Lecture Note: Rationality of Ayurvedic Prescriptions & Hridroga (Part-6)

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Rationality of Ayurvedic Prescriptions & Hridroga
Part-6

Dr. Muralidhara Sharma

based on the lecture available at- Rationality of Ayurvedic Prescriptions & Hridroga

Percentage contribution of major risk factors to ischemic heart disease

The changing patterns of cardiovascular diseases and their risk factors in the states of India: the Global Burden of Disease Study 1990–2016   India State-Level Disease Burden Initiative CVD Collaborators Published: September 11, 2018DOI: https://doi.org/10.1016/ S2214- 109X(18)30407-8

Another crucial and highly valuable study, published in 2019, involved a substantial number of patients from around the world. It identified the most significant cause of cardiac pathology, which is dietary risk. In response to this, our government and health policies have adopted various strategies for addressing cardiovascular pathology, with minimum emphasis on dietary factors.It is essential to stress the importance of diet and lifestyle as a part of preventive measures. We need to recommend and promote these principles, not only to the public but also to ourselves. This proactive approach is vital for overall health and well-being.

Even seemingly minor issues can have a substantial impact. For instance, consider our dietary habits and overall physical activity. Another noteworthy contributor to cardiovascular diseases is the overreliance on vehicles, particularly automobiles. Many people habitually use vehicles for short distances, which has led to a surge in the automobile industry and an increase in cardiovascular complications. The correlation between these factors and cardiovascular problems is quite evident, as shown in similar trends on graphs.

These seemingly minor issues can bring about significant changes. It is possible to make a difference. It is crucial to demonstrate this within our society. For instance, I’ve implemented a personal policy where, within the college campus, I avoid using a car from the moment I arrive until I leave. I prefer walking for short distances. Although these individual changes may not result in a huge transformation, they serve as examples and can be recommended to patients.

For instance, I often opt to walk when traveling from the hospital to the college and rarely use the elevator. Some students may find it challenging, but it’s a simple change that we can advocate and practice. These small steps, when recommended and followed, can lead to significant improvements. There is a pressing need for this kind of awareness and education to reduce the potential complications.

There’s a significant report from various sources, particularly from Germany, summarizing the measures to prevent cardiac complications. While these are not my personal opinions, I wholeheartedly agree with them. These preventive measures are based on statistics and can be highly effective.

Firstly, reducing total cholesterol can reduce the risk by 50%. Lowering blood pressure by six millimetres of mercury can further reduce the risk by another 50%, resulting in a 40% decrease in stroke complications. Avoiding cigarette smoking can reduce the risk by 50%. If you maintain a healthy body weight, you can reduce the risk by another 35 to 50%. Engaging in a minimum of 150 minutes of rigorous exercise per week can lower the risk by 55%. Consuming plenty of fruits and vegetables in your diet can lead to a 20% reduction in risk.When all these factors are considered together, the overall risk can be reduced by 90-95%. This highlights the tremendous potential for intervention without the need for medications. It’s not solely a question of medical management but also practical, lifestyle-related issues. This approach aligns with the principles of Ayurveda, and it’s crucial to practice these measures before educating others.

Kaphaja Hridroga – Myopathies, Pump failure

श्लेष्मणा हृदयं स्तब्धं भारिकं साश्मगर्भवत् |
कासाग्निसादनिष्ठीवनिद्रालस्यारुचिज्वराः।
A.H . Ni 5/42,43

 The symptoms are as if a stone is persisting in the abdomen. This is a very specific and accurate description that many patients with congestive cardiac failure use. In fact, this description can be traced back to Vagbhata. The description in the text is indeed perfect for identifying congestive cardiac failure. The clinical symptoms of breathlessness and the feeling of a stone persisting in the abdomen are common and accurate indicators of this condition.

Nakamura, M., Sadoshima, J. Mechanisms of physiological and pathological cardiac hypertrophy. Nat Rev Cardiol 15, 387–407 (2018). https://doi.org/10.1038/s41569-018-0007-y

Irrespective of the cost, when there’s a burden on the heart, it often leads to heart dilation. However, it’s important to note that having a larger heart is not necessarily a sign of disease. In fact, except for constrictive pericarditis, virtually no diseases result in a diminished heart size. Hypertrophy of the heart is a common occurrence, and it can be identified through simple palpation and auscultation.

It’s crucial to understand that not all forms of hypertrophy indicate a disease, especially when eccentric hypertrophy is present. In eccentric hypertrophy, there’s an increase in heart volume, but the wall thickness does not significantly change. This type of hypertrophy is often a physiological response, as seen in individuals who engage in regular exercise, and it may not indicate a disease. On the other hand, concentric hypertrophy is characterized by thickening of the heart wall and a decrease in ventricular volume. This condition can be identified through echocardiography.

Echocardiography is essential in distinguishing between these types of hypertrophies. Concentric hypertrophy is associated with a higher risk and poorer outcomes, whereas eccentric hypertrophy is typically linked to better outcomes. This factor is also considered when selecting patients for management. If a patient presents with concentric hypertrophy, it’s advisable to be cautious as the prognosis may be less favourable. In cases of eccentric hypertrophy, management can lead to better outcomes and is a safer option in comparison.

NYHA (New York heart association classification)

The fundamental concept behind cardiac failures is cardiac hypertrophy. According to the current classification, they are categorized into four classes. In the first class, there are no symptoms, and there is virtually no limitation on physical activity except during rigorous exercises. As the classes progress, limitations on exercise become more apparent. For instance, in the early stages, a person may easily climb one floor, but on the second floor, they might experience breathlessness. Identifying the possibility of cardiac issues at this stage is crucial, as it can help postpone later complications effectively. In advanced conditions, such as in Class IV, patients experience severe limitations in exercises and exhibit classical clinical features of congestive cardiac oedema. While the identification of these advanced stages may be more apparent, the real challenge lies in identifying mild symptoms in the early stages. Careful auscultation is a crucial aspect of this early identification.

Regardless of the patient’s clinical condition, practicing auscultation of the cardiovascular system is essential. This practice can help identify risks early on, allowing for preventive measures even in asymptomatic patients. The key is to identify potential issues before symptoms manifest, which is critical for effective prevention.

1 year mortality in Congestive cardiac failure [India and other countries comparison]

Global mortality variations in patients with heart failure: results from the International Congestive Heart Failure (INTER-CHF) prospective cohort study Dr Hisham Dokainish, MD Koon Teo, PhD Jun Zhu, MD Lancet ay 02 2017

Once you have identified a patient with congestive cardiac failure, the crucial aspect is the survival period. In the second graphic, focusing on India, the possibility of death due to cardiac complications within a year is highlighted. This mortality risk is significant in our conditions, irrespective of the treatment chosen—whether it’s Ayurvedic or modern treatment. This information is crucial for predicting the risk when dealing with patients.

The image represents the mortality statistics within a year after diagnosing congestive cardiac failure. In the graphic, the red component indicates cardiac deaths, the blue component represents non-cardiac deaths, and the yellow component signifies unknown causes. Regardless of the treatment approach, the possibility of death due to cardiac complications within a year is notable.

I bring attention to these statistics not to suggest a cure for the patient, but rather to emphasize the importance of understanding and predicting the risks associated with congestive cardiac failure. When dealing with patients, this information becomes crucial for providing appropriate support and managing expectations. It’s not about claiming a cure, but about recognizing effective treatment based on statistical outcomes.

Ayurvedic co prescriptions can change the outcome:

My prescription would be with all these reservations like selection of patient and all possible risk factors considering the diagnosis as Kaphaja Shotha or Kaphaja Hrirdoga. When it is Kaphaja Shotha choice would be Pubarnavamandoora while in Kaphaja Hrirdoga it will be Prabhakaravati.

  • Pubarnavamandoora
  • Chandraprabha
  • Prabhakaravati

In such conditions, considering the reservations, patient selection, and potential risk factors, my preference for treatment involves utilizing drugs that are more specific to the cardiac pathology. While the incidence of carditis and pericarditis is relatively less common, it is increasing, especially in diabetic patients. Although statistics indicate a significant rise, the exact reasons remain unclear.

Occasionally, we may encounter patients with pericarditis symptoms, particularly in diabetic patients with chronic diabetes. In these cases, my prescription would include Kaishor Guggulu, Mrutunjay Rasa, and Amritarishta, in addition to the patient’s existing prescriptions. Treatment for pericarditis often involves anti-tubercular therapy, especially in diabetic patients experiencing chronic symptoms of breathlessness.

Echocardiography becomes crucial in these situations, as clinical identification is often challenging. Moderate effusion may be clinically missed during auscultation, making echocardiography a necessary diagnostic tool. Over the past decade, there has been an observed increase in the number of such patients, although the exact reasons for this rise remain unknown. Therefore, a word of caution: for chronic diabetic patients experiencing breathlessness, persistent congestive cardiac evaluation is necessary, and clinical identification alone may not be sufficient.

 Report of ICMR Task Force StudyCommunity Control of Rheumatic Fever and Rheumatic Heart disease, Indian Council of Medical Research, New Delhi

Rheumatic diseases are another area where, of course, I would consider Krimija Hridroga, described by Vagbhat, which is exactly the same as rheumatic diseases and is considered a Shighrakari vyadhi. The incidence of rheumatic diseases is quite significant in our area in India. The incident is noteworthy, and the prevalence in India seems to be reducing according to our I.C.M.R. statistics. The incidence is reduced compared to 1972 to 2007. The reasons, of course, are many, and we won’t go into the issue.

So, incidents of rheumatic diseases have significantly reduced compared to a few years back, as seen in our data. But any patient with throat inflammation, pharyngitis, or tonsillitis has a risk factor, and there’s a possibility of rheumatism. Therefore, take care of the pulse rate; it’s a very simple clinical issue. If the patient shows significant tachycardia, a word of caution is needed. The patient has to be re-evaluated, as there is a possibility that it could be an early sign of rheumatic carditis.

The usual line of treatment recommended for rheumatic carditis is prophylactic penicillin. I have many patients where this prophylactic penicillin could be replaced by our Ayurvedic treatment for Amavata, which includes Gokshuradi Guggulu, Mrityunjaya Rasa, and Amritarishta. The same logic we discussed earlier can be effective, but again, it’s a sensitive issue. Avoiding penicillin prophylaxis may raise concerns, and people may have various issues with it. So, a word of caution about that part. There might be confusion, but if possible or if the patient is willing, we can achieve similar preventive results. However, in acute rheumatic carditis, penicillin prophylaxis may be necessary, and managing it without penicillin prophylaxis may not be possible, as we discussed in our initial conversation about Jwara and Jwara Vyadhi Lakshanas.

Cardiac arrhythmias

Cardiac arrhythmias represent a gray area where patients experiencing arrhythmia, such as missing heartbeats, may have various causes. According to our literature, a skipped heartbeat can result from numerous reasons. Conversely, diseases originating from non-cardiac issues must be identified first. Electrolyte imbalances, thyroid disorders, alcoholism, drugs, stress, sleep apnoea, and genetic factors can be contributors to the arrhythmia, and sometimes there might not be a specific treatment, allowing individuals to live with the arrhythmia. However, if there is a need, the focus should be on addressing the primary disorder.

Cardiac pathologies, such as coronary diseases, high blood pressure, cardiomyopathy, and valve disorders, can also manifest with arrhythmias. In these cases, a thorough evaluation is essential. While not every patient with arrhythmia necessarily has a risk factor, all patients with arrhythmia should undergo an evaluation for potential underlying causes. In critical cases, such as those involving heart attack-induced injuries, effective management becomes imperative. While I don’t propose a specific treatment plan for arrhythmias, my approach revolves around identifying and addressing the root cause.For situations beyond our scope, I do not hesitate to refer patients to facilities equipped for cardiac monitoring or even pacemaker placement. In some instances, conditions may necessitate a pacemaker. While I won’t delve into the specifics of when a pacemaker is required, the primary focus is on filtering patients and identifying those at a higher risk. Every patient with arrhythmia requires evaluation, and while a significant number may not necessitate extensive intervention, a sensitive and elaborate workout is crucial for those who do.

I don’t advocate for a one-size-fits-all approach or specific treatment for arrhythmias. Instead, I prioritize individualized evaluations and targeted interventions based on the underlying causes identified during the assessment.

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