Chapter 7 Cardiovascular/haematological systems
Hypertension
Case history
Tom’s father had two heart attacks shortly after he turned 60, and is now on medication that has stabilised his blood pressure. Tom currently lives alone, has no children and has never been married. It is Tom’s father who encouraged him to visit a CAM therapist because he feels his health was improved significantly by changing his lifestyle and diet to help encourage a healthy heart after his own heart attacks. Now that Tom is approaching the age his father was when he developed cardiac symptoms, Tom is keen for guidance about improving his lifestyle to prevent heart disease. Tom doesn’t think there isn’t anything significantly wrong with his health at the moment, so he didn’t feel it was necessary to see a GP for a medical check-up. He feels dietary and lifestyle advice from a CAM practitioner is all that he needs right now.
| Analogy: Skin of the apple |
I can see you are surprised to have a high blood pressure reading. Can I ask you some more questions so we can consider the possibilities?
Did you feel anxious about having your blood pressure taken today?
Were you feeling stressed before coming for your consultation today?
Did you feel cold while I was taking your blood pressure?
Did you experience physical pain while I was taking your blood pressure?
Did you drink coffee just before coming in for your consultation today?
| Analogy: Core of the apple with the seed of ill health | Core: Holistic assessment to understand the client |
| AREAS OF INVESTIGATION AND EXAMPLE QUESTIONS | CLIENT RESPONSES |
| Emotional health | |
| Do you ever feel sad or depressed? | Sometimes, not often. |
| Occupation | |
| Home life | |
| Who is at home with you? | Just me. At the moment I’m by myself. |
| Education and learning | |
| Action needed to heal | |
| Long-term goals | |
TABLE 7.4 TOM’S SIGNS AND SYMPTOMS [1–5]
| Pulse | 100 bpm irregular |
| Blood pressure | 160/100 (moderate hypertension) |
| Temperature | 36.3°C |
| Respiratory rate | 16 resp/min |
| Body mass index | 31 |
| Waist circumference | 100.3 cm |
| Face | Red and flushed appearance |
| Urinalysis | No glucose or protein; pH normal; no blood or leucocytes detected |
Results of medical investigations
No medical investigations have been carried out.
TABLE 7.5 UNLIKELY DIAGNOSTIC CONSIDERATIONS [3–5, 9, 12, 47, 55]
| CONDITIONS AND CAUSES | WHY UNLIKELY |
|---|---|
| CANCER AND HEART DISEASE | |
| Malignant hypertension: brain lesion/tumour; high blood pressure; intermittent headaches, low temperature, high diastolic reading; headache on waking | Usually symptoms of nausea, severe headache, disturbed speech, vision, unusual sensations, lack of concentration and paralysis; usually slow regular pulse rate; throbbing headache rather than dull |
| Phaeochromocytoma (tumours of sympathetic nervous system where 90% occur in the adrenal gland) high pulse rate, hypertension | Very rare; no sign of fever; no weight loss or diarrhoea or anxiety reported |
| TRAUMA AND PRE-EXISTING ILLNESS | |
| Renal impairment: occurs late in benign and early in malignant hypertension; can cause occipital headache | Urinalysis NAD |
| Subarachnoid haemorrhage: occipital headache | Usually neck stiffness reported and headache is severe with a sudden-onset, not recurrent; usually low regular pulse rate |
| OBSTRUCTION AND FOREIGN BODY | |
| Renal calculi: long-term alcohol and dairy, caffeine consumption, lack of water in diet | No significant acid/alkaline detected in urinalysis; confirm with biochemistry blood test |
| Vascular complications: aneurysms; high blood pressure | Would present as sudden, extreme and life-threatening; clarify whether blood pressure has suddenly increased or this has been a gradual process; no BP history known in this initial consultation |
| INFECTION AND INFLAMMATION | |
| Causal factor: Acute viral or bacterial illness | No signs in full blood count of recent fever or infection |
| Temporal arteritis: cause of headaches for clients over 50 years of age; visual deterioration | Uncommon, more often experienced by elderly women; usually presents as unilateral with low-grade fever; dull ache is not aggravated by bending over |
| Sinus headache: headache worse on waking in the morning | No upper respiratory symptoms mentioned, no frontal facial pain reported; dull ache is not aggravated by bending over |
| ENDOCRINE/REPRODUCTIVE | |
| Diabetes mellitus: overweight and increased alcohol intake are risk factors, headaches can be experienced, high diastolic reading can be associated; palpitations can be common | Urinalysis detected no excess glucose; confirm with fasting blood glucose blood test |
| Cushing’s syndrome: overweight, high blood pressure | No glucose in urine, muscle wasting or weakness reported; typical moon-shaped face not observed |
| STRESS AND NEUROLOGICAL DISEASE | |
| Migraine headache: stress can exacerbate | Severe painful headaches; often unilateral and located in the front and temporal regions of the head; headaches not aggravated by sound or light; headaches usually improve upon waking and after sleep; no indication of nausea and vomiting associated with the headache |
| Cluster headaches: common to begin in males between the ages of 40 and 60; no family history associated with cluster headaches | Extremely severe headaches, stabbing and burning; usually unilateral and pain behind eye radiating to the front of the face |
Case analysis
| Not ruled out by tests/investigations already done [1, 3–5, 8–10, 12, 46–56] | ||
| CONDITION | WHY POSSIBLE | WHY UNLIKELY |
| ALLERGIES AND IRRITANTS | ||
| Causal factor: Food intolerance amine sensitivity | Headaches, drinking red wine, dairy, may be delayed sensitivity | Headaches are in the morning on waking rather than after eating particular foods; usually cause migraine headaches |
| CANCER AND HEART DISEASE | ||
| Congenital cardiac disorder: e.g. coarctation of the aorta | High blood pressure, headaches | No clubbing of finger nails; no nose bleeds reported or cold legs |
| Hyperaldosteronism: (adrenal tumour) increase sodium in blood increases blood volume | High blood pressure | No reported muscle cramps, weakness, urination at night or increased urination |
| Causal factor: Poor left ventricular function [48, 49] | High blood pressure, heart racing on exertion; systemic hypertension | No breathlessness, or difficulty breathing during sleep reported |
| Essential systemic hypertension | High alcohol and sodium intake, obesity, stress, high systolic and diastolic reading; sustained fast irregular pulse rate (atrial fibrillation); congenital (Tom’s father has a history of heart disease) | It is not common for people with hypertension to experience headaches, however, it may develop for some individuals; unknown BP history |
| Symptomatic arrhythmia (sustained): abnormal heart beat; ventricular or atrial; palpitations when tachycardia heart rate sustains > 100 beats per minute or bradycardia sustains < 60 beats per minute [48, 49] | Pulse is 100 beats per minute and irregular; can be due to exercise, alcohol, caffeine, anxiety; less tolerance to stimulants with age; the combination of Tom experiencing sustained palpitations with high blood pressure is a more serious indication of heart disease; atrial fibrillation common in hypertension | |
| TRAUMA AND PRE-EXISTING ILLNESS | ||
| Hypertensive retinopathy | Associated with high blood pressure, eyesight strained | Usually no intermittent headaches |
| Causal factor: Liver disease | High alcohol intake, increased dairy and fatty foods, dull headaches | Usually low pulse regular rate, no jaundice or yellow sclera |
| OBSTRUCTION AND FOREIGN BODY | ||
| Atherosclerosis | High alcohol intake, hypertension, heart racing on exertion | No chest pain |
| OCCUPATIONAL TOXINS AND HAZARDS | ||
| Causal factor: Sick building syndrome | Headaches worse after working a few days in a row | Tom has not mentioned respiratory complaints or fatigue |
| FUNCTIONAL DISEASE | ||
| Causal factor: Obesity | BMI 31, increased caloric intake with drinking alcohol; lack of exercise; usually general distribution of weight gain; can be associated with high blood pressure | Usually no other health features other than being overweight; need to determine if any familial history of obesity; need to determine if weight gain has been gradual and if oedema is present |
| Hyperdynamic circulation | Rapid pulse rate after exercise | Check if Tom’s symptoms occur after intense emotion, stress; pulse usually rapid and regular |
| Causal factor: Sleep apnoea | High blood pressure, drinking alcohol at night, increased weight | No significant fatigue reported |
| Causal factor: TMJ dysfunction | Headache on waking | Tom did not mention pain in his jaw or ear; check if he grinds his teeth at night |
| Causal factor: Postural cause | Possible postural issues when sleeping | Check what mattress and pillow Tom is using |
| Causal factor: Exertional headache | Headache | Check if the headache also comes on after exercise, cough or sexual intercourse |
| Causal factor: Eye strain | Dull headaches at the base of the head (occiput area) typical of eye strain; Tom’s work requires close vision work; headaches will generally occur after working for a few days in a row | |
| DEGENERATIVE AND DEFICIENCY | ||
| Anaemia | Heart racing on exertion, no red meat in diet; headaches can be a symptom | Unsure if Tom is fatigued |
| Paget’s disease: causes increase cardiac output and often located in the skull (rapid bone remodelling causing calcium excess) | High blood pressure, dull headache, more often seen in those over 40 years of age | Can present with alkaline urine (high pH) |
| INFECTION AND INFLAMMATION | ||
| Cervical arthritis | Headache at the base of the head/neck area; more likely to develop in this age group | No specific neck pain reported |
| SUPPLEMENTS AND SIDE EFFECTS OF MEDICATION | ||
| Causal factor: Drug-induced hypertension: NSAIDs, steroids, alcohol, thyroid medication, amphetamines, epinephrine, nasal decongestants, caffeine | High blood pressure, fast pulse rate, drinking alcohol and caffeine every day | Check if Tom is taking any stimulant drugs or medications such as amphetamines, cocaine, digitalis glycosides, psychotropic agents, thyroid hormone; check if Tom has ever taken over-the-counter weight-loss products |
| ENDOCRINE/REPRODUCTIVE | ||
| Hypothyroidism | Obesity, low temperature, can sometimes have high blood pressure | Usually low regular pulse rate |
| Hyperthyroidism | High blood pressure, increased pulse rate that is irregular and sustained | Usually weight loss, increased heat intolerance, sweating, skin changes |
| STRESS AND NEUROLOGICAL DISEASE | ||
| Causal factor: Stress | High blood pressure, palpitations, busy employment, working full time | |
| Causal factor: Anxiety | Working long hours, palpitations, taking many stimulants, dull headaches, fast pulse | |
| Causal factor: Hyperventilation | Anxiety, palpitations | Tom has not mentioned dizziness or tingling in his hands or feet |
| Causal factor: White coat syndrome [57] | High blood pressure in a clinical setting | Tom has other lifestyle factors that put him in the risk category for hypertension such as alcohol intake, weight gain, lack of exercise, family history of cardiac disease |
| Causal factor: Muscle contraction: tension headache | Dull headaches; usually due to a psychogenic cause influenced by work; can be caused by prolonged mental concentration, family and home issues; often occipital and on waking | Need to ask if the intensity increases during the day and lessens in the evening; more common in females |
| EATING HABITS AND ENERGY | ||
| Causal factor: Dehydration | Lack of water in diet, dull headaches, drinking excess tea and coffee, drinking alcohol | |
TABLE 7.7 DECISION TABLE FOR REFERRAL [3–6, 8, 9, 11]
| COMPLAINT | CONTEXT | CORE |
|---|---|---|
| Referral for presenting complaint | Referral for all associated physical, dietary and lifestyle concerns | Referral for contributing emotional, mental, spiritual, metaphysical, lifestyle and constitutional factors |
| REFERRAL FLAGS | REFERRAL FLAGS | REFERRAL FLAGS |
TABLE 7.8 FURTHER INVESTIGATIONS THAT MAY BE NECESSARY [1–5, 9, 10, 59]
| TEST/INVESTIGATION | REASON FOR TEST/INVESTIGATION |
|---|---|
| FIRST-LINE INVESTIGATIONS: | |
| Blood pressure testing: multiple times | Definite hypertension; a persistence of hypertensive readings once all variables have been ruled out |
| Chest examination: auscultation, palpation | Arrhythmia |
| Urinalysis: multiple times | Blood and protein indicating renal cause for hypertension, diabetes |
| Electrocardiogram | Sinus rhythm will tell if there is cardiac arrhythmia or organic heart disease |
| Fasting blood lipid test | When in excess they deposit in fatty tissues and cause a risk of coronary and vascular disease; can rise with alcohol ingestion and fatty foods |
| Cholesterol blood test | Risk of heart disease |
| Fasting blood glucose test | More definitive test for risk of diabetes |
| Eye test | Check if degeneration of sight affecting symptoms |
| Full blood count | Indicates infection and anaemia; platelet count |
| ESR | Temporal arteritis |
| Urea, creatinine and electrolytes (sodium, potassium, chloride, bicarbonate) blood test | Signals muscle breakdown and tissue damage and gives an indicator for renal excretory function as urea and blood creatinine is excreted entirely by the kidneys; this will show in renal abnormalities and diabetes; impaired renal function can cause hypertension; electrolyte values can give an indication of a danger of cardiac arrest and cardiac arrhythmia |
| Cardiac enzymes: creatine kinase, aspartate transferase, lactic dehydrogenase | Raised in silent myocardial infarction presenting as arrhythmia |
| Liver function test | High concentrations of biliary enzyme GGT (gamma-glutamyl transpeptidase) are found in liver and heart; can be raised in high alcohol ingestion, even at small intakes |
| Forced hyperventilation for 3–4 minutes in a paper bag | Check if palpitations occur after hyperventilation |
| Eye test | May need glasses for reading and working on the computer for long hours |
| Muscle testing: grade 0–5 | Paralysis associated with hypertension |
| Headache diary | Track the pattern of the headaches more closely |
| IF NECESSARY: | |
| Stress echocardiography [59] | Exercise or pharmacologically induced |
| Chest x-ray | Exclusion or confirmation of organic heart disease |
| Neurological examination | Tumours affecting nerves and the brain |
| Serum cortisol blood test | Phaeochromocytoma, aldosteronism (adrenal tumour or hyperplasia) |
| Glucagon stimulation test | Phaeochromocytoma |
| Thyroid function test | Thyroid function contributing to weight gain |
| Radiograph of TMJ | Teeth grinding and muscle contraction in jaw |
| Radiograph of cervical spine | Cervical arthritis |
| Brain and cardiac CT scan or MRI | Signs of malignancy or tumour; to confirm or rule out brain tumour/lesion; heart muscle damage |
Confirmed diagnosis
Tom and essential systemic hypertension
Tom is a 55-year-old man who has come to the CAM clinic for a general check-up and guidance to improve his lifestyle and diet to enhance his general health, and cardiac health in particular. Tom’s father encouraged him to come to the clinic because he suffered two heart attacks around the age Tom is now and found CAM very helpful to improve his health and wellbeing. Tom has a busy lifestyle and lives alone. He enjoys cooking and drinking wine in the evenings. Tom has been experiencing dull early morning headaches during the working week. He knows he is overweight and unfit, but has not pursued exercise after he experienced exercise-induced palpitations on more than one occasion. Overall Tom is convinced his general health is fine and because of this has not had a medical check-up for some time. During the consultation he is very surprised to learn that his blood pressure is 160/100 and his resting pulse rate is 100 beats per minute. During the consultation it is explained why immediate referral for a medical opinion is necessary in order to rule out definitive primary and secondary causes of high blood pressure before CAM treatment or medicines can be prescribed.
It is extremely important to diagnose the cause of hypertension correctly to avoid unnecessary prescription of medication which eventuates in side effects that are better to avoid [46]. The decision to commence drug therapy may be delayed for up to six months while lifestyle and environmental changes are implemented. Regular monitoring of blood pressure occurs during this time. In other circumstances where the blood pressure is extremely elevated, it may be deemed necessary to commence drug treatment sooner while evaluating possible primary and secondary causes.
General references used in this diagnosis: 3–5, 9, 12, 46, 52–54
Prescribed medication [46, 58, 60]
• Statin drugs will be considered if Tom’s cholesterol continues to increase
• Blood pressure monitor to check Tom’s blood pressure levels on a daily basis
TABLE 7.9 DECISION TABLE FOR TREATMENT (ONCE DIAGNOSIS IS CONFIRMED)
• Lifestyle and physical therapy recommendations to improve fitness, assist weight loss and improve general health
• Dietary recommendations to improve general nutrition and overall health
• Dietary recommendations to reduce alcohol and coffee consumption and to replace with herbal tea and water
• Dietary recommendations and supplements to normalise triglycerides and cholesterol
• Herbal tonic or tablet containing herbs with antioxidant, adaptogenic, cardiotonic and hepatoprotective properties
• Nutritional supplements with antioxidant, cardioprotective and cholesterol and triglyceride-lowering action
• Lifestyle and physical therapy suggestions to help reduce stress
• Recommendation for Tom to engage in social interactions outside of work
• Herbal tonic or tablets containing adaptogenic, anxiolytic and nervine herbs
• Herbal tea to replace coffee with anxiolytic herbs to help reduce Tom’s stress levels
Treatment aims
• Reduce Tom’s blood pressure using DASH (dietary approaches to stop hypertension) [13, 15] and lifestyle changes [13–16].
• Prevent complications of hypertension such as stroke and myocardial infarction [15].
• Weight loss: bring Tom’s BMI into normal range [14–16].
• Significantly reduce or avoid alcohol consumption [13–16].
• Reduce coffee consumption [14–16].
• Reduce dietary sodium intake [13–16] and increase dietary potassium intake [13–16].
• Support Tom’s liver function (history of excessive alcohol consumption).
• Improve Tom’s blood lipid profile.
Lifestyle alterations/considerations
• Encourage Tom to make changes to his lifestyle to reduce stress [14–16] and live a more balanced lifestyle.
• Tom may find stress-reduction techniques, such as meditation, relaxation exercises and yoga, are beneficial [15, 16, 31]. Transcendental meditation has been shown to reduce blood pressure [30].
• Weight loss of 10 per cent is likely to reduce both systolic and diastolic blood pressure [13, 32, 33]; therefore, a weight-loss program aiming to bring Tom back into a normal BMI range would be most beneficial [14–16].
• Ideally Tom should try dietary modification and lifestyle measures to reduce his blood pressure [16]. He may also choose to utilise nutritional supplements and herbal therapy; however, the long-term goal is for diet and lifestyle changes to maintain his blood pressure at normal levels without the need for supplemental nutrients, herbal therapy or drug therapy [13–16].
• Encourage Tom to consider socialising with other people outside of work. He may find attending cooking classes is helpful because he can combine his love of cooking with a social activity.
Dietary suggestions
• Encourage Tom to restrict or eliminate sodium chloride (salt) intake [13–16, 32] and consume less than 2 g sodium (less than 1 tsp salt) from all sources daily [13]. Tom can replace table salt with potassium salt [15].
• Encourage Tom to reduce intake of refined sugar and refined carbohydrates [14].
• Encourage Tom to increase consumption of garlic and onions [14, 15]. Consuming 600–900 mg of fresh garlic (bruised, crushed or chewed) each day can reduce his blood pressure [14, 15, 17].
• Encourage Tom to restrict consumption of saturated fat [15, 16, 41] and avoid trans fats [41]. Encourage consumption of foods containing omega-3 fatty acids [15, 41] and oils from nuts, seeds and avocado [14].
• Encourage Tom to reduce consumption of dairy products [15]. If he chooses to consume dairy products, he should have low-fat or fat-free dairy products only [13, 14, 16].
• Encourage Tom to increase consumption of whole, antioxidant-rich foods from a wide range of whole foods, fruit and vegetables [13–16].
• Encourage Tom to follow the DASH recommendations [13, 16]. These include doubling the average daily serving of fruit and vegetables, and reducing consumption of fats and oils by half, red meat by two-thirds and snacks and sweets by three-quarters [13].
• Encourage Tom to include cold-pressed extra virgin olive oil in his diet every day [14, 16].
• Encourage Tom to increase consumption of soluble fibre and legumes [14, 16].
• Encourage Tom to increase consumption of foods high in potassium [13–16] and magnesium [35].
• Encourage Tom to eliminate or significantly reduce coffee consumption [14–16].
• Encourage Tom to eliminate or significantly reduce alcohol consumption [13–16].
Physical treatment suggestions
• Tom may find benefit from acupuncture to reduce both stress [26] and blood pressure [24, 25].
• Massage therapy is likely to reduce Tom’s stress [27] and blood pressure [27, 28].
• Aerobic exercise reduces blood pressure [29]. Tom should exercise for 30–40 minutes at 70 per cent of his heart rate maximum (HRMAX) at least three times per week [16]. Tom would be wise to undertake a supervised exercised program to ensure he does not put excessive stress on his cardiovascular system [29].
• Hydrotherapy: alternating arm and foot baths with the hot component no longer than 15 minutes and cold for five minutes – up to three times a day [37]. Note: ice cold applications can initially increase blood pressure [37]. Low workload, full-body water exercise [38]. Constitutional hydrotherapy [39, 40]. A hot compress (two minutes) alternating with cold compress (30 seconds) over tired eyes [37].
| Alternative to coffee | ||
| HERB | FORMULA | RATIONALE |
| Passionflower Passiflora incarnata |
2 parts | Anxiolytic [17, 23]; sedative [17, 23]; to reduce stress |
| Peppermint Mentha × piperita |
1 part | CNS sedative [17, 19]; analgesic [17, 19]; antioxidant [17]; enhances cognitive performance [17]; useful to alleviate headache [17, 19]; pleasant taste helps to improve compliance |
| Lime flowers Tilia cordata |
1 part | Mild sedative [20, 23]; peripheral vasodilator [20, 23]; indicated in hypertension [20, 23] |
Infusion: 1 tsp per cup – 1 cup 3 times daily
TABLE 7.11 HERBAL FORMULA (1:2 LIQUID EXTRACTS)
| Made with ethanolic extract herbal liquids (alcohol removed) | ||
| HERB | FORMULA | RATIONALE |
| Hawthorn leaves Crataegus spp |
50 mL | Hypotensive [17, 19]; antiarrythmic [17, 19]; cardiotonic [17, 19]; antioxidant [17, 19]; lipid lowering [17, 19]; beneficial effects are expected within 2–6 weeks of continuous use [17] |
| Motherwort Leonurus cardiaca |
30 mL | Hypotensive [22]; cardiotonic [22]; antiarrhythmic [20, 22] |
| St Mary’s thistle Silybum marianum |
50 mL | Hepatoprotective [17, 19]; hepatic trophorestorative [17, 19]; antioxidant [17, 19]; hypolipidaemic [17, 19]; beneficial to protect against alcoholic liver damage [19] |
| Coleus Coleus forskohlii |
70 mL | Hypotensive [18]; antiplatelet [18]; cardiotonic [18] |
| Supply: | 200 mL | Dose: 10 mL twice daily |
| Tablet alternative to herbal liquid: may improve compliance | ||
| HERB | DOSE PER TABLET | RATIONALE |
| Dan shen Salvia miltiorrhiza |
500 mg | Hypotensive [18]; cardioprotective [18]; hepatoprotective [18]; anticoagulant [18] |
| Hawthorn
Cratageus spp |
750 mg | See above |
| Coleus Coleus forskolii |
700 mg | See above |
| Valerian
Valeriana officinalis |
450 mg | Anxiolytic [17, 19]; relieves stress [17, 19] |
Dose: 2 tablets twice daily
TABLE 7.13 NUTRITIONAL SUPPLEMENTS
| SUPPLEMENT AND DOSE | RATIONALE |
|---|---|
| Coenzyme Q10 100 mg daily [13, 16, 17] |
Antihypertensive [17, 21, 43]; cardioprotective [17]; antioxidant [17, 42] |
| Magnesium citrate Providing 600 mg elemental magnesium daily in divided doses [16, 17] |
Antihypertensive [14, 16, 17]; magnesium acts as a natural calcium channel blocker, reducing vasoconstriction [16]; decreased serum magnesium levels contribute to arterial stiffness in hypertension [34]; magnesium deficiency is implicated in hypertension [35] |
| High-potency practitioner-quality multivitamin, mineral and antioxidant supplement providing therapeutic doses of essential micronutrients and antioxidants along with a daily dose of 100 mg vitamin B6, 250 mcg vitamin B12 and 500 mcg folate [14, 15, 17, 42] Dosage as recommended by manufacturer to achieve the abovementioned daily doses |
A broad range of balanced nutrients and antioxidants; supplementation with a broad-spectrum multivitamin and antioxidant supplementation may lower the risk of cardiovascular disease [36]; supplemental vitamin B6, B12 and folate reduce homocysteine levels [13, 17, 21, 42]; elevated homocysteine levels are associated with hypertension and cardiovascular disease [44, 45] |
| Omega-3 fish oil 7000 mg daily in divided doses [14, 17] |
Omega-3 oils are effective in lowering blood pressure [14–17, 22]; omega-3 oils significantly lower triglyceride levels [17, 21, 22]; beneficial for the secondary prevention of coronary heart disease [22] |
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