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In diseases of peripheral vessels, the effectiveness of using drugs based on garlic, ginkgo biloba, omega-3 PUFA, Padma 28 (a mixture of herbs from 22 different ingredients) and vitamin E has been studied. Results of randomized controlled studies, systematic reviews and meta-analyzes indicate the effectiveness of ginkgo biloba compared with placebo in patients with intermittent claudication.

There is also evidence of the effectiveness of Padma 28, but they are few. It has been shown that in case of venous insufficiency, an extract of horse chestnut seed is effective.

a) Ginkgo biloba leaf extract. Ginkgo biloba (Ginkgo biloba) is used to treat intermittent claudication in patients with PAD. A review of research findings suggests that ginkgo biloba extract more effectively placebo reduces the symptoms of intermittent claudication (Peripheral Arterial Disease Fontaine study, stage II).

In clinical studies, doses of 120-160 mg / day were used and the walking distance without pain and the maximum walking distance were analyzed. Ginkgo biloba leaves and their extract contain several biologically active substances, including flavonoids, terpenoids and organic acids. The main active substances are bilobalide and ginkgolides.

As in the case of any herbal remedies, several components of the extract of ginkgo biloba can cause positive effects. Ginkgo biloba does not interact with cardiac glycosides while using these drugs. Thus, against the background of the use of ginkgo biloba, a small positive effect on BAP is found, possibly due to the destruction of free radicals, anti-platelet action, anti-inflammatory effects, vasodilation and a decrease in blood viscosity.

The usual dose is 40 mg of the standardized extract of ginkgo biloba 3 times a day. Ginkgo biloba is considered a relatively safe drug, rare adverse events include mild gastrointestinal dysfunction, nausea, dyspepsia and headache. Ginkgo biloba is noted to increase the risk of bleeding. One hundred concomitant use with aspirin, NSAIDs and anticoagulants such as warfarin and heparin is not recommended.

b) Horse chestnut. Horse chestnut extract (Aesculus hippocastanum) contains saponins, coumarins, flavonoids and tannins. The biological activity of the extract is associated with saponins (escin). A systematic review of 17 randomized placebo-controlled trials of this drug has recently been carried out.

In 6 studies (n = 543). in which the pain in the legs when walking was assessed, the decrease in the severity of this symptom was reliably established compared with placebo. In 4 of 5 studies (n = 420) in patients taking horse chestnut extract, there was a significant decrease in edema compared with placebo. Also, while taking horse chestnut extract, the circumference of the lower leg and ankle decreases.

One study noted the effectiveness of horse chestnut extract in combination with wearing elastic stockings. The effective dose of horse chestnut extract is standardized so that the patient receives 100-150 mg of escin per day. While taking a horse chestnut extract, symptoms such as itching, fatigue and apathy are reduced. Adverse events are rare, but gastrointestinal irritation, dizziness, nausea, headache and itching are possible. There are 2 cases of toxic nephropathy.

Contraindications include hypersensitivity to escin, as well as abnormal liver function or kidney function. Escine – the main horse chestnut extract saponin – binds to plasma proteins and can affect the binding of other drugs. There is an assumption about the possible hypoglycemic effects of horse chestnut extract. German Commission E approved the use of horse chestnut extract for venous insufficiency; horse chestnut products are also available on the US market.

Traditional dietary supplements (BAA) and nutritional supplements used in hyperlipidemia (HLP) include foods that should reduce the production of lipids in the liver, such as artichoke extract (Cynara scolumus), garlic, polycosanol, and red yeast rice (Monascus purpureus).

The products that should reduce lipid absorption include stanols and sterols, chitosan, barley, psyllium, and oat bran. In addition, the effects of fish oil, DHA, EPA, and soy are studied in clinical studies. The following describes the effects of Guggulipid (Commiphora guggul) chewing gum containing myrrh tree resin extract and policosanol.

Chewing gum Guggulipid. This chewing gum has been used in ayurvedic medicine for a long time.

In the first randomized controlled study of Guggulipid chewing gum in the United States, in which 103 volunteers with HCS used 1000-2000 mg of Guggulipid chewing gum containing 2.5% guggulsterones, no improvement in the lipid profile was observed. A small number of study participants recorded a rash associated with hypersensitivity to the drug.

The effects of Guggulipid chewing gum on HDL were mixed. The standard dose of guggulsteron 75-150 mg is given in the form of a chewing gum Guggulipid 1000-2000 mg 2-3 times a day. Guggulipid chewing gum can cause abnormalities in the digestive tract, headache, nausea, vomiting, hiccups and rash.

Simultaneous intake per os of this chewing gum and preparations of propranolol and diltiazem may help to reduce their bioavailability and effectiveness. Guggulipid chewing gum can also have anti-platelet and anticoagulant effects. Data on the safety and efficacy of its use against the background of the western type of nutrition is not enough.

Policosanol Policosanol is extracted from cane sugar extract or wheat germ oil. It is a mixture of aliphatic alcohols. Hypolyidemic effects may include inhibition of cholesterol synthesis in the liver and an increase in LDL cleavage.

In 15 randomized, placebo-controlled studies of the efficacy of policosanol at a dose of 5–20 mg / day for a period of 6 weeks to 1 year,> 1,000 patients took part.

When using policosanol at a dose of 10–20 mg / day, a significant decrease in cholesterol levels (17–21%) and LDL (21–29%) with an increase in cholesterol level (8–15%) is observed. There is no data on the effect on endpoints.

Although, in general, policosanol is well tolerated, caution is needed when it is combined with antiplatelet and anticoagulant drugs, including preparations of garlic, ginkgo biloba and high doses of vitamin E, since it has been proven that policosanol inhibits platelet aggregation in both healthy individuals and patients with various diseases.

Independent verification of its effectiveness is necessary for the widespread introduction of policosanol into clinical practice.

Randomized clinical studies of the effectiveness of garlic (Allium sativum), ginkgo biloba (Ginkgo biloba), hawthorn (Crataegus), pycnogenol, or Pinto martima bark extract, Oea leaf extract (Oea) have been used in arterial hypertension (AH), garlic (Allium sativum). , Asian ginseng root (ginseng wounds), coenzyme Q10, calcium and magnesium.

The results vary, and the effect is usually small. In a meta-analysis, it was shown that, compared with placebo, the use of garlic leads to a decrease in CAD, an average of 8 mm Hg. Art., and dad – 5 mm Hg. However, in a systematic review of 27 small, randomized, placebo-controlled studies of short duration, in 26 of which only adult patients participated, mixed, but always small effects of different garlic-based drugs in relation to blood pressure were obtained.

Most studies did not reveal significant differences in blood pressure levels in patients randomly assigned to the garlic group compared with the placebo group. The undesirable effects of oral intake of garlic included bad breath and body odor.

Other possible, but unproven, adverse events included flatulence, pain in the esophagus and abdomen, small bowel obstruction, contact dermatitis, rhinitis, asthma, bleeding, and MI.

In a systematic review of the use of coenzyme Q10 in arterial hypertension (AH) in 8 studies showed an average decrease in the GARDEN by 16 mm Hg. Art. and DBP – at 10 mm Hg. however, only 50% of the studies were placebo-controlled. The latest Cochrane review confirmed the ineffectiveness of the combined dietary supplement containing calcium, magnesium and potassium in terms of treating primary hypertension in adults.

Stress is one of the significant risk factors (RF) for the development of cardiovascular diseases (CVD), therefore stress correction methods are very important.

Effect of stress on cardiovascular disease (CVD) factors. Stress can cause the development of hypertension as a result of repeated rises in blood pressure and an increase in the concentrations of vasoconstrictor hormones. The stress factors that increase the risk of developing hypertension include increased workload, social environment, emotional stress, a visit to the doctor (“white coat hypertension”), and the ethnic identity of influenivaum plays a certain role.

The Framingham Study showed that hypertension accounts for 80% of all tornadoes for her from cardiovascular diseases (CVD). In addition, the risk of death associated with hypertension is 2 times higher than the risk of death associated with smoking or increasing the level of cholesterol. Currently, an increase in blood pressure was recorded in 50 million Americans.

Stress correction methods:
1. Pets. Caring for pets reduces psycho-emotional stress by creating a goal in life and reducing the feeling of loneliness. The study showed that in patients with CVD, pet care can lead to increased heart rate variability.
2. Correction of stress through internal concentration. Correction of stress based on methods of internal concentration includes methods of internal meditation, yoga and coordinated deep breathing, aimed at reducing pain and reducing anxiety. In a meta-analysis, it was shown that the methods of inner concentration contribute to the reduction of stress and suffering associated with various diseases.
3. The method of controlled imagination. This therapeutic method allows the patient to use their own imagination to connect the body and mind in order to achieve the desired results, for example, to reduce the perception of pain or reduce anxiety. The method of controlled imagination in studies involving patients before and after surgery. In a study involving patients who underwent surgery on the heart, it was found that the method of controlled imagination can reliably reduce both pain and anxiety. In a continuing study at Scripps Clinic, it is noted that the use of guided imagination and healing touch before surgery on the heart and after the intervention is accompanied by a 50% reduction in pain and anxiety.
4. Transcendental meditation. Transcendental meditation is a unique method of meditation and relaxation, which is the most studied method of DAM. Studies of transcendental meditation began in the 1970s. Studies have shown that transcendental meditation lowers blood pressure and such a component of MS, as IL, and also improves the tone of the autonomic nervous system (VIS).
5. Biofeedback method. The biofeedback method is a way to change a person’s habitual reactions to stress. In patients with CHD, using this method increases heart rate variability.

6. Food additives and natural products. Eating certain components of the diet leads to a reduction in the risk of cardiovascular diseases (CVD). These components include plant sterols and stanols, soluble fibers, omega-3 PUFAs, garlic, soy, tea, and small amounts of alcohol. The 1994 Dietary Supplement Health and Education Act (DSHEA) amended the pre-existing dietary supplement definition given by the Federal Food, Drug and Cosmetic Act.

According to the new definition, dietary supplements are any product (with the exception of tobacco) that contains vitamins, minerals, herbs, or other plant components or amino acids and is taken as a supplement to the diet. Currently, food supplements in the USA can be labeled as dietary supplements. Accordingly, these products are not intended to diagnose, treat, cure or prevent diseases (the requirement for traditional drugs), nor are they traditional foods. According to U.S. Food and Drug Administration (FDA), in 2000 there were> 29 thousand dietary supplements in the US market, and every year there are 1,000 new ones.

In some countries (for example, in Germany, France, Sweden, Canada and Australia), licensing strategies for herbal preparations, including testing before entering the market, have been introduced. In the US, licensing of these drugs is not required.

Currently, a number of herbal substances with proven effect are widely used, for example, digoxin, atropine, reserpine and amiodarone. However, only with respect to a small number of commercial herbal remedies sold in the United States, studies of their effectiveness in cardiovascular diseases (CVD) have been conducted. Hawthorn (heart and coronary insufficiency), garlic (atherosclerosis), ginkgo biloba (artery occlusion) and horse chestnut (chronic venous insufficiency) were studied.

Rigid formalization and standardization necessary for conducting clinical trials are possible only for a few supplements. Herbal supplements, unlike most traditional drugs, are a complex mixture of biologically active substances, each of which may or may not have a therapeutic effect. Very often, the active ingredient is unknown, a complete description of the chemical composition is missing. Like many traditional medicines, herbal remedies can have a therapeutic effect in one dose and toxic in another.

Concomitant use of herbs can mask, enhance, or level the effects of other drugs. In cardiology, the problem of unrecognized interactions of herbs and traditional cardiovascular drugs, many of which have a narrow therapeutic dosing range, is very important. The table below lists the sources of detailed information on nutritional supplements and herbal preparations.

The herb-drug interaction can be described as pharmacodynamic or pharmacokinetic. Pharmacodynamic interaction develops when the components of the herbal preparation have a synergistic or antagonistic effect on the traditional drug, thereby affecting the effects of the drug at the receptor level. Pharmacokinetic interaction is a violation of the absorption, distribution, metabolism or elimination of a traditional drug under the influence of herbal remedies or food supplements.

Herbal remedies contain several components that are metabolized in phases 1 and 2 of drug metabolism, especially with the participation of cytochrome P450 (CYP3A4), and also are substrates of certain transporter proteins and P-glycoprotein. In vivo and in vitro studies have shown that P-glycoprotein-mediated elimination and / or CYP metabolism is the most likely interaction of a drug with a herbal remedy, which can reduce the effectiveness of the drug and increase its toxicity.

The clinical significance of this interaction depends on a variety of factors: the dose, frequency and time of administration of the herbal remedies, the dosage regimen and the route of intake of the drug and its therapeutic range. In addition, the use of herbal remedies can lead to a significant change in the results of laboratory tests. Deviations of laboratory tests from the norm may indicate the need for careful collection of anamnesis about the patient’s intake of herbal remedies and nutritional supplements.

Herbal remedies can affect the results of laboratory tests due to the direct impact on the studied parameters, most often immunological, due to physiological effects due to toxicity and induction of enzymes, or due to the presence of pollutants.

Complementary and Alternative Medicine (DAM) is a term used by the National Institute of Health (NIH) to describe this section of medicine. Additional, alternative and complex methods of treatment include treatment with herbs, vitamins, special foods, as well as treatment, including effects on the spiritual world, bioenergy (for example, acupuncture or energy fields), and psychosomatic therapy.

According to the National Center for Complementary and Alternative Medicine (NCCAM) and the National Center for Health Statistics (NCHS), 36% of adult Americans use some form of DAM, and if you include in the definition of DAM prayers for improving health, this figure will increase to 62 % It is important to note that the methods of complementary and alternative medicine (DAM) are used in 25 US medical centers.

The great doctors interacted with the patient on the physical, mental and spiritual levels, using the principles of the ability to listen, cause trust and express sympathy. The introduction of DAM in practical medicine should be based on the principles of compassion for the patient, but on a scientific basis; The main goal of the implementation should be to strengthen the doctor’s interaction with the patient, since human relationships are central to the process of providing medical care.

The physician must establish a trusting relationship with the patient so that, understanding his problems, goals and preferences, he can offer the patient accurate and adequate information about a rational and mutually acceptable treatment plan. Most patients use DAM methods, so it is very important to respect the patient’s perceptions about this and preserve his love, not trying to persuade, even if the doctor does not completely trust these methods.

In addition, since patients believe that many doctors are not interested in DAM methods, i.e. the patient takes what medicinal herbs and biologically active additives (BAA), then the patients do not give this information to the doctor. Ego can lead to the development of heavy allopathic drug interactions with herbs and dietary supplements. In order to avoid such problems, it is extremely important to obtain information from the patient about everything that he uses for treatment.

Effective prevention and treatment of chronic diseases require multi-component therapy combined with lifestyle changes. Since there is currently very little evidence of evidence of melicins regarding the efficacy and safety of nutritional supplements and herbal remedies, the physician must study and record the use of dietary supplements in order to provide the patient with relevant information and follow his preferences.

Many patients cannot attend controlled physical training (PT), because the cardio-rehabilitation program is unavailable to them or it is inconvenient for them to attend controlled physical training (PT). Despite this, all patients with coronary artery disease should be recommended training to improve cardiovascular prognosis.

Patients without orthopedic problems of the lower limb should be recommended to walk fast as a method of FT. Patients in unsupervised programs should train before they develop mild dyspnea. This approach eliminates the need to control the pulse. Many patients either cannot control their heart rate accurately, or become overly concerned with pulse interruptions caused by atrial or ventricular extrasystoles. Patients who train independently can be recommended to use the “conversational test” (that is, to train with a load that allows comfortable conversation) to assess the intensity of the FN. This level of load corresponds to the training recommended for cardiac patients.

Other components of comprehensive cardiac rehabilitation. In 1994, the American Heart Association recommended the expansion of cardiac rehabilitation programs with the inclusion of other strategies aimed at reducing cardiovascular risk. Among them are nutritional, psychological and social-labor counseling, as well as correction of such RFs as DLP, increased blood pressure and smoking. These components of secondary prevention of KBS, of course, are very important. It has repeatedly been shown that a decrease in lipid levels during treatment with statins leads to a decrease in the frequency of repeated cardiac events in patients with coronary heart disease (CHD). A review of 20 prospective cohort studies showed that in patients with CHD who give up smoking, the overall mortality rate decreases by 36%.

The inclusion of these aspects in cardiac rehabilitation programs requires a balance between the role of the staff of the cardiac rehabilitation program and the role of the polyclinic doctor. Cardiac rehabilitation program personnel usually provide advice on managing the FR, and also provide information on the interpretation of laboratory results and doctor’s instructions. In relation to the correction of lipid levels, the program staff can evaluate the results of laboratory tests and invite the patient to ask the attending physician for more stringent tactics to achieve the target cholesterol level.

Cardiac rehabilitation programs vary in counseling and patient education. Assessing the ability of patients to learn can increase the potential of educational programs. In many programs, the aerobic part of FT, when the patient is on the simulator, is used for training. In some programs, patients simply provide printed materials. Other programs use televisions and special video programs that provide information on risk factors and risk reduction. But in some programs, FT has been replaced by educational programs. We oppose this approach, given the positive physiological effects of physical training (FT).

Training programs can be creatively modified depending on the needs of patients, but should be complementary to the FT. Ideally, the components of the educational program on nutrition, lipid correction, smoking cessation and psychological problems should be provided by specialists from relevant fields of medicine, but usually all the components of the educational program are provided by the rehabilitation program staff.

Before rehabilitation, patients should take an exercise test to eliminate the symptoms of ischemia or arrhythmias, which may require special intervention before physical activity. The load test also allows you to set the initial FN and determine the maximum heart rate for training. These tests are usually performed on the background of prescribed medication to get the heart rate, which is most likely to be during the FN.

Usually, physical training (PT) for cardiac rehabilitation has 3 phases: warm up (5 minutes), workout (20 minutes) and completion (5-15 minutes). Warm up consists of stretching and light gymnastics. Some static load, involving the use of light weights or power trainers, is performed, as a rule, after aerobic exercise as part of the third phase (completion). Exercises such as swinging the biceps, stretching the triceps, pushing up (for patients without problems in the shoulder girdle), shoulders, bending and half-squatting, increase the working capacity of patients to perform work tasks and daily loads, which often require lifting and carrying weights.

Aerobic physical training (PT) is usually performed at the level of 60-70% of VO2max, which corresponds to 70-80% of the maximum heart rate (HR). Lower-intensity FN is recommended for some patients. Although 20-minute FTs are considered standard, even shorter workouts are useful, and longer loads almost certainly provide an additional effect. Most cardiac rehabilitation programs recommend other types of FA: gardening and walking on days when patients do not attend controlled TF.

It is recommended that a stress test be performed prior to cardiac rehabilitation, but not all patients will perform an exercise test, especially after a recent MI. Patients who did not pass the stress test before being included in the program can train with a heart rate of 20 beats / min higher than at rest. Another approach: to train at the level of heart rate plus an additional% of heart rate | for example, for example, for 1 month the patient is trained at the level of heart rate plus 20-30% of heart rate; 2 months – ChSSpokoy plus 20-40% of ChSSpokoy; 3 months – ChSSpokoy plus 20-50% ChSSpokoy. Alternatively, patients can train to have shortness of breath and maintain this level throughout the session. As mentioned earlier, the onset of dyspnea approximately corresponds to the respiratory threshold and is an adequate reference for the load. Finally, patients can train at a fairly high level using quantitative FN scales, specifically designed to assess the intensity of FN, for example, the modified Borg scale.

Staff. The standard cardiac rehabilitation program has a manager (director) who is a doctor. The rehabilitation team also includes a full-time nurse and other nurses, or personnel trained in conducting and monitoring TF and conducting patient education. In accordance with the requirements of insurance companies in the United States, programs for Stage 2 cardiac rehabilitation are carried out only in the presence of a doctor. In addition, to receive insurance payments to patients during each program visit, an ECG must be performed, which should be recorded and interpreted.

There is no definition of the term “physician’s presence at the time of TF”, but it is usually meant that the doctor must be somewhere close to be able to provide assistance in acute situations. The entire staff of the program should be trained in the rules of cardiac resuscitation. During FT, a nurse should also be there to intervene in acute conditions and apply medications. The recommended staffing level is: 1 employee per 5 patients in the programs of stage 2 and 1 employee per 10-15 patients in the programs of stages 3-4.

Cardiac rehabilitation programs are usually divided into 3 or 4 stages in accordance with the clinical status of patients. Stage 1 includes programs conducted in the hospital shortly after an acute coronary event or intervention. Stage 1 cardiac rehabilitation programs are currently not very common due to the short hospital stay, however, in some European countries, they still have inpatient cardiac rehabilitation programs that can last several weeks.

Even with the short duration of hospitalization of cardiac patients, the stage 1 cardiac rehabilitation program remains useful for activating elderly patients after complicated cardiac events and in many patients after cardiac surgery. Stage 1 cardiac rehabilitation programs in the United States are often performed by the physiotherapy departments of hospitals or by special personnel trained in the principles of cardiac rehabilitation.

Stage 1 is also an excellent period to familiarize the patient with the concept of cardiac rehabilitation and to facilitate his involvement in this program.

Stage 2 includes outpatient cardio-rehabilitation programs in the presence of a doctor. Control by the doctor and ECG control in these programs are mandatory conditions imposed by the majority of insurance companies when issuing compensation. Historically, patients in the programs of stage 2 train 3 times a week for 3 months.

Other approaches to cardiac rehabilitation include simple, self-controlled home programs, home programs with a nurse visit, and home programs with telephone ECG monitoring. A comparison was made of these approaches in the framework of scientific research and standard medical practice. It turned out that the physical performance of patients improves more with physical training (TF) at home, although this improvement may be due to a tendency to reveal positive results.

Another duration of rehabilitation programs was also studied, for example, 1 lesson per week for 1 year. Such a program can improve the physical performance of patients and contribute to adaptation to ongoing physical rehabilitation, however, standard 12-week programs are most common, because insurance companies only cover these programs.

The programs of stage 3 cardiac rehabilitation are carried out without a doctor and an ECG cat. These programs are supportive; they are provided by the same institutions as the programs of stage 2. Some insurance companies partially reimburse the costs of the programs of stage 3.

Phase 4 programs for cardiac rehabilitation are carried out without medical supervision (usually in health clubs and fitness centers). In the United States, insurance companies do not reimburse Stage 4 programs.

As in the case of coronary heart disease (CHD), there is not a single research that is sufficiently powerful to judge the effect of physical training (TF) on survival rates in patients with HF. The HF-ACTION study (Heart Failure and a Controlled Trial Investigating Outcomes of Exercise Training), funded by the National Institutes of Health, aims to study the effect of PT on heart morbidity and mortality in patients with systolic dysfunction.

The study included 3 thousand patients randomly assigned to the TF group and a group of patients who were recommended to participate in the cardiac rehabilitation program.

Meta-analysis confirms the positive effects of physical training (PT) in heart failure (HF). Smart N. and Marwick T.N. analyzed the results of 81 studies in which 2387 patients with HF were included. In trained patients, VO2 increased by 16%.

The same results were obtained in 622 trained patients and 575 patients from the control group. The overall frequency of adverse outcomes over 5.9 months of follow-up in the training and control groups did not differ. At the same time, in the FT group there were 29% less deaths (p = 0.06).

These results indicate that physical training not only increases physical performance, but can also reduce heart mortality in patients with systolic heart failure. However, final conclusions can be made after completing the HF-ACTION study.