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Journal of the American College of Cardiology© 2005 by the American College of Cardiology FoundationPublished by Elsevier Inc.Vol. 46, No. 1, 2005ISSN 0735-1097/05/$30.00doi:10.1016/j.jacc.2005.05.031ACCF COMPLEMENTARY MEDICINE EXPERT CONSENSUS DOCUMENTIntegrating ComplementaryMedicine Into Cardiovascular MedicineA Report of the American College of Cardiology FoundationTask Force on Clinical Expert Consensus Documents(Writing Committee to Develop an Expert ConsensusDocument on Complementary and Integrative Medicine)WRITING COMMITTEE MEMBERSJOHN H. K. VOGEL, MD, MACC, ChairSTEVEN F. BOLLING, MD, FACCREBECCA B. COSTELLO, PHDERMINIA M. GUARNERI, MD, FACCMITCHELL W. KRUCOFF, MD, FACC, FCCPJOHN C. LONGHURST, MD, PHD, FACCBRIAN OLSHANSKY, MD, FACCKENNETH R. PELLETIER, MD(HC), PHDCYNTHIA M. TRACY, MD, FACCROBERT A. VOGEL, MD, FACCTASK FORCE MEMBERSROBERT A. VOGEL, MD, FACC, ChairJONATHAN ABRAMS, MD, FACCJEFFREY L. ANDERSON, MD, FACCERIC R. BATES, MD, FACCBRUCE R. BRODIE, MD, FACC*CINDY L. GRINES, MD, FACCPETER G. DANIAS, MD, PHD, FACC*GABRIEL GREGORATOS, MD, FACC*MARK A. HLATKY, MD, FACCJUDITH S. HOCHMAN, MD, FACC*SANJIV KAUL, MBBS, FACCROBERT C. LICHTENBERG, MD, FACCJONATHAN R. LINDNER, MD, FACCROBERT A. O’ROURKE, MD, FACC†GERALD M. POHOST, MD, FACCRICHARD S. SCHOFIELD, MD, FACCSAMUEL J. SHUBROOKS, MD, FACCCYNTHIA M. TRACY, MD, FACC*WILLIAM L. WINTERS, JR, MD, MACC**Former members of Task Force; †Former chair of Task ForceThe recommendations set forth in this report are those of the Writing Committeeand do not necessarily reflect the official position of the American College of Cardiology Foundation.When citing this document, the American College of Cardiology Foundationwould appreciate the following citation format: Vogel JHK, Bolling SF, Costello RB,Guarneri EM, Krucoff MW, Longhurst JC, Olshansky B, Pelletier KR, Tracy CM,Vogel RA. Integrating complementary medicine into cardiovascular medicine: areport of the American College of Cardiology Foundation Task Force on ClinicalExpert Consensus Documents (Writing Committee to Develop an Expert ConsensusDocument on Complementary and Integrative Medicine). J Am Coll Cardiol2005;46:184 –221.Copies: This document is available on the World Wide Web site of the American Collegeof Cardiology (www.acc.org). Reprints of this document may be purchased for $10 each bycalling 1-800-253-4636, ext. 694, or by writing to the American College of Cardiology,Educational Services, 9111 Old Georgetown Road, Bethesda, MD 20814-1699.Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of theAmerican College of Cardiology Foundation. Please direct requests to:copyright [email protected]JACC Vol. 46, No. 1, 2005July 5, 2005:184–221TABLE OF CONTENTSPreamble....................................................................................185I. Introduction .......................................................................185Organization of Committee and Evidence Review ......185Background ....................................................................186Purpose of This CECD ................................................186II. Nutrition and Supplements ...............................................187Nutrition ........................................................................187Bioactive Components in Foods ...................................188Vitamin and Mineral Supplements ...............................191Herbal Preparations.......................................................194Herb-Drug Interactions: What We Need to Know.....196Related Alternative Therapy .........................................199III. Mind/Body and Placebo....................................................200The Mind/Body Relationship and its Correlationto CVD..........................................................................200Impact of Stress on CVD Risk Factors........................201Depression and the Development of CVD ..................202Placebo...........................................................................203IV. Acupuncture.......................................................................203V. Bioenergetics (Energy Medicine) ......................................205Methods to Study Bioenergy ........................................205Forms of Bioenergetics..................................................206Caveats...........................................................................207Recommendations..........................................................207VI. Spirituality/Intentionality ..................................................207Spirituality in Cardiovascular Applications ...................207Compendia ....................................................................208Review Articles and Meta-Analyses..............................208Specific Reports of Spirituality andCardiovascular Care.......................................................208Key Issues in Spirituality Applied toCardiovascular Care.......................................................209Delivery Roles, Accreditation, and CertificationStandards .......................................................................210Summary and General Recommendations....................210Staff ...........................................................................................210Appendix I: Relationships With Industry ................................210Appendix II: Glossary...............................................................210The following additional appendices are located on www.acc.org only:Appendix III: Internet Sources for Complementary MedicineInformationAppendix IV: Review of the Literature for Cardiovascular-RelatedIntegrative MedicineAppendix V: Dietary Supplement Intake FormAppendix VI: Books and Compendia on Spirituality in Cardiovascular ApplicationsAppendix VII: Structured Reviews and Meta-Analyses of SpiritualDescriptors and Therapies and Their Correlations With(Noncardiology) Clinical OutcomesPREAMBLEThis document was commissioned by the American Collegeof Cardiology Foundation (ACCF) Task Force on ClinicalExpert Consensus Documents (CECDs) to provide a perspective on the current state of complementary, alternative,and integrative medical therapies specifically as they relateto cardiovascular diseases (CVDs). It is intended to informVogel et al.ACCF Complementary Medicine Expert Consensus Document185practitioners, payers, and other interested parties of manyevolving areas of clinical practice and/or technologies associated with this topic that are widely available or new to thepractice community. Topics chosen for coverage by CECDare so designated because the evidence base and experiencewith technology or clinical practice are not consideredsufficiently well developed to be evaluated by the formalAmerican College of Cardiology/American Heart Association (ACC/AHA) Practice Guidelines process. Often, thetopic is the subject of considerable ongoing investigation.The Task Force on CECDs recognizes that considerabledebate exists regarding the clinical utility of alternativemedicine practices. By their nature, alternative medicinepractices differ widely in their scientific support. Despitethis varying evidence base, these practices are widely employed by patients, including those with CVD. Manypractitioners are not familiar with many alternative medicine techniques. Thus, the reader should view this CECDas the best attempt of the ACCF to inform and guideclinical practice in an area where rigorous evidence is not yetavailable or the evidence to date is not widely accepted.Where feasible, CECDs include indications or contraindications. The ACC/AHA Practice Guidelines Committeemay subsequently address some topics covered by CECDs.The Task Force on Clinical Expert Consensus Documents makes every effort to avoid any actual or potentialconflicts of interest that might arise as a result of an outsiderelationship or personal interest of a member of the writingpanel. Specifically, all members of the writing panel areasked to provide disclosure statements of all such relationships that might be perceived as real or potential conflicts ofinterest. These statements are reviewed by the parent taskforce and updated as changes occur. Please see Appendix Ifor the relationship with industry information pertinent tothis document.Robert A. Vogel, MD, FACCChair, ACCF Task Force on Clinical ExpertConsensus DocumentsI. INTRODUCTIONOrganization of Committee and Evidence ReviewThe Writing Committee consisted of acknowledged expertsin the field of complementary, alternative, and integrativemedicine. Both the academic and private sectors wererepresented. The document was reviewed by five officialreviewers nominated by the ACCF, representatives fromthe American Association of Critical Care Nurses, AHA,American Nurses Association, Preventive CardiovascularNurses Association, and the Society of Thoracic Surgeons,as well as 20 content reviewers nominated by the WritingCommittee. This document will be considered current untilthe Task Force on CECDs revises or withdraws it frompublication.186Vogel et al.ACCF Complementary Medicine Expert Consensus DocumentBackgroundAlternative medical therapies encompass a broad spectrumof practices and beliefs (1). From a historical standpoint,they may be defined as, “ . . . practices that are not acceptedas correct, proper, or appropriate or are not in conformitywith the beliefs or standards of the dominant group ofmedical practitioners in a society” (2). The Institute ofMedicine (IOM) has recently reviewed complementary andalternative medical practices in the U.S. from a generalviewpoint (3). This document will focus on cardiac aspectsof complementary medicine. From a functional standpoint,alternative (also known as “complementary” or “integrative”)therapies may be defined as interventions neither taughtwidely in medical schools nor generally available in hospitals(4). Ernst et al. (5) contend that “complementary medicaltechniques [complement] mainstream medicine by contributing to a common whole, by satisfying a demand not metby orthodoxy or by diversifying the conceptual frameworksof medicine.” The terminology currently in use to describethese practices remains controversial. Many commonly usedlabels (e.g., “alternative,” “unconventional,” or “unproven”)are judgmental and may inhibit the collaborative inquiry anddiscourse necessary to distinguish useful from useless techniques (6). Complementary and alternative medicine (CAM)is the language currently used by the National Institutes ofHealth (NIH) to describe this field of inquiry. The term“integrative medicine” has been used with increased frequency. Several recently published studies and editorialswrestle with the challenges of properly labeling and describing this field of inquiry (7–12). Herbs, vitamins, andnon-herbal dietary products, as well as therapies conductedaround issues such as spirituality, bioenergetics (i.e., acupuncture and energy fields), and mind/body, are all considered to be forms of complementary, alternative, or integrative medicine.Purpose of This CECDThe purpose of this CECD is to put the emerging area ofCAM treatment and investigation into focus in order toenable the physician to provide better patient care in ameaningful and safe manner. The document will be concerned with the most recent advances and utilization ofCAMs and therapies in a traditional cardiovascular practice.In 2000, nearly 50% of all Americans sought the help ofan alternative health care practitioner. This represents over600 million visits (13). Nearly $30 billion was spent in theyear 2001 on CAM (13,14). Many CAM interventions,including numerous herbal supplements, have been employed in an attempt to treat CVD. Of prime importance isputting CAM into perspective with its potential benefitsand knowledge of important interactions with traditionalcardiovascular medicines. In response to an enormous involvement in CAM, medical facilities have developed specialized CAM centers to investigate the potential benefitsJACC Vol. 46, No. 1, 2005July 5, 2005:184–221and integrate those benefits into routine care and lifestylemanagement.The most complete and comprehensive findings to dateon Americans’ use of CAM were released on May 27, 2004,by the National Center for Complementary and AlternativeMedicine (NCCAM) and the National Center for HealthStatistics (NCHS, part of the Centers for Disease Controland Prevention) (15). The new data came from a detailedsurvey on CAM included for the first time in 2002 in theNational Health Interview Survey (NHIS). The NHIS, asurvey done annually by the NCHS, interviews people intens of thousands of American households about theirhealth- and illness-related experiences.The findings are yielding (and will continue to yield,through future analyses) a wealth of information on whouses CAM, what they use, and why. In addition, researcherscan examine CAM use as it relates to many other factorssuch as age, race/ethnicity, place of residence, income,educational level, marital status, health problems, and thepractice of certain behaviors that impact health (such assmoking cigarettes or drinking alcohol).The survey showed that a large percentage of Americanadults are using some form of CAM—36% (15). Whenprayer specifically for health reasons is included in thedefinition of CAM, that figure rises to 62%. Dr. Stephen E.Straus, NCCAM Director, said, “The survey data will providenew and more detailed information about CAM use and thecharacteristics of people who use CAM. One benefit will be tohelp us target NCCAM’s research, training, and outreachefforts, especially as we plan NCCAM’s second five years, 2005through 2009.”There is little doubt that CAM represents a revolutionwithin our health care delivery system. Nevertheless, ourtraditional views of the medical establishment do not fullysupport CAM. There. Vogel RA. Integrating complementary medicine into cardiovascular medicine: a report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine). J Am Coll Cardiol 2005;46:184–221.

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