Tabinda Ashfaq

Role of garlic usage in cardiovascular disease prevention: an evidence-based approach.

Introduction. Rapidly growing prevalence of cardiovascular disease is a major threat for the developed as well as developing world warranting urgent need of intervention. Complementary and alternative medicines are gaining popularity among general population because of their safety profile and easy administration. Garlic, in particular, is considered to be one of the best disease-preventive foods because of its potent and widespread effects. This study was done to find out the role of garlic usage in cardiovascular disease prevention. Methodology. Major databases including Google, PubMed, MEDLINE, and Cochrane library view were used for the literature search. Clinical trials conducted on humans assessing role of garlic usage in cardiovascular disease prevention and the possible mechanisms responsible for such therapeutic actions were assessed. Results. Various clinical trials and meta-analyses conducted have shown positive impact of garlic in cardiovascular-disease prevention especially its effects on lipid levels; however, some contradictory results are also reported. Similarly, its effects on hypertension control, and platelet are also mild with limited data availability. The possible reason for these inconsistent results is the difference in preparations with diverse composition, variations in sulphur content present in different garlic preparations used, and methodological variations in subject recruitment, duration of study, dietary control and so forth. Conclusion. Garlic can be used as an adjuvant with lipid-lowering drugs for control of lipids, however, its role as a main therapeutic agent cannot be recommended and it is suggested that more meta-analyses using standardized preparations with a close watch on methodological shortfalls should be conducted to prove its role.

Herbal Medicines for Cardiovascular Diseases

The global burden of disease has driven a broad shift from communicable, maternal, neonatal, and nutritional causes to noncommunicable diseases. Cardiovascular diseases (CVDs) remain the most prevalent cause of human morbidity and mortality all over the world [1]. According to the survey by Global Burden of Disease Study, 29.6% of all deaths worldwide were caused by CVDs in 2010 [2]. It is estimated that the number of people that die from CVDs, mainly from heart disease and stroke, will increase to more than 24 million by 2030 [3]. Despite progress in molecular medicine and biology and translational scientific efforts on improvement of diagnostic and therapeutic strategies over the past 20 years, CVDs continue to be a major global health problem. The use of herbal medicines, one of the main therapeutic approaches of complementary and alternative medicine (CAM), can be tracked back thousands of years ago in the East [4]. Currently, there is a recent resurgence of the use of herbal medicines in popularity among patients in the West and they were consumed by more than 15 million people in the US [5]. With increasing enhancement of peoples awareness of self-care and concerning on the inevitable adverse effects of conventional medicine, herbal medicines are favored by people with CVDs all over the world for their unique advantages in preventing and curing diseases, rehabilitation, and health care [6]. There is growing evidence showing that many herbal medicines and their active ingredients contribute to the standard therapy for CVDs, for example, aspirin, digitalis, and reserpine [7]. Despite enormous interests in the medicinal uses by consumers, there is still a great deal of confusion and misunderstanding about their identification, effectiveness, pharmacology, toxicology, and herb-drug interaction to science world [8]. Therefore, the role of herbal medicines in CVDs still needs more scientific and clinical data proving their efficacy and safety. The special issue aims to summarize the current progress of promising herbal medicines and their extractions for various CVDs. Altogether, we gathered 31 papers for publication, out of which 14 papers were accepted. The original research articles and reviews in this issue cover a wide range of topics, including coronary heart disease, hypertension, heart failure, dyslipidemia, and arrhythmia. Five papers addressed the clinical application and the mechanism of herbal medicines in the treatment of coronary heart disease. “A multicentre randomized clinical trial on efficacy and safety of huxin formula in patients undergoing percutaneous coronary intervention” provided evidence on huxin formula, an experienced Chinese medicine formula, for the treatment of patients undergoing percutaneous coronary intervention. “Traditional formula, modern application: Chinese medicine formula sini tang improves early ventricular remodeling and cardiac function after myocardial infarction in rats” evaluated the improvement of early ventricular remodeling and cardiac function in myocardial infarction in rats by sini tang, which is a traditional Chinese classical herbal formula first described by Zhongjing Zhang (150–219 A.D.). “The comparative study on expression of SIRT1 signal transduction by xuefuzhuyu capsule” tested the protective effect of xuefuzhuyu formula, another classical herbal formula in traditional Chinese medicine (TCM), on ischemic myocardial cells induced by ischemia through SIRT1-mediated signal transduction pathway. “Protective effects of shen-yuan-dan, a traditional Chinese medicine, against myocardial ischemia/reperfusion injury in vivo and in vitro” investigated the effectiveness and mechanisms of shen-yuan-dans pharmacological postconditioning on myocardial ischemia/reperfusion injury by targeting the phosphatidylinositol 3-kinase/Akt (PI3K/Akt) pathway. “Ligusticum wallichii extract inhibited the expression of IL-1β after AMI in rats” addressed the effects of Ligusticum wallichii (chuanxiong) extract on IL-1βexpression in myocardium and central nervous system after acute myocardial infarction. Hypertension is an important public-health challenge worldwide and a major risk factor for stroke, myocardial infarction, vascular disease, and chronic kidney disease. Prevention, detection, treatment, and control of this condition should receive high priority. How about the role of TCM for managing hypertension? One review article “Traditional Chinese medicine syndromes for essential hypertension: a literature analysis of 13,272 patients” analyzed the diagnosis rules and common TCM syndromes of hypertension and recommended the corresponding Chinese herbal medicines and formulas. “Chinese herbal medicine bushen qinggan formula for blood pressure variability and endothelial injury in hypertensive patients: a randomized controlled pilot clinical trial” examined the therapeutic effects of bushen qinggan formula as adjunctive therapy for antihypertensive drugs on mean blood pressure, blood pressure variability, and endothelial function for hypertension. One paper “Yiqi huoxue recipe improves heart function through inhibiting apoptosis related to endoplasmic reticulum stress in myocardial infarction model of rats” explored the mechanism of cardioprotective effects of yiqi huoxue formula in rats with myocardial infarction-induced heart failure by inhibiting endoplasmic reticulum stress response pathway. Two papers discussed the cardiovascular protective effects of Hawthorn (Crataegus oxyacantha). “Effect of Crataegus usage in cardiovascular disease prevention: an evidence-based approach” reviewed the cardiovascular pharmacological properties of Crataegus in vivo and in vitro. “Evaluation of a Crataegus-based multiherb formula for dyslipidemia: a randomized, double-blind, placebo-controlled clinical trial” examined the effects of a multiherb formula containing Crataegus pinnatifida on plasma lipid and glucose levels in Chinese patients with dyslipidemia. Finally, “Yiqihuoxuejiedu formula inhibits vascular remodeling by reducing proliferation and secretion of adventitial fibroblast after balloon injury” analyzed effects and mechanisms of the yiqihuoxuejiedu formula on inhibiting vascular remodeling, especially adventitial remodeling. “Ganoderma lucidum polysaccharides reduce lipopolysaccharide-induced interleukin-1β expression in cultured smooth muscle cells and in thoracic aortas in mice” examined the effects of an extract of Ganoderma lucidum (Reishi) polysaccharides on interleukin-1β expression by human aortic smooth muscle cells (HASMCs) and the underlying mechanism. A review article “Aspirin resistance and promoting blood circulation and removing blood stasis: current situation and prospectives” provided insight into the relationship between aspirin resistance and blood stasis syndrome and explored the therapeutic role of Chinese herbal medicines with promoting blood circulation and removing blood stasis for this condition. Recently, a great progress has been made focusing on the effectiveness and safety of herbal medicines in patients with CVDs. Some RCTs and systematic reviews provided strong evidence for clinical usage. The special issue presented the updated knowledge of partial herbal medicines for CVDs, which unraveled a complex posttranscriptional gene-regulating machinery and paved the evidence-based way. Xingjiang Xiong Francesca Borrelli Arthur de Sa Ferreira Tabinda Ashfaq Bo Feng

Effect of dietary supplementation of black seed (N. Sativa L.) on lipid profile of patients suffering from diabetes.

Diabetes is a chronic metabolic problem closely related to cardiovascular disease leading to premature death. Dyslipidemia is an important risk factor responsible for cardiovascular disease in patients with diabetes. This paper is based on review of articles published to observe the effect of N. Sativa (black seed) on lipid levels in patients suffering from Diabetes Mellitus. A search of indexed papers and clinical trials was done using MEDLINE and PubMed and Cochrane search engine. All studies assessing the effect of N. Sativa ingestion on lipid levels among diabetics (animal or human) were included. A total of 12 trials (6 human studies and 6 animal studies) fulfilling the inclusion criteria were reviewed. Majority of human and animal trials done among humans and animals with diabetes or metabolic syndrome demonstrated reduction in weight and improvement in serum lipid levels including decrease total lipids, triglycerides, LDL levels. However, increase in HDL level showed questionable results. N. Sativa L and its different preparations can be used as an adjuvant with lipid lowering drugs for control of lipids however its role as a main therapeutic agent cannot be recommended and more metanalysis using standardized preparations with a close watch on methodological short falls is suggested to prove its role.

Role of complementary and alternative medicine in cardiovascular diseases.

Introduction. This special issue focuses on the role of complementary and alternative medicine (CAM) in cardiovascular diseases (CVD). The role of CAM in healthcare specifically in cardiovascular diseases (CVDs) has been a contentious issue for centuries. With demographic shifts, urbanization, and changing lifestyles, disease burden of cardiovascular diseases (CVDs) has increased dramatically and can further increase in the future. Despite the growing popularity of CAM therapies, limited information is available regarding patterns of use of CAM therapies in cardiovascular diseases. The definition of CAM has continued to evolve. As defined by the National Center of complementary and alternative medicine (NCCAM), “it is a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine.” The 5 domains of CAM as classified by the NCCAM are whole medical systems (e.g., homeopathy, and ayurvedic medicine), mind-body interventions (e.g., yoga, meditation, and hypnotherapy), biologically based therapies (e.g., herbal treatments, mega-dose vitamins), manipulative and body-based methods (e.g., chiropractic therapy), and energy therapies (e.g., Reiki, and magnetic therapy). Over the last several decades, the use of CAM has become increasingly popular in both developed and the developing countries. A high proportion of patients using CAM believe CAM has remedial benefits and are safe compared to their prescribed treatments; this serves as a strong motivational factor for both present and future use of CAM. In addition, patients with CVD might be more likely to seek CAM treatments to decrease the psychological stress associated with this condition. Misconceptions regarding their efficacy have largely driven the popularity of these products whereas the adverse effects have been underreported. In disadvantaged societies where access to biomedical services is poor, the reliance on traditional/herbal medicines is more. In affluent population CAM is more used for disease prevention and health promotion. Data from the National Health Interview Surveys (NHIS) reported that 38% of adults in the USA were using CAM therapy in 2007 and among those 36% had CVD. CVD patients are often unwilling to inform their medical practitioners of CAM use and the majority of attending physicians do not discuss CAM use with their patients. Since many commonly used CAM products have the potential to interfere with the intended action of concomitant prescription medications, this could lead to serious drug interactions. In addition, the use of CAM may have negative impact on the compliance with prescription medications. A number of CAM therapies have purported cardiovascular effects; but most research on these products is either inconclusive, conflicting, or shows no benefit for their use. Several systematic reviews and meta-analysis on the effectiveness and possible side effects of CAM interventions suggest that some approaches may be beneficial as adjuncts to conventional management of cardiovascular disease, but no evidence exists to support their role as primary treatment. Dietary supplements (fish oil, coenzyme Q10, garlic, etc.) are among the most commonly used treatment modalities in patients with CVD. Fish oil supplements are accepted as a part of the treatment regimen for elevated serum triglycerides and the maintenance of vascular wall health. However, the efficacy of vitamin E has been questionable. Another intervention of CAM, that is, mind-body therapies (relaxation, stress management, meditation, etc.) have minimal side effects. However, in some countries unavailability of trained professionals in the field poses hindrance in its usage. Several styles of meditation have been tested and found to reduce blood pressure, improve heart rate, and even provide survival benefit. Evidence-based trials have been supportive of the conclusion that yoga can lower blood pressure and improve physical fitness. This one issue cannot answer all the questions regarding the safety, quality, and effectiveness of CAM therapies in CVDs. However, the main purpose of this issue is to open the communication line between patients and physicians on CAM use. It also illustrates the necessity of more rigorous researches to determine the precise pharmacological effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. Altogether, 27 papers were submitted for publication, out of which 19 papers were accepted. The articles in this issue represent a wide range of therapeutic approaches of CAM in preventing cardiovascular diseases. There are papers on extracts of herbal plants such as Nigella sativa, extract of black chokeberry, Salvia miltiorrhiza, polyphenol and Pueraria lobata, and their cardioprotective role in treating hypertension. Ethanolic extract of black chokeberry fruits has a potential role as prophylactic agent but can also function as a nutritional supplement in the management of arterial hypertension. In addition, a study on the use of repeatedly heated oil (a common practice in Asian countries) concluded that it has the predisposing factor of atherosclerosis leading to cardiovascular diseases. Therefore, it is advisable to avoid the consumption of repeatedly heated palm oil. This special issue also has a number of reviews on the role of CAM in preventing CVD. There is a review on the role of garlic in cardiovascular diseases: treatment and prevention which concluded that garlic can be used as an adjuvant with lipid lowering drugs for control of lipids. Moreover, another evidence-based review discusses CAM and CVDs; this review recommends that more rigorous researches are needed to determine the precise physiologic effects and long-term benefits on cardiovascular morbidity and mortality with CAM usage. In addition, there is a review on Chinese herbal medications (CHM) for hypertension. This review on 10 systematic reviews found that the majority of the RCTs (randomised controlled trials) do not include primary endpoints and therefore their conclusions remain uncertain. Another review on a traditional Chinese herbal formula, Zhen Gan Xi Feng Decoction, appears to be effective in improving blood pressure and symptoms in patients with essential hypertension. The edition also includes a paper on protein kinase II signal transduction pathway that inhibits cardiac arrhythmias in rats with myocardial infarction. Another study on palm tocotrienol-rich fraction found that it was comparable to folate in reducing high-methionine diet-induced plasma hyperhomocysteinemia, aortic oxidative stress, and inflammatory changes in rats. Conclusion. The articles presented in this issue represent the recognition of CAMs role in CVD patients. Nevertheless, better education of patients and medical practitioners is needed to improve the understanding of the risks and benefits of CAM use in CVD patients. Further pieces of evidence are required to determine the impacts of CAM use in CVD patients, particularly its clinical and prognostic impact when used in conjunction with prescription medicines. An open dialogue between healthcare professionals and patients regarding intended or present CAM use is also warranted. Acknowledgments. We hope that this special issue informs and stimulates thinking about the rationale use of CAM in CVD patients. We also hope that readers will find the papers included in this issue a valuable contribution to the field and it reflects the recent trends. We would like to thank the contributors to this special issue for their insightful papers. We would also like to acknowledge the many reviewers for their detailed comments and constructive suggestions. I wish to express my gratitude to all the Guest Editors for encouraging this project throughout, and meticulously carrying out the numerous and often arduous tasks involved with this project. Waris Qidwai Peng Nam Yeoh Victor Inem Kashmira Nanji Tabinda Ashfaq

Equity in healthcare: status, barriers, and challenges

(1) Waris Qidwai Department of Family medicine, Aga Khan University E-mail: waris.qidwai@aku.edu (2) Tabinda Ashfaq Department of Family Medicine Aga Khan University E-mail: tabinda.ashfaq@aku.edu (3) Tawfik A M Khoja Director General, Executive Board, Health Ministers’ Council for Cooperation Council States Email: sgh@sgh.org.sa (4) Ketki Merchant Consultant, Mumbai, India E-mail: ketkimerchant@hotmail.com

Frequency and associated factors for care giving among elderly patients visiting a teaching hospital in Karachi, Pakistan.

Objective To study frequency and associated factors for care giving among elderly patients visiting a teaching hospital in Karachi, Pakistan. Methodology A cross sectional questionnaire-based study was conducted at the Community Health Centre (CHC), Aga Khan University Hospital (AKUH) Karachi, Pakistan from September to November 2009. All individuals, visiting the CHC and aged 65 years or above were interviewed after taking written informed consent. Results A total of 400 elderly completed the interview. Majority were females, 65–69 years age, More than half of the individuals ie: 227 (85%) had received Care Giver experience for assistance and among these 195(72%) had care provided by an immediate family member. A large proportion of them stated that their Care Givers managed to provide less than four hours in a day for care giving. Around 37% showed substantial improvement in their relationship with the care givers. About 70% of the respondents stated that the care provided by the Care Giver improved their quality of life. Conclusion Elderly care is provided by majority of the family members resulting in increased satisfaction level, however small number still not satisfied due to unfulfilled need of these older people. This demands that efforts should be made to strengthen the family support by increasing awareness regarding elderly care and arranging support system by the government.