Ayurvedic approach to treat Hridroga (valvular heart disease): A case report

Abstract

Kabhatika Hridroga (valvular heart disease) embodies a significant part of cardiovascular disease. There are many causes for valvular heart disease of which, the rheumatic fever is an important one. This study is a case report of a patient awaiting mitral valve transplant for valvular heart disease (i.e., mitral stenosis attributed to rheumatic fever), who responded well to Ayurvedic management. After 11 months of treatment, 3D cardiovascular cartography showed increase in mitral valve area from 1.3 sq cm to 3.52 sq cm (normal size is 4–6 sq cm). The present case report showed that Ayurveda has a great potential for the treatment of valvular heart disease and merits further research.

1. Introduction

The word ‘Hrudaya’ in Ayurveda is a synonym for heart in Modern medicine. The name itself indicates the function of this vital organ. ‘Hru’ means, one which draws fluid or blood from the body forcibly [1] and ‘Da’ which means to donate. Simply saying, Rasa (body fluids) and Rakta (blood) are circulated in the body, by the dual action of forcible collection and supply by the heart and thus the name Hrudaya in Ayurveda. This is the fundamental function of the heart. According to Ayurvedic texts, the heart originates from the essence of Rakta and Kapha, predominantly from maternal side, and develops into a muscular organ [2] Movement of the heart is controlled by Vyanavayu and so is the case of valvular disorders. It can be assumed that the pericardium is developed from Meda, myocardium from Mamasa and endocardium from Rasa and Rakta. Retention of vitiated rasa and rakta circulated in the endocardium may gradually develop valvular inflammation which in due course turns to another state of infection and ultimately in state developing Krimis. If this state continues for a prolonged period, due to mamsadusti, valves become degenerate, and valvular disorders like stenosis and regurgitation occurs. Characteristic feature of valvular heart disease is the presence of murmur. Mostly this disease is rheumatic in origin. This may be considered as a synonym for amavatha. So the treatment aims fundamentally to correct the imbalanced vata, rasa, rakta and mamsa. No synonym is found in Ayurvedic texts for valvular heart disease. Yet, they can be successfully treated by Ayurvedic medicines. Hundreds of formulations are portrayed in Ayurvedic classics.

2. Presenting complaints and medical history

A 40 year old married lady consulted in an Ayurvedic clinic at Kottayam, Kerala on 31.05.2015 with cardinal symptoms of breathing problem, chest pain followed by fainting for few seconds, difficulty in climbing steps. Other complaints included mild Bhrama (vertigo) breathing problem, Anaha (bloating), Agnimandya (Loss of appetite), palpitation, tiredness, burning ankle joints, left elbow joint pain, mild pain in right calcaneal area, regular throat irritation and colds, sneezing and severe klama (fatigue). Patient was not responded to earlier treatment ie., with Ecosprin and Anti hypertensive medicines. Use of antihypertensive medicine resulted in severe BP fall, and when the medicine to correct BP fall was administered the BP will again shoot up. So they dropped antihypertensive medicine.

In 2012, diagnosis of valvular heart disease was made, based on clinical findings, cardiomegaly on X-ray (04.06.2012) and ECHO findings (31.07 2012), confirming Valvular Heart Disease. For a long time, the case was under the surveillance of a leading Cardiac Surgeon at Chennai, and waiting for a surgical transplantation of Mitral Valve. Her medical history is notable for Addison's disease, diagnosed in 1993 and treated with wysolone for twelve years. She stopped medicines for Addison's disease by 2005, after APA - IGG and APA -IGM become normal. She has a history of two abortions. There was no family history of valvular heart diseases.

3. Clinical findings

On examination she had multiple joints pain that was deep seated, Aortic Rub, right calcaneal pain, silent nasal polyps, mid inter phalangeal and distal inter phalangeal deformities and decolouration on that area was also seen. Abdomen was distended. Liver was mildly palpable.

ECHO done on 31.07.2012 showed: Aortic Valve Disease, Trileaflet Aortic Valve, Thickened Edges, Mild Grade II AR and Mild MR, Grade I Diastolic Dysfunction, Good LV Systolic Function.

ECHO done on 04.08.2016 showed thickened aortic valve, aortic regurgitation mild, mitral valve appears thickened with mild regurgitation normal chamber dimensions, no regional wall motion abnormality, normal LV systolic function and contraction.

On USG, hepatomegaly seen. AntiphospholipidA (APA) -Ig G was 48.4, APA-Ig M was 13.5, both found elevated during the episode of Addison's disease. Advised the patient to undergo a non-invasive test 3D Cardiovascular Cartography. Test was done on 05.06.2015. Mitral Valve Orifice was reduced to 1.3 sq.cms (Normal above 4 sq.cms) Aortic Valve orifice was normal (4.35 sq.cms). Blood pressure was high (130/120), Systemic vascular resistance, Rate pressure product, Pulmonary vascular resistance etc., was high. In pulmonary dynamics air retention, pulmonary capillary resistance and pulmonary vascular resistance were found high. Fluid retention was marginal. ANS activity in reactive hyperaemia study was sympathetic. ANS Predominance is an excellent indicator of forced cardiac activity. Predominantly Sympathathetic subjects are prone to Cardiac anomalies including Cardiac Sudden Death Syndrome. Sympathetic activation has other important effects, which can be deleterious, including ventricular hypertrophy, enhanced arrhythmogenesis and molecular, and biochemical changes that lead to further dysfunction over time. It actually exacerbates heart failure. Total arterial compliance was impaired in basal study. It is very difficult to have a comparison, because Valvular heart disease as such has no place in Ayurveda. In such cases the only tool available for Ayurvedic diagnosis is the lakshana samuchaya and conceptual interpretation of clinical features and investigative findings in terms of doshadushyaadhishtan involved in the diseased state in a patient. However, this can be stated as a tridoshaj disorder, where dushya is mamasa, marma and adhishtan is hrudaya. This condition can be placed as a complication of amavat. According to Ayurveda, presence of Hrudayavidradhi for a prolonged period, without getting a specific treatment, may lead to the shosham or vaikalyam of valves.

4. Diagnostic focus and assessment

To assess the actual condition of the patient, three main investigations are done. One is 3D Cardiovascular Cartography test images. By this non-invasive test we can critically analyse for an early detection of Coronary Heart Disease. It measures the reduction of blood flow to the various regions of the heart. If there is a significant reduction of the blood flow, it is suggestive of the presence of obstruction (blockage) in blood vessel, which is decreasing the blood flow. It also provides an assessment of the functional status of heart, including how stiff the blood vessels are, the likelihood of clot formation, pumping capacity of the heart, size of the mitral valve, global cardiac efficiency and aortic valve orifice etc. This produces a complete cardiovascular physiological profile of a patient consisting over 64 cardiovascular functional parameters that directly aid in perfect diagnosis. Secondly the echo tests. Thirdly laboratory investigations, as follows.

5. Therapeutic focus and assessment

In this case, Ayurvedic diagnosis and interpretation is, accounting modern diagnosis also. Heart disease is the well known complication of amavatha. Ayurvedic texts mention two complications of amavata ie., Hrudayavishudhi (unclean state of heart) and Hrudgraha (impaired function of heart). In this case treatment is for hrudgraha, since Valvular heart disease is a complication of amavata. Basic principles of treatment applied here is as follows.

• 1.Lamghana: i.e., fasting or light diet, Restriction of diets as mentioned in Ayurvedic texts such as Characa.
• 2.Virechana: Mild purgation at regular intervals helps in getting rid of accumulated ama from the body.
• 3.Deepan Pachan medicines: Bitter pungent and deepan-pachan medicines which help digestion of ama. Deepan medicines act indirectly by stimulating digestive and tissue enzymes. While, pachana medicines help digestion by their direct action on food.
• 4.Rasayana and Ojaskara Oushadhas: After entire ama has been completely eradicated from the body as evidenced by feeling of body lightness, devoid of earlier presenting complaints, zeal, absence of joint swelling etc. Rasayanojaskara medicine are administered. In this case Punarnava Baladi ksheerapaka is given during the entire period of treatment, because of its Deepan, pachan, shodhan, sophahara, and Srotho shodhana properties. Besides, it is pushtikrit and khayanashana. Here we want the valves to be repaired by pushtikrit medicines. This will purify and rebuild the vitiated Ras,Rakta, Mamsa and medas. Rasayana and pushtikrit -khayanashana medicine can do this function effectively. Selection of medicines were, to serve the above purpose.
• 5.All the medicines except Herrak Bhasmam were given in usual dose. Heerak Bhasmam 100 mg was divided to 15 parts and one part with honey was advised in the morning after food and another doze in the night.
• 6.The patient was treated with Kashayams such as Dashamoola Punarnavadi, Thryantyadi, Rasna Dasamoolam, Punarnava Abhayadi, Vidaryadi, Nimbathwagadi Kashayam, and Padhyapunarnavadi Kashyam, Arishtas such as Partharishtam, Dasamoolarishtam, Roheetakarishtam, tablets such as Tab.Cardinox, Caps.Heartin, Tab.Hepano, Tab.Hridayarnavras,Tab.Sankara Bati, Tab.Chintamoni Ras, Tab. Sidhamakaradhwajam, Dasamoolahareetaki, Brahma Rasyan, Heerak Bhasmam, Punarnava Baladi ksheerpakam, Arogyavardhini, Pacnchakolachoornam (Rice Kanji), Arjuna kheerapakam, Dhanwantharamtailam pichu on chest, Gandharva Hastadi Erandam or Nakulatailam for mild purgation weekly twice. Symptom of hepatomegaly may be the result of prolonged use of steroids. Special instructions were given to calm the mind by breathing exercise and meditation. The details of treatment are given in Table 1, Table 2.

Table 1.

Timeline of events.

Sl. No	Date of Consultation	Symptoms	Clinical findings	Laboratory findings	Treatment given
1	07.06.2015	Breathing problem, Chest pain and fainting, Recurrent episodes of throat pain and cold. Difficulty in climbing steps	Multiple joints pain, Calcaneal pain, Mild deformities, Ayortic rub, Mild bhrama, body pain, fatigue	As in lab chart	Dasamoola Punarnavadi and Thrayanthyadikwath,Caps. Sing nada Gulgulu, Tab.Hridayarnavras, Caps.Heartin,Aswagandharjunras,HridayaSudha, Tab.Cardinox, Tab.Cosliv,Tab.SankaraBati, HeerakBhasmam, PunarnavaBaladiKsheeraPakam, GandharvaHastadiErnadam, BrihatSaindhavadiTailam, Dhavalalepam
2	22.10.2015	Feels better for above symptoms	Palpitation, Distension	As in lab chart	PunarnavaAbhayadi and Thrayanthyadi, Tab.ChintamoniRas (Instead of Tab.Sankarabati) Other medicines continued.
3.	31.12.2015	Body oedema mild, fatigue	Mild oedema seen on joints	As in lab chart	DasamoolaPunarnavadi and RasnaDasamoolam, Caps.Heartin, Caps Bonton, AswagandharjunRas, Caps.Heartin, Caps Bonton, AswagandharjunRas, Dasamoolarishtam,Tab.Cardinox,TabHepano, DashamoolaHareetaki,Caps.Obesil,Tab.SankaraBati, PunarnavaBaladiKsheeraPakam, Kethakeemooladi+ KarpooradiTailam, HeerakBhasmam, DhanwantharamTailam (Pichu), GandharvaHastadiErandam
4.	24.03.2016	Body itching, sramam, Klamam	Oedema subsided, liver palpable	As in Lab Chart	Dasmoola, Punarnavadi, Thrayanthyadi, Caps.Heartin,Caps.Liv Plus, Tab.Cardinox,TabHepano, Brahma Rasayan,Tab.Vidaryadi, Tab.Sidhamakaradwajam, PunarnavaBaldiKsheerapakam, HeerakBhasmam, DhanwantharamTaila (pichu), NakulaTailam (instead of Gandharvahastadierandam), HareedraKhandam
5.	10.05.2016	Itching decreased, Total health Better, Mild Aruchi, No breathing problem, No Chest pain, No fainting, No throat pain, No Cold. Climbing steps withoutdifficulty.	Sramam mildly better, periods time pain, Mild loss of appetite	Advised for 3D CCG, followup	DasamolaPunarnavadi and PadhyaPunarnavadi, Tab.Sankarabati (instead of Tab.Sidhamakaradwajam) HareedraKhandam stopped, PanchakolaChoornam (forpreparing Kanji).ArjunaKsheerapakam (instead of PunarnavaBaladi). NimbathwagadiKwath one doze daily with Tab.Arogyavardhini Other medicines continued

Table 2.

Laboratory tests.

Test Name	Result Date	Result Date	Result Date	Result Date
	05.06.2015	22.10.2015	02.01.2016	24.03.2016
Hb%	12	12.2	11.5	11.6
TC	9800	9200	8800	9400
Poly	65	60	60	62
Lymph	30	37	36	34
Esnophils	5	3%	4	4
Monocytes	Nil	Nil	Nil	Nil
ESR	48	35	35	37
ANA	9.82	9.27	3.59	3.95
Anti Ds DNA	3.25	3.65	3.02	14.12
ASO Titer	154.85	132.05	142.31	143.28
CRP	3.53	1.99	3.14	1.62
S.Calcium	9.1	9.4	8.6	8.4
S.Uric Acid	7.6	7.3	5.6	5.6
RA	9.4	9.45	9.1	9.52
Hs CRP	0.925	0.248	0.39	0.625
RBS	89	82	86	85
S.Bilirubin	0.9	0.8	0.8	0.6
Direct	0.4	0.4	0.4	0.5
Indirect	0.4	0.4	0.4	0.4
SGOT	39	35	39	23
SGPT	48	43	31	28
BUN	15	14	14	15.4
S.Creatinine	1.2	1.01	1.14	1.22
Ratio B/C	13.8:1	13.05:1	12.2:1	11.1:1
AFP				4.4

6. Follow up and outcomes

Follow up has done regularly. After five months treatment patient felt good health and devoid of major complaints. Treatment continued for a further period of six months altering few medicines according to presenting sysmptoms.(see the time line chart). On 13.05.16 a follow up 3D Cardio Vascular Cartography test was done. It was found that the Mitral valve orifice rebuild to 3.52 Sq.cms from 1.37 Sq.cms. Total arterial compliance becomes normal. Refer the 3DCCG Summary, before treatment and the 3DCCG Summary, after treatment to assess the improvement.

7. Discussion

In Ayurvedic texts, two complications of Amavata are explained, one is Hridayavishuddhi and another is Hridgraha (Cardiology in Ayurveda by Dr.V.B.Athavale). Hridayvishudhi may be considered as the unclean state of the heart and Hridgraha as the impaired condition. Due to regular and prolonged accumulation of the Ama in the heart, the proper function of the heart may get impaired. Accumulation of ama in the endocardium gives rise to valvular heart disease [1] . In amajwara, Hridyavishuddhi is one of the symptoms. In charaka samhita there are so many clinical features of hridroga, which may correspond symptoms of valvular heart disease. Vaivarnya, Kasa, Swasa, Murcha, Ruja and Jwara are mentioned in charakasamhita. Swasa (dyspnoea) and tamakaswasa are differentiated. In which Tamakaswasa is a sign of Hridayavishuddhi and whose cardinal symptom is-‘Asine labhatesaukhyam’ [2]. So, swasa may be correlated to Hridgraha, an advanced impaired sate of heart. In this case, valvular heart disease is included in Hridgraha category. Medicines selected are mainly having Deepana-Pachana-Hridya properties. Another aim was to rebuild or correct the degenerated valves to its original texture by administering pushtikrit or kshayanashanam medicines. Before and after treatment, special care was given to apply techniques and methods of modern science to test and validate the results. Most of the modern doctors didn't accept the 3D cardiovascular test, so an echo test was also done for the acceptance of modern fraternity and to establish the efficacy of the age old indigenous System, Ayurveda.

8. Conclusion

This case emphasises, the need of the era to develop Ayurvedic Cardiology Management widely. In such cases surgical intervention is the only remedy in modern medicine. While, in Ayurveda so many drugs are available to treat different conditions of heart disorders, which are helpful in preventing, treating, relieving the symptoms and take care of the valves from further damage. By intensive practical study we can sort it out. In this case no Panchakarma Therapy was advised due to the patient's job related inconvenience. Surely, Panchakarma will fortify the effect of the normal treatment and we can minimize the period of medication to a certain extent.

8.1. Patient viewpoint

The patient was highly satisfied with the line of treatment. She has no chest pain and associated symptoms now. No fatigue. She is doing routine work effortlessly. Recently, she climbed a hilly area without any discomfort. The quality of personal and official life of the patient has improved a lot. Instead of a blank future she has now developed confidence and total well being.

8.2. Patient consent

Written permission for publication of the case study had been obtained from the patient.

Sources of funding

None.

Conflicts of interest

None.