Hi friends,
I am very glad to say you that  'Arogya Tulasi' had taken birth today :  vaishakha shukla panchami; Gurubasara  in presence of my grand father Sri Santanu Thakur ,  parents  Sri Gokulanand Thakur,  Smt Soudamini Thakur and gurujanas. Dedicated to my loving grand mother Lt Smt Tulasa Thakur .

Aai Maa (1934-2002)

In the blessings of yajna agni and all devadevis starting a new journey. A long way to go for final goal. blessings of all awaited....
Jai Jagannath
Vande Mataram

Welcome to the world of Ayurveda. The first step of my dream realization – my clinic ‘Arogya Tulasi’ in the memory of my grand mother Lt.  Smt. Tulasa Thakur is going to start next month. I need your blessings and support to bloom, grow and touch the high of nara seva-narayana seva-bharata seva.

Vande mataram

Dr. Abhiram Thakur

Purna pada, Bhawanipatana

Kalahandi, Odisha

Pin – 766001

abhirambharat@gmail.com

Cardiac diseases : an Ayurvedic consideration with special reference to CAD

Dr. Abhiram Thakur, MS(Ay)Scholar

Dr. K.B. Sudhikumar, Prof. and Head

Dept. Of Salyatantra, GAC, Tripunithura

In the history of health science up to last century, infectious disease were the leading cause of mortality and morbidity. The humanity was struggling for life in the shade of diseases like tuberculosis, diarrhoea and leprosy. However the health scenario of the present world is different . It is struggling for chronic diseases like cancer Cardio Vascular Diseases etc.. Coronary Artery Diseases are the leading pathology of heart responsible for sufferings and death. Ayurveda is the oldest medicinal system of the globe and it has got own special understanding of cardiac diseases under the heading of Hŗdroga.

As we discussed Coronary Artery Disease is the most common form of Heart disease and the single most important cause of premature death in many part of the globe. Sudden cardiac death is a prominent feature of CAD. One in every six coronary attack s found to present with sudden death as the first, last, and only symptom. Diseases of the coronary arteries is always due to atheroma(Fatty degeneration or thickening of the walls of the larger arteries occurring in atherosclerosis) and its complications, particularly thrombosis, the common clinical  manifestations and pathological correlate with conditions like -

· Stable angina : Ischemia due to fixed atheromatous stenosis of one or more coronary arteries is the pathology involved.

· Unstable angina : Ischemia caused by dynamic obstruction of a coronary artery due to plaque rupture with superimposed thrombosis and spasm is the pathology involved.

· Myocardial infarction: Myocardial necrosis caused by acute occlusion of a coronary artery due to plaque rupture and thrombosis is the pathology.

· Heart Failure : Myocardial dysfunction due to infarction or ischaemia pathology .

· Arrhythmia : Altered conduction due to ischemia or infarction is the pathology involved

· Sudden Death : Ventricular arrhythmia, asystole or massive myocardial infarction is the pathology involved

Occasionally coronary arteries are involved in the other disorders like aortitis, polyarteritis and connective tissue disorders.

Risk factors for CAD

CAD  is an atherosclerotic disease which is multi-factorial in origin, giving rise to the risk-factor concept. Certain living habits promote atherogenic traits in genetically susceptible persons. A number of 'risk' factors are known to predispose to the condition .However, all patients with CAD or myocardial infarction may not have these identified  risk factors always. Atherosclerotic disease manifest in one vascular bed is often advanced in other territories. The disease can be asymptomatic in its most severe form, with one in three myocardial infarctions going unrecognized. Atherosclerotic disease begins early in life but those at high risk of CAD cannot be identified at an early age, and therefore prevention must be aimed at the whole  population.

 Traditional risk factors

Age : CAD rates increase with age. Atherosclerosis is rare in childhood, except in familial hyperlipidaemia, but is often detectable in young men between 20 and 30 years of age.

Gender: Men have a higher incidence of coronary artery disease than premenopausal women. However, after the menopause, the incidence of atheroma in women approaches that in men.

Family history: CAD is often found in several members of the same family.

Smoking : In men, the risk of developing CAD is directly related to the number of cigarettes smoked. It is estimated that about 20% of deaths from CAD in men and 17% of deaths from CAD in women are due to smoking.

Diet and obesity : Diets high in fats are associated with ischemic heart disease, as are those with low intakes of antioxidants (i.e. fruit and vegetables). Supplementation with antioxidants has been shown to be unhelpful in RCTs . It is estimated that about 5% of deaths from CAD in men and that 6% of such deaths in  women are due to obesity . About 36% of deaths from CAD in men and 38% of deaths from CAD in women are due to lack of physical activity.

Hypertension: Both systolic and diastolic hypertension are associated with an increased risk of CAD

Hyperlipidaemia: High serum cholesterol, especially when associated with a low value of high-density lipoproteins (HDL), is strongly associated with coronary atheroma.  High-density lipoprotein cholesterol (HDL -cholesterol) is the fraction of cholesterol that removes cholesterol (via the liver) from the blood. Low levels of HDL-cholesterol are associated with an increased risk of CAD and a worse prognosis after a heart attack.

Diabetes mellitus: Diabetes, an abnormal glucose tolerance or raised fasting glucose is strongly associated with vascular disease. Diabetes substantially increases the risk of CAD.

Sedentary lifestyle: Lack of exercise is an independent risk factor for CAD equal to hypertension, hyperlipidaemia and smoking. Regular exercise probably protects against its development .

Genetic factors: A number of genetic factors have been linked with coronary artery disease. The angiotensin converting enzyme (ACE) gene contains an insertion/deletion (I/D) polymorphism, the DD genotype of which has been associated with a predisposition to coronary artery disease and myocardial infarction.

Risk Factors with Unclear Roles include Homocysteine and Vitamin B Deficiencies, C-Reactive Protein, pneumoniae and Other Infectious Organisms, Sleep Apnea, some factors before Birth and in Infancy like Low birth weight etc and Seasonal Differences.

Hence, the most important culprit of CAD is atherosclerosis i.e. nothing but the hardening of vessels hence have a look at the process of coronary atherosclerosis -

Coronary atherosclerosis is a complex inflammatory process characterized by the accumulation of lipid, macrophages and smooth muscle cells in intimal plaques in the large and medium-sized epicardial coronary arteries. The vascular endothelium plays a critical role in maintaining vascular integrity and homeostasis.

· Mechanical shear stresses (e.g. from morbid  hypertension),

· Biochemical abnormalities (e.g. elevated and modified LDL, diabetes mellitus, elevated plasma  homocysteine),

· Immunological factors (e.g. free radicals from smoking),

· Inflammation (e.g. infection such as Chlamydia pneumonia and Helicobactor pylori)

· Genetic alteration may contribute to the initial endothelial 'injury' or dysfunction, which is believed to trigger atherogenesis.

The development of atherosclerosis follows the endothelial dysfunction, with increased permeability to and accumulation of oxidized lipoproteins, which are taken up by macrophages at focal sites within the endothelium to produce lipid-laden foam cells. Macroscopically, these lesions are seen as flat yellow dots or lines on the endothelium of the artery and are known as 'fatty streaks'. The 'fatty streak' progresses with the appearance of  extracellular lipid within the endothelium ('transitional plaque'). Release of cytokines such as platelet-derived growth factor and transforming growth factor-(5 (TGF-P) by monocytes, macrophages or the damaged endothelium promotes further accumulation of macrophages as well as smooth muscle cell migration and proliferation. The proliferation of smooth muscle with the formation of a layer of cells covering the extracellular lipid separates it from the adaptive smooth muscle thickening in the endothelium. Collagen is produced in larger and larger  quantities by the smooth muscle and the whole sequence of events cumulates as an 'advanced or raised fibrolipidplaque'. The 'advanced plaque' may grow slowly and encroach on the lumen or become unstable, undergo thrombosis and produce an obstruction (‘complicated plaque’). Two different  mechanisms are responsible for thrombosis on the plaques.

The first process is superficial endothelial injury, which involves denudation of the endothelial covering over the plaque. Subendocardial connective tissue matrix is then exposed and platelet adhesion occurs because of  reaction with collagen. The thrombus is adherent to the surface of the plaque.

The second process is deep endothelial fissuring, which involves an advanced plaque with a lipid core. The plaque cap tears (ulcerates, fissures or ruptures), allowing blood from the lumen to enter the inside of the plaque itself. The core with lamellar lipid surfaces, tissue factor (which triggers platelet adhesion and activation) produced by macrophages and exposed collagen, is highly thrombogenic. Thrombus forms within the plaque, expanding its volume and distorting its shape. Thrombosis may then extend into the lumen. A 50% reduction in luminal diameter (producing a reduction in luminal cross- sectional area of approximately 70%) causes a haemodynamically significant stenosis. At this point the maller distal intramyocardial arteries and arterioles are maximally dilated (coronary flow reserve is near zero), and any increase in myocardial oxygen demand provokes ischemia.

Ayurvedic consideration

                Definition of  heart diseases, Aetiology,  pathogenesis & clinical features of  the  disease are scattered in literatures of Ayurveda. After going through all literatures it is clear that there was an incidence of heart disease in India and Ancient Ayurvedic physicians made attempt to understand the syndrome of heart disease on the basis of clinical manifestations.

Concept of Hŗdaya in Ancient time and Ayurvedic classics: The term Hŗdaya has been used at several places in Rig veda. The term “Hŗdaya” appears to be derived from the word “Hŗd”. In Śata patha- Brāhmaņa varrious words like Hŗdayam, puritata, stombhaga and Āditya are mentioned. The word Hŗdayam originated from the root word “Hŗd”. Hŗdaya is derived from three various verbal roots i.e. Hŗ, Da, Ya, having the meaning of receiving, giving and moving respectively.    

In Ayurvedic texts, the authors and commentators have different opinions regarding the term Hŗdaya   . Caraka states that it beats (spandayati) ,  Heart is the seat of consciousness which is primarily a function  of the brain. Suśruta has Observed that heart i.e. placed in the thoracic cavity between both nipples and extends up to the end of stomach, it is a sirāmarma and it is one in number . He also includes it as the base of prānavaha Dhamanya.

Physiological Concept of Hŗdaya:      Bhela describes that blood circulates in whole body through the arteries and it is returns back to the heart. Arunadatta, the commentator of Aşṭānga Hŗdayam stated that purified blood from the lungs returns to heart, then Vyāna Vāyu presses it to flow in the whole body. Hridaya have been stated as the seat of circulatory system (Rasavaha Srotas)  as well as respiratory system (Prāņavah srotas) thus it is an important organ of cardio respiratory system. It has been considered as a vital organ.

                Heart is being described as prāņayatana by Caraka and seat of cetanā and manas. In addition to this heart is considered among three chief marma (Vital spots) Heart is also described as the seat of ojas. The doṣa sthiti told in heart are - Vyāna vāyu, Prāṇa Vāyu, sādhakapitta and Avalambaka Kapha

Hŗdroga in Ayurvedic Classics:

Caraka Samhitā ·    Sūtrasthāna ·   Cikitsā sthāna ·    Siddhi sthāna	· Kiyantah sirasiyadhyaya (17) · Trimarmiyā Cikitsā (26) · Trimarmiya siddhi  ( 9)	· Type aetiology sings, & symptomatology ·  Aetiology, type, symptomatology pathology & Treatment of Hŗdroga ·  Importance of Hŗdaya
Suśruta samhitā ·    Uttarstantra	· Hŗdrogo pratisedhanam (43) · Gulma pratisedhaopa krama varņana	·  Aetiology, type, symptomatology pathology & treatment of Hŗdrogo ·   Regordial precardial pain
Astānga Hŗdayam ·   Nidāna sthāna ·   Cikitsā sthāna	· Rajayakşmādi nidānama (5th) ·  Chardi, Hŗdroga, Tŗşņācikitsā	·  Type & symptomatology of Hŗdroga ·  Treatment of Hŗdroga.
Astānga Samgraham ·   Nidāna sthāna ·  Cikitsā sthāna	· Rajayaks+madi nidānama (5th) · Chardi, Hrdroga, Trsnācikitsa, (8th)	·  Type & symptomatology of Hŗdroga ·  Treatment of Hŗdroga.
Mādhava Nidāna	·  Hŗdroga Nidānam (29)	·  Aetiology, type, pathalogy symptomatology & complications of Hŗdroga.

Aetiology of Hŗdroga :-

                Nidāna (Aetiological factors) for hŗdroga have been described on a general basis in Caraka & Suśruta Samhitā detailed in the table bellow. According to Vāgabhaṭa the general aetiological factors of Hŗdroga are the same which has been described for Gulma roga.  

General Aetiological factors of Hŗdroga in classics.

Aetiological factors	Caraka	Suśruta
·         Āhāra Tikşņa (irritant artical) Uşņa (hot         ,,        ) Rūkşa (dry       ,,        ) Atimātrā sevana (food in excessive quantity ) Virudha bhojana (incompatible diet ) Adhyaśana (taking food before digestion) Ajirnā bhojana (indigestion) Asātmya bhojana (uncongenial food) ·         Vihāra Vyāyāma (over exercise) Vega Sandhāraņa (Suppression of urges) ·         Āghāta Abhighāta (injury) ·         Mānas ·         Cintā (worry) ·         Bhaya (fear) ·         Trāsa (terror) ·         Nidānārthakara Gadāticārā (improper treatment of disease) Chardi (emesis) Āma (indigestive material, toxic ) ·         Iatrogenic Ati-virēka (excessive purgation) Ati vasti (  ,,   enema) ·         Others Karsana (emaciation)	+ - - - - - - - + + + + + + +	- + + + + + + + - + + - - - -

 Pathogenesis of Hŗdroga.

                With the analysis of literatures we find the description of two  paths of pathogenesis of the disease.

1.Deals with the derangement of Rasa  : Suśruta  narrates that the derangment of Rasa is supposed to be due to doşika changes in the area of heart (Vyānvāyu, Sādhkapitta, Avalambaka Kapha & prānavayu). When the nutrition of cardiac muscle is affected, its function is also deranged causing clinical manifestations of the disease.

2. In the context of kŗmija hŗdroga, the second type is described. Organic changes in the cardiac structure with the formation of nodules and distortion of normal structure Occurs which causes a space for accumulation of  fluids (Kleda) The microorganisms are likely to grow in this area, which may cause obstruction in the cardiac functions.

Hŗdroga Samprāpti Ghataka(w.s.r. to CAD)

1. Dośa                   -  Vata, Kapha

2. Dūśya                 -   Rasa, Meda

3. Agni                   -   Mandāgni

4. Āma                    -  Jatharāgni janya āma,Sāma rasa (Hyperlipidemia)

5.Śrotasa                 -  Rasavaha srotasa, Pranavaha śrotasa

6. Srotodusti            -   Sanga (Atheroselerosis)

7. Udbhave sthān      -  Amāsayotth

8. Vyakta Sthān         -   Hrdaya, Ura

9. Sancaya sthan        -   Dhamani

10. Roga Mārga          -   Madhyama

Clinical feature of Hŗdroga.

                Caraka, Suśruta  and Vāgabhaṭa have described specific symptomatology for various types of heart diseases but there are some variation in their clinical presentation.

General features of Hŗdroga :- 

Following features of the diseases have been told by Caraka in the Trimarmiya cikitsā chapter.

               Vaivarnya    (Abnormal complexion)

                Mūrchā  (Fainting)

                Jvara     (Fever)

                Kāsa      (Cough)

                Hikkā     (Hiccup)

                Śvāsa     (Dyspnoea)

                Āsyavairasya  (Tastelessness)

                Tŗşņā   (Thirst)

                Pramoha  (Mental Confusion)

                Chardi     (Vomiting)

                Kaphotkleśha (Nausea)

                Rujā  (Pain)

                Aruci  (Anorexia.)

Types of Hŗdroga: –

The disease has been devided into five kind by Madhava Nidana, Charaka, Suśruta  as well Vāgbhaṭa as i.e. Vataja, Paittika , Kaphaja and Kŗmija .

Specific sign and symptoms of  Vātaja Hŗdroga includes symptoms like – Vacantness in Heart , palpitation ,  increasing heart rate,  Tearing like sensation, cardiac cramps , Feeling of obstruction , Drawing pain ,   Pricking pain, churning pain , Cutting pain, Breaking pain, Splitting pain , Drying Up, Steadyness , Dyspnoea  in heart and other general symptoms like Wasting , Tremors ,  – Inability to withstand noice  , Little sleep , Mental Confusion ,  Giddiness , Feeling of helplessness ,  Grief ,  Fear etc.

Pittaja Hŗdroga includes clinical features like – Burning sensation , Hotness , Cardiac exhaustion , fever, Pallor, Thirst , Hot feeling, Sucking Pain , Perspiration , Dryness of Mouth , Acidity , Vomiting of sour bile, Bitterness in mouth, Dumāyana – Fuming eructation , Bitter and sour eructation , Feeling of darkness , Mental Confusion , Terror , Fainting  , Narcosis,  Giddiness etc.

Kaphaja Hŗdroga includes clinical features like - Feeling of obstruction ,  Heaviness , Dull ache, Numbness  , Pain as if pressed with stone , Stiffness , Salivation , fever, Cough, Anorexia,  Mild digestive power, Sweetness of the mouth, Expectoration ,Drowsiness   etc

Kŗmija Hŗdroga  may accompany with the features like - Intense discomfort, niddle pricking like pain ,  pain as if cut by weapons, Intense pain , pain like Cutting by saw , Itching, Anorexia , Darkish eye, Wasting , Nausea , Discharge of Kapha , Feeling of entering in to the dark etc.

Another important pathology described by Ācārya Suśruta  is Hŗcchūla . It  has been described separately in uttartantra chapter 42 as a separate disease entity. According to this description, vāta associated with vitiated rasa and obstructed by kapha and pitta produces pain in the heart and is associated with severe dyspnoea. Suśruta has given a concluding remark that Hŗcchūla is due to disorder of rasa and vāyu. We do not get the separate description of Hŗcchūla by  Caraka .

                Ḍalhaṇa has emphasized in the commentary of  Hŗcchūla that it is a peculiar type of Heart disease which is associated with pain and severe dyspnoea and thus it should be treated as a separate disease entity than the hŗdroga.  

Complication of Hŗdroga: Klama (tiredness), Avasāda (fatigue), Bhrama(mental confussion), Śotha(oedema) are the complication of Hŗdroga told by Mādhava Kara.

Sādhyāsādhyata of Hŗdroga: Vāta, Pitta, Kaphaja Hŗdroga  – Sādhya (Curable), Sannipāta, Kŗmija Hŗdroga    -  Asādhya (Incurable)

Mostly vātaja hŗdroga and hŗucchula  resembles the CAD. Most of the commentator use to correlate hrcchula with angina, as the management described in Ayurveda like sŗnga bhasma also mostly effective in this condition. There is srotorodha indicating the presence of atherosclerosis i.e. Dhamanī praticaya leading to reduced supply to the heart producing the pain.

Description of Hŗtśula may be a more specification by āchāryas. It too resembles mostly with the CAD mostly angina and MI. Hŗdaya being the root of Rasavaha Srotas , the most of the etiology initially are associated with rasa dusti leading to āsayadusti too. Along with the involvement of Vyāna Vāyu in the samprāpti of the disease ,the condition of srotorodha is also very clear. These pathogenesis may give important clue in the management.

Considering the pathogenesis of CAD, same srotarodha occours with artherosclerosis i.e. nothing but the hardening of vessels, which  causes vāta prakopa due to sanga . Hence, most of the commentator like to relate  Hypertension  with vyana vrutta vata , which mostly occurs as a consequence of artherosclerosis . Circulation is the most important function attributed to Vyāna and Kapha meda mostly play a important role in srotarodha , in the contemporary explanations in modern science too hyperlipidemia later leads to formation of artheroma and at last leads to conditions like angina or MI.

Ayurvedic Management

Ayurveda texts has got details of Management of Hŗdroga but the often emerging emergency situations in CAD had made a situation of confusion in the mind of many Ayurveda physician. Lack of proper researches to establish the traditional treatment and presence of high-tech management modalities in modern medical science force to opt for a contemporary measure. As we discussed the whole picture of the disease , emergency management is  not only the solution ,it is being the consequence of a long pathology and Ayurveda can do a lot in the preventive as well as to obstruct the pathogenesis . Present researches  had proved many aspects of these theory .

Goals of Treatment

1.       Rectification of underlying causes like diabetes, hypercholestremia, obesity etc.

2.       Pacification of Vāta and maintenance of balance state.

3.       Maintaining a healthy heart

4.       Opening the srotas i.e. to cure mārgāvarodha

5.       Maintaining of a healthy psychological state

Line of Treatment

 1. Nidāna Parivarjana is the first line of treatment advised by ācāryas. In CAD it has got an important role . We will discuss detail in the preventive treatment .

 2. Śodhana Chikitsā

Considering the etiopathogenesis of disease we need to determine first whether the patient is fit for a Santarpaṇa cikitsā or Apatarpaņa Chikitsā and we should proceed. In Santarpaņa cikitsā with or without mild śodhana we can proceed for a śaman treatment.

As discussed previously many of the patients may be with obesity. In those cases we can proceed for apatarpaņa mode of treatment i.e. the śodhana purvaka treatment or purification treatment.

·         Vamana with decoction added with snehalavaņa after a proper snehana have been told  by Ācharya Suśruta later being accepted in A.H., Bhaiṣajya ratnāvali as a initial treatment of Vātaja Hŗdroga. Later vamana had been contraindicated for cardiac patients in caraka samhita, but in case of vahu kapha, and valaban rogi vamana can be opted considering other conditions of roga and rogi.

·         Vasti:  Ācārya Vāgbhaṭa had described a taila cooked with Vilwa, Rāsnā,Yava, Kola, Devadāru, Punarnavā, Kulattha, Panchamula and prescribed to use as nasya or vasti. Some other vastis described in different context can also use given below-

-       Eranḑamulādi Niruha Vasti(indicated for kaphāvŗtta māruta in C.Si.3)

-      Rodhrādi Niruha Vasti ( indicated for for Hŗdroga, gulma in Su. Ci.38)

-      Balādi yāpana Vasti (C.Si.12)

-      Daśamulādya anuvāsana vasti  (described as Sarvavātavikāra nut in C.Si.4)

‘Vastirvātaharāņām’ i.e. vasti is the best treatment for pacification of vāta and in avrtta vata yapana vasti have been specially indicated by Caraka.Though virecana is not directly indicated eranḑataila is told to use for snigdha virecana in gulma cikitsā can also be adopted for proper vātānulomana.

Before Vamana or Vasti Mild Snehana and Swedana  should be adopted as snehana may cause vŗmhaņa and swedana is contraindicated in medaroga.

3. Śamana Treatment

Śamana or Pacification treatment is for both santarpaņa as well as apatarpaņa janya vyādhita patient. Before selecting a drugs for a CAD patient we have to consider the the etiopathogenesis of the condition in the patient. Ayurveda views a specific human body as a specific entity of creation and argue for specific treatment. A physician should take care of these fact while selecting a drug. Following drugs can be selected according to decision by the physician.

a.        Kaşāya (Decoction)

1.       Puşkaramulādi Kaşāya (C.Chi.26)

2.       Yavanilavaņādi Kaşāya (A.H.Chi.6)

3.       Viratarvādigaņa Kaşāya (S.Su.)

4.       Varunādigaņa Kaşāya (S.Su.)

5.       Utpalādi gaņa Kaşāya (S.Su.)

6.       Dasamulādi Kaşāya (Vŗhat Nighaņṭu Ratnākara)

7.       Nāgarādi Kaşāya(Vŗhat Nighaņṭu Ratnākara)

b.       Curna (Powder)

1.       Dāḍimādi Curna (A.H.)

2.       Hingwādi Curna

3.       Puşkaramulādi Curna (B.R.)

4.       Vaiswānara Curna (B.P.)

5.       Haritakyādi Curna (B.P./B.R.)

6.       Pippalyelādi Curna (B.R.)

c.        Taila/Ghrita

7.       Punarnavādi Taila (C.Chi)

8.       Souvarcalādi Ghŗtam

9.       Arjuna siddha Ghŗtam (B.P.)

d.       Āsaba-Arişṭa

1.       Pārthyādyārişṭa

2.       Daśamulārişṭa

3.       Jirakādyarişṭa

e.       Rasa-rasāyana

1.       Vŗhat vāta cintāmaņi

2.       Yogendra Rasa

3.       Hŗdayārņava Rasa

4.       Yākuti

5.       Yavāhar mohrā

6.       Viśveśwara Rasa

7.       Nagārjunābhra

f.         Others

1.       Śŗngabhasma with ghŗtam in Śula condition (B.P.)

2.       Raśona Kşīra pāka

3.       Arjuna Kşīra pāka

g.        Rasāyana Prayoga /Kalpa prayoga

Guggulu Rasāyana

Śilājatu Rasāyana

Raśona Rasāyana

 Ācāryas write that Rasāyana has got the capability to enhance the life expectancy of a human being, as it strengthen the tissues all over the body by its action on minute cellular level. It can alter the tissue death level too. Hence rasāyana like guggulu, raśona and śilājatu detail described in  bŗhattrayis can be a better choice. Some of them had proved to have regenerate the dead cardiac tissues after a ischemia in animal model. As it is told to practice rasāyana to avoid arişṭa lakşaņas by Suśruta  and Vāgbhata prefers to initiate rasāyana treatment in case of failure with all treatment at end stage of a disease. Actions of single drugs have been detailed bellow and some of them can be used as a kalpa cikitsā, which able to saturate the body with its functional principles .

Some other Considerations

Hŗdayagata Vāta Cikitsā : Ācārya Caraka had advised Amśumati kşīra pāka in this case and can be used.

Avŗtta Vāta Cikitsā: Yāpanā vasti and Rasāyana Cikitsā may be helpfull in CAD.

Gulma cikitsā principles  : these may be help full because Ācārya vāgbhaṭa says that both are having the same aetiogenesis.

Single Drugs

1.       Arjuna

2.       Raśona

3.       Guggulu

4.       Śilājatu

5.       Jiraka

Many researches in last few decades have established a good rationality of using these drugs. Few of them are cited bellow -

·         An experimental study was carried out in 50 dugs by ligating coronary artery and Arjuna decoction was administered . At the end of the study histopathological study revealed that Arjuna successfully regenerated the cardiac tissue in the infracted area. After carrying out coronary angiography in dogs treated with arjuna it was noticed that new coronary vessels developed (Gupta, 1972)

·         Antiarrythmic activity of rasona was shown as the Bulb in rat ration at 1 % for 10 weeks decreased coronary artery ligation induced arrythmia  . Garlic increased fibrinolytic activity significantly and inhibited platelet aggregation in vitro and in vivo .

·         A clinical study on patients of hypercholesterolemia associated with obesity. Ischaemic heart disease, Hypertension and diabetes was conducted at Banaras Hindu University, Varanasi, Crude Guggulu, 6-12 gm thrice a day in divided doses was administered orally for one month. Fall in total serum cholesterol and phospholipids were noted in all the cases treated with Guggulu. Body weight was also reduced significantly in all the patients.

·         In an animal experiment on rat given Inula before and after experimental MI shown to have an smaller increase in SGOT, LDH, CPK, CAMP, cortisol, pyruvate , lactate and glucose than those in untreated.

·         In a clinical trial it was given along with guggulu in about 200 subjects with CAD and found to have better result with reduction of dyspnoea and chest pain in about 80% .

Emergency Management

In a disease like CAD a medical emergency is possible at any moment. With the  availability of advance technology it is now possible to save thousands of life from death. Ayurvedic management in this particular direction lacks documentation, though various vaidyas are still managing this kind of situation reported from the various part of the country. Sanyāsa cikitsā along with hŗdroga cikitsā can be the line of management here. Śŗnga bhasma , Makardhwaja rasa can be administered immediately with honey as anupanam. Javahār moharā can also given with lukewarm milk.

Preventive Treatment

 Avoidance of Causative factor is of greater importance for management of a disease. It is of more importance for CAD patients. The risk factors have already have been discussed in detail earlier. So , Nidana Parivarjana includes-

-      Maintaining the serum cholesterol levels in risk groups

-      Maintainance of proper blood glucose level in diabetic patients.

-      Maintainance of blood pressure in hypertensive patients.

-      Avoidance of Smoking

-      Alcohol intake to be maintained in a proper dose.

-      Proper regular exercise

-      Maintenance of psychological harmony.

Importance of Vyāyāma

Proper exercise brings out following changes in body –

Lightness, Ability to work, Stability, Resistance to discomfort, Alleviation of doşas (mostly kapha) ,Stimulates agni.

Epidemiological studies on exercise and artheroscloretic disorders and CAD are confound by ‘healthy lifestyle’ changes, including changes in diet and weight reduction. The physicsl exercises should be regular and aerobic such as brisk walking . It may be regulate according to age. Three vigorous session a week may be appropriate for fit younger patients and brisk walking for 20 minutes a day may be appropriate for old patients. But we should always keep in mind that vigorous exercise may be dangerous for a angina patient oand other cardiac patients too.

Pathya āhāra and vihāra for Hŗdrogi

-      Light foods including śālidhānya, mudga etc.

-      Fruits like āmalaki, dāḑima, drākşā,

-      Vegetables like radish,Kusmānḑa, Paṭola, Banana

-      Buttermilk, rāga, sāḑaba , old jiggery etc

-      Śunṭhi, yavāni, rasona, haritaki, kustha, dhanyaka

-      Honey and vāruņi (must be in proper dose) , drinks made of candana

Apathya āhāra and vihāra for Hŗdrogi

-      Retention of urges of urine, vomiting, thirst, flatus etc.

-      Viruddhāhāra

-      Excessive intake of Uşņa, Guru, tikta, amla dravya

-      Śuşkaśāka

-      Kşāra, raktamokşaņa

-      Oily, spicy diet

-      More strainous labour, anger, mental tension, sexual act, excessive talking

-      Excessive intake of sun rays etc

 So, considering the pathyāpathya guidelines of ayurvedic texts and epidemiological recommendations following guidelines may be followed –

-      Diet should contain high fruit and vegetable and low  dairy products

-      Reduction of saturated fats in diet

-      Reduction of alcohol intake

-      Salt intake may be reduced if associated with HTN

Adravya Cikitsā : This includes Yoga, āsana, mantra and other mānasika chikitsā.Yoga is a effective measure to be adopted by a cardiac patient with proper expert supervision . Mostly āsana, prāņāyama nad dhyāna can be adopted for cardiac patients . Many clinical trials also proved the lipid lowering as well as emprovent in the cardiac function . CAD patients need regular exercise and Prāņyama can fulfill the motto behind it easily. Prāņāyama mostly encourage the tissue oxidation there by improvement in the blood circulation as well as srotas śodhana. A simple anuloma-vilomaPrāņayama may be practiced . However it may not be always suitable for all cardiac patients and should be done under proper supervision. Dhyāna or meditation can improve the psychic tranquility in stress condition and may prove beneficial for CAD patients under stress. As preventive care in high risk groups with obesity and diabetes bhastrikā, Uḑḑiyānabandha may be helpful. Suryanamaskar accompanies a group of postures that influences all the body system and can induce a better wet reduction as well as other required effect. Along with yoga ayurvedic concepts of Mānasika Cikitsā can be adopted in bringing a psychological .

Conclusion

So, Ayurveda has got a options for the management of cardiac pathologies both in curative as well as preventive aspect. Mostly the daily regimens, seasonal regimens and sadvŗttas may be emphasised for cardiac patients along with medication. However, we should not hesitate to take the help of emerging high-tech medical technologies for the betterment of the patients. As the whole medical system is only meant for the betterment of humanity. Sometimes a combined approach of Modern science and ancient system of medicine can serve the humanity in a better way.

Reference

1.      Amarakosa by Amarasingh

2.      Astangahridaya commentary by Atridev Gupta, Chaukhamba, Varanasi

3.      Caraka Samhita: Brahmananda Tripathi commentary , Chaukhamba , Varanasi

4.      Astanga Samgraha: Atridev Gupta CommentaryKrishna das academy , Varanasi

5.      Susruta Samhita : Ambikadutta Sastri commentary, Chaukhamba, Varanasi

6.      Susruta Samhita : Ghanekar Commentary,

7.      Madhava Nidana: Yadunandan Upadhyaya commentary, Chaukhamba, Varanasi

8.      Ayurvediya Kriyasarira: Vd. Ranjit Rai desai, Baidyanath Publication, Nagpur

9.      Bhabaprakash: Hariharaprasad Pandey commentary, Chaukhamba, Varanasi

10.  Dravyaguna Vijnana, P.V. Sharma, Chaukhamba, Varanasi

11.  Dravyaguna Vijnana, J.L.N.Sastri, Chaukhamba, Varanasi

12.  FLRHT, Banglore Compliation of Herbs CD ROM

13.  Bhaisajyaratnabali: Lalchandji vaidya commentary, Motilal Vanarasidas

14.  Rasatantrasara va Siddhaprayoga, Krishna gopal Ayurveda  bhavan, Kaleda, Ajmer

15.  Davidson’s Principle of Medicine, 19^th edition, Edited by Christopher Haslet, Churchil Livingstone

16.  Harrison's Principles of Internal Medicine, 17th Edition, Mc GraHill Publication

17.  Current Medical Diagnosis & Treatment 2007, Mc GraHill Publication

18.  API Medicine Update, Vol.18, 2008, API, India

19.  Vaidyan-KAPL-jan-march2007

20.  International Journal of Yoga , Vol. 1:1, Jan-Jun-2008

21.  International Journal of Pharmacology-april2009

22.  Asian Pacific Journal of Cancer Prevention, Vol 3, 2002

23.  www.who.int

24.  www.pubmed.com

25.  www.emed.com

 * The article have been published in the souvenir of National Seminar Hrdaya-09, organised by students Union, Govt. Ayurveda College, Tripunithura, Kochi, Kerala

Dr. Abhiram Thakur, MS (Ay) Scholar

Dr. S. G. Chandini, M.D. (Ay)

Dr. K.B. Sudhikumar, M.D. (Ay)

Leech application is an age old therapy of thousand years around the various corners of  the globe.  Ayurveda as the oldest existing system of medicine thought to be the first to  have the description of this. Apart from us Greek and Romans had also this practice from about two thousand years.                                           

       Around six hundred and fifty species of leech are known till date. Among them about fifteen are in use.  Hirudo medicinalis is mostly used all over as medicinal leech. A Leech can suck  about ten times its own weight without giving any pain sensation. Hence it found to be an useful therapeutic aid in blood letting  all over. In last few decades it had got a good recognition through out the world in the name of Hirudo therapy or leech therapy . Few years before US Food and drug Administration given green signal for the use of leech in America. 

History

As told previously Ayurveda is thought to be the first system t to use leeches. Some historicians differ some times in this regard.  The first Western citation is credited to the Greek, Nicander of Colophon (c 130 BC). In the middle of  19^th century it regained  acceptance . for this many authors refer various events -

In 1985, a Harvard physician was having great difficulty in reattaching the ear of a five-year-old child; the tiny veins kept clotting. He decided to use leeches and the ear was saved. Some author refers that  Contemporary leech therapy was pioneered by the surgeons, M. Derganc and F. Zdravic, who published a paper in 1960 describing the use of leeches to assist in tissue flap surgery. Some other says that a  more contemporary use of leeches was dicovered in 1957 by Markwardt.

Today leeches are bred in farms  in many institutions including Bristol Zoo Gardens and grown a business field too . A huge numbers of leeches are imported from England, Scotland  France, Hungary, the Ukraine, Turkey, Rumania, Russia, Egypt and Algeria.  Leeches have gained new fame in microsurgery, where doctors require the precision of the leech to drain congested blood from wound sites. Plastic surgeons are particularly grateful for the contribution made by the leech, due to their use in the treatment of difficult grafts and reconstructive surgery.

Present  Scenario of  Leech  application

Leech application is in practice in india traditionally from thousands of years. About no modification we have obtained in our procedure. How ever world scenario is some what different. Years before leech therapy was thought to be an orthodox way of treatment. As we saw only in the middle of twentieth century it was reestablished . Now many researches have been conducted all over the world on the effect of leech application in  various pathological conditions. Leech application to reduce venous congestion in reconstructive surgery, osteoarthritis are the leading field where it has been proved clinically too.  It is reported that Nadine Connor , scientist from University of Wisconsin at Madison have developed a mechanical leech. The device, which looks a little like a small bottle attached to a suction cup, delivers an anti-clotting drug to damaged tissue and then gently sucks out as much blood as needed. Many advantage and disadvantage are associated with it.

Major contemporary  application

 Reconstructive surgery

Leeches are now in use to  save lives and limbs, by reducing severe and dangerous venous engorgement post-surgery in fingers, toes, ear, and scalp reattachments., limb transplants, skin flap surgery; and breast reconstruction.

The surgeon usually has little difficult connecting the two ends of small arteries, since arteries are thick-walled and relatively simple to suture  However, veins are thin-walled, fragile, and difficult to suture. The surgeon may thus get blood flowing in the reattached arteries but not in the veins. With the venous circulation severely compromised, the blood going to the reattached body part becomes congested and stagnant. The reattached part turns blue and lifeless and is at risk of being lost. In this stage  of threatening venous insufficiency, but in presence of  adequate arterial flow leech application are proving to be an emerging successful therapy.

In this contest we may remember the jalouka indication as ‘grathite jalajanmabhih’ in our texts. But, now many cases are reported to be prone to be infected by Aeromonas hydrophila and some viruses occasionally.. Hence a preventive measure is essential for this , especially in sophisticated surgeries.

Osteoarthritis

Acharya Vagbhatta has indicated raktamokshana in Gridhrasi at the region of knee joint and in case of krostukashirsaka at gulpha . but generally raktamokshana is contraindicated in vatavyadhi. So, generally Indian Ayurveda physcician are not practicing jalouka karma in OA.

A group of doctors from essen, germany have published a research report  as  significant success in the management of pain, stiffness and function of the joints after leech application, with comparison to topical diclofenac application. Many researchers and physician from different part of the globe are also having reports in its favor. However the property of leech saliva is not yet clearly explained regarding its pharmacology of action.

Many researches indicate that the leech saliva possesses the effect of normalization and improvement of capillary circulation,  anti-inflammatory effect, antistressful and adaptogene effects, immunostimulating and  immunomodulating effects, anesthesia, anticoagulation, antibacterial effect, improvement of an endocellular exhange .

Haematoma

Boxers in the United States traditionally  use leech in the swollen haematomas formed  after boxing  so-called "blue eye" . By the employment  swelling  mostly disappear  with in few days of  leech therapy . Even our texts advise blood letting by jalouka in sopha yukta vrana. In clinical practice also we are getting good result in the same.

Eye diseases

 It is observed in different trials that the acute accumulation with Glaucoma responds well to a leech therapy. The headache and the eye pain mostly omit after setting the leech relatively rapidly and the internal pressure of the eyes regains its normacy. Apart from glaucoma leech application are practiced in many other diseases inside  India as well as abroad .Acharya Sushruta has indicated it   ….                        Some western authors advise the therapy in some inflammatory eye diseases like -  Chorioiditis, Chorioretinitis, Iridochorioiditis, Keratoiritis, Retrobulbaerneuritis, Skleritis etc.

Varicose vein

Many researchers from different corners of the globe had obtained impressive result in management of complications of varicose vein. Study by a panel of doctors in King Edward VII memorial hospital, Mumbai reported to obtain good relieve from oedema, hyper pigmentation like complications by leech application.

 Pain relieve and other uses

Egypt has a long tradition of leech application. With addition to blood vitiated disorder physcician of this region use leech in management of pain like headache, pain due to muscular cramp etc. Some texts advise it in complaints like  - Rheumatism, Arthrosis, Volume disk problems, Pulling, Bruises, Muscular pains, Muscle injuries.

Leech application is also widely practiced in other diseses related to circulatory insufficiency like – Thrombose , Cramp veins, Hemorrhoid, Cardiac infarct, Impact accumulations, Calcifying the containers, Tinnitus.

Ayurveda and modern approach of action of Leech application.

Acharya Sushruta describes that as leeches lives in water, it is  having cold character and is madhura in rasa. Hence iffective in the management of Pitta dusti.  During the process of feeding, leeches secrete a complex mixture of different biologically and pharmacologically active substances into the wound. Hirudin is the best known component of leech saliva. Hirudin is the most important active ingredient  in leech saliva. Many other active substances  and thir actions are:

Hirudin	Inhibits blood coagulation by binding to thrombin
Calin	Inhibits blood coagulation by blocking the binding of von Willebrand factor to collagen. Inhibits collagen- mediated platelet aggregation
Destabilase	Monomerizing activity. Dissolves fibrin. Thrombolytic effects
Hirustasin	Inhibits kallikrein, trypsin, chymotrypsin, neutropholic cathepsin G
Bdellins	Anti-inflammatory. Inhibits trypsin, plasmin, acrosin
Hyaluronidase	Increases interstitial viscosity. Antibiotic
Tryptase inhibitor	Inhibits proteolytic enzymes of host mast cells
Eglins	Anti-inflammatory. Inhibit the activity of alpha-chymotrypsin, chymase, substilisin, elastase, cathepsin G
Factor Xa inhibitor	Inhibits the activity of coagulation factor xa by forming equimolar complexes
Complement inhibitors	May possibly replace natural complement inhibitors if they are deficient
Carboxypeptidase A inhibitors	Increases the inflow of blood at the bite site
Histaminelike substances	Vasodilator. Increases the inflow of blood at the bite site
Acetylcholine	Vasodilator
Anesthetics subsctance	Anesthetic

Some Excellency in leech therapy :-

• Leech therapy in gross penoscrotal oedema in terminally ill patients with advanced prostate carcinoma:-Penoscrotal oedema in patients with hormone-refractory prostate cancer is an uncommon but very distressing complication. Management in these terminally ill patients should provide swift symptomatic relief.  The use of leech in these cases has been reported to have a better effect.  The use of leeches has also been reported in the successful treatment of postoperative penile swelling as well as scrotal haematoma.
• Meningococcal purpura fulminans treated with medicinal leeches :- According to a report by Department of Paediatrics and Child Health, University of Stellenbosch, Tygerberg Children's Hospital, Tygerberg, South Africa : A 5-wk-old female infant with meningococcal meningitis and septicemia and progressive purpura fulminans of the left hand was treated with medicinal leeches. Medicinal leeches were applied to the left dorsal hand on a daily basis for 4 consecutive days. In result it was noted that the swelling and limited functionality visibly improved after 48 hrs, and by 120 hrs, perfusion in the distal phalanges of the thumb and middle finger was evident. Reperfusion of the distal phalanges was not fully sustained, and at 6 wks the plastic surgery department debrided the distal phalanges of her left hand, excluding the thumb. She fully recovered from the meningococcal septicemic shock; the functionality of her left thumb was preserved, and she has limited functionality of her left hand.
• Leech application in Systemic Lupus Erythematus:- A RCT conducted by Nephrology Department, People's Hospital of Guizhou Province, Guiyang, China has obtained a significant reduction in the levels of plasma endothelin and soluble interleukin-2 receptor in patients with systemic lupus erythematosus.

In this way some excellent case reprt as well as researches have proved the efficacy of Leech application in the globe.

Discussion

So, these are the saga of leech therapy , those being used in various diseases according to the consideration of physicians. Mostly to improve blood supply to a region, getting out the pooled blood  and inducing haemolysis for a topical lesion it has got tremendous success. However the infection by Aeromonas hydrophila in cases of plastic surgery cases have opened a new  window to think about the prophylaxis measure in future. In this regard detail description of leech application, detoxification of the animal before use with Turmeric water exhibits the Excellancy of Indians. “Pragyanam brahma” being narrated  by our ancestors it will be a step     forward for “ Krunwanthu Viswam Aryam” if some more research and expansion of this sutrakrit knowledge will also be completed in India again.