Adjuvant Ayurvedic Management in Coronary Artery Disease with Coronary Microvascular Dysfunction

Summary

This case report describes an integrative management of coronary microvascular disease using Ayurvedic and modern medicine. Ayurvedic interventions, including Panchakarma, improved symptoms. Caution is advised as it is a single case. Rigorous research is crucial to validate findings and investigate the efficacy and mechanisms of such approaches in cardiac disorders.

Abstract

This case study presents a 59-year-old obese, hypertensive female with a 10-year history of Coronary Microvascular Dysfunction and Coronary Artery Disease, presenting with associated symptoms including mild to moderate body aches, pain in the left ankle, and insomnia. Diagnosed with Vataj Hridroga according to Ayurvedic principles, the patient underwent a 14-day inpatient Ayurvedic treatment regimen, followed by 16 weeks of outpatient oral Ayurvedic medications, alongside her existing modern medical prescriptions. The inpatient regimen included daily Panchakarma therapies: Abhyanga and Nadi Swedana for pain and edema; Shirodhara was administered for insomnia. Oral medications, including Simhanada Guggulu, Ajmodadi Churna, Dashmoola Kwatha, and Bramhi Vati, were prescribed. The integrative strategy involved close monitoring by both Ayurvedic and modern medicine physicians, allowing for necessary adjustments to contemporary medication. Significant improvements in the symptoms were observed: leg pain reduced from a baseline score of 6 to 1 by day 16 and resolved by week 16; grade 2 edema resolved by day 16; and insomnia improved, evidenced by a reduction in Pittsburgh Sleep Quality Index score from 16/21 at baseline to 9/21 by both day 16 and week 26. This report highlights the adjunctive role of Ayurvedic interventions in managing associated symptoms in a complex patient with CMVD and CAD, along with relevant risk factors. This protocol emphasizes the strategic integration of Ayurvedic Panchakarma and oral treatments with contemporary medical therapies. Further rigorous research is warranted to elucidate the mechanisms of action and assess the effectiveness of such integrative approaches combining Ayurveda with conventional medicine, particularly in cardiac disorders.

Introduction

Small vessel disease encompasses abnormalities affecting the microvasculature of organs such as the heart, brain, and kidneys¹. When small vessel disease occurs in the heart, it is also referred to as coronary microvascular dysfunction (CMVD)^2,3. While the pathophysiology and diagnosis of coronary artery disease are well-established, coronary microvascular dysfunction remains less understood⁴. The clinical presentation of CMVD can mimic that of coronary artery disease; a key distinguishing feature is the angina without angiographic evidence of atherosclerosis^3,4.

Specifically, CMVD is characterized by a triad of pathophysiological mechanisms: structural abnormalities within the microvasculature, extravascular compressive forces that impede coronary blood flow, and dysfunctional regulation of coronary vascular tone¹. These factors contribute to endothelial dysfunction, which plays a crucial role in the pathogenesis of CMVD⁵. Endothelial dysfunction, a critical early event in the development of CMVD, involves a multifaceted disruption of the normal homeostatic functions of the endothelium, the single-celled layer lining the inner surface of blood vessels. It is characterized by impaired nitric oxide production and increased vasoconstrictor release⁶.

Endothelial dysfunction is not merely a passive consequence of other cardiovascular insults but an active contributor to the pathogenesis and progression of CMVD⁶. Previous studies reveal that inflammation plays a significant role in CMVD and can impact vascular function, potentially leading to endothelial dysfunction^6,7. Cytokines, such as interleukin 6, are markedly augmented in symptomatic patients with CMVD compared with healthy controls⁸. In the context of coronary microvascular dysfunction, endothelial dysfunction emerges as a pivotal factor, intricately woven into the complex mechanisms that govern microvascular health and myocardial perfusion⁹.

In 2020, the European Society of Cardiology (ESC) Working Group on Coronary Pathophysiology and Microcirculation categorized coronary microvascular dysfunction into five groups based on the presence or absence of obstructive coronary artery disease, the chronicity or acuity of the coronary syndrome, and the occurrence of coronary no-reflow in re-perfused acute myocardial infarction. Notably, CMVD is increasingly recognized as a primary factor in angina or heart failure following successful AMI reperfusion therapy¹⁰.

Clinically, CMVD manifests across a spectrum of cardiac conditions, including stable and acute coronary syndromes, as well as heart failure. Notably, CMVD is more prevalent and associated with higher morbidity and mortality in women compared to men¹.

Studies estimate that CMVD affects approximately 3 to 4 million individuals in the United States⁴. Data from the WISE database indicates that 3 to 4 million Americans experience myocardial ischemia despite lacking obstructive atherosclerosis¹¹. This population faces diminished quality of life, psychological distress, and healthcare expenditures comparable to those with obstructive CAD. Moreover, microvascular disease carries a 2.5% annual risk of major adverse cardiovascular events¹². While coronary artery disease rates have declined in developed Western nations over the past three decades, India has witnessed a concerning increase. Studies of Indians globally indicate a 3-4-fold higher risk of CAD compared to white Americans¹³, and the exact prevalence rate of CMVD in India is still unknown.

Differentiating coronary microvascular disease from epicardial coronary artery disease based solely on clinical presentation is not feasible. Non-invasive imaging techniques, such as echocardiography and nuclear perfusion, lack the sensitivity for definitive diagnosis. The current diagnostic approach relies on a combination of factors: a normal coronary angiogram, absence of epicardial spasm during acetylcholine provocation, and a coronary flow reserve less than 2.5 during adenosine-induced hyperemia¹³. However, each of these criteria has limitations. A strictly binary interpretation of invasive evaluation data should be avoided, favoring a more nuanced approach¹⁴.

Pharmacological treatments for coronary microvascular dysfunction include antianginal medications like beta-blockers, calcium channel blockers, and nitrates^15,16. These medications reduce myocardial oxygen demand and improve coronary blood flow. Ranolazine can reduce angina symptoms and improve exercise tolerance. Statins and ACE inhibitors may improve microvascular function and reduce cardiovascular risk by targeting endothelial dysfunction¹⁴.

Scientific inquiry into the efficacy of Ayurvedic interventions for cardiac diseases remains limited. While Ayurvedic treatments for heart disease are not as widely established as conventional approaches, they are gaining recognition as potential adjuvant therapies¹⁷. In Ayurveda, heart diseases are understood holistically, encompassing physical and psychological dimensions. Ayurvedic interventions aim to address imbalances in Doshas and promote overall well-being, but the detailed descriptions of specific heart conditions may differ from modern medical classifications¹⁸.

Given the potential for cardiac emergencies, many patients initially choose modern medicine as the primary treatment, with Ayurveda often serving as a complementary approach^19,20. However, some studies suggest that Ayurveda could play a more significant role in managing heart conditions^17,19,20, especially when integrated with lifestyle modifications and stress management techniques. Further rigorous research is needed to validate the efficacy and safety of specific Ayurvedic treatments for heart diseases^21,22.

A randomized clinical trial involving over 70 chronic heart failure patients investigated the effects of heart failure reversal therapy (HFRT), consisting of Panchakarma therapies in conjunction with standard Chronic Heart Failure (CHF) treatment, compared to standard CHF therapy alone over 6 weeks. The study demonstrated superior outcomes in the group receiving HFRT²³. Another trial evaluated HFRT in 52 CHF patients with ejection fractions between 10%-30%, also highlighting the efficacy of HFRT²⁴. A study involving 147 patients at Madhavbaug Clinics between July and December 2018 analyzed the impact of heart failure reversal therapy on aerobic capacity. Changes in VO2 max and metabolic equivalents were assessed at 30 days post-HFRT initiation and compared to baseline. Regression analysis revealed that HFRT significantly improved both VO2 max and METs in chronic heart failure patients, suggesting enhanced aerobic capacity²⁵. However, neither of these studies specifically addressed coronary microvascular dysfunction.

In a patient with diagnosed coronary artery disease and coronary microvascular dysfunction, alongside risk factors including female sex, advanced age, and obesity, a 14-day Panchakarma course followed by a 16-week regimen of oral Ayurvedic medication, in conjunction with conventional medical treatment, led to a noticeable reduction in associated symptoms. Given the limited research on Ayurvedic interventions for cardiac conditions, this case report offers a potentially novel perspective on managing this complex presentation. The Ayurvedic protocol employed in this case involved readily accessible, cost-effective interventions²⁶.

Case presentation: A 59-year-old female presented to our hospital on February 27, 2024, accompanied by her husband. She reported a 10-15-day history of worsening mild to moderate body aches, left ankle pain with edema, and insomnia. Additionally, she experienced dyspnea on exertion and chest pain. The patient's ambulation was restricted to 10 steps due to leg pain. The patient's medical history was notable for a 10+ year diagnosis of Coronary Microvascular Dysfunction (CMVD), hypertension managed by a cardiologist, along with a sedentary lifestyle initiated 20-30 years prior and subsequent obesity. Menopause occurred 5-6 years prior, followed by generalized debility and increased irritability. She denied any significant history of diabetes, thyroid disorders, psychiatric conditions, trauma, allergies, or adverse obstetric events. Physical examination revealed normal vital signs. She was obese with a body weight of 86 kg and height of 160 cm (BMI-33.59). She experienced severe body aches after minimal physical activity, which significantly impaired her daily functioning.

Diagnosis, assessment, and plan: A pitting edema was seen over her left ankle joint. The pit was 5 mm deep and took 20 s to vanish (grade 2). The patient exhibited anxiety related to upcoming travel. Medical records, including prior investigations and treatments, were reviewed. Complete blood count (Hemogram), Kidney Function Test (KFT), Liver Function Test (LFT), and Blood Sugar Level (BSL) are provided in Table 1. Her 2-D color Doppler Echocardiography examination revealed Normal Left Ventricular (LV) size, normal LV systolic function (LVEF=60%), no RWMA at rest, reduced LV compliance, all cardiac valves normal, Trivial MR, no AR, Trivial TR, no significant PAH, RVSP-26 mmHg, no pericardial effusion or vegetation, no I/C mass, no coarctation. The dimensions were as follows: LV: Dd/Ds:42/27 mm, IVSd: 10 mm, LVPWd mm, LA:28 mm, AO: 30 mm (Table 2, Table 3, Figure 1). Current medical documentation indicated a diagnosis of coronary microvascular dysfunction (CMVD) with coronary artery disease. She remained hemodynamically stable without active cardiac symptoms. An Ayurvedic assessment yielded a diagnosis of Vataj Hridroga. A symptom-based Ayurvedic treatment plan was initiated in conjunction with the continuation of current medications as prescribed by the patient's cardiologist. The primary treatment goal was to alleviate the presenting symptoms without exacerbating the underlying cardiac condition. The patient expressed concerns about undertaking a long-haul flight to Australia in 15 days. Her cardiologist indicated that there is no definitive treatment for coronary microvascular dysfunction (CMVD) or its associated symptoms. The Ayurvedic treatment plan consisted of two phases: an initial 14-day Panchakarma therapeutic course administered during a 19-day inpatient admission (February 27, 2024, to March 16, 2024), followed by a 16-week course of oral Ayurvedic medications (Table 4).

Protocol

This study was conducted in accordance with the guidelines and Standard Operating Procedures established by the Manjushree Research Institute of Ayurvedic Science, Piplaj, Gujarat, India. The patient, diagnosed with coronary microvascular dysfunction, and coronary artery disease, received treatment after being fully informed about the Ayurvedic Panchakarma procedures, potential risks, and benefits involved. Written informed consent was obtained from the patient prior to the commencement of treatment, as documented by reference number 235/2024, dated February 27, 2024.

1. Medical treatment management

1. The patient's existing medication regimen, prescribed by her physician, was maintained. This included daily doses of Aspirin (150 mg), Clopidogrel (75 mg post-prandial), Amlodipine (4.5 mg at bedtime), Atorvastatin (10 mg at bedtime), a combination of Domperidone (20 mg) and Rabeprazole (30 mg at bedtime), and 2x daily doses of Levocarnitine (150 mg) and Tocopherol (200 mg). The prescribed duration for this regimen was 180 days. The patient was advised against discontinuing any of these medications without consulting her cardiologist.

2. Panchakarma therapies

1. Abhyanga
   1. Preparation of the room: A private room was prepared specifically for Ayurvedic oil massage. The room was equipped with a massage table, a hotplate, 100 mL of Ayurvedic medicated oil (e.g., Bala oil) for each session, utensils, and cleaning materials such as clothes and cotton.
   2. Patient preparation: The patient was asked to disrobe and lie on the massage table.
   3. Oil selection: Bala oil, manufactured by any reputable manufacturer (e.g., Arya Vaidyasala, Kottakal, Kerala, India), was selected as the medicated oil. This oil contains Bala, known for its muscle-strengthening and analgesic properties. The oil was warmed to enhance its absorption and soothing effects²⁷.
   4. Massage procedure: The massage was performed each morning in different positions, including sitting, supine, left lateral, prone, right lateral, supine and sitting, for 30-45 min. Light pressure was used, adhering to the Ayurvedic principle of Samvahana, considered beneficial for insomnia.
   5. Post-massage care: After the procedure, the patient's body was cleansed with clean, dry towels. The patient was encouraged to drink lukewarm water during the Panchakarma course.
   6. Safety measures: The massage was conducted in a hygienic environment to mitigate potential risks²⁸. It was ensured that the therapist's nails were trimmed, and no metallic objects were present that could cause injury during the massage²⁹. The temperature of the oil was kept appropriate to prevent burns.
   7. Follow-up: Immediately following the massage, Swedana (sudation therapy) was given.
2. Swedana
   ​NOTE: The following outlines the procedure for Nadi Sweda using a Dashmoola decoction³⁰.
   1. Treatment room: A private room was selected, ensuring it is free from drafts to maintain a stable and consistent temperature.
   2. Dashmoola decoction: To prepare it, 2 kg of raw Dashmoola was added to 32 L of water. The mixture was heated until the volume was reduced to 4 L, concentrating on the herbal extracts.
   3. Setting up the steam generator: The prepared Dashmoola decoction was transferred to a steam generator and heated rapidly.
   4. Connecting the Tubing: One end of a flexible tube was attached to the steam generator outlet.
   5. Direct vapor flow: The therapist was instructed to direct the opposite end of the tube towards the patient's exposed body parts.
   6. Maintaining safe distance and motion: To prevent burns, approximately 30 cm was maintained between the tube's outlet and the patient's skin. The vapor was applied in a continuous, gentle motion across the skin.
   7. Swedana administration: The process was continued for 10-15 min, or until perspiration becomes evident. The focus was to apply Swedana to the entire body, paying particular attention to painful areas to ensure thorough heating.
   8. Maintaining hygiene: Hygiene protocols were strictly adhered to throughout the procedure.
   9. Post-treatment cleaning: Following the treatment, the patient's body was cleansed with a clean, dry towel.
   10. Hot Water Bath: The patient was advised to take a hot water bath after the procedure.
   11. Contraindications: The importance of avoiding cold water or food intake, as well as exposure to cold wind, immediately following Swedana was emphasized. Also, it was advised to avoid exercise during Swedana³¹.
       NOTE: This Nadi Swedana procedure, utilizing vapors generated from a Dashmoola decoction, is indicated for patients presenting with Vataj Hridroga. Swedana is traditionally administered after Abhyanga, as the synergistic effects of these therapies are believed to alleviate Vata Dosha. Dashmoola is known to reduce vitiated Tridosha³¹. Given that Swedana is generally contraindicated over the precordial region, specific precautions were undertaken during the administration of Nadi Swedana. Only a minimal amount of localized heat was applied to the precordium to ensure patient safety while maintaining therapeutic efficacy.
3. Shirodhara
   1. Preparation of the treatment room: A private, soundproof room was selected. The necessary equipment was assembled, such as Droni, Shirodhara pot, hot plate, utensils, and cleaning materials.
   2. Preparation of the Shirodhara pot: A pot approximately 5-6 inches in depth with an open mouth and a rounded bottom, capable of holding about 2 L, was chosen. The pot had a small hole, roughly the size of a little finger, at its center, and three equidistant holes along the rim to attach strings for suspension from a stand.
   3. Insertion of Dhara Varthi: A Dhara Varthi, a wick of loosely packed cotton threads, was inserted, allowing about 4 inches to protrude through the hole in the Dhara vessel. The threads were packed just firmly enough to prevent slippage, yet loosely enough to permit a consistent and even flow of the oil poured into the vessel.
   4. Selection and heating of the oil: An appropriate Ayurvedic medicated oil, such as Bala, was selected and manufactured according to the parameters outlined in the Ayurvedic Pharmacopoeia of India³². Between 1 L and 1.5 L of the chosen oil was heated to 38-40 °C.
   5. Transferring oil to Shirodhara pot: The heated oil was transferred to Shirodhara pot.
   6. Positioning of the patient: The patient was positioned supine on a Droni.
   7. Protecting Eyes and Ears: Earbuds were used, and eye pads were placed over the patient's eyes to prevent oil entry.
   8. Commencing oil streaming: The oil stream was poured over the patient's forehead, moving it rhythmically over the entire forehead slowly.
   9. Maintaining silence: Silence was maintained to facilitate the patient's concentration throughout the procedure. The patient was asked to relax their body.
   10. Continuing treatment: The procedure was carried out for 30-45 min. The patient falling asleep during the procedure is normal, and the procedure can be paused.
   11. Maintaining oil temperature: The oil temperature was maintained at 38-40 °C throughout the procedure. If the oil cooled, heated oil was added to the Shirodhara pot.
   12. post-treatment cleaning: After the procedure, the eye pads and ear buds were removed.
       Following the procedure, the patient's hair underwent cleansing with warm water and was subsequently dried using a clean towel.
   13. Post-treatment care: The patient was instructed to take a hot water bath and drink lukewarm water during the Shirodhara course.
   14. Maintaining hygiene and safety: Hygiene was maintained throughout the procedure, and the oil temperature was monitored to prevent burns.
       NOTE: The rationale behind Shirodhara's use for insomnia centers on the idea that the continuous, gentle flow of liquid on the forehead can soothe the central nervous system, decrease anxiety, and balance the body's energies, thereby facilitating sleep³³.
   15. Duration of Panchakarma course: While the patient was admitted to our hospital, Panchakarma procedures were administered once daily in the morning. Assessments were conducted daily for 14 days.

3. Shaman Chikitsa (Oral Ayurvedic medication)

1. Simhanada Guggulu
   1. The following formulation, referenced from Bhaishajyaratnavali Aamvatadhikar, was prepared, which contains Trifala, Shuddha Gandhaka, Guggulu, and Chitra Taila (castor oil). The patient was asked to take 250 mg, 3x a day with warm water after food.
      NOTE: Guggulu, the main ingredient, is known for its anti-inflammatory and detoxifying properties. It helps remove Ama from the body³⁴. By reducing inflammation in the joints and tissues, Simhanada Guggulu can alleviate pain and swelling in the legs. Some formulations of Guggulu are believed to improve circulation³⁵. This could help reduce edema by promoting better fluid drainage from the legs.
2. Ajmodadi Churna
   1. The following formulation, sourced from Rasatantrasara, was prepared, which comprises Ajmoda, Vidang, Saindhav, Devdaru, Chitrak, Pippalimul, Shatapushpa, Trikatu, Pathya, and Vriddhadaruk. The patient was prescribed 1 g, 2x a day with warm water after food.
      NOTE: Ajmodadi Churna is traditionally used as a carminative and antispasmodic³⁶. While this doesn't directly address joint pain or edema, these properties may help improve digestion and reduce bloating, which can indirectly alleviate discomfort. It is believed to help in painful conditions like sciatica and stiffness in the back. In Ayurveda, joint pain is often associated with the accumulation of Ama (metabolic toxins). Ajmodadi Churna, with its blend of herbs, might aid in digesting Ama, potentially reducing inflammation and pain in the joints. Inflammation is a major component of many diseases, including rheumatoid arthritis³⁶.
3. Dashmoola Kwatha
   1. The following classical Ayurvedic formulation was administered which contains Bilva, Agnimantha, Gambhari, Shyonaka, Patla, Brihati, Shalaparni, Kantakari, Gokshura, and Prishnaparni. The patient was prescribed 10 mL, which should be mixed with an equal volume of cold water and taken 2x a day after food.
      NOTE: In Ayurveda, edema can be associated with an imbalance of Vata dosha. Vata governs movement and fluid balance in the body, and its aggravation can disrupt these processes, potentially leading to fluid accumulation. Some herbs in Dashmoola Kwatha may possess mild diuretic properties, which could help promote fluid elimination and reduce edema. Some of the individual herbs in Dashmoola have anti-inflammatory properties. By reducing inflammation, Dashmoola Kwatha could indirectly alleviate edema caused by inflammatory conditions. Dashmoola is thought to work on the Pelvis, Bladder, Colon, Kidney, Bones, Ears, and lower limbs³⁷.
4. Bramhi Vati
   1. The following formulation which contains Bramhi, Shankhapushpi, Gojivha, Vacha, Swarnamaakshik, Rasasindoor, Krishnamarich, and Jatamansi was prepared. The patient was prescribed 500 mg to be taken 2x a day with cold water after food.
      NOTE: Brahmi, a key ingredient, is considered a Medhya Rasayana in Ayurveda, meaning it's a rejuvenate herb that may promote intellect and memory. Brahmi has anxiolytic properties that can help calm the mind, making it easier to fall asleep.

4. Post-treatment evaluation

1. The patient received inpatient Panchakarma therapies and oral Ayurvedic medications for 16 days, followed by a 16-week regimen of oral Ayurvedic medications alone. Treatment was continued for 16 weeks due to observed symptomatic relief. The patient demonstrated good tolerability to the Ayurvedic treatment regimen, and no adverse drug reactions were reported.
2. To assess the impact of the treatment, patient evaluations were systematically conducted at baseline, discharge, and during a follow-up period at Week 16. These assessments focused on specific symptoms and utilized validated scales to quantify changes.
   1. Leg pain intensity was quantified using a 0-10 Visual Analogue Scale. Edema of the left ankle was assessed via a standardized 0-4 pitting edema grading scale³⁸. Insomnia was evaluated using the Pittsburgh Sleep Quality Index³⁹, which measures overall sleep quality based on 19 self-reported items and yields a global score ranging from 0 to 21.

Results

In this complicated case of coronary artery disease with cardiac microvascular dysfunction, a treatment protocol was designed to integrate Ayurvedic therapies with modern medicine. This protocol aimed to alleviate specific symptoms: leg pain, insomnia, and edema. To evaluate the treatment's effectiveness, the following assessment tools were employed:
Self-Reported Leg Pain Assessment: To quantify the patient's subjective experience of leg pain.
Edema Assessment: To objectively measure the degree of edema present....

Discussion

This case report presents the symptomatic relief achieved in an elderly female patient with coronary artery disease (CAD) and coronary microvascular dysfunction (CMVD) through an integrative approach. Adjuvant Ayurvedic therapies, including Panchakarma procedures such as Abhyanga, Swedana, and Shirodhara, along with oral Ayurvedic medications, were administered in conjunction with modern pharmacological treatments. This combined regimen led to a notable reduction in the patient's symptoms.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Aegle marmelos	Dishant Ayurvedic Supplier,	k952
Ajamoda	MRIAS Teaching Pharmacy, Piplaj, Gandhinagar
Bacopa monnieri	Dishant Ayurvedic Suppliers	p1032
Sida cordifolia	AVS Pharma Kottakal
Terminalia chebula	Dishant Ayurvedic Supplier,	T4237