The Integrative Approach to Cardiovascular Disease

Q&A with Dr. Aditi Nerurkar

Aditi Nerurkar, MD, is a primary care physician with Beth Israel Deaconess Medical Center's Health Care Associates and Assistant Medical Director of the Cheng-Tsui Integrated Health Center. The Center was founded in 2011 to offer evidence-based integrative healing practices in conjunction with conventional medicine. Examples include acupuncture, integrative nutrition, massage therapy, meditation, tai chi and yoga. Heartmail spoke with Dr. Nerurkar about integrative practices that can help patients with cardiovascular disease.

Q. For which heart and vascular conditions is there evidence that integrative therapies are helpful?

Dr. Aditi NerurkarDr. Nerurkar: There's preliminary evidence supporting the use of mind-body therapies for certain cardiovascular conditions. "Mind-body therapies" is a broad term that encompasses things like meditation, yoga, tai chi, progressive muscle relaxation, guided imagery and other relaxation therapies. A study published recently in Circulation found a 48 percent risk reduction in mortality among patients with cardiovascular disease who meditated. That's an impressive finding! And we have prior data to show that tai chi may benefit patients with congestive heart failure through improvements in their quality of life and capacity to exercise.

Also, integrative medicine includes things like exercise, nutrition and stress reduction in its definition. And through Dr. Dean Ornish's work, we know that these two interventions can prevent the progression, and in some cases even reverse, coronary artery disease. So the evidence is there to support to use of integrative therapies, and mind-body therapies in particular, for patients with cardiovascular disease.

Q. Are there integrative practices that actually cure cardiovascular disease, or are they used mainly to address symptoms and increase comfort?

Dr. Nerurkar:I'd say a bit of both. In one sense, integrative medicine can help improve existing cardiovascular disease, and in other cases, prevent its development. But it's important to point out that integrative medical therapies, by definition, are used in conjunction with conventional medical care, not necessarily in place of it. That's the key with integrative medicine, and what differentiates it from "alternative medicine." In integrative medicine, there's a partnership between the patient, their physician and their integrative medicine provider.

Essentially, integrative medicine emphasizes a healthy lifestyle — eating a diet rich in whole foods and plants, getting adequate cardiovascular exercise, and managing stress. We know these practices have a positive impact on blood pressure, cholesterol, and obesity — three of the most significant risk factors for developing heart disease. So by adopting a more integrative approach early on, patients may be able to prevent cardiovascular disease downstream. And patients who have cardiovascular disease may benefit in particular from the Ornish Model, which has been shown to reverse heart disease.

Q. How much research remains to be done in assessing the effectiveness of integrative medicine?

Dr. Nerurkar:We've come a long way in the field, but have much further to go. Most of the research in integrative medicine has been funded by the National Center for Complementary and Alternative Medicine (NCCAM), which became part of the National Institutes of Health in 1998. And one of the reasons it was established was to answer this very question – what is the scientific evidence behind what, at that time, was called "complementary and alternative medicine" and today we call "integrative medicine"? Under NCCAM, scientists began studying these therapies in a way similar way to conventional treatments with rigorous, randomized, controlled trials.

And while there's more work to be done, we do know from prior data that these therapies, particularly mind-body therapies, are becoming more mainstream. We were trying to answer this question: What is the role of mind-body therapies in the conventional setting? We published our findings in the Archives of Internal Medicine in 2011. We found that 41 million Americans used mind-body therapies, and 6.5 million Americans used them on the recommendation of their conventional medical provider. That's like saying for every 30 people in a yoga class, one person is there because their doctor told them to go. That's much higher than we anticipated!

When we dug a little deeper, we found that people who were referred for a mind-body therapy by a physician had more medical conditions and used the health care system, suggesting that physicians are recommending these therapies as a last resort to their sickest patients, when other conventional options have been used up. And this made us wonder: What if we were offered these therapies earlier; would we see a bigger impact on medical outcomes? I think the jury is still out on that, but we'll eventually get there.

Q. Using a broad brush, which alternative practices are of greatest interest to doctors and patients in the realm of cardiovascular medicine?

Dr. Nerurkar: I would say mind-body therapies like yoga, meditation, tai chi, and stress reduction have the most clinical applicability in cardiology, along with nutrition and exercise therapy.

Q. Some physicians question whether emotional stress can cause heart attacks, strokes and other forms of cardiovascular disease. Can you comment on this issue and whether integrative practices can be used to help alleviate stress?

Dr. Nerurkar: I don't think there's much controversy about stress and disease. The evidence is there. And it's mounting for stress and heart disease in particular, and that goes for both acute and chronic stress.

A study in Circulation by Dr. Murray Mittleman's group found a 21-fold increase in the incidence of a heart attack in patients who had undergone acute stress. And chronic stress has been shown in several studies to be a risk factor for cardiovascular disease, even after controlling for traditional risk factors. There's also a condition called Takotsubo cardiomyopathy, a reversible form of heart failure that includes an acute life stressor as a diagnostic criteria for diagnosing the condition.

So there is evidence to link stress to heart disease. Unfortunately, physicians rarely counsel patients about stress, only 3 percent of the time, to be specific. It's actually the least common type of physician counseling offered. And again, it's being offered to complex patients, which tells us that stress management isn't being done as prevention, but rather as a downstream intervention for our sickest patients. Those findings are from a paper we published recently in the Archives of Internal Medicine.

Integrative therapies, especially mind-body therapies, are pretty effective stress busters. And we have enough research that supports the use of these therapies for stress management purposes.

Q. How do you deliver integrative care at the Cheng-Tsui Center? Are integrative therapies ever covered by health insurance?

Dr. Nerurkar: Our center is the first in the U.S. to incorporate integrative medical therapies into primary care within an academic medical center. We have primary care physicians seeing patients, and in the next room there is a massage therapist seeing a patient, working next to an acupuncturist, and an integrative nutritionist, etc. It's a new and innovative model of care.

We know from prior research that patients use integrative medical therapies on their own and don't share their use with their doctor. On the other hand, a doctor who might want their patient to use an integrative medical therapy often doesn't know where to send the patient to start acupuncture or yoga or learn meditation. We are creating a direct path. At our Center, we've already vetted our integrative medical practitioners for our doctors. Another neat thing about our center is the coordination of care. Since our integrative practitioners write notes in the patient's medical chart, physicians can follow up on what was done.

Our center also offers integrative physician visits for integrative sleep, mind-body medicine and stress management. And we will soon be offering classes for yoga, tai chi, meditation, and exercise. Right now, our integrative physician visits are covered by insurance, but the rest of our services are out-of-pocket. We've tried to keep the cost below market rates, so they're affordable for patients.

Q. Can you give an example of a patient with a cardiovascular condition who benefited from the integrated approach?

Dr. Nerurkar: I have lots of patient stories of how integrative medicine has helped. One pretty memorable story is a patient I had with hypertension on a three-drug regimen. She wanted to learn how to meditate. So I taught her a few breathing exercises and she did them consistently. After about a year and a half, we had her down to one medication. In her case, I think meditation helped her get a better handle on her stress. This in turn helped her make better food choices and got her motivated to exercise. Meditation was the catalyst. It was the ripple effect, and sometimes, enough ripples can add up to a wave. That's the power of integrative medicine.

Above content provided by the CardioVascular Institute at Beth Israel Deaconess Medical Center. For advice about your medical care, consult your doctor.

December 2012

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