Kristina M. Erwin Congestive Heart Failure (CHF) is commonly seen in veterinary practice. Understanding the pathophysiology from a conventional and Traditional Chinese Veterinary Medicine (TCVM) viewpoint allows the practitioner to identify multiple pathways for intervention to help stabilize the patient and improve quality of life. An integrative, multi-modal approach including conventional drugs, herbal medicine, acupuncture, rehabilitation, nutrition, and husbandry care further helps to address the primary disease as well as other co-morbidities that often occur with CHF. These techniques can benefit CHF patients throughout the course of their illness from initial diagnoses through to hospice and end-of-life care. Congestive heart failure (CHF) is a complex clinical syndrome arising from structural or functional impairment of ventricular filling or ejection of blood. Decreased cardiac output (CO) causes lower blood velocity and blood to pool. Left sided heart failure leads to congestion in the lungs with edema while right sided failure leads to systemic venous congestion and peripheral edema or ascites. Decreased CO also causes decreased renal blood flow and GFR, leading to further sodium and fluid retention [1]. These physiological changes lead to neuro-hormonal responses that increase vasoconstriction and peripheral vascular resistance to try to improve circulation. The heart rate increases to compensate for decreased CO and the heart chambers may dilate or the muscle itself may hypertrophy. The result is increased sympathetic nervous system activation [1]. Clinical signs of CHF include dyspnea, cough, exercise intolerance, sarcopenia, and collapse. Affected animals progress through three stages of increasing severity with clinical signs for Class I only apparent during vigorous exercise, Class II seen during minimal exercise and Class III animals affected even at rest [1]. Conventional treatment depends on disease severity with prognosis for these patients greatly improved by the availability of newer pharmaceutical drugs as well as the expertise of veterinary cardiologists (Table 19.1). Table 19.1 Common pharmaceuticals for management of CHF (Note: Please check a current veterinary formulary for the most up to date recommendations for dosage and administration). Pimobendan Note: Administer tablets at least one hour before feeding as absorption is reduced when administered with food. Enalapril Benazepril Sotalol Atenolol Aspirin Clopidogrel Taurine Carnitine Potassium An understanding of CHF from a TCVM viewpoint can further give the practitioner opportunities for supporting patients and improving quality of life. In TCVM, the Heart is considered the Emperor of the body and it governs Blood circulation, houses the Shen (spirit), and controls sweating [1, 2]. Heart Qi supplies the power to pump blood through the body, and the Heart, Lung and Liver all play a role in circulating the Blood. The Heart (and Lung) make Blood from nutrients provided by the Spleen. The Blood is the root of the Shen and the Heart/Blood complex directly affects the mental activities of memory, thinking, and sleep. In health, the Shen will be balanced, peaceful, and joyful. If the Shen is deficient, mental activities are weak and anxious [1, 2]. There are six TCVM Heart Patterns involving Qi, Yin, and Yang (Table 19.2) and 2 TCVM Patterns involving Zang-fu organ imbalance (Table 19.3). Table 19.2 Heart TCVM pattern differentiation and treatment [1]. Xie, H et al., 2013; [3]. Beebe, S. 2009. Sheng Mai San, Yi Guan Jian a Dr Xie’s Jing Tang Herbal Inc, Ocala, FL. USA. b Seven Forests Herbal Formulas, Institute for Traditional Medicine (ITM), Portland, OR. USA. Table 19.3 Heart TCVM patterns involving Zang-fu organ imbalance [2]. Pulses: superficial, slippery to toneless Tongue: red, purple red, or dark red. * This formula increases peripheral blood flow, which reduces heart workload; helps clear hilar edema, acts as anti-tussive # This formula can be added to heart failure patients with severe pulmonary congestion. Because CHF is a medically complex disease and most patients are clinically fragile, it is helpful for practitioners to approach case management from a broad perspective. Integrative therapies can improve quality-of-life (QOL) and outcomes for CHF patients. Practitioners should work to match treatment recommendations to client goals, patient tolerance, and the patient’s overall clinical status. Treatment recommendations should be revisited frequently to ensure they are appropriate as the case evolves and changes. Actions: Mild positive inotrope; anti-arrhythmic; antiplatelet aggregation; vasodilating; endothelial protective; decreases arterial blood pressure; antioxidant [4]. Research:
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Integrative Approach to Cardiovascular Disease
Introduction
Pathophysiology of Congestive Heart Failure (Conventional)
Pharmaceutical effect
Example
Phosphodiesterase (PDE) III selective inhibitors
ACE inhibitors
B-Adrenergic receptor blockers/antagonists
Loop diuretics
Furosemide
Aldosterone antagonists
Spironolactone
Pyridine-sulfonyl urea type loop diuretics
Torsemide
Selective phosphodiesterase V inhibitors
Sildenafil
Methylxanthine drugs
Theophylline
Cardiac glycosides
Digoxin
Anti-coagulants
Na-channel blockers
Mexiletine
Ca-channel blockers
Diltiazem
Nutritional supplements
Pathophysiology of Congestive Heart Failure (Traditional Chinese Veterinary Medicine)
TCVM pattern
Etiology
Clinical signs
Treatment goals
Treatment options
Heart Qi-blood stagnation
Excess or deficiency (upper-Jiao), causes blood stagnation or sluggish circulation; blocks heart Qi
Painful back/chest, restless, deep-slow pulse, tongue-grey/purple with petechia; Class I disease
Eliminate stagnation/pain, activate Qi-blood
Compound Dan Shen a
Heart Qi deficiency
Weakened heart (e.g. age, sick, congenital), poor circulation, stagnation with damp accumulation
Shortness of breath, lethargy, pale-tongue, weak-irregular pulse
Tonify Heart Qi
Heart Qi tonica
Heart Yang deficiency
Cold with Qi deficiency, stagnation with phlegm obstruction
Shortness of breath, lethargy, loose stool, cool body, pale/ purple-tongue, weak-irregular pulse
Tonify Heart Qi and warm Yang, strengthen Heart, eliminate cold
Bao Yuan Tang
Heart and Kidney Yang deficiency
Kidney Yang deficiency leads to heart Yang deficiency; Shao Yin pathogens
Ascites, edema rear limbs, cool back/limbs, slow-superficial-toneless pulse, tachycardia
Tonify Kidney and Heart Yang, warm the Yang
Zhen Wu Tang, Epimedium 8 formulab
Heart Yin and Qi deficiency
Qi-Yin damaged, weak Kidney Yin affects fluid balance = increased blood viscosity, false heat encourages phlegm obstruction/stagnation, Qi deficiency weakens heart
Pain in chest exacerbated by moving; dizziness; red tongue; weak-irregular pulse
Tonify Heart Qi and Yin, activate Blood, regulate pulse
Collapse of Yang Qi
Extreme progression of Heart Qi and Yang deficiency with syncope or coma
Coldness limbs/back, urine retention, blue-purple tongue, feeble pulse
Revive Yang to resuscitate collapse
Shen Fu Tang
TCVM pattern
Etiology
Clinical signs
Treatment goals
Treatment options
Wood-Metal imbalance
Cycle of Qi not moving into Lung, fluid accumulation, prevents Blood production, creates Qi stagnation
Pulmonary edema, harsh chronic cough (worse 3–5 AM); thin-weak pulse, lavender tongue, cool extremities
Move Qi and Blood, tonify Blood
Xue Fu Zhu Yu Tang*
Shao Yang disharmony
Excess: Yang trapped internally, Qi-blood trapped in Lung, hindering circulation to periphery
Pulse becomes hard, internalized
Chai Hu Jia Long Gu Mu Li Tang #
Deficient: Yang trapped in upper-Jiao and on body surface; Fluids cannot descend from Lung to Kidney, Yin and Yang cannot integrate, source Qi cannot be made.
Integrative Therapy
Botanicals for Cardiovascular Support
Hawthorn (Crataegus spp.)
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