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 Table of Contents  
Year : 2022  |  Volume : 5  |  Issue : 4  |  Page : 145-150

Add-on effect of Nagabala–Arjunadi yoga on left ventricular ejection fraction and New York Heart Association functional capacity in post- myocardial infarction – An experience

Department of Kayachikitsa, Institute of Teaching and Research in Ayurveda, Jamnagar, Gujarat, India

Date of Submission26-Feb-2022
Date of Acceptance09-Nov-2022
Date of Web Publication29-Dec-2022

Correspondence Address:
Dr. Sushya Surendran
Sukritham, Kavumbhagam, Thalassery, Kannur - 670 101, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jacr.jacr_15_22

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Cardiovascular Diseases (CVDs), especially Coronary Heart Disease (CHD), are epidemic in India. The annual number of deaths from CVD in India is projected to rise from 2.26 million (1990) to 4.77 million (2020). CHD prevalence rates in India have been estimated over the past several decades and have ranged from 1.6% to 7.4% in the rural population and from 1% to 13.2% in the urban population. Myocardial Infarction (MI) is the most common form of CHD. Many clinical and laboratory factors, such as persistent ischemia and depressed Ejection Fraction (EF), have been identified with an increase in cardiovascular risk after initial recovery from MI. Even though conventional medicines are excellent life-saving measures in MI, quality of life is always a concern. A 56-year-old male, presented to Ayurveda hospital with exertional dyspnea and pain in the chest for one year, following secondary prevention, and had two episodes of documented MI in 2017 and 2020, respectively. Two-dimensional echocardiography (dated July 15, 2021) revealed septal and apical wall hypokinesia and an EF of 50%. The two month intervention with Nagabala–Arjunadi yoga improved the EF to 10 percentiles (5%), and wall motion abnormality was reduced to a physiological limit. The overall status of the New York Heart Association classification was improved from Class II to Class I. The quality of life assessed by the MacNew questionnaire also showed a significant difference. This case report revealed that the Ayurvedic internal medication is helpful in improving the post-MI functional capacity of the patient.

Keywords: Ejection fraction, Functional capacity, Hridroga, Medoroga, Myocardial infarction

How to cite this article:
Surendran S, Goyal M. Add-on effect of Nagabala–Arjunadi yoga on left ventricular ejection fraction and New York Heart Association functional capacity in post- myocardial infarction – An experience. J Ayurveda Case Rep 2022;5:145-50

How to cite this URL:
Surendran S, Goyal M. Add-on effect of Nagabala–Arjunadi yoga on left ventricular ejection fraction and New York Heart Association functional capacity in post- myocardial infarction – An experience. J Ayurveda Case Rep [serial online] 2022 [cited 2023 Jan 28];5:145-50. Available from: http://www.ayucare.org/text.asp?2022/5/4/145/365929

  Introduction Top

Cardiovascular Diseases (CVDs) remain the largest contributors to morbidity and mortality in the present era. It assumes increasing importance as it affects people in their most productive life period. The case fatality attributable to CVD in low-income countries, including India, appears to be much higher than in middle- and high-income countries. According to the World Health Organization, it is estimated that 7.4 million deaths are due to Coronary Heart Disease (CHD) in 2015.[1] The most common form of CHD is Myocardial Infarction (MI).[1] In Ayurveda, Hridaya (~heart or cardiac region) is one among the Trimarmas (~three vital points of the body) and is Sadya pranahara marma (~sudden death causing points). Physiologically, Hridaya is the seat of Vyana vata (~a subtype of Vata, that is seated in Hridaya), Sadhaka pitta (~one of the five subtypes of Pitta situated in the Hridaya), and Avalambaka kapha (~one of the subtypes of Kapha situated in the chest region). It is also the abode of Chetana (~sentient) and Ojas (~vitality). As per the Ayurvedic perspective, CVDs can be considered under the broad concept of Hridroga. Cardiac rehabilitation and secondary prevention programs for CVDs provide the most effective means of decreasing mortality and morbidity.[2] Many health-care providers are familiar with the benefits of cardiac rehabilitation for patients after MI, angioplasty, intracoronary stent replacement, coronary artery bypass surgery, and those with stable angina,[3] but many clinical and laboratory factors have been identified that are associated with an increase in cardiovascular risk after initial recovery from MI. Some of the most important factors include persistent ischemia, depressed left ventricular Ejection Fraction (EF) (<40%), rales above the lung bases on physical examination or congestion on chest radiograph, and symptomatic ventricular arrhythmias. Other features associated with increased risk include a history of previous MI, age >75 years, diabetes mellitus, prolonged sinus tachycardia, hypotension, ST-segment changes at rest without angina, and an abnormal electrocardiogram.[4]

Even though evidence-based conventional medicine is an excellent life-saving measure in MI, quality of life is always a concern. Ayurveda has the potential for the prevention and management of many cardiac abnormalities. This case report discusses the outcomes of Ayurvedic intervention as an add-on to conventional treatment. The case report also suggests that an integrative approach can be adopted for these patients to improve their quality of life by increasing the functional capacity of the heart.

  Case Report Top

A 56-year-old, married, self-employed male, a chronic smoker and nonalcoholic with a known history of systemic hypertension (for the past three years) and type 2 diabetes mellitus (for the past seven years) presented at Ayurveda hospital with complaints of pain in the chest and dyspnea on exertion for the past one year. He was on secondary prevention and has good drug compliance. He prefers vegan diet and has good appetite. Bowel and bladder functions were normal. His sleep was 6–7 h. He has been practicing Yoga since 2017. The patient's main concern was pain in the chest while doing exertional work and during deep inspiration. He also experienced breathlessness and fatigue while doing normal activities for the past year. The mother and father of the patient died in the mid-fifties suffering from lung and liver cancer, respectively. No other commodities or cerebrovascular accidents or strokes running in the family. He was always in fear of getting another episode of a heart attack.

In 2017, he had an acute onset of chest pain radiating to the left upper limb. He was medically managed at an allopathic hospital. Coronary Artery Angiography (CAG) revealed a Left Anterior Descending (LAD)-D1 medium-sized 60%–70% ostial lesion, right coronary artery dominant mild plaque, and moderate left ventricular dysfunction. He was thrombolysed and was on aggressive medical management. In October 2020, he had a 2nd similar episode of chest pain. Immediately, he was admitted to the medical college hospital and from there referred to a tertiary care center. CAG revealed 80% proximal lesion, mid 50% and diagonal 60% lesion in LAD. Angioplasty to the LAD was done. Since then, he is on secondary preventives. Despite being on the preventives, he has had dyspnea on exertion and chest pain on deep breathing for a year.

  Clinical Findings Top

A physical examination of the patient showed that he is an average-built and moderately nourished person. With a height of 171 cm and a weight of 65 kg, his body mass index was found to be 22.2 kg/m2. His pulse rate was 72/min and regular, ectopic beats were present. Heart rate was 72/min, S1 and S2 sounds were heard with no added sounds and blood pressure was 110/70 mm Hg. A cardiovascular examination revealed no major abnormality. The chest pain score according to the Visual Analog Scale was 5. New York Heart Association (NYHA) classification for functional capacity was Grade 2. The quality of life score assessed by the MacNew questionnaire was 108.

Ayurveda examination revealed that his Sharira prakriti (~physical constitution) was Vatapitta, and Manasa prakriti (~mental constitution) was Satvaraja. Sara (~excellence of Dushya or tissue elements), Samhanana (~compactness of tissue or organs), Pramana (~anthropometry), Satmya (~suitability or homologation), and Satva (~Psyche) were Madhyama (~medium). Aharasakthi (~capacity of intake of food) examined as Abhyavaharana shakti (~capacity of intake of food), Jaranashakti (~power of digestion), and Vaya (~age) were Madhyama.

  Timeline Top

The timeline of the disease course, interventions, and outcomes is shown in [Table 1].
Table 1: Timeline of disease course, intervention, and outcomes

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  Diagnostic Assessment Top

Complete blood count, fasting blood sugar, postprandial blood sugar, urea, creatinine, uric acid, and lipid profile were within normal limits before and after the intervention. The urine routine before and after the intervention was also normal.

  Therapeutic Intervention Top

The patient was given three tablets (500 mg each) of Nagabala–Arjunadi yoga prepared by seven Bhavanas of Rasonadi kwatha.[5],[6] The intervention is an integrative approach without any dietary modification or Yoga, hence given orally as an add-on to the secondary preventives for two months [Table 2]. Clinical assessment of functional capacity was done by NYHA classification and left ventricular function was assessed through Echocardiography (ECHO) before and after treatment.[7] The quality of life assessment was done before and after the intervention using the MacNew questionnaire.[8]
Table 2: Ayurvedic treatment as an add-on to modern intervention

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  Follow-Up and Outcome Top

The patient was encouraged to visit the hospital once per week for two months. Every fortnight, his functional capacity was assessed, and ECHO was assessed only after the period of intervention. The functional capacity of the patient before treatment was class II, and after treatment, it was class I [Table 3]. The ECHO revealed septal plus apical wall hypokinesia with an EF of 50% before treatment, and after the intervention, no regional wall motion abnormality was detected and the EF increased by 10 percentile (5%). MacNew questionnaire Quality of life score before the study was 108 and after the study was 145. Follow-up was done after one month, during this period, interventional medication was stopped. The two-dimensional ECHO revealed that EF was maintained at 55% and no regional wall motion abnormality was detected, NYHA grading was Grade I, and the chest pain VAS score was zero, which signifies the effect of the intervention [Graph 1] and [Graph 2].
Table 3: New York Heart Association functional capacity

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  Discussion Top

Despite being the major cause of mortality and morbidity worldwide, MI affects Indians at least a decade earlier when compared to their counterparts of European ancestry and also in their most productive midlife years. Cigarette smoking, diabetes, hyperlipidemia, and hypertension are the four conventional risk factors for the development of coronary artery disease. In Ayurvedic perspective, CVDs can be considered under the broad concept of Hridroga. A detailed description of the types and treatments of Hridroga is available, but not the pathological evolution of cardiovascular disease. References are available from Samhitas about the Santarpana (~diseases due to over nourishment) and Apatarpana rogas (~diseases due to undernourishment) which can contribute to the development of cardiovascular disorders. Atisthoulya (~obesity) or Medoroga and Prameha (~diabetes mellitus) are the Santharpanotha vikara that have a direct association with CVDs. Apatarpana janya nidana is also considered by Charaka in the description of Hridroga. Dhamani prathichaya mentioned in Samhitas can be correlated to the most important pathological finding, atherosclerosis, in the evolution of coronary artery disease. CHD and MI symptomology have a resemblance with Vatika hridroga.[9] Here, MI can be considered the end-stage sequelae of Avarana (~covering) causing Vata kopa (Vyana) due to the contributing Nidanas (~etiological factors), and Sthanasamshraya (~stage of localization) of Dosha (~ humor) and Dushya (~vitiated dhatus) in Hridaya, which results in Kuposhana (~undernourishment) of Hridaya marma.

Nagabala–Arjunadi yoga, a classical formulation, is a combination containing Nagabala–Arjuna churna prepared by seven Bhavanas of Nagabala–Arjuna churna with Rasonadi kwatha. Nagabala–Arjuna churna is said to be Rasayana, Balya, and Vatahara. The main pharmacological action of Nagabala [Grewia tenax (Frosk.) Fioro] is Balya (~strength promoter), Rasayana (~rejuvenative), and Vrishya (~aphrodisiac).[10] It is also indicated in Hridroga.[11] Methanolic extract of Nagabala has the highest composition of phytochemicals, i.e., alkaloids, flavonoids, saponins, sterols, terpenes, and cardiac glycosides.[12] Cardiac glycosides modulate the electrophysiological properties of the heart and its contractile functions.[13] Arjuna [Terminalia arjuna (Roxb.ex DC.) Wight and Arn.] is referred in Hridroga prakarana. Its main pharmacological actions are Hridya (~beneficial for the heart), Medohara (~antiobesity), Balya, Rakthavikarahara (~alleviating diseases affecting blood tissue), and Mehahara (~ antidiabetic).[14] Evidence from in vitro, in vivo, and clinical trials reveal the pleiotropic effects of Arjuna such as antiatherogenic, hypotensive, inotropic, anti-inflammatory, antithrombotic, and antioxidant actions for the treatment of various cardiovascular disorders.[15],[16],[17],[18] Arjuna also has a significant effect on maintaining endothelial stability.[19]

Rasonadi kwatha [Rasona (Allium sativum Linn.), Karavi (Nigella sativum Linn.), Krishna (Piper longum Linn.) and Sthira (Desmodium gangeticum DC)] possess Vata anulomana (~proper functioning of Vayu) therapeutic action as mentioned in Vata Roga Prakarana of Sahasrayoga. Hence, the combination of both these Yoga is used here, to alleviate Vata and to nourish the Hridaya marma. Studies on Rasona strongly suggest its cardioprotective, anticoagulant, fibrinolytic, and hypocholesterolemic activity.[20] Karavi contains quinine compounds that are mostly responsible for pharmacological actions such as cardioprotective, anticancer, antidiabetic, anti-inflammatory, and antioxidant activity.[21],[22],[23] Relevant studies are available showing the cardiotonic, hypotensive, antiplatelet, hypocholesterolemic, and antioxidant activity of Pippali (Piper longum Linn.).[24],[25],[26],[27] Several in vitro and in vivo studies acknowledged the cardioprotective action in induced MI and also the free-radical scavenging property of Sthira.[28],[29]

Considering the above-mentioned pharmacological action of the drugs, we can assume that these drugs might interfere directly or indirectly with the pathogenesis of the disease or may further stop the pathogenesis. As the ultimate pathology is Avarana and Vata kopa, it can be assumed that this Yoga act as both Dosha shamana (~pacifying humor) and Vyadhi shamana (~pacifying disease). Thus, the combination interferes in the Samprapthi (~pathophysiology) as well as helps in Sthapana of the Ashrayasthana. As the Ashrayasthana is Hridayamarma, it can be concluded that the intervention drug helps in maintaining myocardial integrity. Left Ventricular EF (LVEF) is the central measure of left ventricular systolic function. It is very important for managing patients with cardiovascular disease. It plays an important role in assessing the severity of the disease and the systolic function of the heart and is a powerful indicator of cardiac mortality. In a randomized, placebo-controlled phase 3 mortality trial, it was revealed that improvement in LVEF by ≥ 5 units was a powerful predictor of survival and reduced Heart Failure (HF) hospitalization.[30] In this study, it was found that the LVEF change was equal to 5 units and wall motion abnormality was nil at rest after the treatment, which indicates improvement in the left ventricular function and myocardial integrity. The change in the functional status of the patient by NYHA classification was also due to the change in the EF. The quality of life also improved after the intervention. The patient tolerated the intervention well and no side effects were reported.

  Conclusion Top

Ayurveda pharmacopeia has many potent herbs for Hridroga that are yet to be explored. From this case study, it can be inferred that Nagabala–Arjunadi yoga is effective in the management of post-MI as an add-on to conventional treatment. It improves the functional status of the patient and also the quality of life. Research should also focus on the benefits that Ayurveda can offer in post-MI HF patients with low EFs. Long-term studies using such Ayurvedic intervention should be carried out in large samples to assess mortality and morbidity over the course of time. From a future perspective, studies can be undertaken with regard to drug interaction as well, since the proposed intervention is an add-on treatment. This will ensure the safety of the intervention.

Declaration of patient consent

Authors certify that they have obtained patient consent form, where the patient has given his consent for reporting the case along with the images and other clinical information in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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