Cardiology

Whoever feels compelled to expand on scientifically informed contemporary medicine to include spiritual-scientific aspects of anthroposophy will inevitably encounter the endeavours which the physician Ita Wegman (1876–1943) and the natural and spiritual scientist Rudolf Steiner (1861–1925) made to reflect on and integrate established scientific medicine into their own approach in the best sense of the word. In the introduction of their work Foundations for an extension of the art of healing according to spiritual-scientific insights, the authors write: “This does not entail opposition against practice of medicine based on currently accepted scientific methods; its principles are acknowledged by us in full. And we are of the opinion that what we have to offer should only be used for the art of healing by those who can call themselves full-fledged physicians in the sense of these principles.” The introduction goes on to say: “We merely provide additional insights which can be gained through other methods to what one can know about the human being on the basis of currently accepted scientific methods. Such a broadened understanding of the world and the human being induces us to work towards extending the art of healing.” (1, p. 7). What Ita Wegman and Rudolf Steiner postulated in 1925 has maintained its full validity after all the scientific, technological and industrial developments of the past 90 years. Thus all the insights of physiology, pathophysiology, biochemistry and molecular biology which are accessible to us today as well as all modern diagnostic and therapeutic methods and forms of treatment including interventional and surgical procedures must be taken into account when it comes to the physician’s practice. From an anthroposophical perspective, the insights and techniques which have evolved in the natural sciences need to be extended to an understanding of the world and the human being which makes it possible to explain material conditions at the physical level in the first place, namely through insights into the superordinate principles of the human soul and spirit. These cognitive methods, which lie beyond object-oriented scientific thought, i.e. imagination, inspiration and intuition, have been frequently depicted by Rudolf Steiner and introduced in his seminal work on the extension of medicine due to their central importance for anthroposophy (1).

For all its scientific, pharmacological and technological progress, contemporary established medicine is far from being able to gain a full understanding of diseased human beings in their overall context. Moreover, experiences of the 20^th century have shown that without radical ongoing development of scientific paradigms which are still one-sided in their materialistic orientation, inhumane derailments cannot be ruled out in connection with totalitarian ideologies (2, 3). Since the supersession of natural philosophy by materialistic science in the mid-19th century, limits seem to have been placed on methods of cognition which can only be scrutinized and corrected through an interpretation of physical, emotional and spiritual aspects of human existence immanent to reality (2). In his professorial dissertation (Habilitation), P. Heusser presented a systematic scientific study on questions of cognitive methodology which suggests that in medicine a reconcilability of natural and spiritual science in the anthroposophic sense is indeed possible (4). Medicine “extended” in this sense must be able to go beyond the level of natural science, incorporating the dimension of the soul and the spirit inherent to an understanding of human organs and disease and addressing the consequences which this has for diagnostics and therapy so as to be able to make a substantial contribution to a further development of currently established scientific “doctrine.” In any case, a viable set of terms for the dimensions of health, disease, healing and dying can only evolve by overcoming the scientific ways of thinking solely applicable in the anorganic realm.

If one is to understand the contribution which Rudolf Steiner’s anthroposophy made towards extending prevailing doctrines in the field of cardiology, it is necessary to sketch the development of the scientific paradigms on which our “view of the heart” are founded. The work of Thomas Fuchs on the “mechanization of the heart” (5) and that of Peter Selg on “the sacramental physiology of the heart organ“ (6) treat this topic in great depth, addressing in a representative way the problems and tasks which are inevitably ignored by even the most successful endeavours of medicine as long as it limits itself to purely scientific methods.

After the Galenic system (Galenos of Pergamon, 129–216 A.D.) had remained unchallenged for almost 1400 years, the circulatory system was discovered by William Harvey (1578–1657) at the advent of modern times, in 1628. Under the influence of Aristotelian thought, anatomy and applied mathematics, Harvey succeeded in bringing together Galen‘s complicated construct of two “blood systems,” that of the lungs and the liver, through his recognition that one uniform circulatory system exists whose central organ is the heart. Harvey’s way of thinking was still far from simplifying the physiology of the heart mechanistically, however. He attributed heart-independent motion to the blood since he posited that there must be a force which moves the venous blood to the heart, hence also positing that there must be motion before the contraction of the heart muscle. Moreover, on the basis of his observations of dying animals he showed the pre-conditions for blood motion, calor and spiritus, championing a vitalist position in this way. Rene Descartes (1596–1650), a contemporary of Harvey, immediately seized upon the new circulation theory with great consequence, for despite its vitalistic premises, it lent itself well to being integrated into his system of natural philosophy although it was conceived in purely mechanistic terms. The notion of the motion of blood as something “driven by the soul” (vitalism) was replaced by the notion of a pump-operated circulatory system based on a “soulless” mechanical automatism, i.e. one controlled by reflexes, which merely obeyed the natural laws of physics (mechanicism). Thus a dualistic approach to physiology which separated functions of body and soul became the point of departure for a very controversial scientific discourse which was to last for a long time to come. In the course of this two-century-long scientific dispute, the circulatory system with the heart as its central organ was persistently subjected to the paradigms of mechanicism. The controversies which raged between the vitalists and the mechanicists reached a preliminary end around 1850, however. As the German physiologist Alfred Wilhelm Volkmann (1800–1877) wrote in 1850: “The heart is a pump station and as such it possesses enough force to drive the blood mass in the circulation through the entire system of vessels” (5, p 204). This laid the foundation for an understanding of organs and the human organism which still prevails today, – one which has lost the ability to connect with the superordinate principles of vitality.

This reductionist construct which informs the purely mechanistic “view of the heart” was radically challenged by Rudolf Steiner in the early 20^th century, being subjected to a revision involving a comprehensive reorientation of the relevant premises which encompass human organization in its totality: 1. Blood motion is based on the activity of the individual human being in the organism and is thus only conceivable in the context of the superordinate principles which define the vital aspect (unity of body, soul and spirit) (7, p 58). 2. In terms of its function, the heart is not a pump but rather a sense organ “through which the head perceives everything which goes on in the body” (8, p 59). 3. The heart is an organ which creates a balance between the blood circulation of the “head human being” and that of the “limb human being” (9, p 63). 4. In regard to its organological evolution and its future importance for the development of humankind, the heart must be seen in a cosmological-christological context and can thus only be grasped thoroughly in its spiritual dimension (6). In Rudolf Steiner‘s contributions to the foundations of a form of medicine which integrates the entire human being, his reflections on the heart organ as a revision of the general doctrine prevailing at that time played a central role. At the same time they overcame the limited potential of those mindsets and paradigms which had upheld the irreconcilability of vitalism and mechanicism in the previous centuries.

The early 20th century marks the beginning of a rapid development rooted completely in a physico-mechanistic view of the human being and the heart which coincided conspicuously with Rudolf Steiner’s opposing view of the heart as an organ which completely incorporates the spirit aspect and soul aspect of the human organization. Through its technological achievements, this development – the establishment of cardiology as an independent, scientifically informed field of research – shaped modern medicine as it evolved in North America and Western Europe in an unprecedented way. The publication of the first cardiological journals in France (1907), Austria (1909), England (1910) and the USA (1925) was accompanied by the foundation of various cardiological associations, – that of the American Heart Association in 1924; the Deutsche Gesellschaft für Kardiologie-, Herz- und Kreislaufforschung in 1927, the American College of Cardiology in 1949 and the European Society of Cardiology in 1950. Milestones in cardiology which merit mention are: the invention of electrocardiography in 1903 (Einthoven), the first heart catheterization in 1929 (Forßmann), the first echocardiographs in 1950 and 1954 (Keidel, Edler, Hertz), the first open-heart surgery in 1952 (Lewis), the first use of a heart-lung machine in 1953 (Gibbon), the first pacemaker implantation in 1959 (Senning, Elmqvist), the first implantation of an artificial heart valve in 1960 (Starr, Edwards), the development of coronary angiography in 1962 (Sones), the development of ß-blockers in 1964 (Black), the first coronary bypass in 1967 (Favaloro), the definition of risk factors for cardio-vascular disease in 1966 (Framingham study), the first heart transplantation in 1967 (Barnard), the first percutaneous coronary angioplasty in 1977 (Grünzig), the introduction of thrombolysis in 1978 (Dewar), the first implantation of an internal defibrillator in 1980 (Mirowski), the development of invasive rhythmological forms of treatment such as radiofrequency ablation in the 1980’s, the establishment of full-scale interventional cardiology for treatment of heart attacks from 1993 on, the introduction of ACE inhibitors for cardiac insufficiency therapy in 1987, the establishment of ß-blocker treatment of cardiac insufficiency in 1999, the establishment of resynchronization treatment for severe cardiac insufficiency in 2005, the increasing use of controlled studies and the development of evidence-based cardiology from the 1980’s on and systematic development of data-based national and international guidelines for cardiological disease entities from the 1990’s on (10), (11, p 553).

Thus the current spectrum of cardiological treatment comprises conventional pharmacology including preventive cardiovascular medicine as well as all catheter-assisted procedures of surgical cardiology and electrophysiology, pacemaker technology, cardiosurgery, prevention of sudden cardiac death, transplantation medicine, all currently available heart-assist procedures and intensive-care medicine. It is indisputable that in connection with profound socio-economic changes in society brought about by the introduction and evaluation of modern methods for examination and treatment, enormous progress has been made which has proven to have a favourable effect on the quality of life and the life expectancy of the population (12). In the course of scientifically-oriented developments, the field of cardiology has amply illustrated how “medical nihilism” (13, p 55), a concept coined by the Viennese physician Josef Dietl in the mid-19^th century and challenged by Rudolf Steiner in 1920, has yielded to a manageable, rationalistic combination of diagnostics and therapy at the organ-body level. If one looks to the consequences which such diagnostics and therapy has for the dimension of the human soul and spirit (the relevance for quality and duration of life and the totality of purpose in life), we can say that we find ourselves still caught – perhaps quite acutely – in a cognitive limitation which may be referred to as “medical nihilism.” Creating foundations for forming judgments and making contribution to a holistic medical approach in the full sense of the word is the declared aim and aspiration of current efforts made to extend medicine through anthroposophy.

Whereas in the first half of the 19^th century questions concerning the physiology of heart function and reflections on natural philosophy dominated the often paradigmatically led scientific discourse, an interest in pathogenetic connections, i.e. a scientifically premised understanding of disease, started to emerge around the turn of the 20^th century. The ensuing establishment of cardiology as an independent field of medicine was propelled by a striving to detect the pathological findings lying at the root of the symptoms and to modify or remedy them through medication or interventional and surgical procedures. In connection with the establishment of an internationally positioned medical industry, the availability of new pharmaceuticals, materials and technologies suddenly rose sharply. This development was promoted by demographic changes in the industrial nations; after a decline in child mortality, mortality caused by infectious diseases and a constant increase of life expectancy, cardiovascular diseases and the conditions under which they occur (risk factor concept) became the focus of scientific interest and the physician’s responsibility. Thus the methodological spectrum of cardiology was no longer determined by physiological and pathophysiological reflections but rather by the demands made by demographic change and technological feasibility. Whether in the light of countless new findings the epistemological premises and the heart function paradigms which have prevailed since ca. 1850 still possess uncontested validity remains to be seen. In particular, connections between organ function and manifestation of disease on the one hand and the soul-spirit conditions of human development on the other are not taken into account by currently accepted concepts. Thus there would seem to be an urgent need for formulating new concepts which integrate the demands of the natural sciences and anthropologically oriented spiritual science.

Common general cardiological findings can serve as a point of departure for the development of integrative concepts:

• The broad spectrum of compensation that the peripheral circulation offers and its effective pharmacological manipulation (ß-blockers, ACE inhibitors) in cases of systolic cardiac insufficiency calls the mechanistic notion of heart function as a pump device into question.
• Systematic failure of positive inotropic pharmacological approaches for treating cardiac insufficiency points indirectly to the significance of microcirculation at the organ level, relativizing the postulated significance of the heart as the sole cause of blood motion (14).
• In intensive-care medicine one often observes that it is not possible to reactivate defunct microcirculation through pharmacological intensification of intrinsic heart contractions or external pump systems. This is a further indication that the microcirculation attributable to intact organ function constitutes a relevant prerequisite for blood motion.
• Recent developments which have proven successful in terms of symptoms and prognoses such as resynchronization treatment in cases of severe cardiac insufficiency owe their effectiveness to the reorganization of myocardial motion and thus presumably to energetic improvement of intracavitary blood flow.
• Newly gained insights into forms of formation, movement and nutrition in childhood and their effects on cardiovascular health in adulthood throw a light on the significance of the heart in a comprehensive biographical context.

The development of established cardiology as characterized here became possible on the foundation of a dualistic view of the human being which separates organ function, the emergence of disease and healing from the human soul and spirit. Insofar it is a logical consequence of the supersession of natural philosophy by materialistically and mechanistically oriented natural sciences in the mid-19^th century. Biographies of physiologists who shaped the 19th century such as Johannes Müller can be read in the context of this paradigmatic turn (15, p 265ff.). Nevertheless, all the incontestable successes of science-oriented medicine are unable to belie the deficits which result from a separation of bodily processes such as disease and healing from the dimension of soul and spirit. Cardiology characterized by a high degree of technological development constitutes a system which is, as it were, inherently incapable of integrating the “whole” human being and his life conditions into medical concepts. The – doubtlessly beneficial – modifications and revisions of pathologies are equated with healing although the underlying pathophysiological problems are often not affected at all. Thus disease processes can continue to exist and exert an eminent influence on the destiny of individual patients. The questions “what makes human beings ill?” and “what keeps them healthy or allows them to recover (heal)?” cannot be answered by use of currently accepted concepts; they are projected onto a molecular-biological level at best.

Anthroposophy and anthroposophic medicine do not wish to limit themselves to insights on how diseases emerge (pathogenesis) but rather to focus on disposition of health (salutogenesis) and healing as well so as to ultimately arrive at a therapeutic stance and a therapeutic course of action. A bridge between pathogenesis and salutogenesis can only be built, however, if a sphere of life can be posited as the condition for processes at the bodily level which in turn is subject to the ordering influence of soul and individual-spirit organization. Hence one speaks of the physical body (body level), the etheric body (life sphere), the astral body (soul organization) and the Ego (individual-spirit organization). In this so-called fourfold articulation of the human being, three distinct but interconnected functional areas are to be found: the metabolic-limb system, the rhythmic system and the nerve-sense system (functional threefold organization). Inclusion of such considerations is premised on the view that a healthy physical level can only be realized through participation of the soul and spirit. Apart from extensive study of the functional threefold organization posited in Rudolf Steiner‘s works from 1917 on (16), a large body of literature which can here only be cited exemplarily exists in which this principle is expanded on and applied in an effort to overcome reductionist concepts in medicine (17, 18, 19, 20, 21, 22).

From the perspective of this functional threefold organization, the heart and the lungs represent the rhythmic system in the middle of the human organization. They are embedded between the “upper” nerve-sense system and the “lower” metabolic-limb-system of the human being. Whereas the lungs have rhythmic interchange with the air and allow for “expression of the soul” (voice, language) on the side of the soul and the spirit and for “cell respiration” on the bio-physical side, the heart entertains a rhythmic connection with the “fluid organism.” Mediated by the blood, the heart has a functional connection to all its fluid spaces. Blood motion evolves as the result of the interplay between peripheral shifts of fluid at the capillary level (ca. 80 000 l/day) and central heart motion (ca. 8500 l/day) (23, p 517). Such interplay calls for the highest degree of coordination. Increased digestive activity or intensified limb activity (for example through sports) leads to increased circulation of the metabolic-limb-system pole while nerve-sense functions are sustained. In complementary relation to autoregulation of organ perfusion, the heart thus performs two functions: perception of the “lower” by the “upper” human being and mediation and equalization of these two physiological conditions in line with demand. Evidence of volume receptors, pressure receptors and chemo-receptors as well as release of hormones (ANP) supports this notion in physiological terms (23, S. 538). Thus Rudolf Steiner‘s elucidations on heart function make sense for those who view the heart as a sense organ and a balancing organ, unlike those who subscribe to the generally accepted “doctrine,“ merely viewing it as a mechanical pump (8, 9).

As concerns the functional threefold organization of the heart organ, much has been been written which takes many diverse positions on the subject. The venous side of the heart (the right side) can be correlated with the metabolic-limb system and the arterial side (the left side) with the nerve-sense system. It is also possible to correlate the atrium of the heart to the nerve-sense system (sinoatrial node, receptors of regulatory circuit for haemodynamics) and the ventricular level to the metabolic-limb system (musculature). Concretizations of the functional threefold organization ultimately show that this is systematically applicable in terms of quite diverse aspects, thus being able to contribute substantially to a holistic understanding of the organism (16, 17).

Understanding the effect of the elements of human organization allows us to gain an understanding of healthy and diseased human beings as well to substantiate therapeutic methods used in anthroposophic medicine: the physical body (the matter-filled spatial configuration of the human being, related to the mineral element, “Earth”), the etheric body (the totality of life processes in time, related to the liquid element, “Water”), the astral body (the totality of the soul life, related to the gaseous element, “Air”) and the Ego (the totality of the individual spiritual life, essence of the soul, biographical development, related to “Warmth”) stand in a functional connection among one another during an individual’s life but they are constantly subject to great changes: in the waking state all elements intertwine but in the sleeping state the Ego and the astral body withdraw from the etheric and the physical body (while the unconscious, at best dreaming organism continues to function completely in regard to all life processes). When death occurs, the etheric body also withdraws from the physical organization, leaving the body behind as it becomes cold, devoid of thoughts and sensations and lifeless, now being given over to the laws of the anorganic-mineral realm to ever increasing degrees (24).

The “upper” human being – which expresses a dominance of the nerve-sense functions – shows a clear connection to the Ego as the individual centre of consciousness, while the “lower” human being – which expresses a dominance of the metabolic-limb system – has a connection to the material conditions of the physical body through direct interchange with substances (ingestion and excretion). The “rhythmic” organs stand in the middle: On the one hand they have a special connection to astral organization through the lungs since expression of the soul involves a compelling need for the air element; on the other hand they directly pervade the ethereal organization through the heart since the fluid-bound processes of the life organization find their organic centre here.

Apart from the significance which it has for physiological processes during embryonic development, for waking, sleeping and dying, the articulation of the four elements plays a decisive role for the conditions under which disease and health emerge. In a healthy human organism, the forces of the Ego organization and the astral body, which tend to be degrading and “catabolic”(waking spirit-soul life), and the more or less synthetic and “anabolic” effects of the etheric-vital flow of forces active in the physical body (vegetative sleeping state) constantly balance each other out. Disease processes are made possible by two polar constellations: a dominance of the “upper” entities (Ego organization and astral body) to the disadvantage of the “lower” entities (etheric body and physical body) in metabolic processes leads to reshaping degradation and deposits as can be observed in sclerosis and “defect healing” of scar formation. If on the other hand there is a weakening in the effect of the Ego organization and the astral body in the area of metabolic processes, excessive plant-like growth (etheric) occurs accompanied by a dissolution of structures in the sense of inflammation or uninhibited tissue growth (tumour). Thus healing processes in the actual sense of the word are made possible by reinstating the “upper” and “lower” elements in the “proper relation.” This can be reached primarily by reinvesting the Ego organization and the astral body with the capacity to exert a healing effect on the physical-etheric functionalities (for example through life style modifications in secondary prevention of coronary heart disease) or by making corrections at the physical-etheric level which help the “upper” elements to reintegrate themselves into the physiological processes (for example through revascularization in treatment of coronary heart disease). In the “therapeutic realm of action” between promotion of auto-regulation through activation of spirit-soul autonomy on the one hand and interventional, surgical and pharmacological corrections of pathologies on the other lie all the approaches of scientific pharmacotherapy in conventional medicine, which are oriented to pathogenesis, and the healing methods of anthroposophic medicine, which are based on salutogenesis.

Pathogenetically oriented cardiology is characterized by a rapid development of imaging methods and interventional measures which have yielded extensive approaches for modifying pathologies physically and thus treating them to modify symptoms or prognosis. All such available methods are evaluated scientifically and examined in regard to their benefit for diseased human beings. The current state of scientific insights is summarized and evaluated on an ongoing basis according to guidelines of American and European cardiological associations. Textbooks provide the necessary orientation but they quickly become obsolete; thus the currently valid guidelines must ultimately be consulted (25, 26, 27).

Anamnesis, physical examinations, EKG and lab diagnostics continue to remain the pillars of clinical diagnostics. The most commonly used imaging method is non-invasive echocardiography. This method makes it possible to detect congenital heart disease, cardiomyopathies, perfusion-induced wall motion abnormalities, heart valve diseases, pulmonary hypertension and acute clinical pictures such as acute ventricular stress in cases of pulmonary embolism, endocarditis and pericardial diseases including pericardiac tamponade immediately and to initiate further diagnostics and therapy. This ultrasound-based diagnostics is supplemented by cardiac computer tomography (CT), cardiac magnetic resonance tomography (MRT), scintigraphy and SPECT.

Right heart catheterization and left heart catheterization constitute invasive examination methods for measuring haemodynamics in diseases effecting pulmonary circulation and valve defects as well as for evaluation of coronary heart diseases. The established treatment for coronary heart disease involves recanalization and stent implantation in constricted and closed coronary vessels (PCI, percutaneous coronary intervention) insofar as preference is not given to bypass surgery. In recent years, valve treatment (previously the responsibility of heart surgeons) has gained in importance in interventional cardiology. In particular it has become possible to treat aortic valve stenosis in high-risk patients using catheter-assisted methods (TAVI, transcatheter valve implantation). But diseases of the mitral valve now also lend themselves to catheter-interventional procedures more and more.

Cardiac dysrhythmias can now be described in terms of their physiopathology and treated effectively with lasting success on the basis of physiological findings and technological achievements to an ever-increasing extent as well. On the one hand, symptomatic bradycardia dysrhythmia can now usually be controlled well thanks to relatively simplified procedures for pacemaker implantation and ultra-precise pacemaker therapies, and on the other hand interventional electrophysiology is increasingly able to modify, or even completly correct, tachycardiac dysrhythmias in particular. So-called bi-ventricular pacemaker systems can induce effective resynchronization when dyssychrony of heart motion occurs, with this having an effect on the intracavitary blood flow in cases of severe systolic cardiac insufficiency; if the diagnosis is correct, physical resilience and the patient’s degree of freedom can be improved considerably (cardiac resynchronization therapy, CRT).

Prevention of sudden cardiac death through implantable defibrillators (ICD) is also part of the repertoire of tasks performed in the field of cardiology. As concerns secondary prevention after survived sudden heart death as well as primary prevention in cases of severe systolic cardiac insufficiency, numerous investigations have succeeded in verifying the prognostic benefit of ICDs. This is reflected in the experience which physicians often have with patients who survived sudden heart death through such measures.

In addition to the spectrum of interventional cardiological procedures, techniques used for heart surgery can also be used for treatment of cardiac diseases. These include bypass and valve surgery as well as heart-assist devices and heart transplantation. Since developments in interventional and surgical therapy often compete for the best long-term treatment results and more recent developments involve procedures which require cooperation between cardiologists and cardiac surgeons (for example TAVI), competence in both fields is becoming increasingly necessary, particularly when it comes to severe cases. This is reflected in the establishment of so-called “heart teams.”

Pillars of pharmacotherapy and prevention of cardiac diseases which are essentially pathogenetically oriented encompass, in addition to diuretics therapy, inhibition of the renin-angiotensin-system (ACE inhibitors, AT-II antagonists), blocking of ß -receptors (ß-blockers), inhibitors of platelet aggregation (ASS, P2Y₁₂ receptor blockers), anticoagulation (vitamin-K antagonists and the so-called novel oral anticoagulants (NOACs))., HMG-reductase inhibition (statins) and antiarrhythmic agents. For these groups of medicaments, evidence of benefits has lead to differing recommendations in the current guidelines of professional associations; such evidence shapes general therapeutic practice.

Whereas the potential of medical treatment oriented to the disease process (pathogenesis) is usually exhausted after correction or modification of the underlying disease substrates, therapy approaches which orient themselves to the healing process (salutogenesis) are characterized by the fact that they address the “intrinsic” potential for healing as well as taking the developmental aspect of disease and healing into account. Thus in addition to conventional diagnostic and therapeutic methods, the results of “extended insight into the human being” as described at length in Rudolf Steiner’s seminal works (24,28) and in medical terms in Steiner’s collaboration with the physician Ita Wegman (1) constitute elements of anthroposophic medicine and are a part of the competency attached to anthroposophic treatment. A medical approach extended in this respect is directed towards “development of the spirit, maturation of the soul and healing of the body” (17). Essential aspects are derived from the “functional threefold organization” and from an assessment of the dynamics of the “four elements” of the human being. In his diagnostic and therapeutic endeavours, the anthroposophic physician will always orients himself towards the relationship between the nerve-sense system and the metabolic-limb system as well as to the mediating function of the rhythmic system (functional threefold organization). Moreover, he will be interested in discovering whether the symptoms of disease are rooted in a too strong or too weak intervention of the “upper“ elements (Ego and astral body) or a too strong or too weak activity of the ”lower” ones (physical body and etheric body). (In German, the diagnostic process based on these four levels of human existence has been termed “Wesensgliederdiagnostik”, one could translate it as “four-level-diagnostics.”) He will only succeed in describing and evaluating these dimensions adequately if he examines the development and biography as well as the current life situation of the patient and the questions this patient poses concerning the future. As a result he will be able to decide whether direct treatment of the physical-organic dysfunction is necessary and in addition he will work out how the interplay of forces in the overall human organization must be supported so as to achieve an equilibrium and promote healing. It is self-evident that acute symptoms usually call for immediate intervention at the organic level and that any form of differentiating therapy can only be performed afterwards or in cases of chronic diseases.

In addition to conventional methods, anthroposophic medicine has certain specific medicinal and non-medicinal forms of treatment at its disposal. The goal of therapy using medicinal remedies provided by anthroposophic medicine is to discover, prepare and apply substances from the realms of nature so as to make therapeutic use of the connections between the world and the human being. Remedies are chosen on the basis of the ways in which mineral, plant and animal substances are related to the human organization and its symptoms. The manufacturing process, the level of dilution (potentization) and the type of application (internal, external, etc.) are placed in relation to the human organization and the manifestation of disease, thus being taken into account in therapy as well.

One example which can be cited in this context is the herbal “heart remedy” Cardiodoron® developed by Rudolf Steiner. It 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 (17, 18, 29).

One must explicitly emphasize that recommendations for remedies used in anthroposophic medicine do not issue from any systematic experimental research nor are they evaluated through application of generally recognized study protocols. They are the product of “extended” efforts to gain insights into correspondences between remedies, diseases and the body-soul-spirit constitution of the patient. “Internal” evidence is provided by the physician’s experience with use of remedies developed by anthroposophic medicine for treatment purposes.

Orientation aids for using remedies developed by anthroposophic medicine for treating diseases of the cardiovascular system are introduced in the corresponding chapters of the following, currently valid compendia according to the indication in question and are described there in terms of practical application: Anthroposophische Arzneitherapie für Ärzte und Apotheker (30), Innere Medizin – Grundlagen und therapeutische Konzepte der Anthroposophischen Medizin (18), Vademecum of Anthroposophic Medicines (31).

Apart from its remedies, a special feature of anthroposophic medicine is its large repertoire of non-medicinal therapy procedures. These include 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, poultices and massage. These non-medicinal therapies have originated in anthroposophy itself (for example eurythmy therapy) or have been expanded on by anthroposophy (for example psychotherapy).

The plausibility of these therapeutic methods derives from insights into the functional threefold organization and the four elements of human organization (16, 17): Where diseases of the heart are involved, the task is always to recover the balancing functions of the middle, rhythmic organization so that the “upper” nerve-sense organization and the “lower” metabolic-limb organization are alternatingly available in a way which maintains health. With the help of non-medicinal therapy methods, the will can be nurtured in all cognitive and bodily activities (through eurythmy therapy, for example), feeling as regards perception of the self and others can be promoted (for example through art therapies) and cognition can be developed in orientation to objective truths (for example through meditation). In this way the autonomy of the diseased person and individual, salutogenetically oriented encounters with the disease can be promoted. Thus 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 (32).

In cases of sclerozing cardiovascular diseases, the development of a culture of movement which is adapted to the patient’s individual capacities to counteract the dominance of being moved by external forces through modern means of transportation and changes in the work world and to activate a salutogenetic potential is of particular importance. In the meantime this connection, formulated by Rudolf Steiner in 1920 (33, p 177) and derived from extensive epidemiological data, forms the basis for every primary and secondary concept in cardiology (32, 34). The framework is provided by the notion that deposits and sclerozation connected with coronary heart disease are subjected to a “physiological inflammation aspect” (development of warmth, increase in metabolism) 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 (35).

In view of diverse psychogenic and personality-related influences on the emergence and healing of cardiovascular diseases (36), it is especially important to train and develop the patient’s soul-spirit capacities during treatment of cardiac disease. 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 (17), (37, pp 127ff.). In regard to what are in general deeply rooted impediments which make it difficult for patients with cardiovascular 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. In the works of Aristoteles, Thomas Aquinas and Rudolf Steiner the view of the heart is never limited to the spacio-functional terms of a reductionistic organ concept; instead it is placed in an overall cosmological-anthropological context which opens up the avenue to the central-point phenomena of the cosmos (sun, warmth, light), the development of humankind (Christ, love of neighbour, compassion) and the development of the human being (heart, conscience, karma). The mantras formulated by Rudolf Steiner in regard to the heart organ on the basis of this overall connection possess a potential which can be rendered therapeutically effective under certain individual preconditions (6, 38). 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). Borrowing on the concept of D. Ornish (39) 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 (40, 53). In this way diseases of the heart can lead those affected to an “inner metamorphosis” and even allow certain future capacities to evolve out of given conditions of the past.

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 necessarily 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 validated instruments are applied which are capable of pursuing and evaluating questions concerning the patient’s condition and well-being (soul level) as well as meaning and context (spirit level).Comparative prospective cohort studies which compare conventional treatment of cardiovascular diseases with that extended by anthroposophic medicine do not currently exist, nor does any systematic single-case research (43). In order to avoid randomization of patients who do not wish to be randomized when carrying out comparative studies, several cohorts can 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.

As a necessary supplement to controlled investigation of established “evidence-based medicine,” “additional material for gaining insights” has been suggested for therapy research aimed at exploring medical questions in the sense of anthroposophic medicine: systematic investigation of casuistics qua “cognition-based medicine” aims to make individualized evaluation of treatment methods possible and round out the evaluation (41, S. 232ff.), (42). Moreover, the field of cardiovascular medicine has yet to carry out any thorough scientific processing of data which allows for a comparison of the effects of pathogenetically oriented therapy approaches (for example interventional cardiology) with those of salutogenetically oriented treatment methods (for example lifestyle modifications which even extend into the area of spiritual practice) and evaluation thereof in the context of socio-economic development.

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.

This introduction to anthroposophically extended cardiology was made possible by the work of the professional group of anthroposophically oriented cardiologists which has existed for many years (currently represented by Andreas Fried, Jakob Gruber, Joachim Hötzel, Christoph Kaufmann, Christoph Rubens, Uwe Schulze, Markus Weinbacher). Members of the work group have collaborated with other specialist authors whose work was published in issues of the journal Der Merkurstab in 2006; the work covered a series of topics concerning various issues of cardiology. This also included in a special issue on coronary heart disease in an endeavour to bridge the gap between conventional and anthroposophically extended cardiology. These articles have been into account here extensively. Other works which have addressed this topic as well are cited below (38, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61).

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