Coronary artery disease

Coronary artery disease (CAD) manifests itself starting in middle age, emerging as a chronic or acute clinical picture. In its chronic form it can present as thoracic pain (angina pectoris), dyspnea in differing degrees of severity as a symptom of cardiac insufficiency (ischemic cardiomyopathy) and as sudden cardiac death. As an acute coronary syndrome, ACS, the acute form of coronary artery disease leads to instable angina pectoris (especially thoracic pain during repose or induced by the slightest exertion), heart attack (non-ST-elevation-myocardial infarction, NSTEMI or ST-elevation-myocardial-infarction, STEMI) and sudden cardiac death. The high incidence of coronary artery disease in the second half of life contributes to diseases of the cardiovascular system being the most frequent cause of death in the Western hemisphere.

Under conditions of familial disposition, life style factors (poor diet accompanied by obesity, lack of exercise, smoking, limited emotional and spiritual self-determination) and accompanying diseases (dyslipidemias, diabetes mellitus, arterial hypertonia), atheriosclerotic plaques start to form in the coronary vessels which, as calcifying stenoses, can lead to the symptoms of chronic coronary artery disease or through plaque rupture followed by thrombotic occlusion of the vessel to acute coronary syndrome (heart attack). In addition to anamnesis, diagnostics pertaining to coronary artery disease includes in particular ECGs, imaging (echocardiography, cardio-CT, cardio-MRT), ischemia diagnostics (ergometry, stress echocardiography, myocardial scintigraphy, stress MRT) and invasive angiographic imaging of the coronary vessels (coronary angiography) as the basis for making decisions on which treatments to use (1, 2).

From the perspective of anthroposophic medicine, arteriosclerosis inflammation (dissolution of structures, cell filtration) and sclerozation (deposits and transformations, collagen formation) can stand in a pathophysiologically polar relationship to each other over quite long periods of time without being able to balance each other out in a physiological sense. In cases of coronary artery disease, this pathogenesis takes place in the middle human being, i.e., in the representative of the rhythmic organization (functional threefold organization of the human being). Apart from the circulatory system of the heart (the coronary system), which is devoted to fluid organization, there is the circulatory system of the lungs (“small circulatory system”), which serves the exchange of gases; it is not involved in arteriosclerotic disease processes, however. Sclerosis of the coronary arteries can put limits issuing from the body’s functional center on the degree of freedom which a human being has for taking action (angina pectoris, dyspnoea) or in the case of a plaque rupture lead to imminent or complete separation of the life processes from the physical organization (heart attack, cardiogenic shock, sudden cardiac death). Thus to gain a more in-depth understanding of processes which are typical for such diseases one must have knowledge of the interaction between the four entities of the human being and this must be incorporated into extended diagnostics accordingly. Disease emerges if the “upper entities” (Ego and astral body) exert an effect but no harmonizing influence on the “lower entities” (etheric body and physical body). One-sided transformative (sclerotic) or one-sided dissolving (inflammatory) tendencies can lead to pathologies such as those found in coronary artery disease in the middle human being with all of its clinical manifestations. Whereas the fluid organization (etheric organization) ultimately withdraws from cardiac activity in the course of the arteriosclerosis of the coronary vessels, a pathological awakening of the otherwise dreaming astral body in the middle human being occurs at the soul-spirit level which manifests itself in the form of angina pectoris and fear of death, threatening the person’s entire individuality in this way. The fear of death which accompanies acute coronary syndrome (instable angina pectoris, myocardial infarction) can also become a deadly fear: excessive intervention of the Ego and astral organization could, via cardiogenic shock or ventricular fibrillation (sudden cardiac death), cause the etheric organization to withdraw completely from the physical body (3, 4, 5, 6, 7, 8).

In cases of acute coronary syndrome (ACS, NSTEMI, STEMI), revascularization by means of percutaneous coronary intervention (PCI) as described in the guidelines is viewed as a recognized evidence-based primary therapy not only because it has an immediate effect on symptoms but also because it improves the long-term prognosis. The effect of revascularization is reinforced by medicinal anti-coagulation and thrombocyte aggregation inhibition and supported by prompt initiation of secondary prevention. This includes making lifestyle modifications in regard to smoking, diet and exercise as well as influencing fat metabolism (through use of statins), high blood pressure and diabetes pharmacologically. When left-ventricular function is limited, early initiation of treatment for heart insufficiency is necessary. In cases of symptomatic chronic coronary artery disease one must decide whether interventional (PCI) or surgical treatment (aortocoronary bypasses, CABG) is called for depending on the angiographic finding and after evaluating the clinical importance of coronary stenosis (evidence of ischemia, measurement of fractional flow reserve). Here thrombocyte aggregation inhibition and medicinal or lifestyle-modifying secondary prevention as well as heart insufficiency treatment in cases of limited left-ventricular function follow as well. In the framework of individualized decision-making processes, treatment of ischemic cardiomyopathy also includes primary prophylaxis of sudden cardiac death through use of an implanted defibrillator (ICD) after risk stratification has been performed and, in cases of survived sudden cardiac death due to ventricular fibrillation, secondary protection through an ICD (2).

After beneficial and often life-saving corrections and modifications of the disease substrates have been made, the potential of medical treatment oriented to the disease process (pathogenesis) is usually exhausted. This part of the treatment is often equated with healing, however, even though the underlying pathophysiologies are not affected in any causative sense. Thus disease processes can continue to exist and exert an eminent influence on the destiny of the individual patient. In contrast, therapy approaches which are oriented to the healing process (salutogenesis) are characterized by the fact that they place the disease in its overall context and support healing through additional therapeutic measures and medicines. If the physician searches for the healing requirement in cases of coronary artery disease this ultimately involves ensuring that the upper entities (Ego, astral body) exert a healing rather than a detrimental effect on the lower entities (etheric body, physical body). The heart organ and heart activity are essentially the archetype of the life-giving rhythm which preserves the middle and integrates the past, the present and the future in simultaneity. In cases of disease, the healing intervention of the upper entities needs the supportive therapeutic help of the physical, the soul and the spirit level. This can primarily be achieved if the Ego organization and the astral body regain the capacity to exert an ordering effect on the physico-etheric functionalities (for example through lifestyle modifications in secondary prevention of coronary artery disease) or if corrections are made at the physico-etheric level which succeed in reincorporating the “upper” entities into the physiological processes in the first place (for example revascularization in treatment of coronary artery disease).

Anthroposophic medicines derived from natural realms are used because they rely on the regulatory capacity of human beings in the sense of an active healing principle and are able to support physico-etheric processes under the guidance of the upper entities. Disease processes (sclerosis) can abate and healing processes (inflammation in the sense of physiological contra-regulation) can be supported (9). One example which can be cited in this context is the herbal “heart remedy” Cardiodoron® developed by Rudolf Steiner, which is obtained from the blossom of the primrose (Primula officinalis), the leaf of the black henbane (Hyoscyamus niger) and the blossom of the cotton thistle (Onopordon acanthium). A characterization of these plants elicits an image of polarities (nerve-sense system and metabolic-limb system) connected by the rhythmic centre (rhythmic system), i.e. the heart function itself : the blossom of the primrose, which is the expression of a plant entirely immersed in the fluid-soft element of spring-like forces of growth, and the blossom of the cotton thistle, which is native to the dry-hard element of midsummer, are connected by the rhythmically evolved image of the black henbane. From this a broad indication for treating disorders of the cardiovascular system is derived, with Cardiodoron® constituting a time-tested basis for supplementary treatment. Modifications of cardiovascular function in healthy human beings in the sense of a capacity for salutogenic regulation have manifested themselves here. (3, 10).

Orientation aids for using remedies developed by anthroposophic medicine for treating coronary artery disease are introduced in the corresponding chapters of the following, currently valid compendia: “Innere Medizin – Grundlagen und therapeutische Konzepte der Anthroposophischen Medizin” (3), “Vademecum of Anthroposophic Medicines” (11), “Anthroposophische Arzneitherapie für Ärzte und Apotheker” (12).

In anthroposophic medicine, the repertoire of non-medicinal therapies for treating coronary artery disease includes eurythmy therapy and art therapies such as therapeutic painting, speech and music therapy and sculpture as well as physiotherapy, nutritional medicine and psychotherapy. The therapeutic spectrum is supplemented by qualified health care through external applications such as special inunctions and poultices. The general aim of this therapeutic spectrum in its use for patients with coronary artery disease is the “development of the spirit, maturation of the soul and healing of the body” (3).

Training of the will in all cognitive and bodily activities (through eurythmy therapy, for example), promotion of feeling as regards perception of the self and others (for example through art therapies) and development of cognition through orientation to objective truths (for example through meditation) all promote the autonomy of the diseased individual and with it his salutogenetic potential in his encounter with the disease. In this way the ultimately indispensable prerequisites for successful lifestyle modification, which forms the basis for all primary and secondary prevention of cardiovascular diseases and is also called for in the current international guidelines, can be fulfilled. (13)

In cases of sclerozing cardiovascular diseases such as coronary artery disease, the development of a culture of movement which is adapted to the patient’s individual capacities and allows him to counteract, through proper motion, the dominance of being moved by external forces through modern means of transportation and changes in the work world is particularly important. The connection between the disease-promoting condition of being moved by external forces and the healing effect of proper motion as formulated by Rudolf Steiner in 1920 (14, p. 177) on the basis of extensive epidemiological data has become the premise for every primary and secondary concept in cardiology (13, 15). The framework is provided by the notion that deposits and sclerozation connected with coronary artery disease are subjected to a “physiological inflammation aspect” (development of warmth, increase in metabolism) through proper motion and transformed into a healing process as a result. In eurythmy therapy the aspect of movement is enhanced by individualized “penetration of the soul” and verifiably intensified in its therapeutic function (16).

In view of diverse psychogenic and personality-related influences on the emergence and healing of coronary artery disease (17), it is especially important to train and develop the patient’s soul-spirit capacities during treatment. The central elements of anthroposophically extended “psychocardiology” are the development of regulated thought, consistency of action, forbearance (tolerance) and impartiality (positivity) as well as equanimity (being unprejudiced) in the emotional life (1), (18, pp. 127ff.). In regard to what are in general deeply rooted impediments which make it difficult for patients with coronary artery disease to make long-lasting lifestyle modifications, the value of a form of “psychocardiology” which trains the spirit and the soul concretely while promoting the autonomy of the individual to the maximum possible degree cannot be overemphasized.

It ultimately opens up the spiritual dimensions of human existence, disease and healing. The mantras formulated by Rudolf Steiner in regard to the heart organ possess a potential which can be rendered therapeutically effective under certain individual preconditions (19, 20). An intensification and stabilization of the actively exercising elements of non-medicinal therapy procedures of anthroposophic medicine which are aimed towards development is the goal of so-called heart schools like those which have been established in Berlin, for example (Havelhöher Herzschule) and in the meantime at four other locations as well. Borrowing on the concept of D. Ornish (21) expanded to include aspects of anthroposophic medicine, these schools aim for stabilization of lifestyle modifications which are to be made in the framework of an ongoing programme (abstention from nicotine, dietary and exercise training, psychotherapy, nurturing of creativity and imagination) in such a way as to trigger long-term “inner” development, the result of which is the visible transformation of lifestyle habits (22, 23). In this way coronary artery disease can lead those affected to an inner transformation which allows them to master the task of shaping certain future capacities out of given conditions of the past in the sense of an inner path (spiritual training).

Since the core concern of anthroposophic medicine is to achieve a highly individualized degree of medical treatment, its success depends to a decisive degree on the ability of the physician to recognize the characteristics of the disease in question and the possibilities which the patient has for “recovering health.” Individualized, multi-modal therapy, the patient’s free will, the freedom of the physician to make decisions and the ethics which inevitably emerges as a result are the pillars of anthroposophic medicine. Clinical endpoints and criteria for describing quality of life for purposes of scientific measurement can be used in anthroposophic medicine as well but they cannot be compared with other forms of treatment through blinding and randomization of individual patients. In addition to findings-oriented and prognosis-related endpoints (physical level), the effectiveness and benefit of medical interventions can only be depicted in the sense of anthroposophic medicine if questions concerning the patient’s condition and well-being (soul level) as well as connotation and meaning (spirit level) are also pursued and evaluated (24), (3, p. 79ff.). Comparative prospective cohort studies which compare conventional treatment of coronary artery disease with that extended by anthroposophic medicine do not currently exist, nor does any systematic single-case research (25). In order to avoid randomization of patients who do not wish to be randomized when carrying out comparative studies, several cohorts could be formed, for example: a group receiving conventional treatment, a group receiving anthroposophic therapy in combination with conventional treatment, a group receiving anthroposophic therapy but no conventional treatment and so forth. In this way the question could be pursued, for example, as to whether anthroposophic medicine offers remedies and methods of treatment which constitute a substantial extension of scientifically established treatment of coronary artery disease. In addition, cardiovascular medicine stands before the task of processing data scientifically in detail which make it possible to compare the effects of pathogenetically oriented treatment approaches (for. ex. interventional cardiology) with those of salutogenetically oriented treatment methods (for. ex. life style modifications and even spiritual practice) in the context of socioeconomic development, thus rendering them assessable.

While such scientific developments are still underway, the anthroposophic approach to cardiology has evolved into a medico-therapeutic application that has stood the test for decades, earning itself the serious trust of patients and sought after in the practices of family physicians and internistic cardiologists as well as in hospitals specialized in this area.

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