the progress of the disease. In

this regard, there is great potential for identifying outstanding Ayurvedic components or

its active principles, especially in consideration of the fact that such substances may

provide maximum benefit with cost effectiveness, minimum side effects, and enhancement

of patient compliance.

The focus of this chapter will be to explore the scientific basis for the Ayurvedic treatment

of IHD with herbs, herbal formulae, and dietary interventions by using modern technologies

with a view to establishing a scientific rationale for therapeutic acceptance. The

modes of administration and the associated lifestyle changes required for the treatment

to be effective will be described.

30.2 Definition

In Ayurveda, IHD, or

hridroga

, is clinically characterized by chest pain produced by

increased workload on the heart. The pain is felt mostly over the sternum. The pain spreads

toward the left side of the chest and radiates to the left arm, neck, and upper part of the

abdomen. There are several types depending upon the characteristic features of the pain.

If the pain is acute and has a shifting nature, it is known as

vatika

heart disease. If it is

associated with a burning sensation, it is called

pitaja

heart disease. If the pain is mild and

is associated with heaviness, nausea, and cough, it is called

kaphaja

heart disease

.

In modern medicine, IHD is characterized by the atherosclerotic narrowing of the lumen

of coronary arteries and reduction in the blood flow to the heart muscle. The symptoms

described are the same as described in Ayurveda. There may be a burning sensation in

the chest radiating to the arms, back, abdomen, and jaw; there may also be a pressure —

a feeling of tightness within the chest or a feeling of heaviness. These symptoms arise

under physical or emotional exertion; later on they appear in the resting state.

30.3 Clinical Description

One of the classical Ayurvedic texts,

Rugviniscaya

, lists a variety of symptoms of heart

diseases often experienced by patients:

1. Stiffness of the cardiac region (

hrdayayama

)

2. Stabbing pain in the heart region

(

hrdaya dirana

)

3. Heaviness of heart

(

hrdaya gautaca

)

4. Weakness of heart

(

hridayaksobha

or

hrdaya klams

or

hridaya upahata

)

5. Cutting pain in the heart

(

hrdayapatna

)

6. Fluttering of the heart

(

hrdayanirmathana

)

7. Pericardial discomfort

(

hridaya pidana

)

8. Pain in the heart

(

hridayaruja

)

9. Feeling of emptiness of heart

(

hridaya sunyata

)

10. Cutting pain in the heart region

(

hridaya sphotana

)

11. Pericardial suppression

(

hridayastambha

)

12. Heaviness of heart

(

hridayastyana

or

hrtstyana

)

13. Pricking pain in the pericardium

(

hridayatoda

)

14. Cardiac pain

(

hridayavyadha, hrdsula

)

15. Burning sensation in the region of the heart

(

hrddaha

)

16. Discomfort in the pericardium

(

hrdgraha

)

17. Tachycardia and pericardial muscular twitching

(

hrtkampa

)

18. Pericardial pain

(

hrdruk

)

19. Pricking pain in the pericardial region

(

hrdisula

)

20. Tachycardia

(

hrdvega

)

21. Pain and discomfort in the region of the heart

(

hrtpida

)

There are five clinical descriptions of ischemic heart disease according to Ayurveda

based on vitiated

dosas

and other causes: (1)

vataja,

(2)

pitaja,

(3)

kaphaja,

(4)

Tridosaja,

and

(5)

kramija

(caused by worms or parasite infections)

.

30.3.1 Vataja Heart Disease

The features of

vataja

heart diseases are a stretching, pinching, grinding, cracking, and

tearing types of pain in the heart. The other symptoms seen are abnormal complexion,

fainting, fever, cough, hiccups, dyspnea, distaste in mouth, thirst, mental confusion, vomiting,

excitement of

kapha

and consequent distress, anorexia, palpitation, wasting, tearing,

obstructed movement, severe pricking, piercing, bursting, constricting, or splitting pain,

dryness, immobility, emptiness, increased heart rate, unfounded helplessness, grief or fear,

tremors, body contractions, dislike for noise, obstructed breathing, dark rings around the

eyes, hypersensitivity, and attacks of fear, anxiety, worry, and fainting.

30.3.2

Pittaja

Heart Disease

Pittaja

heart disease is characterized by morbid thirst, heating sensation, burning sensation,

cardiac fatigue, a feeling of being inside a smoke-filled place, fainting, sweating, and

dryness of the mouth. Other symptoms are feeling of being in a dark place, distress, mental

confusion, terror, heat, pyrexia, dizziness, acidity, exhaustion, vomiting (sourness), yellowish

skin, eyes, and stool, fever, and flushed or bloodshot eyes.

30.3.3

Kaphaja

Heart Disease

Kaphaja

heart disease is characterized by heaviness, excessive salivation, anorexia, stiffness,

suppression of the power of digestion, and sweet taste in the mouth. The movements of

the heart become obstructed by

kapha

, which gives the feeling of dullness, fever, cough,

and drowsiness. The other features are stiffness feeling of the heart, expectorating mucus,

excess of sleep, lassitude, fever, cardiac edema, and heaviness of the limbs.

30.3.4

Tridosaja

Heart Disease

This type of heart disease is characterized by the manifestation of symptoms of all the

three varieties of heart diseases related to three

dosas

described above. The main symptoms

are constricting pain and discomfort as a result of the vitiation of all three

dosas

simultaneously,

spitting of sticky mucus, stabbing pain, colic pain, sensation as if entering into

darkness, anorexia, grayish coloration of eyes, and dryness.

30.3.5

Kramija

Heart Disease

If a patient suffering from this type of heart disease consumes oils, milk, and jaggery, then

nodules (

granthis

) appear on and around the area of the heart, and fluids (

rasa

) located

there become sticky. Because of this stickiness, germs appear. The patients shows dark

discoloration around the eyes, dry irritated skin, and excess mucus expectoration; the

patient is prone to fainting.

In modern medicine, the clinical descriptions of IHD are angina, myocardial infarction,

chronic postischemic cardiac failure, and sudden ischemic cardiac death.

30.3.6 Angina

The pain that occurs during periods of myocardial ischemia consists of retrosternal constricting

discomfort that may radiate to the arms, throat, or jaw; it is associated with

shortness of breath. Three types of angina syndromes are clinically recognized: stable

angina, unstable angina, and variant angina.

2

30.3.6.1 Stable Angina

Stable angina may be provoked by any stimulus that increases myocardial oxygen demand

through increments in blood pressure or heart rate. Typically, it is provoked by exertion

(e.g., exercise, hurrying, or sexual activity) or emotions (e.g., stress, anger, fright, or

frustration) and is relieved within 2 to 10 min by resting. Symptoms are usually worse in

the morning shortly after getting up, probably because the blood pressure is at its peak

level at this time of the day; symptoms tend to worsen in cold weather and also after a

heavy meal, which increases heart rate. Patients seek medical help for troublesome or

fighting chest discomfort, usually described as heaviness, pressure, squeezing, smothering,

or choking; it is rarely described as frank pain. This symptom is usually crescendo or

decrescendo and lasts 1 to 5 min. Angina can radiate to the left shoulder and to both arms,

especially to the ulnar surfaces of the forearm and hand. It can also radiate to the back,

neck, jaw, teeth, and epigastrium.

2

30.3.6.2 Unstable Angina

This is accompanied by objective electrocardiographic evidence of transient myocardial

ischemia (chest pain associated with [ST] segment changes in electrocardiogram [ECG]

or T-wave inversions). It is mostly associated with critical stenoses in one or more major

epicardial coronary arteries. The following three groups of patients may be said to have

unstable angina: (1) patients with new onset (<2 months) angina that is severe or frequent

(

≥

3 episode/day), (2) patients with accelerating angina (i.e., those with chronic stable

angina who developed angina that is distinctly more frequent, severe, prolonged, or

precipitated by less exertion), and (3) those with angina at rest. Unstable angina may

be primary (i.e., occurs in the absence of an extra cardiac condition that has intensified

myocardial ischemia, such as anemia, fever, infection, tachyarrhythmias, emotional

stress, or hypoxemia). Unstable angina may also develop shortly after myocardial infarction.

2

30.3.6.3 Variant Angina

This unusual angina symptom is characterized by an unprovoked episode of chest pain

which may be associated with ST segment depression in the ECG. IHD is present in 70%

of cases, but the remainder of the coronary arteries appears normal. An exaggerated

increase in coronary arterial tone (spasm) has been demonstrated in these patients during

attacks of angina. These patients are at risk of cardiac arrhythmias, and prolonged attacks

of spasm may result in myocardial infarction. The spasm is usually of focal distribution,

and even in the absence of coronary artery disease, it can restrict flow sufficiently to

produce profound myocardial ischemia.

30.3.7 Myocardial Infarction

In myocardial infarction, the pain is deep and visceral. Patients describe it as a heavy,

squeezing, and crushing feeling in the chest around the area of the heart. It is similar in

character to the discomfort of angina pectoris, but is usually more severe and lasts longer.

Typically, the pain involves the central portion of the chest and radiates to the left arm. Less

common sites of radiation are the abdomen, back, lower jaw, and neck. The location of the

pain beneath the xiphoid and the patients’ denial of heart attack are two main causes

responsible for the mistaken diagnosis of indigestion. The pain of myocardial infarction

may radiate as high as the occipital area but not below the umbilicus. Weakness, sweating,

nausea, vomiting, giddiness, and anxiety often accompany the pain. The discomfort usually

commences when the patient is at rest. When the pain begins during a period of exertion,

in contrast to angina pectoris, it usually does not subside with cessation of activity. Other

less common symptoms, with or without pain, include sudden loss of consciousness, a

confused state, a sensation of profound weakness, the appearance of an arrhythmia, evidence

of peripheral embolism, or an unexplained drop in arterial pressure.

3

30.3.8 Sudden Ischemic Cardiac Death

Sudden ischemic cardiac death occurs due to abrupt rupture of an atheromatous plaque

and coronary thrombosis along with left ventricular failure.

4

30.4 History and Epidemiology

Heart diseases are well described in Ayuravedic texts.

Charaka Samhita

, compiled during

10th century

A

.

D., describes the reasons for cardiac problems and the means for their

prevention as follows:

Cardiac diseases of kapha type are born by the intake of fatty meals and over eating,

and also by excessive indulgence in sleep, sedentary habits.

The person desiring to be protected from the adverse effects upon his heart, coronary

blood vessels, and the contents thereof should particularly avoid all that causes mental

affliction.

Charaka Sutra, 30/13

Modern medicine has provided excellent tertiary care and means for the treatment in

the form of very effective drugs, angioplasty procedures, radio therapeutics, and sophisticated

advanced surgical techniques that can beneficially treat CVD. Despite declines in

mortality in the past 2 decades, occlusive atherosclerotic coronary artery disease remains

a major cause of morbidity and mortality all over the world. The overall mortality from

coronary artery disease has declined by almost 50% since reaching its peak in the mid

1960s. Nonetheless, there is still an excess of 500,000 deaths annually in the U.S. attributable

to coronary artery disease. The incidence of myocardial infarction, the most dramatic

manifestation of coronary artery disease, remains alarmingly high. Up to 1,500,000 persons

sustain a myocardial infarction each year in India; unfortunately, many of them die

suddenly, and only 50% survive long enough to receive hospital care.1

30.4.1 Public Health Scenario

Three of trends of IHD are observed1:

1. In the U.S., where the epidemic started as early as 1920, the death rate due to IHD

is declining without change in morbidity since 1968. Similar trends can be seen

in Australia, New Zealand, and Canada.

2. In countries where the epidemic started late, either no change is noticed or there

is an increase in the incidence and mortality. Most of the European countries fall

into this category.

3. The developing countries have started experiencing the epidemic only recently;

no clear trend can be described due to the short period. India is in the third

category of trend of IHD. Some of the major surveys conducted indicate that

the prevalence of IHD ranges from 22.8 to 65.4/1000 in males and 17.3 to 47.8/

1000 in females worldwide. With a progressive adaptation of a Westernized

lifestyle and increasing life expectancy, India is experiencing both a health and

an epidemiological transition with the progressive decline in mortality rate and

disability; this is attributable to infectious disease and nutritional deficiencies

and is accompanied by the emergences of lifestyle related to other chronic

disease epidemics.5

It has been projected by the World Bank Health Sectoral Priority Review that in India,

CVD alone will account for 33.5% of deaths at all ages by 2015. There is, therefore, sufficient

cause of concern that CVD will be the major public health threat by the end of the

millennium (Ministry of Health and Family Welfare, Government of India).

30.5 Etiology

In Ayurveda, kapha (atherosclerosis) is the major underlying mechanism of heart diseases.

Om Tat Sat

                                                        

(Continued...) 

(My humble salutations to H H Maharshi ji,  Brahmasri Sreeman Lakshmi Chandra Mishra ji and other eminent medical scholars and doctors   for the collection)