ournal of the American College of Cardiology
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Abstract
Herbal medications are commonly used for clinical purposes, including the treatment of cardiovascular conditions. Compared with conventional medications, herbal medications do not require clinical studies before their marketing or formal approval from regulatory agencies, and for this reason their efficacy and safety are rarely proven. In this review, we summarize available evidence on herbal medications mostly used in cardiovascular medicine. We show that the use of these medications for the treatment of cardiovascular diseases is often not supported by scientific evidence. Despite most of these herbs showing an effect on biological mechanisms related to the cardiovascular system, data on their clinical effects are lacking. Potential relevant side effects, including increased risk of drug interactions, are described, and the possibility of contamination or substitution with other medications represents a concern. Physicians should always assess the use of herbal medications with patients and discuss the possible benefits and side effects with them.
Footnotes
- The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received July 29, 2016.
- Revision received October 11, 2016.
- Accepted November 7, 2016.
- 2017 American College of Cardiology Foundation
Journal of the American College of Cardiology
Correction
Liperoti R, Vetrano DL, Bernabei R, Onder G
Herbal Medications in Cardiovascular Medicine
J Am Coll Cardiol 2017;69:1188–99.
On page 1195, the 15th line of the second paragraph reads: Cranberries, which are used to prevent urinary tract infections in women, and Asian ginseng might inhibit the activity of CYP2C9, the primary isoenzyme involved in the metabolism of warfarin, causing elevation of the international normalized ratio and increased risk of bleeding (18,122). In contrast, St. John’s wort, which has been shown in clinical studies to be effective in the treatment of depression, can induce CYP3A4 and CYP2C9 activity, reducing the efficacy of medications metabolized by these enzymes.
It should have read: Cranberries, which are used to prevent urinary tract infections in women, might inhibit the activity of CYP2C9, the primary isoenzyme involved in the metabolism of warfarin, causing elevation of the international normalized ratio and increased risk of bleeding (18,122). In contrast, St. John’s wort, which has been shown in clinical studies to be effective in the treatment of depression and Asian Ginseng can induce CYP activity, reducing the efficacy of medications metabolized by these enzymes, including warfarin.
Also, the first line of Table 2 was incorrect. The first column read:
| Herbal Medication (Ref. #) | Interacting Cardiovascular Medication(s) | Mechanism of Action | Potential Side Effect |
|---|---|---|---|
| Asian ginseng (18) | Warfarin | Inhibition of CYP2C9 | ↑ Risk of bleeding |
It should have read:
| Herbal Medication (Ref. #) | Interacting Cardiovascular Medication(s) | Mechanism of Action | Potential Side Effect |
|---|---|---|---|
| Asian ginseng (14,123) | Warfarin | Induction of CYP2C9 | ↓ Effect |
The full corrected table is below.
| Herbal Medication (Ref. #) | Interacting Cardiovascular Medication(s) | Mechanism of Action | Potential Side Effect |
|---|---|---|---|
| Asian ginseng (14,123) | Warfarin | Induction of CYP2C9 | ↓ Effect |
| Cranberry (18,122) | Warfarin | Inhibition of CYP2C9 | ↑ Risk of bleeding |
| European elder (125) | Diuretics | Additive diuretic effect | ↑ Diuresis |
| Garlic (55,124) | Aspirin and anticoagulant agents | Reduction of platelet function | ↑ Risk of bleeding |
| Ginkgo (63,64,124) | Aspirin and anticoagulant agents | Reduction of platelet function | ↑ Risk of bleeding |
| Goldenseal (121) | Medications metabolized by CYP2D6 and CYP3A4 | Inhibition of CYP2D6 and CYP3A4 | ↑ Effect |
| Green tea (76,77) | Warfarin | Contains vitamin K | ↓ Effect |
| Hawthorn (102) | Digoxin | Increased blood concentration of digoxin | Arrhythmias |
| Licorice root (126) | Loop and thiazide diuretic agents | Mineralocorticoid-like effect | Hypokalemia |
| Salvia miltiorrhiza (120) | Warfarin | Reduction in binding to albumin | ↑ Risk of bleeding |
| St. John’s wort (123) | Medications metabolized by CYP3A4 and CYP2C9 | Induction of CYP3A4 and CYP2C9 | ↓ Effect |
CYP = cytochrome.
Table 2
Most Relevant Interactions Between Herbal Medications (Used Both for the Treatment of Cardiovascular Diseases and for Other Conditions) and Cardiovascular Medications
The authors apologize for this error.
The online version of the article has been corrected to reflect these changes.
- 2017 American College of Cardiology Foundation
