Cardiovascular Risk and Pathology

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

Sections

The Problems with Standard Therapy and the Need for a Comprehensive Approach with Integrative Medicine to fully address the causes of cardiovascular risk

The first assumption promoted by standard medicine for decades is that taking drugs to reduce cholesterol and hypertension to ever lower levels will protect the patient from cardiovascular risk, and that significant attention to cardiovascular health is therefore not necessary. Recommendations to adopt commercial foods labeled low-fat was the only significant dietary recommendation in standard medicine. This advice has been proven false. The second assumption in standard medicine, that anticoagulation agents and antiplatelet drugs are useful, has been problematic in long-term study as well.

In 2002, researchers at John Hopkins University School of Medicine (Sen, Oppenheimer, Lima, and Cohen), concluded that "anticoagulation and antiplatelet agents are frequently used to treat stroke patients with aortic atheroma without any definitive evidence of beneficial effect in prevention of distal embolization." They concluded that there were too few studies that tried to identify the cause of these atheroembolisms, and that what we saw in available studies was evidence that there was both progression and regression of atherosclerotic embolisms. They noted that therapies were needed to reduce aortic atheromas larger than 4 millimeters. Their finding suggested that high homocysteine levels were associated heavily with atherosclerotic progression. Their conclusion was that: "Stroke and transient ischemic attack patients with aortic atheroma should undergo assessment of homocysteine levels, which, if elevated, may be treated with vitamins in an effort to arrest atheroma progression." Research has found that supplementation with Vitamin B6 (P5P) and sublingual B12, and with folic acid (5MTHF), is effective. Niacin, Vitamin E, and various herbs have also been found effective, as have choline and betaine. For instance, in 2012, researchers at the University of Louisville, Kentucky, found that a chemical in Chinese herbs, tetrahydrocurcumin, significantly reduced high homocysteine levels, and decreased oxidative damage in laboratory studies of research animals, and recommended that curcumin (now in optimized form) be integrated in treatment of cerebral ischemia (stroke) (PMID: 22212488). This is just one of the many studies being conducted proving the benefits of herbal medicine to reduce high homocysteine and provide an array of benefits to treat cardiovascular disease.

Another aspect of high homocysteine levels and the correlation with stroke risk must also be considered. It is now generally accepted that high homocysteine is a marker for disease, not a cause. The high homocysteine is a marker that the glutathione metabolism is not balanced, and this metabolism is the chief antioxidant and cellular detoxification mechanism in our bodies. Perhaps we need to take a holistic approach to this problem. You may go to the article on this website entitled glutathione balance to better understand this important aspect to cardiovascular health. The reasons behind the high homocysteine levels, as well as the high CRP, triglycerides, low HDL etc. need to be addressed. These underlying problems may be more pertinent than the actual levels in your blood. A complete assessment of all of the pertinent aspects of your health that could reduce the risk of stroke, atherosclerois or recurrence of stroke or TIA should be performed by a competent holistic physician, such as a Licensed Acupuncturist and herbalist.

The reason why homocysteine is associated with cardiovascular risk is that the homocysteine derivative, homocysteine thiolactone, inhibits antithrombin activity. Antithrombin is one of the most important inhibitors of blood coagulation in your body. Acrolein is another important inhibitor and is a component of cigarette smoke, other environmental chemicals, and is generated in your body by lipid peroxidation and phagocyte metabolism. Acrolein inactivates an enzyme (paraoxonase) in HDL that protects against oxidative damage. This enzyme is calcium-dependant. Since calcium regulation is dependent on hormonal balance, this could be an underlying factor. Other systems in the body, such as liver function, are also key aspects of the whole picture, since the liver system regulates lipids, triglycerides, protein enzymes etc. A comprehensive approach would involve incorporation of many of these key elements in your therapeutic protocol, including antioxidants, essential fatty acids, proteolytic enzymes, key vitamins, herbs, other nutrients, and acupuncture.

Cardiovascular Risk: A Reality Check

The questions concerning the effectiveness and benefits, as well as the long adverse effects, or risks, associated with cholesterol lowering statin drugs are legitimate. As the long-term studies on hypertensive drug protocol have revealed, such as the ALLHAT study of the NIH's National Heart, Lung and Blood Institute, the benefits and effectiveness of hypertensive drugs may also be limited, and the adverse effects in the long term with multiple drug regimens may be greater than the benefits (see the article on High Blood Pressure on this website). Intelligent patients, as well as an increasing number of medical doctors, are finally taking a serious look at the reality of our present standard protocol to reduce cardiovascular risk, and finding that we are not doing enough to decrease risk and improve the cardiovascular health. The false sense of security that is promoted with the standard drug protocol is not real.

Another aspect of the standard cardiovascular protocol that is widely overlooked, both by patients and prescribing doctors, is the increased risks of cardiovascular ill health from other commonly prescribed medications. Assessment of individual cardiovascular risk and avoidance of medications that increase this risk is not being performed. Instead, patients are being led to believe that when they are taking drugs that increase cardiovascular risk, they are safe as long as they take cholesterol and hypertensive medications with these drugs. The scientific data does not support this attitude.

Which drugs do we take that may increase the risk of cardiovascular disease and poor maintenance of cardiovascular health? Most people do not realize that the most commonly prescribed medications dramatically increase cardiovascular risk. Non-steroidal anti-inflammatory drugs for chronic pain (NSAIDs), synthetic hormonal drugs in the form of contraceptives and hormone replacement regimens, and even some of the newer drugs to treat diabetes are all linked to a higher risk of cardiovascular death and disease. FDA warnings have been issued concerning the high cardiovascular risks of the sulfonylurea drugs to treat diabetes, including Glyburide, Glipizide, Tolazamide, Diabinase and Orinase. Actos, or pioglitazone, was withdrawn from the market or banned in Europe due to concerns of cardiovascular risk, and its competitor Avandia has faced similar criticisms and warnings, with updated FDA warnings on 11/4/2011 requiring healthcare providers to enroll in a medicines access program if they wish to prescribe these rosiglitazone medications to outpatients or nursing homes, because of the high cardiovascular risk.

Large studies by the NIH and the Women's Health Initiative found that a greater than one year use of progestin estrogen combination drugs increased cardiovascular risk by 29 percent, and the NIH halted a large study in 2002 because of the concerns of high cardiovascular risk. Newer forms of synthetic hormonal contraceptives were touted as carrying less cardiovascular risk, and instead, long term studies prompted an FDA warning that the risk of embolisms and thromboses from greater than one year of use of these drugs was almost double that of the prior class of hormonal contraceptives, increasing risk increases of as much as 79 percent! A large study by Hull York Medical School in the UK, released in 2011 (PMID: 21980265), prompted by the large number of randomised studies highlighting cardiovascular risks of NSAIDs, used a systematic analysis of all published studies to determine which of these pain relievers had the lowest and highest risk of cardiovascular death. The results revealed that the highest risks were seen with rofecoxib (Vioxx), diclofenac (Cambia, Cataflam, Voltaren, Voltarol, Zipsor), celecoxib (Celebrex), and the lowest with Naproxen. Of course, Vioxx was removed from the American market due to high incidence of cardiovascular deaths, and the ensuing study of NSAIDs prompted warnings on all of these medications. Studies find that the risk of cardiovascular disease and injury is associated with higher dosage and prolonged use.

Besides these very commonly prescribed medications, a number of other medications come with cardiovascular risks as well. The combination of drugs with cardiovascular risk needs to be considered in the overall assessment of risk versus benefit as well. Concurrant prescription of medications is very high today, especially in the aging population, with many patients prescribed 5 to 10 medications concurrently. This aging population is also at a higher risk of cardiovascular disease, events and death. Is the treatment protocol designed to achieve the healthiest outcomes for these patients, or is it driven by a medical system where monetary rewards are tied to increased drug prescription? If true healthcare reform occurred in the form of rewarding outcomes of therapy rather than the amount of expensive drugs and other protocols prescribed and performed, this practice might be changed, and more attention might be paid to the risk versus benefit assessment overall.

Medications with less, but still significant, cardiovascular risk include antidepressants, where ventricular arrhythmias and sudden cardiac deaths have drawn attention, and numerous studies have produced varied results evaluating overall risk of ischemic disorders due to inhibition of platelet function. Some studies have shown increased overall risk of stroke and heart attack, while others have shown modest decrease in risk with antidepressant use. The findings of inhibition of platelet activity by SSRI antidepressant medications has been used as a potential reason for increased prescription to patients with cardiovascular disease. Patients are beginning to question such logic.

One of the most popularly prescribed drugs in the world today is the type 5 phosphodiesterase (PDE5) inhibitors for erectile dysfunction (ED), such as Viagra, Cialis, Levitra et al, and after a large study (SSRC-PM) found that nearly 93 percent of men diagnosed with ischemic heart disease were diagnosed with erectile dysfunction, alarms went off at the offices of the European Society of Urology. Warnings were issued that changes in life style and other health corrections needed to be made before prescription of drugs to treat erectile dysfunction. The cardiovascular ramifications for these drugs involves sudden drops in blood pressure and heart function, exemplified by severe warnings for concurrent use of nitrate drugs for angina. Other studies have now explored the role in common hypertension medications that come with a significant percentage of patients experiencing erectile dysfunction as a side effect, particularly beta-adrenergic blockers and angiotensin converting enzyme inhibitors (ACE inhibitors). In other words, medical doctors have been increasing the prescriptions of drugs that cause or contribute to erectile dysfunction, and then adding prescriptions of drugs to correct erectile dysfunction that come with significant cardiovascular risk. The response in standard medicine to this dilemma has not been what you would expect, and not what is recommended by leading health researchers. The Mount Sinai School of Medicine showed that there was a clear and indisuputable connection between erectile dysfunction and atherosclerosis, and recommended an evaluation of inflammatory markers, endothelial function, and cardiac stress testing before prescribing any erectile dysfunction drugs. Instead, standard medicine has recommended prescribing erectile dysfunction drugs more often to men with ischemic heart disease, marketed under the guise that ED is highly associated with heart disease. The fact that treatment with the ED drugs does not address the underlying inflammatory and oxidative stresses, or the endothelial health considerations and calcifications causing these pathologies is not made clear. Prescibing protocols run counter to the patient welfare and only mask the health problems and treat superficial symptoms. This appears to be standard practice.

This problem of ignoring the overall risks versus benefits for pharmaceutical prescription, especially concerning cardiovascular risk, has become an enormous problem in public health. In February of 2012, the FDA finally issued a warning that these erectile dysfunction drugs that come with considerable long-term cardiovascular risk, are now being sold as natural herbal supplements for erectile dysfunction, aids to better sexual enjoyment, and even promoters of increased size of the penis. A list of over 100 of these now common herbal sex aids was provided by the FDA, with a warning that all of them contained a PDE5 drug, unlisted on the label. Herbal medicine was coopted to fool the public into believing that these products for sexual enhancement were safe. The resulting profits were enormous, eclipsing the total profits of the professional herbal medicine field. Our government failed to stop this public health threat to cardiovascular health with a wink and a nod, and instead allowed the advertisment of these products on the television and in print to become ubiquitous. Even though our most respected health authorities have recommended that the public address the underlying health of their cardiovascular system to improve the sexual function, this advice is largely ignored. The public is finally learning that it is up to them to turn to Complementary Medicine and integrate this with standard health care to solve these common health problems, restore the cardiovascular health, and achieve a better quality of life.

Evaluating standard medical protocols in prevention of cardiovascular disease

In 2011, serious questions are being raised concerning the standard treatment guidelines in cardiovascular medicine. A study published in the Archives of Internal Medicine and reviewed in the March 29, 2011 issue of the New York Times found that 56 percent of medical experts writing the clinical practice guidelines for the American College of Cardiology and the American Heart Association reported a financial conflict of interest concerning the pharmaceutical, medical equipment, or other company with financial interest in these practice guidelines used to guide the advice and prescription of drugs and interventions for patients with cardiovascular problems. Payment concerning consultant fees or membership on an advisory board were the most common types of conflict of interest. A call for serious health care reform in this area of clinical practice guidelines was made by the authors and the institutions that sponsored this large study, including the Harvard Medical School, Mongan Institute for Health Policy, the University of Pennsylvania Center for Bioethics, and Thomas Jefferson University. Consultant fees in medicine have been the subject of a number of New York Times investigative articles in recent years. In 2010, a study published on the web site of The Archives of Internal Medicine found that of 32 medical doctors and doctoral researchers who were paid at least $1 million in 2007 and published one or more professional articles in medical journals the following year, that 25 of these experts did not disclose financial connections to companies affected by these articles. Dr. Marcia Angell, a former editor of the prestigious New England Journal of Medicine, was quoted in the New York Times, stating "it is one more indicaton of the widespread corruption of the medical profession by industry money." With both research and guidelines affected by financial conflicts of interest, the public is responding with a sense of personal skepticism concerning the best way to reduce cardiovascular risk.

Medical doctors, especially cardiologists, are compelled to follow standard practice guidelines. The threat of malpractice lawsuit has created an entity that today we call "defensive medicine". Ignoring standard clinical practice guidelines in cardiovascular care leaves the medical doctor open to malpractice accusation if the patient experiences cardiovascular harm. Since cardiovascular harm is the most prevalent threat to our health in the United States today, this is a serious consideration. The intelligent patient realizes this scenario, and takes a proactive approach in deciding the individual guidelines for their cardiovascular care. As patients are becoming more proactive and informed, the growth in utilization of Complementary Medicine, integrated into standard care, is growing exponentially. With increasing manipulation of medical research, published medical articles, and medical guidelines, there are a large number of conflicting sources of information. Today, most medical doctors are employed by corporations or companies, and fewer and fewer medical doctors are in private practice in the United States. What this means to the patient is that corporations and large companies are determining what treatment guidelines and which research is to be utilized in practice. Patients are choosing their health care based on cost of the insurance, often based on the cost of the copay, and ignoring the implications concerning their care. The prevalent attitude is that there is no variance in standard medical care and practice, but this is a false assumption.

In 2010, the American Academy of Cardiology presented its study findings on the current array of drugs prescribed to reduce cardiovascular risk in patients with Metabolic Syndrome (still commonly called type 2 diabetes or pre-diabetic state, for some reason), and the study found that this array of drugs actually increases cardiovascular risk for most patients (see the article cited below in additional information). Metabolic syndrome describes most of the classic high risk factors in cardiovascular disease, such as high LDL, low HDL, high triglycerides, high blood pressure, insulin resistance, obesity, and high transient blood sugar, and about one third of heart attack patients suffer from metabolic syndrome. Currently, medical doctors, due to failure of past drug regimens, prescribe on average 3.4 drugs just to lower the blood pressure for patients with metabolic syndrome, and many patients are now prescribed 5 or more drugs to lower the cardiovascular risk. The current studies showed that lowering of systolic blood pressure did not reduce risk. Maintaining a lower diastolic blood pressure, or the pressure in the arteries when the heart is at rest, has long been the focus in hypertension. Studies also showed that enhancing insulin secretion to reduce post-prandial (after eating) blood sugars did not reduce cardiovascular risk. Now that a number of current studies show that this intensive drug regimen is not healthy for most patients, where do the medical doctors and patients turn? The answer lies in restoring natural healthy balance in the body, or homeostasis, and utilizing Complementary Medicine and patient education to help with this complex task.

The other major medical treatment touted in recent years, the use of a stent to surgically open the arteries, has also been shown to be ineffective. The first large-scale study showed that patients with the stent did not do any better than those treated just with statins after 5 years. Although the stents increased blood flow to the heart, they didn't reduce symptoms or deaths in the long run better than drugs, and were found to actually cause harmful blood clots in many patients. A high percentage of patients experience chronic symptoms such as episodic shortness of breath after insertion of a stent. A New York Times Health article from Dec. 5, 2010, revealed that insertion of unnecessary stents is a very large problem, with economic incentives resulting in 585 stents inserted that were medically unnecessary by just one cardiologist in Maryland from 2007 to 2009, and Dr. Steven Nissen, chief of cardiovascular medicine at the reknowned Cleveland Clinic stating "What was going on in Baltimore is going on right now in every city in America." The costs of unnecessary stents do not only impact the individual patients, with negative health consequences and risks, but add billions of dollars to America's health care costs unnecessarily, with the bulk of these costs usually passed on to Medicare and the taxpayer, increasing our federal deficit. Senate investigation into this one hospital found that Medicare had paid $3.8 million for medically unnecessary stents over two years. To read this article, click on this link: http://www.nytimes.com/2010/12/06/health/06stent.html?ref=health.

Often, chronic use of blood thinning drugs is also used. Some studies have shown that the standard blood thinner, coumadin, is no more effective than low dose aspirin, has chronic side effects, and has been shown to be contaminated in production. One problem with coumadin/warfarin is that common foods that are rich in potassium may alter the effective circulating dose, causing overdose complications. Since many types of healthy foods common in the diet are rich in potassium, this is problematic. Many doctors now prescribe the alternative blood thinning drug, plavix, because of these inherent problems with coumadin, but in 2006, the American College of Cardiology concluded that the costs and risks of Plavix are too great to recommend its use. A study by the Cleveland Clinic of over 15,000 patients found that Plavix did not reduce the risks of heart attacks or strokes in most groups compared to aspirin. In 2005, the New England Journal of Medicine reported that Plavix users had 12 times the incidence of stomach and intestinal ulcers than patients taking aspirin with a heartburn medication. These studies should be discussed with the prescribing M.D., and patients should be careful when deciding issues of starting or stopping these medications. If you and your doctor decide that these medications are necessary, Complementary Medicine may help you to prevent or alleviate side effects. Even in the U.S. many medical doctors are now turning to Complementary Medicine as an effective alternative or complement to standard drug therapy.

With the introduction of the more expensive Plavix to the market, tests were developed that reportedly determined whether patients were "aspirin-resistant", measuring the effect of platelet aggregation. A study in 2012, published in the journal of the American Heart Association, Circulation, and headed by scientists at the University of Pennsylvania, Perelman School of Medicine, led by Dr. Tilo Grosser and Dr. Garrett Fitzgerald, showed that this reported "aspirin-resistance" was no more than a difficulty for about one fifth to one third of patients to utilize aspirin with enteric coating. This enteric coating was developed to protect against stomach irritation, but these researchers showed that the coating did not protect the patient taking low-dose aspirin any better than regular aspirin. The researchers also discovered that almost all aspirin now on the market was enterically coated. This coating delayed absorption of the aspirin, leading to a "pseudoresistance", according to this large study. The changing of low-dose aspirin to a product with enteric coating appears to be a tactic to attain a diagnosis of so-called "aspirin-resistance" by prescribing doctors thereby increasing sales of Plavix. Such tactics continue to erode the trust of patients. Cardiologists might better serve their patients by recommending low-dose aspirin and using the monetary savings to integrate Complementary Medicine into the preventive treatment protocol.

So what sort of prevention and treatment strategy can the patient depend on? Obviously, the pharmaceutical and surgical approaches often have limited benefits and serious side effects. The quantity of cardiovascular medicines and procedures have increased dramatically in the last few decades, but the incidence and mortality from cardiovascular problems have not been significantly reduced. Most of the reduction in cardiovascular deaths occurred decades ago, and were due to a combination of improved diet and lifestyle, and improved emergency cardiac care. Why are the benefits of standard therapy limited? One reason is that these procedures and drugs are narrowly focused to solve a single problem without looking at the big picture. This is where Complementary Medicine and an integrated approach comes into play. Intelligent Complementary Medicine can improve the whole health picture, play a significant role in the overall protocol to reduce cardiovascular risk, and help reduce the side effects of surgical and pharmaceutical treatments as well. Improving one's health with an array of simple protocols, including dietary changes, a little increased exercise, and integration of acupuncture, herbal medicine and nutrient medicine, not only will decrease cardiovascular risk, but will result in a more productive and higher quality life, with less dependence on drug therapies and less chance of resorting to surgical intervention. Effective Complementary Medicine should be managed by a professional. Many Complementary therapies outside of standard care are being touted in the press, though, and the patients are seeing lots of advertised claims and articles. Be aware that the FDA does not regulate herbs and nutrient medicines, and quality of product is often a big problem, as well as misleading claims in advertising. Let the professional Complementary Medicine physician guide you through this array of information as you seek to utilize it to improve overall cardiovascular health. Most of the certified professional herbalists in this country are either Licensed Acpuncturists or Naturopathic doctors.

Research into the real and specific dangers of thrombi, or blood clots, which break off and cause strokes, found that spontaneous platelet aggregration, or quick qrowing blood clots, presented the most dangerous type of thrombi. These fast growth thrombi may more easily break off and cause a stroke. A 1994 British study at The Manchester Metropolitan University published in Atherosclerosis, Vol 112, Issue 1, stated that "increased spontaneous aggregation appeared to be independent of serum cholesterol and triglyceride concentrations, as well as age and sex per se." The study found that women, but not men, with fluctuating levels of lipids in the blood, or dyslipidemia, and patients with non-insulin dependant diabetes, now called metabolic syndrome, were more at risk for developing increased spontaneous platelet aggregation, or thrombi that might break off easily. This study 14 years ago showed us that we need to pay attention to all of these other factors mentioned above, rather than just high cholesterol and triglycerides when assessing stroke risk. We also need to pay special attention to the hormonal imbalances that lead to metabolic syndrome and insulin resistance, as well as the chronic inflammatory dysfunction in our population. Acupuncture and Complementary Medicine addresses this issue of holistic approaches to better liver function and hormonal balance.

  • Research by the University of Kentucky found that long term use of anti-depressant drugs may result in compromised cardiac function. (Reported at the FASEB conference, Experimental Biology, 1999, Washington, D.C.) If you are taking a variety of common pharmaceutical drugs, your risk of cardiovascular problems may be increased. If this is the case, the need for addition of a Complementary Medicine protocol is increased to insure success in prevention of stroke, heart attack, TIA, atherosclerosis, or to insure less risk of recurrence.
  • The common use of CT or CAT scans with strokes is now being heavily questioned. A CT or CAT scan is a computerized tomography that utilizes hundreds of x-rays to scan the body. The 2009 President's Council on Cancer stated that the increased use of radiology in medicine was now responsible for a high percentage of cancers in this country. A series of articles subsequently by the New York Times found that there was a high incidence of overradiating and damage to patients, sometime deadly, with CAT scans (see article links below). While most patients do not experience acute overdosage of radiation with these scans, the amount of radiation in normal use is very high, and the recommendation by the President's Council on Cancer is to curb the use of CT or CAT scans considerably. In the past, a simple X-ray with contrast dye injected into the blood produced a highly explicit picture of the cardiovascular problems in the brain with stroke. This procedure is cheaper, safer, and perhaps more detailed. CT or CAT scans are more profitable, quicker to analyze, and may benefit the bottom line more than the patient. Patient awareness may be the key in decision making when choosing the safest testing with cardiovascular problems.

The Issue of Herb-Drug Contraindications with Blood Thinners and Other Cardiovascular Medications - The LIST: actual contraindications with blood thinning drugs - from WebMD and confirmed by other sources

When using a anti-coagulant drug, commonly referred to as a blood thinner, there is a growing concern of improper blood concentration and dosage. Excess blood concentration may occur when other drugs, foods, and herbs are consumed. The potential for altered blood concentrations with concurrent use of other medications, or drugs, is the area of most concern, but even such common foods as kale, spinach, and other green leafy vegetables, green tea, grapefruit, and cranberry may alter the drug concentration and inhibit the ability of the body to use clotting factors to repair weak areas of the arteries. In addition, each individual may have differing levels of the natural pro-coagulant Vitamin K, altering the effects of coumadin. These drugs and foods pose potential negative interactions with Coumadin/Warfarin:

  • catecholamines (ephedrine diet pills or allergy/asthma pills, or dopamine effectors, such as antidepressants or anti-anxiety agents that inhibit dopamine reuptake), anti-depressants or anti-anxiety drugs that are reuptake inhibitors or MOA inhibitors, beta-adrenergic blockers (hypertension meds or asthma/allergy medications), diuretics, cholesterol lowering drugs such as statins or dietary cholesterol inhibitors (Zetia), antibiotics, steroids, diabetic medications, antacid medications, aspirin, thyroid medications, anti-fungal agents, 5-lipoxygenase inhibitors that treat COPD, allergy, asthma et al, such as Zileuton, like corticosteroids, and many others. The list includes acetaminophen, aspirin, alcohol, celebrex, vioxx, cortisone, erythromycin, neomycin, lovastatin, simvastatin, fluvastatin, pravastatin, atorvastatin, clozapine, flu vaccine, ibuprofen, prednisone, Dilantin, phenobarbital, tamoxifen, atenolol, propranolol/Inderol/Dociton/Blocadren, and more. Ask me to review your medication list or look in my physicians desk reference if your M.D. doesn't make clear which of your medications may be included in this list.
  • Foods, supplements and herbs that may potentially interact with coumadin to alter the effects (although no actual incidents of injury have been proven or documented yet, and rxlist.com states that few adequate well-controlled studies exist that evaluate the potential metabolic or pharmacologic interactions between botanicals and Coumadin) include: high dose vitamin C, alcohol, St. Johns wort, danshen, gingko biloba, ginseng, feverfew, yarrow, willow, goldenseal, danggui, juemingzi, shengma/black cohosh, coenzyme Q10, arnica, nettle, parsley, celery, chamomile, anise, fennel, clove, licorice, dandelion, horseradish, asa foetida, cayenne, passion flower, pau'd'arco, garlic, onion, cocoa, tamarind, sarsaparilla, aloe, sweet clover, boldo, buchu. While these herb and drug negative interactions remain unproven, there is a general agreement that foods rich in potasssium may alter the circulating levels of coumadin. Potassium-rich foods include a wide variety of common healthy foods, as well as some popular snacks. Since effectiveness and safety of coumadin are so widely questioned, many patients are discussing whether it would be better to eat healthy foods and take herbs instead. Discuss this with your medical doctor.
  • SIDE EFFECTS THAT ARE COMMON WITH USE OF COUMADIN ARE: headache, numbness and tingling, muscle or joint pain, dizziness, shortness of breath, low blood pressure, easy bleeding, and poor tissue health leading to chronic inflammatory conditions. Infrequent side effects include: poor liver function, allergic reactions, cold sensitivity, diarrhea, itch and rash, fatigue, and balding. If you are experiencing these side effects, discuss them with your M.D. and discuss the possibility of discontinuing Coumadin use and the actual risk if other alternative health regimens are used and you maintain optimum health.

NOTE: the few studies that deal with herb drug interactions have produced questionable data. For instance, the main herb studied, St. Johns Wort, was found to compete with the liver enzyme that broke down digoxin, increasing blood levels acutely, but with use greater than 2 weeks induced greater amounts and efficiency of this liver enzyme, bringing the digoxin levels to normal. A 2005 statement published in Fundamentals of Clinical Pharmacology stated: "the majority of interactions are theoretical and based on case reports, in vitro assays, animal studies, and/or speculation." The actual cases reported that confirm such negative herb drug interactions is zero. Also, the dosage of herbal chemicals in normal professional use is low, and this may also contribute to the lack of clinical problems recorded.

The Real Evidence of Contraindications between Coumadin and other drugs, foods and herbs

Coumadin/Warfarin has been used for many years, as have herbs and common foods. A MEDLINE and TOXLINE review of all databases from 1966 to 1993 revealed only 43 instances reported of highly probable interactions in the English speaking world. These interactions occurred with:

  • 6 antibiotics: erythromycin, cotromoxazole, fluconazole, isoniazid, metronidazole and micoonazole increased the anticoagulant or 'blood-thinning' effect
  • 5 cardiac drugs: propranolol, clofibrate, amiodarone, propafenone and sulfinpyrazone increased the anticoagulant effect
  • alcohol increased the anticoagulant effect only if there was liver dysfunction
  • cimetadine: Tagamet is a histamine type 2 inhibitor that decreases gastric secretions, and is widely available now off the shelf at drugstores to treat heartburn and GERD
  • omeprazole: Prilosec is a proton-pump inhibitor that decreases gastric secretions, and over-prescription is now highly criticized
  • phenylbutazone: Diclofenac is a non-steroidal anti-inflammatory drug used for pain relief
  • piroxicam: Feldene is a non-steroidal anti-inflammatory drug that treats pain and arthritis
  • 3 antibiotics: rifampin, nafcillin, griseofulvin inhibited the anticoagulant effects
  • 3 central nervous system drugs: barbiturates, carbamazepine, and chlordiazepoxide inhibited the anticoagulant effect
  • cholestyramine: Prevalite is a cholesterol lowering drug that works by bile acid sequestration
  • sucralfate: Carafate is an aluminum complex that treats stomach ulcers and gastric pain
  • foods high in vitamin K is eaten in excess: asparagus, broccoli, blackstrap molasses, brussel sprouts, dark leafy greens, cabbage, cauliflower, egg yolk, oatmeal, oats, rye, safflower oil, soybeans, wheat, alfalfa, green tea, blueberry, nettle, and kelp.
  • large amounts of avocado

There is no vitamin K in ginseng, aged garlic, parsley, danshen, danggui, yarrow, or the other substances with warnings or potential interactions. If these foods and herbs had caused problems in the past they would have been cited in the above review of 17 years of worldwide English interactions.

A 2006 study proved that there was no discernable negative interaction between aged garlic extract and coumadin. (PMID: 16484565)

A 2003 study in Britain found that of 631 coumadin users, 99 were taking an herb or supplement that was potentially able to negatively interact with coumadin. None of these patients reported any problems. (PMID: 16115136)