Complementary Alternative Cardiovascular Medicine

Chapter 1 / CAM and CVD 3
patients reported using CAM therapies, which was reduced to 44% if vitamins
and prayer were excluded. Their findings that only 17% of patients
using CAM therapies discussed this with their physician and that neither
age, gender, race or education level predicted usage are consistent with prior
studies of the general population. Equally importantly, most patients
responded that they did not wish to reveal their CAM use even when directly
prompted. It is clearly not possible for a clinican, using socioeconomic
information, to predict the likelihood of their patients using CAM for cardiovascular
disease. Given the prevalence of its usage, cardiovascular physicians
face this challenge on a daily basis.
Additionally, health care providers need to know about CAM,
because patient use in the context of physician-directed conventional
therapy may represent a source of conflict between a patient requesting
CAM therapies and a clinician advising against or rejecting such treatments.
An obvious source of conflict is patient risk of harm from CAM
treatment related adverse events or supplement—drug interactions with
conventional therapy. In addition, the failing, by the physician, to provide
informed counsel could result in the patient forgoing a safe CAM
form that would be beneficial. Such benefits may be related directly to the
use of the CAM therapy or may be a result of the integration of safe CAM
therapies with conventional treatments, permitting a better fit of the
overall treatment plan to a patient’s belief system and affording the
patient a proactive role and sense of control in his or her health care.
Once clinicians are convinced of the importance of CAM, they are
faced with the question: “What do I need to know?” Unfortunately,
physicians often cannot adhere to evidence-based medicine for many
CAM therapies since the gold standard of evidence-based care—the
large, randomly assigned, blinded, placebo-controlled study (clinical
trials)—does not exist. Therefore, the health care provider must use best
available evidence to determine safety and efficacy and must practice
with the knowledge that such “best” evidence may be refuted by future
studies. A recent example of this occurence is sentiments concerning
conventional medical treatment using hormone replacement therapy
(HRT) for women who are postmenopausal (8). Large case cohort studies
suggested clinical efficacy, but subsequent clinical trials demonstrated
lack of efficacy and, in some instances, increased cardiovascular
and noncardiovascular events and mortality.
Unfortunately, some CAM therapies, despite widespread use and,
occasionally, substantial historical recognition and supportive anecdotal
reports, will not be the subject of large well-designed clinical trails in the
United States in the near future. As discussed in the text, the cost of such
trials is prohibitive to a for-profit source that cannot have patent protec-