Medical Advisor Journals

Friday, August 24, 2012

Hydrocephalus

Hydrocephalus, also known as "water in the brain" is defined as complex and multifactorial neurological disorders of accumulation of cerebrospinal fluid (CSF) in the cavity of brain of that can lead to intracranial pressure inside the side, resulting of brain trauma, stroke, infection, tumor, etc.

I. Types of Hydrocephalus
1. Congenital hydrocephalus
Congenital hydrocephalus is a condition presented at birth as a result of genetic defect or abnormal fetal development. In the study to illustrate the value of knockout mice in identifying genetic factors involved in the development of congenital hydrocephalus, showed that dysfunctional motile cilia represent the underlying pathogenetic mechanism in 8 of the 12 lines (Ulk4, Nme5, Nme7, Kif27, Stk36, Dpcd, Ak7, and Ak8)... characterization of mouse models can enhance understanding of important cell signaling and developmental pathways involved in the pathogenesis of hydrocephalus(1). At least 43 mutants/loci linked to hereditary hydrocephalus have been identified in animal models and humans. Up to date, 9 genes associated with hydrocephalus have been identified in animal models. In contrast, only one such gene has been identified in humans. Most of known hydrocephalus gene products are the important cytokines, growth factors or related molecules in the cellular signal pathways during early brain development(2).

2. Acquired hydrocephalus
Acquired hydrocephalus is a condition developed after birth as a result of injure or diseases.

3. Communicating hydrocephalus or non-obstructive hydrocephalus,
Communicating hydrocephalus is defined as condition as the cerebrospinal fluid (CSF) can still flow between the ventricles.

4. Non communicating hydrocephalus or obstructive hydrocephalus
Non communicating hydrocephalus is defined as a condition as the cerebrospinal fluid (CSF) is blocked and can not flow between the ventricles.

II. Causes and risk factors
A. Causes
Although the actual causes of Hydrocephalus is unknown, some researchers suggested that
1. Genetic defect
Congenital hydrocephalus id associated with dysfunctional motile cilia represent the underlying pathogenetic mechanism in 8 of the 12 lines (Ulk4, Nme5, Nme7, Kif27, Stk36, Dpcd, Ak7, and Ak8).(3). Other researchers suggested that Although hydrocephalus is usually a sporadic disorder, there exist some rare but well delineated syndroms, in which recurrence is to be expected. The here presented Bickers-Adams-Syndrome of sex-linked hydrocephalus is caused by congenital aqueductal stenosis(4).

2. Meningitis
Hydrocephalus is associated with the complications of tuberculous meningitis (TBM) occurred in up to 85% of children with the disease. It is more severe in children than in adults. It could be either of the communicating type or the obstructive type with the former being more frequently seen(5).

3. Neural tube defect
Congenital hydrocephalus is a relatively uncommon abnormality in population malformation surveys accounting for between four and ten out of every 10,000 births. In the review of Sixty cases of 28 with NTD (group 1) and 32 without NTD (group 2). The groups were similar in terms of maternal and child variables at birth and hospitalization days during the 1st year of life. The mortality (including intrauterine deaths and deaths of babies with malformations incompatible with life that characterize a very poor prognosis) until 1 year of age was 36% in group 1 and 59% in group 2 (p = 0.077). The rate of cardiac malformations was higher in the group without NTD (p = 0.015). The length of hospital stay after birth (1st admission) was significantly higher in the group with NTD (p = 0.007)(6).

5. Intraventricular hemorrhage
Intraventricular hemorrhage and posthemorrhagic hydrocephalus are common causes of neonatal morbidity and mortality among preterm and low-birth weight infants (PT-LBWIs), but Intraventricular hemorrhage in PT-LBWIs remains a significant problem, particularly when it is associated with PHH leading to long-term neurological impairment and decreased survival rate(7).

6. PTB Deficiency
Polypyrimidine tract-binding protein (PTB) is a well-characterized RNA-binding protein and known to be preferentially expressed in neural stem cells (NSCs) in the central nervous system. Dr. Shibasaki T and the research team at the Center for Experimental Medicine and Systems Biology. showed that PTB depletion in the dorsal telencephalon is causally involved in the development of HC and that PTB is important for the maintenance of AJs in the NSCs of the dorsal telencephalon(8).

6. Tumors
Tumor-associated hydrocephalus is common in primary pediatric brain tumors. In the study of a total of 56.7% of cases presented hydrocephalus, including hydrocephalus that occurred at tumor diagnosis (51.5%), and hydrocephalus developed after tumor diagnosis (5.1%). At tumor diagnosis, the hydrocephalus was mainly obstructive type (98%) and rarely communicating type (1.9%). Definite shunting procedures in this series comprised of ventriculoperitoneal (VP) shunt in 54.4%, endoscopic third ventriculostomy (ETV) in 10.9%, subduroperitoneal (SP) shunt in 4.8%, septostomy in 0.7%, lumboperitoneal shunt in 0.6%, and ventriculoatrial shunt in 0.1% of patients with hydrocephalus(9).

7. Traumatic head injury
Post-traumatic hydrocephalus (PTH) is considered a frequent complication after severe head injury (HI). External hydrocephalus is a well-established entity in infants which is benign and usually resolves without shunting [1, 2]. The term “External Hydrocephalus” has also been used to describe the presence of extra ventricular cerebrospinal fluid (CSF) collections accompanied by hydrocephalus, particularly in cases of adults suffering from aneurysmal subarachnoid hemorrhage and severe head injuries [3–6]. Several other terms have been used to describe this entity [7] which has lead to confusion about this disease(10).

8. Subarachnoid hemorrhage
Acute hydrocephalus as a consequence of subarachnoid hemorrhage is a relatively frequent problem. Dr. Suarez-Rivera O. at the National Institute of Neurology and Neurosurgery, Mexico City, indicated that that acute hydrocephalus is present in 20% of patients with subarachnoid hemorrhage. One third of them may be asymptomatic on admission; 50% of those who have clinical hydrocephalus recover spontaneously within the first 24 h(11)

9. Etc.

B. Risk factors
1. Family history

Family studies suggested that the risk to siblings of a child with uncomplicated congenital hydrocephalus, where the anatomical site is not specified, is about 1 in 50 (1 in 40 for males, 1 in 80 for females). With aqueduct stenosis, the risk to brothers of affected boys is 1 in 22, to sisters only 1 in 50. The risks to siblings of sisters is less. Probably less than 2% of uncomplicated hydrocephalus has an X-linked basis and such an aetiology should be suspected if the special clinical features are present, there is more than one male sibling affected, or there are affected male relatives on the mother's side(12).

2. Nontumoral aqueductal stenosis, nontectal tumor and tectal glioma
Hydrocephalus was most commonly due to nontumoral aqueductal stenosis (43%), nontectal tumor (25%), or tectal glioma (13%). Five patients (16%) had multicystic/loculated hydrocephalus(13).

3. Preterm and low-birth weight infants
Preterm and low-birth weight infants are associated with increased risk of intraventricular and/or periventricular hemorrhage (IVH and PVH, respectively) of that can lead to Hydrocephalus(14).

4. Other factors
Although the precise nature of the neuropsychological deficits in hydrocephalus are not completely known, several factors such as etiology, raised intracranial pressure, ventricular size, and changes in gray and white matter tissue composition as well as shunt treatment complications have been shown to influence cognition. In fact, the presence of complications and other brain abnormalities in addition to hydrocephalus such as infections, trauma, intraventricular hemorrhage, low birthweight, and asphyxia are important determinants of the ultimate cognitive status, placing the child at a high risk of cognitive impairment(15).

5. Etc.

III. Symptoms
A. In infancy
1. Increase in head circumference or an unusually large head size
Fluid accumulated will result in Increase in head circumference or an unusually large head size in infant regardless to the types of hydrocephalus due to bulge of the fontanelle (soft spot), Dr. Bhasker B and the research team in the reports a new finding in two siblings with primary hypomagnesaemia as a result of renal magnesium wasting, namely, rapidly increasing head size. External hydrocephalus and brain shrinkage in primary hypomagnesaemia seen on computed tomography of the brain with reversibility after magnesium treatment has not been reported previously(16).

2. Rapid eye movement sleep
In the monitor of Intracranial pressure (ICP) for 24 h in 30 hydrocephalic patients (21 infants, 9 children) showed that during sleep related to a period of rapid eye movement (REM) fairly regular steep-rising waves of raised ICP recurred every 50-75 min, decreasing slowly to previous levels in 25-40 min(17).

3. Sleepiness, Irritability, Sunsetting of the eyes, Seizures are most common symptoms in infant(18)

4. Other symptoms
Dr. Kirkpatrick M and scientists at the Royal Hospital for Sick Children, in the study of Symptoms and signs of progressive hydrocephalus, showed that in the clinical features of 107 cases of children with hydrocephalus and measured raised intraventricular pressure were analysed retrospectively. Fifty one children had recently been diagnosed as having hydrocephalus, and the remainder had had shunts injected to direct the cerebrospinal fluid. The most common symptoms in the group were vomiting, behavioural changes, drowsiness, and headaches. The most common clinical signs were inappropriately increasing occipitofrontal head circumferences, tense anterior fontanelles, splayed sutures, and distension of the scalp veins. Half the infantile cases of hydrocephalus were without symptoms, and a quarter of the cases with cerebrospinal fluid shunts and measured raised intraventricular pressure were without signs. There were no fewer than 33 different clinical signs including several unusual ones, such as macular rash and sweating. We believe that the presentation of hydrocephalus with raised intraventricular pressure is sufficiently variable, unusual, or even absent to justify the direct measurement of intracranial pressure(19).

8. Etc.

B. Children and adults
Beside some symptoms mentioned in the infant section, Children and adults with the disease may also be experience other symptoms because of the head can no longer expand to accommodated to the accumulation of the fluid
1. The most common symptoms in the group were vomiting, behavioural changes, drowsiness, and headaches. The most common clinical signs were inappropriately increasing occipitofrontal head circumferences, tense anterior fontanelles, splayed sutures, and distension of the scalp veins(19).

2. Diplopia, headaches, and papilledema
Hydrocephalus can also cause symptoms of diplopia, headaches, and papilledema, There is a report of a 48-year-old woman was admitted to the hospital because of diplopia, headaches, and papilledema. Imaging revealed cysts in the fourth ventricle and spinal canal(20)

3. Headache, hearing difficulty and blurred vision
Headache and blurred vision are also associated with symptoms of hydrocephalus. There is a report of a
patient of 25-year-old female, admitted to the department of otorhinolaryngology with complaints of hearing difficulty, headache and blurred vision(21).

4. Other symptoms
Dr. Kubo Y and research team at the Osaka University Graduate School of Medicine, in the study of Validation of grading scale for evaluating symptoms of idiopathic normal-pressure hydrocephalus, showed that the interrater reliability of this scale was high. The iNPHGS cognitive domain score significantly correlated with the cognitive test scores, including the Mini-Mental State Examination (MMSE), the gait domain score with the Up and Go Test and Gait Status Scale scores, and the urinary domain score with the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score. The MMSE, Gait Status Scale and ICIQ-SF scores significantly improved in patients whose iNPHGS scores improved after CSF tapping but not in those whose iNPHGS scores did not improve after CSF tapping. Fourteen of the 38 patients received shunt operations. In these 14 patients, changes in the iNPHGS cognitive and urinary domains after CSF tapping were significantly associated with the changes after the shunt operation(22). Other found that the most frequently observed neuropsychiatric symptom in the iNPH patients was apathy followed by anxiety and aggression. No symptom was more prevalent or more severe in iNPH than in AD. The severity of cognitive impairment was correlated with both aberrant motor activity and apathy(23).

5. Etc.

IV. Diagnosis
A. Misdiagnosis
Because some of these symptoms may also be experienced in other disorders, sometimes normal pressure hydrocephalus is incorrectly diagnosed and never properly treated, including
1. Tuberculosis
Neurosarcoidosis, a complication of sarcoidosis in which inflammation occurs in the brain, spinal cord, and other areas of the nervous system is observed in approximately 5% of sarcoidosis. Its common manifestations are facial palsy (50% of patients with neurosarcoidosis) and optic neuritis. Hydrocephalus is a very uncommon reported finding. Although the typical presentation of sarcoidosis such as facial palsy is not a diagnostic dilemma, more atypical presentations such as hydrocephalus with altered mentality in a tuberculosis patient can lead to a misdiagnosis(24).

2. Alzheimer's disease
Dr. Silverberg GD and scientists at the Stanford University School of Medicine in the study of Alzheimer's disease and normal-pressure hydrocephalus, suggested that if all else being equal, the initially dominant physiological change determines whether CSF circulatory failure manifests as Alzheimer's disease (AD) or as normal-pressure hydrocephalus (NPH). If CSF production failure predominates, AD develops. However, if resistance to CSF outflow predominates, NPH results. Once either disease process takes hold, the risk of the other disorder may rise. In AD, increased deposition of Abeta in the meninges leads to greater resistance to CSF outflow. In NPH, raised CSF pressure causes lower CSF production and less clearance of Abeta(25).

3. Parkinson's disease
There are several reports of cases with the characteristic clinical manifestations of normal pressure hydrocephalus--progressive dementia, gait difficulty and urinary incontinence--have been published earlier, it was Adams and Hakim who emphasized the clinical triad and the effect of shunting the cerebrospinal fluid as a means of treatment. Messert and Baker stressed that the gait disturbance had a close resemblance to the freezing gait of parkinsonism but Dr. Lobo Antunes J, and the the research team suggested that recognition of the existence of both disorders in the same patients is important since appropriate treatment of each of them led to marked improvement of their symptoms(26).

4. Creutzfeldt-Jakob disease
There is a report of two different dementing diseases, Creutzfeldt-Jakob disease and normal-pressure hydrocephalus in a single patient. The inefficacy of a shunt procedure in this particular case, and the need of a brain biopsy in patients with normal-pressure hydrocephalus before undergoing cerebrospinal fluid shunting are stressed. A purely coincidental occurrence, or a possible aetiopathogenic relationship between both diseases are postulated(27).

5. Etc.

B. Diagnosis(28)
According to Dr. Michael Kiefer and the research team, in the study of the Differential Diagnosis and Treatment of Normal-Pressure Hydrocephalus suggested that
B.1. Diagnosis according to patient impairement
1. For patient of Gait impairment, differential diagnosis include the Characteristics of Externally rotated posture of the feet, Particular difficulty turning on the body’s long axis and Absence of apraxia.

2. For patients with Cognitive deficits/dementia, aside from reactive depression (without depressive thought content), patients with NPH generally do not have any psychiatric abnormalities. Thus, changes of mood, personality, and behavior steer the differential diagnosis toward a neurodegenerative disorder of another type. An objective examination should be performed with the aid of specific psychometric tests for the assessment of subcortical frontal lobe deficits.

Some suitable tests of this type are :

2.1 The grooved pegboard test

2.2. The Stroop test

2.3. The digit span test

2.4. The trail-making A/B test

2.5. The Rey auditory-verbal learning test

3. For patients with Incontinence

Disturbances of bladder function in NPH result from detrusor hyperactivity owing to the partial or total absence of central inhibitory control. Patients initially suffer from increased urinary frequency (– ); later developments are urge incontinence and, finally, permanent urinary incontinence. Fecal incontinence is rare in NPH (2) and should arouse suspicion of another type of neurodegenerative disease. If present in a patient with NPH, it implies severe frontal subcortical dysfunction.

CSF shunting can improve bladder dysfunction in as many as 80% of iNPH patients if performed early, but in no more than 50% to 60% if performed in an advanced stage of the disease (e15, , ).

4. NPH and other neurodegenerative disorders

Findings that make NPH less likely

4.1. Asymmetrical findings

4.2. Cortical deficits, e.g., aphasia, apraxia, paresis

4.3. Progressive dementia without gait disturbance

4.5. Lack of progression of symptoms

B.2. General Diagnosis and tests

1. Computerized tomography (CT) or magnetic resonance imaging (MRI)

Either computerized tomography (CT) or magnetic resonance imaging (MRI) of the brain is necessary—yet, alone, never sufficient to establish the diagnosis of NPH.

2. Invasive diagnostic testing

The aim of the tests is needed to raise the prognostic accuracy above 80%

2.1. Spinal tap test: lumbar puncture with the removal of 30 to 70 mL of CSF. This can be repeated on two or three consecutive days

2.2. Continuous spinal drainage of 150 to 200 mL of CSF per day for 2 to 7 days (1– 2)

If the number of steps taken in a 10 m gait test, and the time needed to walk 10 m, are reduced by at least 20%, and/or psychometric tests show an improvement of at least 10%.

3. Other invasive tests

Long-term ICP measurement for 24 to 72 hours is performed in no more than a few centers. Special pressure waves and brain pulse amplitudes are measured Such techniques are not recommended for routine use, both because their predictive value has not yet been sufficiently documented and because they require specialized equipment and expertise

VI. Preventions
Other than structures abnormalities caused by genetic defects, accidence, etc., most acquired hydrocephalus can be prevented by enhancing the immune system in fighting against forming of free radicals causes of irregular cells growth and foreign invasion such virus and bacteria and reduce the risk of diseases cause of Hydrocephalus, such as dementia.
A. Do's and Do Not's list
1. Mediterranean diet
If you are typical American dieter, you are at increased to develop dementia when you get older as the diet is classified as one of the most unhealthy diet in the existence, as the study of ,researchers wrote in an older population of Southern Italy with a typical Mediterranean diet, high monounsaturated fatty acids energy intake appeared to be associated with a high protection against cognitive decline. In addition, dietary fat and energy in older people seem to be risk factors, while fish consumption and cereals are found to reduce the prevalence of AD in the European and North American countries(1). Also recent research supports the hypothesis that calorie intake, among other non-genetic factors, can influence the risk of clinical dementia.(29).

2. Yoga
Yoga is believed to have beneficial effects on cognition, attenuation of emotional intensity and stress reduction. In the study to evaluate the effects of yoga on memory and psychophysiological parameters related to stress, comparing yoga practice and conventional physical exercises in healthy men (previously yoga-naïve). Memory tests, salivary cortisol levels and stress, anxiety, and depression inventories were assessed before and after 6months of practice. Yoga practitioners showed improvement of the memory performance, as well as improvements in psychophysiological parameters(30). Other researchers at the G.J. Patel Ayurved College, showed that Mind and body are inseparable entities and influences each other until death. Many factors such as stress, anxiety, depression, negative thoughts, unhealthy life style, unwholesome diet etc., disturb mental and physical wellbeing. Senile dementia is the mental deterioration, i.e, loss of intellectual ability associated with old age. It causes progressive deterioration of mental faculties, e.g., memory, intellect, attention, thinking, comprehension and personality, with preservation of normal level of consciousness.(31). Other suggested that the effect of stress on the immune system and examine how relaxation techniques such as Yoga and meditation could regulate the cytokine levels and hence, the immune responses during stress(31a).

3. Aging of theory of mind
In the study to predict that educational level and cognitive processing are two factors influencing the pattern of the aging of ToM at Anhui Medical University, showed that the younger group and the older group with equally high education outperformed the older group with less education in false-belief and faux-pas tasks. However, there was no significant difference between the two former groups. The three groups of participants performed equivalently in the eyes test as well as in control tasks (false-belief control question, faux-pas control question, faux-pas control story, and Eyes Test control task). The younger group outperformed the other two groups in the cognitive processing tasks(32)

3. Moderate alcohol drinking
Moderate alcohol drinking of less than 2 cups for men and 1 cups for women are said to offers possible health benefits(3), but Binge drinking in midlife is associated with an increased risk of dementia, according to the follow-up, 103 participants had developed dementia. Binge drinking (ie, alcohol exceeding the amount of 5 bottles of beer or a bottle of wine on 1 occasion at least monthly), as reported in 1975, was associated with a relative risk of 3.2 (95% confidence interval=1.2-8.6) for dementia. Passing out at least twice as a result of excessive alcohol use during the previous year, as reported in 1981, was associated with a relative risk of 10.5 (2.4-46) for dementia in drinkers.(33). Other in the study to evaluated how (1) the number of alcoholic drinks the subjects consumed per month and (2) the drinking cessation of certain subjects were associated with their relative and absolute T, B, CD4, and CD8 lymphocyte counts and immunoglobulin A (IgA), IgM, and IgG levels, indicated that indicated that measures of immune status differed among the drinking categories and that, generally, the differences changed after adjustment for covariates. These differences consisted, as alcohol consumption increased, of higher IgA and IgM levels, relative T and CD4 lymphocytes, and the ratio of CD4 to CD8 cells, and of lower IgG levels, relative B and CD8 lymphocytes, absolute lymphocyte, and lymphocyte subset counts after adjusting for other covariates(33a).

4. Stop Smoking or never smoke before
Smoking is a risk factor for several life-threatening diseases, but its long-term association with dementia is controversial and somewhat understudied.In a studyof a total of 5367 people (25.4%) were diagnosed as having dementia (including 1136 cases of AD and 416 cases of VaD) during a mean follow-up period of 23 years. Results were adjusted for age, sex, education, race, marital status, hypertension, hyperlipidemia, body mass index, diabetes, heart disease, stroke, and alcohol use, Dr. Rusanen M, and the team at the University of Eastern Finland, said " heavy smoking in midlife was associated with a greater than 100% increase in risk of dementia, AD, and VaD more than 2 decades later. These results suggest that the brain is not immune to long-term consequences of heavy smoking"(34).

5. Drink you tea and coffee
Caffeine in tea and coffee may enhance cognitive function acutely. In Aging and Dementia (CAIDE) study, the findings of the previous studies are somewhat inconsistent, but most studies (3 out of 5) support coffee's favorable effects against cognitive decline, dementia or AD. In addition, two studies had combined coffee and tea drinking and indicated some positive effects on cognitive functioning. For tea drinking, protective effects against cognitive decline/dementia are still less evident. In the CAIDE study, coffee drinking of 3-5 cups per day at midlife was associated with a decreased risk of dementia/AD by about 65% at late-life. coffee(35). Others in the study of Immunomodulatory effects of decaffeinated green tea (Camellia sinensis) on the immune system of rainbow trout (Oncorhynchus mykiss), showed that decaffeinated green tea in lower doses of administration could be optimum to enhance the immunity of rainbow trout(36a).

6. Eat you fruits and veggies
Fruits and veggies contains high amounts of antioxidant which enhance the immune system in fighting against forming of free radicals in which can cause damage to the brain cells of that lead to dementia. Researchers at The Johns Hopkins University indicated that use of vitamin E and vitamin C supplements in combination is associated with reduced prevalence and incidence of AD. Antioxidant supplements merit further study as agents for the primary prevention of AD(36).

7. Regular exercise and moderate exercise for elder
In the study to evaluate to the effects of regular exercise versus a single bout of exercise on cognition, anxiety, and mood were systematically examined in healthy, sedentary young adults who were genotyped to determine brain-derived neurotrophic factor (BDNF) allelic status, indicaed that altered activity-dependent release of BDNF in Met allele carriers may attenuate the cognitive benefits of exercise. Importantly, exercise-induced changes in cognition were not correlated with changes in mood/anxiety, suggesting that separate neural systems mediate these effects(37). Other indicated that Overall, in healthy older adults, regular, particularly aerobic, exercise appears to be a friend of the immune system, helping to offset diminished adaptive responses and chronic inflammation. The possibility exists that particularly strenuous exercise may cause acute immunologic changes, such as diminished NK cell activity, which could predispose to infection in certain individuals(37a)

8. Avoid nutritional deficiency with balance diet
Beyond our believe, in the study to highlight how an excess of dietary carbohydrates, particularly fructose, alongside a relative deficiency in dietary fats and cholesterol, may lead to the development of Alzheimer's disease and a first step in the pathophysiology of the disease is represented by advanced glycation end-products in crucial plasma proteins concerned with fat, cholesterol, and oxygen transport.(38). Dr Pae M, and the research team at the Jean Mayer USDA Human Nutrition Research Center on Aging at Tufts University, suggested that the need for a more in-depth, wholestic approach to determining the optimal nutritional strategies that would maintain a healthy immune system in the elderly and promote their resistance to infection and other immune-related diseases(38a).

9. Avoid environment risk of dementia(39)
Certain environment toxins produced as a result of industrialization or naturally have been linked to cognitive degenerative diseases. Researchers at the University of British Columbia in the investugation of Novel environmental toxins: steryl glycosides as a potential etiological factor for age-related neurodegenerative diseases, showed that Mice fed washed cycad flour show signs that mimic ALS-PDC, which include progressive deficits in motor, cognitive, and olfactory functions associated with neuron loss in the spinal cord, nigrostriatal system, cortex, hippocampus, and olfactory bulb. Through a series of chemical extractions of washed cycad flour, we identified steryl glycoside molecules as bioactive molecules that are neurotoxic in culture and in mice. A detailed review of this class of molecule revealed that the molecules are abundant in the environment, particularly in plants and bacteria. Lipid analysis showed that some bacteria that are associated with some forms of neurodegenerative disorders have the capacity to synthesize steryl glycosides. Furthermore, certain steryl glycosides have been found to be a cell stress mediator and may have some immunomodulary effects. Others researchers showed that Parkinson disease (PD) and Alzheimer disease (AD), are of purely genetic origin in a minority of cases and appear in most instances to arise through interactions among genetic and environmental factors and early environmental origins of neurodegenerative disease in later life. Also environment toxins can reduce the immune function in protecting against other diseases.

10. No illicit drug, please(40)
Illicit drug used may cause nervous system impairment as a result of direct and indirect effects on the integrity and function of nervous system tissue and, potentially, through immune effects. HIV-1 infection poses an additional risk of impairment, and this risk may be decreased as a result of antiretroviral drug treatment. Others researchers suggested that injection drug use represents the primary risk factor for up to 40% of patients with HIV infection. Illicit drug also can effect the CNS and weaken the immune system.

11. Prevent prolonged period of using certain drug(41)
As aging, accumulation of toxins of certain medication used to treat certain diseases, such as antidepressants, sedatives, cardiovascular drugs and anti-anxiety medications may cause increased risk of cognitive dysfunction leading to produced dementia-like symptoms. Certain medication can suppress the immune system.

12. Etc.

B. Diet to prevent Hydrocephalus
The aims of the diet is to provide sufficient nutrients to body and enhance the immune function in fighting against inflammation and weakened immune system causes of Hydrocephalus
B.1. Black beans (Phaseolus)
1. Antioxidant effect
In the evaluation of the indigestible fraction (IF)of the cooked seeds of three pulses (black bean, chickpea and lentil) and their antioxidant effect found that Condensed tannins were retained to some extent in the IF that exhibited significant antioxidant capacity. The total IF of the three pulses produced short chain fatty acids (SCFA) after 24 h of in vitro fermentation by human colonic microflora. IF from black bean and lentil were best substrates for the fermentative production of butyric acid, according to "In vitro fermentability and antioxidant capacity of the indigestible fraction of cooked black beans (Phaseolus vulgaris L.), lentils (Lens culinaris L.) and chickpeas (Cicer arietinum L.)" by Hernández-Salazar M, Osorio-Diaz P, Loarca-Piña G, Reynoso-Camacho R, Tovar J, Bello-Pérez LA.(42)

2. Molybdenum
Molybdenum cofactor is vital for human enzymes, including xanthine oxidase, sulfite oxidase, and aldehyde oxidase, Deficiency may cause
a. Prenatal brain disruption, according to the study of "Prenatal brain disruption in molybdenum cofactor deficiency" by Carmi-Nawi N, Malinger G, Mandel H, Ichida K, Lerman-Sagie T, Lev D.(43)

3. Nervous system
Protein is essential for the brain in transmitting information between themselves and cells in the other parts of the body, thus reducing the blood sugar levels from rising too rapidly after a meal, reducing the risk of nervous symptoms cause of anxiety, stress and depression, etc., according to the study of "The planar polarity protein Scribble1 is essential for neuronal plasticity and brain function" by Moreau MM, Piguel N, Papouin T, Koehl M, Durand CM, Rubio ME, Loll F, Richard EM, Mazzocco C, Racca C, Oliet SH, Abrous DN, Montcouquiol M, Sans N, posted in PubMed (44)

B.2. Brown rice
1. Selenium
Oat contains trace minerals selenium which is essential for the healthy function of the thyroid and immune system as it increases the antioxidant defense system by fighting against the forming of free radicals and reduce the risk of irregular cells growth causes of tumor and cancer, according to the study of "Selenium in the immune system" by Arthur JR, McKenzie RC, Beckett GJ.(45)

2. Antioxidants
Beside containing high levels of magnesium which is necessary for the synthesis of fatty acids to produce energy for our body needs, it also is one of the important component of antioxidant enzyme of which increases the body in fighting against the forming of free radical, according to the study of "Analysis of antioxidant enzyme activity and magnesium level in chronic obstructive pulmonary disease (COPD)" by Kurys E, Kurys P, Kuźniar A, Kieszko R., posted in PubMed(46)

B.3. Asparagus
1. Immunomodulatory activity
In the research of Roots of Asparagus racemosus Willd (Shatavari in vernacular) and its effect on immunostimulation found that asparagus racemosus root aqueous extract (ARE) also showed higher antibody titres and DTH responses. ARE, in combination with LPS, Con A or SRBC, produced a significant proliferation suggesting effect on activated lymphocytes and suggested that mixed Th1/Th2 activity of ARE supports its immunoadjuvant potential, according to "Immunomodulatory activity of Asparagus racemosus on systemic Th1/Th2 immunity: implications for immunoadjuvant potential" by Gautam M, Saha S, Bani S, Kaul A, Mishra S, Patil D, Satti NK, Suri KA, Gairola S, Suresh K, Jadhav S, Qazi GN, Patwardhan B.(47)

2. Antioxidants
Asparagus contains some kinds of antioxidant that help to improve the immune system in fighting against the forming of radicals, thus promoting synthesis DNA and regulates cell division, according to "The role of antioxidant supplement in immune system, neoplastic, and neurodegenerative disorders: a point of view for an assessment of the risk/benefit profile" by Brambilla D, Mancuso C, Scuderi MR, Bosco P, Cantarella G, Lempereur L, Di Benedetto G, Pezzino S, Bernardini R.(48)

B.4. Leek
1. Vitamin K
Since leak contains a measure amount of vitamin K, it helps to protect against aging diseases and the under layers of the skin, thus reducing the risk of wrinkle due to aging and enhances the absorption of calcium, thus promoting the formation of healthy bones, according to the study of "Vitamin K, osteoporosis and degenerative diseases of ageing" by Vermeer C, Theuwissen E., researchers found that According to the triage theory, long-term vitamin K inadequacy is an independent, but modifiable risk factor for the development of degenerative diseases of ageing including osteoporosis and atherosclerosis.(49)

2. Antioxidant activities
In the investigation of the methanol extract of dried skin of Allium cepa and its isolation of quercetin-3'-O-beta-D-glucoside [1] found that the antioxidant activity of 1 was evaluated in the oxygen radical absorbance capacity assay; it showed 3.04 micromol Trolox equivalents/mmol. 1 was shown to be a promising ingredient that could be useful for treating hyperpigmentation and for protecting against oxidative stress, according to "Melanin biosynthesis inhibitory and antioxidant activities of quercetin-3'-O-beta-D-glucoside isolated from Allium cepa" by Arung ET, Furuta S, Ishikawa H, Tanaka H, Shimizu K, Kondo R.(50)

B.5. Etc.

C. Photochemical to prevent Hydrocephalus
C.1. Rosemarinol, is a phytochemical monophenols, found in essential oil of labiate herbs like Rosemary and also in variety of other plants.
1. Chemical stabilization of fish oil
In the study of fish oil undergoes multiple changes in its physical properties and its autoxidation occurred found that rosemary extract rich in carnosic acid to ternary blends of tocopherols, ascorbyl palmitate and lecithin or Citrem significantly retarded autoxidation, according to "Chemical stabilization of oils rich in long-chain polyunsaturated fatty acids during storage" by Pop F.

2. Anti-inflammatory effects
In the research of the extract of rosemary leaves from supercritical fluid extraction and its anti inflammatory effects found that the yield of 3.92% and total phenolics of 213.5 mg/g extract obtained from the most effective extraction conditions showed a high inhibitory effect on lipid peroxidation (IC(50) 33.4 μg/mL). Both the SC-CO(2) extract and CA markedly suppressed the LPS-induced production of nitric oxide (NO) and tumor necrosis factor-α (TNF-α), as well as the expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2), phosphorylated inhibitor-kappaB (P-IκB), and nuclear factor-kappaB (NF-κB)/p65 in a dose-dependent manner, according to the study of "Anti-inflammatory effects of supercritical carbon dioxide extract and its isolated carnosic acid from Rosmarinus officinalis leaves" by Kuo CF, Su JD, Chiu CH, Peng CC, Chang CH, Sung TY, Huang SH, Lee WC, Chyau CC.(51)

3. Supercritical fluid
In the investigation of rosemary extract could enhance antioxidant defenses and improve antioxidant status in aged rats found that rosemary extract produced a decrease in antioxidant enzyme activity, lipid peroxidation and ROS levels that was significant for catalase activity in heart and brain, NOS in heart, and LPO and ROS levels in different brain tissues. These observations suggest that the rosemary supplement improved the oxidative stress status in old rats, according to "Protective effect of supercritical fluid rosemary extract, Rosmarinus officinalis, on antioxidants of major organs of aged rats" by Posadas SJ, Caz V, Largo C, De la Gándara B, Matallanas B, Reglero G, De Miguel E.(52)

C.2. Gingerole
Gingerole, is also known as gingerol, a phytochemical of Flavonoids (polyphenols) found in fresh ginger. and in variety of other plants. The herb has been used to treat nausea and vomiting of pregnancy, motion sickness, rheumatoid arthritis, relieve migraine, etc.
1. Antioxidant and anti-inflammatory effects
In the investigation of the effectiveness of chemical constituents of Zingiber officinale Rosc. (Zingiberaceae)in treating oxidative stress found that compounds [6]-gingerol, [8]-gingerol, [10]-gingerol and [6]-shogaol of the herb scavenges of 1,1-diphenyl-2-picyrlhydrazyl (DPPH), superoxide and hydroxyl radicals, inhibitsof N-formyl-methionyl-leucyl-phenylalanine (f-MLP) induced reactive oxygen species (ROS) production in human polymorphonuclear neutrophils (PMN), lipopolysaccharide induced nitrite and prostaglandin E(2) production in RAW 264.7 cells, according to the study of "Comparative antioxidant and anti-inflammatory effects of [6]-gingerol, [8]-gingerol, [10]-gingerol and [6]-shogaol" by Dugasani S, Pichika MR, Nadarajah VD, Balijepalli MK, Tandra S, Korlakunta JN(53)

2. Dementia
In the study of Ginger effectiveness in treating dementia in South Asia with A 70% aqueous/methanolic extract of dried ginger (Zo.Cr) was used. Zo.Cr tested positive for the presence of terpenoids, flavonoids, secondary amines, phenols, alkaloids and saponins found that
specific inhibition of butyrylcholinesterase (BuChE) rather than acetylcholinesterase enzyme. Different pure compounds of ginger also showed spasmolytic activity in stomach fundus, with 6-gingerol being the most potent. 6-Gingerol also showed a specific anti-BuChE effect, according to "Muscarinic, Ca(++) antagonist and specific butyrylcholinesterase inhibitory activity of dried ginger extract might explain its use in dementia" by Ghayur MN, Gilani AH, Ahmed T, Khalid A, Nawaz SA, Agbedahunsi JM, Choudhary MI, Houghton PJ.(54)

C.3. Naringenin
Naringenin, a flavanone, belonging to the red, blue, purple pigments of Flavonoids (polyphenols) found predominantly in citrus fruits is considered as one of powerful antioxiant with many health benefits.
1. Antioxidant, radical scavenging and biomolecule activity
In the affirmation of the capacity of flavonoid naringenin and its glycoside naringin in the comparison of theirs antioxidant capacities, radical scavenging and biomolecule activities found that naringenin exhibited higher antioxidant capacity and hydroxyl and superoxide radical scavenger efficiency than naringin and both flavanones were equally effective in reducing DNA damage. However, they show no protective effect on oxidation of GSH, according to the study of "Antioxidant properties, radical scavenging activity and biomolecule protection capacity of flavonoid naringenin and its glycoside naringin: a comparative study" by Cavia-Saiz M, Busto MD, Pilar-Izquierdo MC, Ortega N, Perez-Mateos M, Muñiz P.(55)

2. Anti-inflammatory effects
In the evaluation of the mechanisms of action of the effective compounds. Flavone, the isoflavones daidzein and genistein, the flavonols isorhamnetin, kaempferol and quercetin, the flavanone naringenin, and the anthocyanin pelargonidin amd theirs anti-inflammatory effects found that they inhibited iNOS protein and mRNA expression and also NO production in a dose-dependent manner, according to "Anti-inflammatory effects of flavonoids: genistein, kaempferol, quercetin, and daidzein inhibit STAT-1 and NF-kappaB activations, whereas flavone, isorhamnetin, naringenin, and pelargonidin inhibit only NF-kappaB activation along with their inhibitory effect on iNOS expression and NO production in activated macrophages" by Hämäläinen M, Nieminen R, Vuorela P, Heinonen M, Moilanen E.(56)

3. Immunity
In the unvestigation of Naringenin, a flavonoid in grapefruits and citrus fruits and its effec in immune system found that naringenin potently suppressed picryl chloride (PCl)-induced contact hypersensitivity by inhibiting the proliferation and activation of T lymphocytes. In vitro, both of the activated hapten-specific T cells and the T cells stimulated with anti-CD3/anti-CD28 showed growth arrest after naringenin treatment, according to "A novel regulatory mechanism of naringenin through inhibition of T lymphocyte function in contact hypersensitivity suppression" by Fang F, Tang Y, Gao Z, Xu Q.(57)

C.4. Tangeritin
Tangeritin, one of the flavones, is found in tangerine and many citrus peels
1. Neuroprotective effects
In the evaluation of neuroprotective effects of a natural antioxidant tangeretin, a citrus flavonoid and its effect on Parkinson's disease found that tangeretin crosses the blood-brain barrier. The significant protection of striato-nigral integrity and functionality by tangeretin suggests its potential use as a neuroprotective agent, according to "Tissue distribution and neuroprotective effects of citrus flavonoid tangeretin in a rat model of Parkinson's disease" by Datla KP, Christidou M, Widmer WW, Rooprai HK, Dexter DT.(58)

2. Antioxidants
In the comparison of hand-pressed juice of polymethoxylated flavones (PMFs) and flavanone glycosides (FGs) and the peeled fruit of 'Sainampueng' tangerines ( Citrus reticulata Blanco cv. Sainampueng) antioxidant effects found that hand-pressed juice of C. reticulata Blanco cv. Sainampueng serves as a rich source of PMFs, FGs, carotenoids, and antioxidants: 4-5 tangerine fruits ( approximately 80 g of each fruit) giving one glass of 200 mL hand-pressed juice would provide more than 5 mg of nobiletin and tangeretin and 36 mg of hesperidin, narirutin, and didymin, as well as 30 mg of ascorbic acid, >1 mg of provitamin A active beta-cryptoxanthin, and 200 microg of alpha-tocopherol, according to "Polymethoxylated flavones, flavanone glycosides, carotenoids, and antioxidants in different cultivation types of tangerines ( Citrus reticulata Blanco cv. Sainampueng) from Northern Thailand" by Stuetz W, Prapamontol T, Hongsibsong S, Biesalski HK.(59)

C.5. Etc.

D. Antioxidants to prevent Hydrocephalus(60)
D.1. Antioxidant enzymes
Antioxidant enzymes are chemical substances found in plants that can protect the body from damage of free radicals by terminating the chain reactions by removing free radical intermediates and inhibiting other oxidation reactions.
1. Catalase
Catalase is an enzyme, found in most living organisms that are exposed to oxygen helped to converse hydrogen peroxide (free radicals) to water and oxygen as a rate of 40 million molecules of hydrogen peroxide to water and oxygen each second, using either an iron or manganese cofactor.

2. Glutathione peroxidase
The function of glutathione peroxidase is to protect the organism from oxidative damage by reducing lipid hydroperoxides, an oxidation of lipid cell membranes which can easily break and form free radicals of the form RO and converting free hydrogen peroxide to oxygen and water.

3. Glutathione reductase
Glutathione reductase, an enzyme reduces pair of sulfur atoms glutathione to the a organosulfur compound form of antioxidant (consisting of three amino acids joined by peptide bonds) which helps to prevent damage of important cellular components caused by free radicals and peroxides.

4. Super oxide dismutase (both Cu-Zn and Mn)
Super oxide dismutase is an important antioxidant defense in nearly all cells exposed to oxygen by converting superoxide into oxygen and hydrogen peroxide depending on the metal cofactor such as both Cu-Zn and Mn.

D.2. Metals binding proteins
1. Ceruloplasmin
Ceruloplasmin, the major copper-carrying protein in the blood plays a role in iron metabolism. It prevents the oxidation that leads to the forming of oxidation from Fe²⁺ (ferrous iron) into Fe³⁺ (ferric iron) by exhibiting a copper-dependent oxidase activity, causing mutations in the ceruloplasmin gene cause of iron overload in the brain, liver, pancreas, and retina.

2. Ferritin
Ferritin, the protein produced by almost all living organisms, acts as a component to fight against iron deficiency and iron overload, keep in a soluble and non-toxic form and transport it to the body needs, including organs. It enhances the immune system in the presence of an infection or cancer and prevent the infectious agent attempts to bind iron to become free radicals by migrating from the plasma to within cells.

3. Lactoferrin
Lactoferrin, a multifunctional protein of the transferrin family, is one of the components of the immune system of the body by fighting against foreign invasion of bacteria and virus and lipid oxidation by inhibiting oxidation in a concentration-dependent manner even at concentrations beyond its capacity.

4. Metallotheinein
Metallotheinein, a family of cysteine-rich, low molecular weight proteins helps to bind both physiological heavy metals through the organosulfur compound of its cysteine residues. It also captures harmful superoxide and hydroxyl radicals by liberating the metal ions which were bound to cysteine.

5. Transferrin
Transferrin is a glycoprotein that binds iron very tightly but reversibly. It enhance the immune system in fighting against infection, inflammation by creating an environment low in free iron that impedes bacteria survival and cell oxidation.

6. Hemoglobin
Hemoglobin is the protein molecule in red blood cells that enhances the carrying of oxygen from the lungs to the body's tissues and return CO2 from the tissues to the lungs.
During oxidate stress, the cell membrane is protected by intraerythrocytic hemoglobin from the forming of free radical.

7. Myoglobin
Myoglobin is an iron- and oxygen-binding protein found in the muscle tissue of vertebrates. The binding of oxygen by myoglobin is unaffected by the oxidation or chain of oxidative reaction in the surrounding tissue, thus reducing the free radicals damage caused by oxidate stress.

8. Etc.

VII. Treatment
A. In Conventional medicine perspective
A.1. Surgical treatment
In general, treatment of Hydrocephalus involves the placement of a tube made of silastic, into the cerebral ventricles to bypass the flow obstruction and drain the excess fluid into other body cavities, where the fluid can be reabsorbed. In the study of Lumboperitoneal shunts for the treatment of normal pressure hydrocephalus, Dr. Bloch O, and Dr.McDermott MW. indicated that Studies have reported shunt complication rates up to 38%, with subdural hemorrhage rates as high as 10%. Lumboperitoneal (LP) shunts with horizontal-vertical valves (HVV) are an alternative for cerebrospinal fluid (CSF) diversion that avoids direct cerebral injury and may reduce the risk of overdrainage. They also showed that
in 33 patients with LP-HVV shunts inserted for the treatment of iNPH from 1998 to 2009. Patients were evaluated for improvements in gait, urinary function, and dementia after shunt placement. All patients had evidence of ventriculomegaly and a positive response to pre-operative lumbar puncture or extended lumbar drainage. All 33 (100%) patients had pre-operative gait dysfunction, 28 (85%) had incontinence, and 20 (61%) had memory deficits. Mean follow-up time was 19 months. Following shunt placement, 33/33 (100%) patients demonstrated improved gait, 13/28 (46%) had improvement in incontinence, and 11/20 (55%) had improvement in memory. Shunt failures requiring revision occurred in nine patients (27%), with an average time to failure of 11 months. Infections occurred in two patients (6%). There were no neurologic complications, including no hemorrhages. Thus, LP-HVV shunt placement is a safe and effective alternative to ventriculoperitoneal shunting for iNPH, resulting in significant symptomatic improvement with a low risk of overdrainage. It should be considered as an option for the treatment of patients with iNPH who demonstrate clinical improvement following lumbar drainage(61).
Other cautioned of The incidence of infection and malfunction with an LP shunt is significantly lower than that with a VP shunt. An LP shunt is also indicated for pediatric patients, although a relatively higher incidence of malfunction is noted compared to adults(62)

A.2. Non Medical treatment
1. Occupational therapy and physical therapy
In the study to examine effectiveness of standardized occupational therapy and physical therapy assessments in detecting functional changes and predicting clinical improvement in patients with suspected normal pressure hydrocephalus undergoing cerebrospinal fluid drainage, indicated that specific occupational therapy and physical therapy assessments demonstrate sensitivity to change and predictive value with patients with suspected normal pressure hydrocephalus undergoing cerebrospinal fluid drainage(63).

2. Psycological and Speech therapy
In the review of the literature on psychic disturbance in normal pressure hydrocephalus, showed that in the 26 cases of CSF drainage, impairment of memory and concentration were always present in normal pressure hydrocephalus; behaviour disorders were very frequent and characterized by both types of frontal behaviour; the mental picture also comprised difficulties of calculation, writing, visuoconstructive praxis and, less frequently, impaired speech and reading ability. CSF drainage brought clinical improvement in 73% of the cases. Disorders of consciousness, mental function and behaviour regressed generally progressively as soon as the operation had been performed(64).

3. Etc.

B. In herbal medicine perspective
There is no specific herbs formula or herbs
According to the article of Hydrocephalus by Dherbs, Hydrocephalus is a result of the building up of toxins cause of accumulations of fluid on the brain as he provide each step
1. Toxins removal
a. Blood and Lymphatic with ECHINACEA ANGUSTIFOLIA, BEET ROOT, DRAGONS BLOOD, SPIRULINA, DANDELION, BURDOCK, MANJISTHA, BITTER MELON, RED CLOVER, CHICKWEED, SASSAFRAS, AMLA FRUIT, CLEAVERS, VIDANGA, INDIGO, POKE ROOT, NETTLE, IRON WEED, CAPSICUM, RED ROOT, YELLOW DOCK, PAU D’ARCO, ANANTAMUL, SOLOMON SEAL, OLIVE LEAF, GOLDENSEAL.

b. Cardiovascular with GARLIC, CAPSICUM, HAWTHORN BERRIES, LILY OF THE VALLEY, ARJUNA, SIBERIAN GINSENG, REISHI MUSHROOM, MOTHERWORT, DANDELION LEAF, MYRRH, GINGER, BALA, PUNARNAVA, MISTLETOE, GINGKO BILOBA, PRICKLY ASH, MULBERRY.

c. Liver and Gallbladder with MANJISTHA ROOT, ANANTAMUL, SCHIZANDRA, BEET ROOT, DANDENLION, BHUMYAMALAKI, ARTICHOKE, ROSEMARY, TURMERIC, LICORICE, BUPLEURUM, AMALAKI FRUIT, PIPPALI FRUIT, MILK THISTLE SEEDS, PEONY ROOT, BHRINGARAJ, RHUBARB, FENUGREEK, GOLDENSEAL.

d. Lungs and Respiratory with GOKSHURA FRUIT, JUNIPER BERRY, GUDUCHI, CORN SILK, CORIANDER SEED, FENNEL SEED, PUNARNAVA, UVA URSI, ASPARAGUS, BUCHU, CRANBERRY, TRIBULUS, CLEAVERS, GOLDENROD, CELERY SEED, ANANTAMUL, PARSLEY LEAF, GRAVEL ROOT, PIPSISSEWA, HORSETAIL, NETTLE.

e. Colon and Digestive Tract with SENNA LEAVES AND PODS, OAT BRAN, BARLEY GRASS, SLIPPERLY ELM, BLACK PEPPER, CASCARA SAGRADA, CARBON (ACTIVATED CHARCOAL), BUCKTHORN, HARITAKI, TURMERIC, PSYLLIUM HUSK, IRISH MOSS, ALOE VERA, GINGER, CLAY BENTONITE, POKE ROOT, CAYENNE PEPPER, HINGVASTAK.

f. Carbon (also known as Activated Charcoal) is not a formula but the residue of burnt plant matter (Willow bark) that is carbon and copper-based and therefore ELECTRICAL

2. 10 DAYS ELECTRIC GREENS COMBO REGIMEN
10-day Cleanse that helps cleanse, build, and nourish the body at the same time. It is a unique cleanse consisting of a mix of super green foods such as alfalfa, nettle, kamut grass, blue green algae, spirulina, chlorella, and wheat grass to name a few.

3. Soften and dissolve hardened, stubborn mucus and phlegm of which can cause toxins accumulation with LICORICE, CALENDULA, MULLEIN LEAVES, RED CLOVER, QUASSIA, PLANTAIN, FENUGREEK.

4. Enhance circulation with HAWTHORNE BERRY, CAYENNE (40,000), CINNAMON, AND GINGER.

5. Release fluid with UVA URSI, LILY OF THE VALLEY, DANDELION LEAF & ROOT, CORN SILK, BILBERRY, ANISE, CELERY, FENNEL, BLACK COHOSH, MULLEIN LEAF, ROSEMARY, QUEEN OF THE MEADOW, PARSLEY, AND BURDOCK ROOT.

6. Nourish, strengthen, and tone the veins and venous system with HORSE CHESTNUT, BILBERRY, ORANGE PEEL, BUTCHER’S BROOM, GOTU KOLA, MANJISTHA, CINNAMON, GINGER, HORSETAIL, WHITE OAK BARK, LEMON PEEL, AND CALENDULA.

7. Colon and intestinal complaints and helps to maintain overall colon and intestinal health and wellbeing! with SENNA LEAVES, CHAMOMILE, GINGER, PEPPERMINT, LICORICE, and STEVIA .

8. Etc.
For more information of DHerbssolution, please visit (65)

C. In Traditional Chinese medicine perspective
According to the article of Hydrocephalus posted on Dicovery TCM, Hydrocephalusis a result of

1. Deficiency of the kidney qi

a. Main symptoms and signs

Marked enlargement of skull, widened fontanel with separation of sutures,sluggish expression, dimness in the eyes, dropping eyeballs like "the setting sun", large anteverted head with thin neck, strabismus, vomiting and convulsion in severe cases, whitish complexion, poor appetite, loose stools, pale tongue with a little fur, weak pulse and bluish superficial venule of index finger.

b. Therapeutic method

Tonifying the kidney and marrow.

c. Prescription and drugs The prescription used is the modified Bushen Dihuang Pill (Rehmannia Pill for Tonifying the kidney) composed of 10 g of Shudihuang ( Radix Rehmanniae Praeparata ), 10 g of Shanyao (Rhizoma Dioscoreae ), 10 g of Shanzhuyu ( Fructus Corni), 10 g of Fuling (Poria), 10 g of Zexie (Rhizoma Alismatis), 10 g of Mudanpi ( Cortex Moutan Radicis), 6 g of Niuxi (RadixAchyranthis Bidentatae), 6 g of Lujiaojiao (colla Comus Cervi) (melted) and 6 g of Danggui ( Radix Angelicae Sinensis )

Modification For the patients with concurrent talantropia, strabismus or blurred vision, 10 g of Gouqizi (Fructus Lycii), 8 g of Tusizi (Semen Cuscutae), 10 g of Juemingzi ( Semen Cassiae ) and 10 g of Juhua ( Flos Chrysanthemi) are added.

2. Hyperactivity of the liver due to asthenia of the kidney
a. Main symptoms and signs

Separation of skull sutures, large and wide anterior fontanel, dropping eyeballs with more white than black, brightless eyes, dry mouth, dysphoria, feverish palms and soles, muscular twitching and cramp, occasional scream, red tongue,deep, thready and rapid pulse and purplish superficial venule of index finger

b.Therapeutic methods

Nourishing the kidney yin, calming the liver yang to stop wind.

c. Prescription and drugs The prescription used is the modified Zhibai Dihuang Pill in combination with Sanjia Fumai Decoction composed of 6 g of Shudihuang (Radix Rehmanniae Praeparata), 10 g of Shanyao (Rhizoma Dioscoreae), 8 g of Shanzhuyu (Fructus Corni), 10 g of Fuling ( Poria ), 6 g of Zexie ( Rhizoma Alismatis ), 10 g of Guiban ( Plastrum Testudinis) ( to be decocted first), 6 g of Zhimu (Rhizoma Anemarrhenae), 3 g of Huangbai ( Cortex Phellodendri), 6 g of Ejiao ( Colla COrii Asini) and 12 g of Baishaoyao (Radix Paeoniae Alba ).

Modification For the patients with fever due to yin deficiency, 6 g of Yuzhu (Rhizoma Polygonati Odorati) and 6 g of Baiwei (Radix Cynanchi Atrati ) are added; for the patients with dysphoria, 3 g of Hupofen (powder of Succinum) (taken separately) and 15 g of Zhenzhumu (Concha Margaritifera Usta) (to be decocted first) are included; for patients with muscular twitching and cramp, or occasional scream, 6 g of Tianma ( Rhizoma Gastrodiae ), 10 g of Gouteng ( Bamulus Uncariae cum Uncis) (to be decocted later) and 10 g of Baijiangcan (Bombyx Batryticatus) are added.

3. Water retention due to asthenia of the spleen

a. Main symptoms and signs Wide and large fontanel, separation of fontanel sutures, whitish complexion,lassitude, poor appetite, loose stools, epigastric and abdominal distension, pale tongue with whitish and thin or whitish and greasy fur, thready and weak pulse and light red superficial venule of index finger.

b. Therapeutic method

Warming the spleen to promote water metabolism.

c. Prescription and drugs The prescription used is the modifided Fuzi Lizhong Decoction (Aconite Decoction for Regulating the Middle Energizer) in combination with Wuling Powder (Five-ingredient Powder with Poria) composed of 3 g of Renshen (Radix Ginseng), 10 g of Baizhu (Rhizoma Atractylodis Macrocephalae), 6 g of Ganjiang (Rhizoma Zingiberis), 3 g of Zhifuzi ( Radix Aconiti Praeparata) (to be decocted first), 10 g of Zhuling (Polygorus Umbellatus), 10 g of Fuling (Poria), 6 g of Zexie (Rhizoma Alismatis ) and 6 g of Guizhi ( Ramulus Cinnamomi )

Modification For the patients with poor appetite, 10 g of Jiaoshanzha (carbonized Fructus Crataegi), 10 g of Jiaomaiya (carbonized Fructus Hordei Germinatus ) and 10 g of Jiaoshenqu (carbonized Massa Fermentata Medicinalis) are added; for the patients with loose stools,6 g of Cheqianzi ( Semen Plantaginis) (to be wrapped) and 10 g of Shanyao (Rhizoma Dioscoreae) are included; for the patients with vomiting, 6 g of Banxia (Rhizoma Pinelliae ) and 6 g of Zhuru ( Caulis Bambusae in Taeniam) are added; for the patients with yang deficiency of the spleen and kidney, poor appetite and loose stools,Kidney-regulating Powder may be applied. The powder is composed of 10 g of Shanyao (Rhizoma Dioscoreae), 3 g of Renshen (Radix Ginseng), 10 g of Baifuling (Poria), 10 g of Fushen (Poria cum Ligno Hospite ), 10 g of Baizhu (Rhizoma Atractylodis Macrocephalae), 12 g of Baishaoyao (Radix Paeoniae Alba ), 6 g of Shudihuang (Radix Rehmanniae Praeparata), 8 g of Danggui (Radix Angelicae Sinensis ), 10 g of Huangqi (Radix Astragall seu Hedysari), 6 g of Chuanxiong (Rhizoma Ligustici Chuanxiong) , 3 g of Zhigancao (Radix Glycyrrhizae Praeparata) and 10 g of Shichangpu ( Rhizoma Acori Graminei). The ingredients are ground into fine powder, 10 g of which is decocted with ginger and Chinese dates to be taken each time.

4. Stagnation of preponderant heat and toxin

a. Main symptoms and signs Gradual enlargement of skull, prominent and distending fontanel, closure of fontanel sutures with recurrent separation, dropping eyes, fever, short breath, dysphoria with cry and tantrum, flushed complexion with red lips or strabismus, spasm of limbs, dark and scanty and deep yellow urine, constipation, red tongue with yellowish fur, taut and rapid pulse, purple and sluggish superficial venule of index finger.

b. Therapeutic methods

Clearing away heat and removing toxin, removing blood stasis and dredging collaterals.

c. Prescription and drugs The prescription used is the modified Xidi Qingluo Decoction (Decoction of Rhinoceros Horn and Rehmannia Root for Clearing away Heat from Collaterals) composed of 15g of Shuiniujiaopian (slices ofcornu Bubali) (to be decocted first), 10 g of Shengdihuang ( Radix Rehmanniae ), 10 g of Lianqiao ( Fructus Forsythiae ), 3 g of Dengxincao ( Medulla Junci), 10 g of Mudanpi ( Cortex Moutan Radicis ),10 g of Chishaoyao ( Radix Paeoniae Rubra ), 6 g of Taoren (Semen Persicae ) and 10 g of Baimaogen (Rhizoma Imperatae ) .

Modification For the patients with stagnation of phlegm and heat, chest distress with nausea, red tongue with yellowish fur, 6 g of Danxing (Arisaema cum Bile), 10 g of Shichangpu ( Rhizoma Acori Graminei ) ,6 g of Dilong ( Lumbricus ) and 10 g of Tianzhuhuang (concretio silicea Bambusae ) are added; for the patients with clonic convulsion, 6 g of Quanxie (Scorpio), 10 g of Gouteng (Bamulus Uncariae cure Uncis) (to be decocted later) and 12 g of Baishaoyao (Radix Paeoniae Alba) are included. For enlargement of skull, separation of fontanel sutures without closure, visible local bluish superficial venules, tongue with ecchymosis, or deafness and dumbness, hypophrenia and paralysis of limbs resulted from the fact that blood stasis obstructs cerebral collaterals, constricts cerebral marrow and blocks cerebral orifices, the therapeutic method is removing blood stasis to eliminate obstructive orifices. The prescription used is the modified Tongqiao Huoxue Decoction (Decoction for Removing Obstruction from Orifices and Activating Blood Circulation) composed of 10 g of Danggui (Radix Angelicae Sinensis ), 8 g of Chuanxiong ( Rhizoma Ligustici Chuanxiong), 10 g of Chishaoyao (Radix Paeoniae Rubra), 6 g of Taoren ( Semen Persicae), 6 g of Honghua (Flos Carthami ), 10 g of Danshen ( Radix Salviae Miltiorrhizea), 8 g of Dilong (Lumbricus), O. 05 g of Shexiang (artificial Moschus) (to be infused separately),8 g of Niuxi (RadixAchyranthis Bidentatae) and 10 g of Fuling (Poria).

For more information of TCM in treating please visit (66)

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Tuesday, August 14, 2012

The Article and Polycystic Ovarian Syndrome's research

Part I. The article
Part II. The research
Please scroll down for part II of PCO's research

I. The article
Polycystic Ovarian Syndrome is defined as endocrinologic diseases caused by undeveloped follicles clumping on the ovaries that interferes with the function of the normal ovaries as resulting of enlarged ovaries, leading to hormone imbalance( excessive androgen), resulting in male pattern hair development, acne,irregular period or absence of period, weight gain and effecting fertility. It effects over 5% of women population or 1 in 20 women.

Ovarian cysts affect women of all ages, especially during a woman's childbearing years. Most ovarian cysts are functional and benign but some can become cancerous. Some ovarian cysts can cause bleeding and pain such as endometriomas/chocolate cysts and surgery is required for any cyst larger than 5 cms in diameter or if the cyst has interfered with the extruding of mature follicle. Traditional Chinese medicine defines ovarian cyst is a medical condition caused by excess- dampness (caused by blood and fluid stasis) accumulated in the abdomen and gradually coalesces into phlegm, that can manifest as that can manifest as ovarian cysts or various kinds, including chocolate cysts. In conventional medicine, ovarian cysts is defined as a collection of fluid, surrounded by a very thin wall, within an ovary.

Over the years as health article writer and researcher, I have received hundreds if not thousand of enquiry from women who have suffered from the affects of Ovarian cysts and Polycystic Ovarian Syndrome. Through the extensive research, some articles were written(1-5)) with an aim to help enquirers to understand more about the diseases, how they can manage the symptoms as well as treatments in conventional and holistic medicine perspective. Many recommendations have been given in herbal treatments from traditional Chinese and herbal medicine with medical studies proofs(6 -10). Unfortunately, all these types of treatment are required the correct differentiation of the diseases with specialists. Women who listened to these approaches have complained that they ended up with thousands of dollars expenses and spent lengthy time in the herbal specialist office before the diseases were cured. Women with less financial secure were recommended to a self help holistic treatment, the Ovarian Cyst Miracle written by Carol Foster with the same successful result.
Many women who know me through their friends recommendation and have tried the approaches insisted that the self help holistic treatment is the best as it is less financial burden (only $40) but to get rid of the Ovarian Cysts and and PCOs within 2 months, determination to follow the recommendations of the book is absolutely necessary. I, therefore recommend this book to all women who have suffered from the affects of Ovarian Cysts and PCOs to follow the approaches to eliminate all Ovarian Cysts and PCOS issues safely and naturally and regain the quality of life, click here.
Kyle J. Norton

All right reserves. Any reproduction of the article must have all link intact.

Sources
Polycystic Ovarian Syndrome
1. In Conventional Medicine Perspective
2.In Traditional Chinese Medicine Perspective
3. In Weight Loss Perspective
Ovarian Cysts
4. Ovarian Cysts In Conventional Medicine Perspective
5. Ovarian Cysts In Traditional Chinese Medicine Perspective
6. [Clinical observation on treatment of 43 women with polycystic ovary syndrome based on syndrome differentiation]
7. [Observation on therapeutic effect of acupuncture combined with chinese herbs on polycystic ovary syndrome of kidney deficiency and phlegm stasis type].
8. Treating adolescent ovarian cysts with Chinese herbs: a case report
9. Treating ovarian cysts with Chinese herbs: a case report.
10. Progress of integrative Chinese and Western medicine in treating polycystic ovarian syndrome caused infertility

II. The research
Polycystic Ovarian Syndrome is defined as endocrinologic diseases caused by undeveloped follicles clumping on the ovaries that interferes with the function of the normal ovaries as resulting of enlarged ovaries, leading to hormone imbalance( excessive androgen), resulting in male pattern hair development, acne,irregular period or absence of period, weight gain and effecting fertility. It effects over 5% of women population or 1 in 20 women.

1. Adipose tissue hormones and appetite and body weight regulators in insulin resistance
2. Physiopathology review of Polycystic ovary syndrome
3. Altered adipocyte function in polycystic ovary syndrome
4. Adiponectin and resistin serum levels in women with polycystic ovary syndrome
5. Cardiovascular Risk in Women With PCOS
6. Rosiglitazone treatment increases plasma levels of adiponectin and decreases levels of resistin in overweight women with PCOS

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Wednesday, August 8, 2012

Angina pectoris

Angina pectoris, also known as Angina, a symptoms of Ischemic heart disease, is defined as a condition of chest pain caused by poor blood flow through the blood vessels due to obstruction or spasm of the coronary arteries resulting of lack of blood that lead to lack of oxygen supply and waste removal.

Types of Angina pectoris
1. Stable angina res
Stable angina is the chest pain occurred after physical activity or stress and may last up to 10 minutes. the symptoms may improve or go away when stop or slow down the exercise.

2. Unstable angina
Unstable angina is a type of angina with chest pain occurs even at rest, with Crescendo angina and/or new-onset angina(1)

Symptoms
Beside chest pain or discomfort, patients with angina may also experience heaviness, tightness, squeezing, burning, or choking sensation of the chest and pain in the back, neck area, jaw, or shoulders. These are results of the pain perceived at a location other than the chest depending to the spinal level that receives visceral sensation.

Causes and risk factors
A. Causes
A.1. Stable angina
Physical exertion is the most common cause of stable angina as a result of severely narrowed arteries of that interfere with the blood flow to the heart.

A.2. Unstable angina
Unstable angina is a condition of blood clots causes of partially or totally block of an artery as a result of rupture of an artery. If severe case, large blood clot can increase the risk of cardiovascular diseases,
Blood clots may form, partially dissolve, and later form again. Angina can occur each time a clot blocks an artery.

B. Risk factors
1. Cigarette smoking
Men who are smokers are at higher risk to develop angina. According to the study of Framingham Heart Study, posted by Harvard University, indicated that those less than 60 years of age at angina onset who were nonsmokers or quitters during follow-up had a definite prognostic advantage over similarly aged continuing smokers. These results could not be explained by differences in coronary risk factors prior to symptom onset or by changes in factors other than smoking during follow-up. The findings suggest that stopping the cigarette smoking habit can improve both short-term and long-term prognosis in the younger patient and angina pectoris(2).

2. Obesity
in the study to evaluate the effects of moderate weight loss, in overweight patients with angina, on plasma coagulation, fibrinolytic indicies and pain frequency, at the University of Glasgow, researchers found that after the 12-week dietary intervention period, mean body weight fell by 3.5 (s.d. 2.6) kg or 4.3% (P=0.0001), range -11.7 to +1.7 kg. Mean angina frequency fell by 1.8 (s.d. 3.6) from 3.2 to 1.4 episodes/week (P=0.009) and plasma cholesterol by 0.4 (s.d. 0.7) from 6.3 to 5.9 mmol/l (P=0.0001). HDL cholesterol and triglyceride were unchanged. Of the coagulation and fibrinolytic factors, factor VII activity and RCA were significantly reduced by 5 (s.d. 20), IU/dl (P=0.04) and 1.3 (s.d. 1.3) arbitrary units (P=0.014), respectively(3).

3. Diabetes
In the study of nineteen diabetic and 25 nondiabetic patients with exertional angina were exercised on a treadmill to measure anginal perceptual threshold, researchers at the Newham General Hospital found that the diabetic group had a longer anginal perceptual threshold (138 +/- 64 seconds vs 34 +/- 51 seconds, p less than 0.001), which correlated positively with the somatic pain threshold (r = 0.5, p = 0.03); patients with more prolonged anginal perceptual thresholds tended to have higher somatic pain thresholds. In the diabetic group anginal perceptual (r = -0.3, p = NS) and somatic pain (r = -0.4, p = 0.05) thresholds tended to increase as the ratio of peak to minimal heart rate during the Valsalva maneuver fell below 1.21, but these variables were unrelated in the nondiabetic group(4).

4. High cholesterol
According to the study of The Heart Center of Chonnam National University Hospita of 34 stable angina pectoris (SAP) patients showed that these patients had unstable plaques (UPs) (61.6±9.2 years, 24 males, 12.8%). The percentage of plaque area in the minimum luminal area in high low density lipoprotein-cholesterol (LDL-C)/high density lipoprotein-cholesterol (HDL-C) ratio patients was significantly higher than in low LDL-C/HDL-C ratio patients (72.7±9.5% vs. 69.9±9.3%, p=0.035). An LDL-C/HDL-C ratio >2.0 was an independent predictor for UPs in SAP patients (odds ratio 5.252, 95% confidence interval 1.132-24.372, p=0.034)(5).

5. High blood pressure
Hypertension is associated to increased risk of Angina pectoris. In the study ofManagement of patients with hypertension and angina pectoris, reserachers showed that in managing the patient with hypertension and angina pectoris, it is important to determine whether the angina occurs in the setting of hypertensive hypertrophic disease alone or coexists with coronary arterial stenoses(6).

6. Sedentary lifestyle and Unhealthy diet
Lifestyle with no or irregular physical activity is associated with increased risk of Angina pectoris. Diet high in saturated and trans fat with less fruits and vegetables enhances the building up of blood cholesterol of that increase the risk of angina.

7. Family history of early heart disease
If you have a family history of early heart disease, you are at higher risk to develop angina pectoris as family history of premature coronary artery disease increase the risk of an imbalance between myocardial oxygen supply and demand that may result of angina.

8. Coronary artery disease
Coronary artery disease can cause decreased blood flow to the coronary arteries from the heart as a result of narrowing of the small blood vessels that supply blood and oxygen to the heart.

9. Other heart diseases
Increased blood flow for patients with preexisting ischemic heart disease may reduced the risk of angina pertoris, according to the study of Efficacy of early invasive strategy of diagnostics and treatment of unstable angina at the background of preexisting ischemic heart disease, indicated that detection of indications for myocardial revascularization in patients with unstable angina including those at medium and low risk confirms necessity of application of early invasive strategy as conventional strategy ensuring timeliness of pathogenetic treatment. Absence of indications to myocardial revascularization in a limited group of patients gives an opportunity to clarify diagnosis, prescribe drug therapy and prevent unjustified hospitalizations(7)

10. Previous heart attack
Heart attack victims may experience a diversity of symptoms, including chest pain, heaviness, tightness, squeezing, burning, or choking sensation of the chest and pain in the back, neck area, jaw, or shoulders.

11. Age and lower socioeconomic status
According to the study of Dr. Sekhri N, and the research team at the Barts and the London NHS Trust, here is evidence of underutilisation of chest pain clinics by older people and those from lower socioeconomic status. More robust and patient focused administrative pathways need to be developed to detect inequity, correction of which has the potential to substantially reduce coronary mortality(8).

12. Etc,

Diagnosis

Chest pain is not always as a indication of angina. Certain medication and medical conditions can cause chest pain, including Pleuritis ( Inflammation of the lining of the lungs), long term smoking cause depletion of lung function, Pericarditis: Pericarditis (inflammation of the lining around the heart), Shingles (Nerve irritation), etc. If you are exoerience chest pain or discomfort, several tests can help to determine the causes

1. Blood test

Blood test may be to rule out other conditions causes of angina or to check for levels of fats,
C-reactive protein (CRP), high levels of CRP may be a sign of CVD,

2. Chest X ray

the aim of the test is to show the structure of the chest to rule out other causes of angina, as it can reveal the sign of heart failure and lung disorder cause of chest pain, etc.

3. Electrocardiogram (ECG)

Electrocardiogram or electrocardiography (ECG) is the test to diagnose the heart conditions by measuring the electrical activity of the heart and highly recommendation for patients showing symptoms of severe chest pain. An abnormal patterns on the EKG may be an indication of Ischemia. In some cases, exercise testing, an exercise ECG test or 'stress test' as ECG recording is taken while you are exercising to induce the symptoms of chest pain in finding the causes.

4. Stress test

An exercise stress test such as walk or run on a treadmill or pedal a stationary bike is a screening tool used to test how your heart function under exercise stress. Medications can be necessary to simulate the stress on the heart normally brought on by exercise, if patient can not undergo exercise as a result of certain condition

5. Coronary angiography

Coronary angiography is an imaging test that uses a special dye (contrast material) and x-rays to see inside the arteries and how blood flows through your heart with the a mild sedative to help you relax.

6. Heart CT scan

Heart CT scan is a computed tomography (CT) scan of the heart with the use of uses x-rays to create detailed pictures of the heart and its blood vessels.

7. Computed Tomography angiography

A noninvasive way 3D technique with a contrast material to produce pictures of major blood vessels throughout the body with the use of x-rays with catheters, or computed tomography (CT) or magnetic resonance imaging (MRI).

8. Etc.

Preventions

A. The do and do not list

1. Life style change

a. Relaxation

Stress and emotion may increase the risk of Angina pectoris, a symptoms of schemic heart disease. According to the study of Emotional triggering of cardiac events at the University College London. Dr Steptoe A, and the research team indicated that the psychobiological processes underlying emotional triggering may include stress-induced haemodynamic responses, autonomic dysfunction and parasympathetic withdrawal, neuroendocrine activation, inflammatory responses involving cytokines and chemokines, and prothrombotic responses, notably platelet activation. These factors in turn promote coronary plaque disruption, myocardial ischaemia, cardiac dysrhythmia and thrombus formation(9). Music listening may have a beneficial effect on blood pressure, heart rate, respiratory rate, anxiety, and pain in persons with CHD. However, the quality of the evidence is not strong and the clinical significance unclear. Most studies examined the effects of listening to pre-recorded music. More research is needed on the effects of music offered by a trained music therapist(10). Other researchers in the study to determine the prevalence of anxiety and depressive symptoms in patients referred to a cardiology outpatient clinic for performing the stress test suggested that the prevalence of anxiety and depressive symptoms was estimated to be 42% and 31%, respectively, in the total chest pain population. Males with abnormal test were depressed but females experienced more anxiety symptoms. Patients with negative tests had significantly higher scores for anxiety and higher depression scores than those with positive tests. Eleven percent of the patients with positive tests were women and 23% were men(11).

b. If the disease is caused by physical activity, slow down or take rest more often can be helpful

2. Healthy diet

In the study to compare two strategies for atherosclerosis treatment: drugs and healthy lifestyle, found that Statins act mainly as lipid-lowering drugs but pleiotropic actions are also present. Healthy lifestyle, on the other hand, is effective and inexpensive and has no harmful effects. Five items are associated with lower cardiac risk: non-smoking, BMI ≤25, regular exercise (30 min/day), healthy diet (fruits, vegetables, low-saturated fat, and 5-30 g alcohol/day)(12).

a. Low intake of saturated and trans fats

High levels of bad cholesterol and triglyceride partial block the blood flow in the vessels, it not only increases the risk of high blood pressure but also the risk of ischemia if the blood circulation diminishes.

d. Increase intake fish and olive oil

Studies indicate that the use of fish oil is associated with coronary heart disease risk reduction. A number of mechanisms may be responsible for such effects. These include prevention of arrhythmias as well as lowering heart rate and blood pressure, decreasing platelet aggregation, and lowering triglyceride levels. The latter is accomplished by decreasing the production of hepatic triglycerides and increasing the clearance of plasma triglycerides(19). Other researchers indicated that in both sexes consumption of olive oil and vegetable oil was inversely associated with serum cholesterol and glucose levels and systolic blood pressure(13).

c. High amount intake of in fiber

Consumption of dietary fiber from cereals and fruits is inversely associated with risk of coronary heart disease. In a study of over 6 to 10 years of follow-up, 5249 incident total coronary cases and 2011 coronary deaths occurred among 91058 men and 245186 women. After adjustment for demographics, body mass index, and lifestyle factors, each 10-g/d increment of energy-adjusted and measurement error-corrected total dietary fiber was associated with a 14% (relative risk [RR], 0.86; 95% confidence interval [CI], 0.78-0.96) decrease in risk of all coronary events and a 27% (RR, 0.73; 95% CI, 0.61-0.87) decrease in risk of coronary death. For cereal, fruit, and vegetable fiber intake (not error corrected), RRs corresponding to 10-g/d increments were 0.90 (95% CI, 0.77-1.07), 0.84 (95% CI, 0.70-0.99), and 1.00 (95% CI, 0.88-1.13), respectively, for all coronary events and 0.75 (95% CI, 0.63-0.

Fiber is found in whole grains, fruits, and vegetables. A fiber-rich diet not only helps lower your LDL cholesterol level, but also provides nutrients that may help protect against CHD(14).

d. Low intake of salt and sugar

d.1. Manage your blood pressure and reduce intake of salt, beverage and sugar

The worldwide increase in the incidence of metabolic syndrome correlates with marked increase in total fructose intake in the form of high-fructose corn syrup, beverage and table sugar. Increased dietary fructose intake in rodents has been shown to recapitulate many aspects of metabolic syndrome by causing hypertension, insulin resistance and hyperlipidaemia(15).

d.2. Prevent weight gain and control diabetes and prediabetes

In the study to test a 16-week group-based weight reduction intervention combining exercise, diet and behaviour change strategies aimed to increase self-efficacy (Healthy Eating and Exercise Lifestyle Program-HEELP) on weight, body mass index (BMI), waist circumference and exercise, found that The HEELP resulted in weight loss and improved exercise behaviour in obese people with CHD and T2DM(16).

d.3. Mediterranean style low-carb diet

The best approach to the dietary prevention of CVD is a Mediterranean style low-carb diet represented in the LOGI pyramid. Dietary guidelines for the prevention of CVD should to be revised accordingly(17).

2. Tobacco
Cigarette contains high levels of cadmium, inhaling the chemical during smoking or second hand smoke can cause building up of plaque along to the arterial walls as a result of oxidation.

3. Moderate consumption of Green tea, coffee and alcohol

Regular consumption of moderate quantities of coffee and (green) tea seems to be associated with a small protection against CAD, results from randomized clinical trials about their beneficial effects are less evident. As for other diffuse consumption habits, such as that of alcohol, moderation is the key word. In fact, both for coffee and chocolate, the optimal healthy effects on CAD have been observed to be associated with a moderate intake, while healthy outcomes vanish at heavy consumption(18).

4. Maintaining a healthy weight

Obesity increases the risk of ischemia as it is normally associated with high levels of cholesterol, high blood pressure.

5. Managing stress

Music listening may have a beneficial effect on blood pressure, heart rate, respiratory rate, anxiety, and pain in persons with CHD. However, the quality of the evidence is not strong and the clinical significance unclear. Most studies examined the effects of listening to pre-recorded music. More research is needed on the effects of music offered by a trained music therapist(19). Other researchers in the study to determine the prevalence of anxiety and depressive symptoms in patients referred to a cardiology outpatient clinic for performing the stress test suggested that the prevalence of anxiety and depressive symptoms was estimated to be 42% and 31%, respectively, in the total chest pain population. Males with abnormal test were depressed but females experienced more anxiety symptoms. Patients with negative tests had significantly higher scores for anxiety and higher depression scores than those with positive tests. Eleven percent of the patients with positive tests were women and 23% were men(20).

6. Etc.

B. Foods to prevent angina
The aims of the diet is to reduce the unhealthy diet and coronary artery disease risk factors causes of Angina pectoris, the symptom of Ischemic heart disease
1. Avocados are a commercially valuable fruit and are cultivated in tropical climates throughout the world, it is a green-skinned, pear-shaped fruit that ripens after harvesting and native to the Caribbean, Mexico, South America and Central America, belonging to the flowering plant family Lauraceae.
a. Cholesterol
In the determination of the atherogenicity of avocado oil relative to saturated (coconut oil), monounsaturated (olive oil) and polyunsaturated (corn oil) fats found that Coconut oil was the most atherogenic fat. Corn oil was only slightly less atherogenic than either olive or avocado oils. Percentage of serum HDL cholesterol was highest in the rabbits fed the two monounsaturated fats, according to "Cholesterol vehicle in experimental atherosclerosis 24: avocado oil" by Kritchevsky D, Tepper SA, Wright S, Czarnecki SK, Wilson TA, Nicolosi RJ.(21)

b. Dietary fiber
Daily intake of right amount of fibers can prevent and treat Diabetes. Increased consumption of vegetables, whole grains, and soluble and insoluble fiber is associated with improved glucose metabolism in both diabetic and nondiabetic individuals. Improvements in insulin sensitivity and glucose homeostasis were more evident in participants following a plant-based diet compared with other commonly used diets, according to the study of "Efficacy of high-fiber diets in the management of type 2 diabetes mellitus" by Wolfram T, Ismail-Beigi F.(22)

c. Heart diseases
c.1.The chemical compound Beta-Sitosterol is found effectively in reducing the bad cholesterol and leaving the good cholesterol untouched by inhibiting the amount our body can absorb, thus reducing the risk of plague building up in the arterial walls, leading to heart diseases, according to the study of "The Effect of Beta Sitosterol on the Serum Lipids of Young Men with Arteriosclerotic Heart Disease" by JOHN W. FARQUHAR M.D.; RALPH E. SMITH M.D.; MARY E. DEMPSEY M.S., posted in Circulation(23)

c.2. It also reduce the risk of autoimmune diseases such as multiple sclerosis, according to the study of "Effect of vitamin D and β-sitosterol on immune function of macrophages" by Alappat L, Valerio M, Awad AB.(24)

2. Salmon is the common name for Salmonidae. They are anadromous, born in fresh water, migrate to the ocean, then travel thousands of miles in the deep sea cold water throughout their life cycle and within to five years returning to the exacted location where they were born to reproduce and die.
a. Triacylglycerols
In the investigation of Intake of fish and omega-3 (n-3) fatty acids is associated with a reduced concentration of plasma triacylglycerols (TAG) found that intake of cod or salmon when compared with the control group. In conclusion, both lean and fatty fish may lower TAG, possibly by reducing the 18:1n-9/18:0 ratio related to allosteric inhibition of SCD1 activity, rather than by influencing the synthesis of enzyme protein, according to "Daily Intake of Cod or Salmon for 2 Weeks Decreases the 18:1n-9/18:0 Ratio and Serum Triacylglycerols in Healthy Subjects" by Telle-Hansen VH, Larsen LN, Høstmark AT, Molin M, Dahl L, Almendingen K, Ulven SM.(25)

b. Weight loss
In the investigation of supplementation with n3 long-chain polyunsaturated fatty acids (n3-LCPUFA) and its effect in body weight, found that At the end of the 1-month period, 16 children lost weight and 27 children gained weight. Multiple analysis demonstrated that supplementation with n3-LCPUFA decreased HOMA-IR by 15% after adjusting for puberty, treatment adherence, changes in adipokines, and weight loss. Interaction between supplementation and weight loss was significant (p = 0.007), according to "Supplementation of n3 Long-chain Polyunsaturated Fatty Acid Synergistically Decreases Insulin Resistance with Weight Loss of Obese Prepubertal and Pubertal Children" by López-Alarcón M, Martínez-Coronado A, Velarde-Castro O, Rendón-Macías E, Fernández J.(26)

c. Cholesterol
In the assessment of an increasing drive to replace fish oil (FO) in finfish aquaculture diets with vegetable oils (VO), driven by the short supply of FO derived from wild fish stocks,
found that these effects are most likely mediated by SREBP2, which responds to reductions in dietary cholesterol. These changes are sufficient to maintain whole body cholesterol levels but not HUFA levels, according to "Functional genomics reveals increases in cholesterol biosynthetic genes and highly unsaturated fatty acid biosynthesis after dietary substitution of fish oil with vegetable oils in Atlantic salmon (Salmo salar)" by Leaver MJ, Villeneuve LA, Obach A, Jensen L, Bron JE, Tocher DR, Taggart JB.(27)

d. Coronary heart disease
In determination of Omega-3-fatty acids play a protective role in the prevention of CHD,
found that The treatment with salmon oil led to a decrease of triglycerides in patients with hypertriglyceridemia and to an increase of cholesterol in hypercholesterolemia. Following the increase of malondialdehyde as measure of the lipid peroxidation a substitution of antioxidants, like vitamin E and vitamin C, seems to be useful. Further investigations are necessary before wide use of fish-oil capsules, not least to avoid side-effects, according to "[Changes in parameters of lipid metabolism and anti-oxidative potentials in elderly hyperlipoproteinemic patients treated with omega-3 fatty acids].[Article in German]" by Reuter W, Vorberg B, Sauer I, Krumpolt C.(28)

e. Antioxidants
In the research of the antioxidant effect of vitamin E after ingestion of salmon found that that megadoses of vitamin E, far from having pro-oxidative activity, actually increase the anti-oxidative capacity of the liver, especially after ingestion of salmon oil, according to "Effects of megadoses of dietary vitamin E on the antioxidant status of rats fed lard or salmon oil" by Flader D, Brandsch C, Hirche F, Eder K.(29)

3. Soy sauce is a seasoning produced by fermenting soybeans and filamentous fungus, along with water and salt after a period of sometime, it yields a moromi or thick mash of cereal to obtain soy sauce by pressing it to liquid form. Tamari is made by collecting the liquid which was pressed and the liquid drained drains from miso after a certain time of fermentation.
a. Cardiovascular health
In the investigation of dietary proteins and their effect in heart diseases found that a direct cholesterol lowering effect of proteins has not been shown. Despite earlier research indicating that soy protein has cardioprotective effects as compared to other proteins, these observations have not been confirmed by randomized placebo-controlled trials. However, most experts recommend the consumption of foods rich in plant proteins as alternatives to meat and dairy products rich in saturated fat and containing cholesterol, according to "Dietary proteins and atherosclerosis" by Darioli R.(30)

b. Hypolipidemic effect
In the observation of Soy sauce (Shoyu), a traditional Japanese fermented seasoning and its effect on cholesterol level found that in a 4-week randomized, double-blind, placebo-controlled parallel group study, hyperlipidemic men (TG >150 mg/dl) were treated with 600 mg of SPS (n=15) or placebo (n=15) daily. After 4 weeks, serum TG levels in the SPS-treated group were significantly (P<0.05) lower than the baseline (0 week). In conclusion, SPS of soy sauce reduce lipid absorption, and soy sauce is a potentially promising seasoning for the treatment of hyperlipidemia through food, according to "Hypolipidemic effect of Shoyu polysaccharides from soy sauce in animals and humans" by Kobayashi M, Magishi N, Matsushita H, Hashimoto T, Fujimoto M, Suzuki M, Tsuji K, Saito M, Inoue E, Yoshikawa Y, Matsuura T.(31)

4. Tomato is a red, edible fruit, genus Solanum, belongs to family Solanaceae, native to South America. Because of its health benefits, tomato is grown world wide for commercial purpose
and often in green house.
a. Cardiovascular diseases
In the review of patents and products within the context of lycopene and CVD prevention and health claims indicated that in vitro data and results from animal experiments partly showed promising preventive mechanisms of lycopene. In contrast, until now, human intervention studies mostly failed to show any CVD prevention. However, there is still an encouraging situation, giving hints for antioxidant as well as anti-inflammatory effects of lycopene. These mechanisms could be the background for cardio-protective effects of tomatoes and tomato products, according to "Lycopene and heart health" by Böhm V.(32)

b. Antioxidative and Cancer Cell-Inhibiting Activities
In the research of Tomato ( Solanum lycopersicum ) plants synthesize nutrients, pigments, and bioactive compounds and their benefit in nutrition and human health found that Tomato extracts promoted growth in normal liver (Chang) cells, had little effect in normal lung (Hel299) cells, mildly inhibited growth of lung cancer (A549) cells, and first promoted and then, at higher concentrations, inhibited growth in lymphoma (U937) cells. The relationship of cell growth to measured constituents was not apparent, according to "Free Amino Acid and Phenolic Contents and Antioxidative and Cancer Cell-Inhibiting Activities of Extracts of 11 Greenhouse-Grown Tomato Varieties and 13 Tomato-Based Foods" by Choi SH, Kim HR, Kim HJ, Lee IS, Kozukue N, Levin CE, Friedman M.(33)

C. Phytochemicals to prevent angina

1. 1. Omega-3 Fatty Acids
a. Systolic blood pressure, triglycerides and LDL cholesterol
In the ccomparison of the cardiovascular risk-reduction potential of three major polyunsaturated fatty acids in a double-blind study. showed that for the diet supplemented with EPA plus DHA compared with the linoleic acid diet systolic blood pressure fell 5.1 mm Hg (p = 0.01); plasma triglyceride and VLDL cholesterol fell by 39% (p = 0.001) and 49% (p = 0.01), respectively; and LDL cholesterol rose by 9% (p = 0.01). There were no significant changes with the diet supplemented with alpha-linolenic acid. The net effect on cardiovascular risk therefore is complex and the systolic blood pressure reduction was substantial, according to "n-3 fatty acids of marine origin lower systolic blood pressure and triglycerides but raise LDL cholesterol compared with n-3 and n-6 fatty acids from plants" by Kestin M, Clifton P, Belling GB, Nestel PJ.(34)

b. Cardiovascular effects
In the comparison of the effects of alpha-linolenic acid (ALA, C18:3n-3) to those of eicosapentaenoic acid (EPA, C20:5n-3) plus docosahexaenoic acid (DHA, C22:6n-3) on cardiovascular risk markers in healthy elderly subjects, found that Both n-3 fatty acid diets did not change concentrations of total-cholesterol, LDL-cholesterol, HDL-cholesterol, triacylglycerol and apoA-1 when compared with the oleic acid-rich diet. However, after the EPA/DHA-rich diet, LDL-cholesterol increased by 0.39 mmol/l (P = 0.0323, 95% CI (0.030, 0.780 mmol/l)) when compared with the ALA-rich diet. Intake of EPA/DHA also increased apoB concentrations by 14 mg/dl (P = 0.0031, 95% CI (4, 23 mg/dl)) and 12 mg/dl (P = 0.005, 95% CI (3, 21 mg/dl)) versus the oleic acid and ALA-rich diet, respectively. Except for an EPA/DHA-induced increase in tissue factor pathway inhibitor (TFPI) of 14.6% (P = 0.0184 versus ALA diet, 95% CI (1.5, 18.3%)), changes in markers of hemostasis and endothelial integrity did not reach statistical significance following consumption of the two n-3 fatty acid diets, according to "Effects of alpha-linolenic acid versus those of EPA/DHA on cardiovascular risk markers in healthy elderly subjects" by Goyens PL, Mensink RP.(35)

c. Obesity
in the determination of whether obesity modifies the association between plasma phospholipid polyunsaturated fatty acids (PUFAs) and markers of inflammation and endothelial activation in Multi-Ethnic Study of Atherosclerosis (MESA) participants, found that the modifying effect of obesity on the association of plasma PUFAs with IL-6 and sICAM-1 suggests differences in fatty acid metabolism and may also have implications in dietary fatty acid intake for obese individuals, particularly for linoleic and EPAs. Further study is warranted to confirm and explain the strong associations of dihomo-γ-linolenic acid (DGLA) with inflammatory and endothelial activation markers, according to "Obesity modifies the association between plasma phospholipid polyunsaturated fatty acids and markers of inflammation: the Multi-Ethnic Study of Atherosclerosis" by Steffen BT, Steffen LM, Tracy R, Siscovick D, Hanson NQ, Nettleton J, Tsai MY.(36)

3. Catechin

Catechin is phytochemical of Flavan-3-ols, in the group of Flavonoids (polyphenols), found abundantly in white tea, green tea, black tea, grapes, wine, apple juice, cocoa, lentils, etc.
a. Body-weight regulation
Green tea has been proposed as a tool for obesity management as strategies for weight loss and weight maintenance, as researchers found that a green tea-caffeine mixture improves weight maintenance, through thermogenesis, fat oxidation, and sparing fat free mass. The sympathetic nervous system is involved in the regulation of lipolysis, and the sympathetic innervation of white adipose tissue may play an important role in the regulation of total body fat in general, according to "Green tea catechins, caffeine and body-weight regulation" by Westerterp-Plantenga MS.(37)

b. Antioxidant activity
In the research on polyphenolic compounds (included catechins) in the berries of edible honeysuckle and their biological effects, including recommended utilization, are reviewed found that These berries seem to be prospective sources of health-supporting phytochemicals that exhibit beneficial anti-adherence and chemo-protective activities, thus they may provide protection against a number of chronic conditions, e.g., cancer, diabetes mellitus, tumour growth or cardiovascular and neurodegenerative diseases, according to "Phenolic profile of edible honeysuckle berries (genus lonicera) and their biological effects" by Jurikova T, Rop O, Mlcek J, Sochor J, Balla S, Szekeres L, Hegedusova A, Hubalek J, Adam V, Kizek R.(38)

c. Cholesterol and glucose levels
In the examination of the effect of the main green tea catechin, epigallocatechin gallate (EGCG), taken in a green tea extract, Polyphenon E (PPE) and their effect on circulating hormone levels, an established breast cancer risk factor, found that Glucose and insulin levels decreased nonsignificantly in the PPE groups but increased in the placebo group; statistically significant differences in changes in glucose (P=0.008) and insulin (P=0.01) were found. In summary, green tea (400 and 800 mg EGCG as PPE; ~5-10 cups) supplementation for 2 months had suggestive beneficial effects on LDL cholesterol concentrations and glucose-related markers, according to "Effect of 2-month controlled green tea intervention on lipoprotein cholesterol, glucose, and hormonal levels in healthy postmenopausal women" by Wu AH, Spicer D, Stanczyk FZ, Tseng C, Yang CS, Pike MC.(39)

3. Theaflavin with reddish in color, is a phytochemical of Flavan-3-ols, in the group of Flavonoids (polyphenols), formed in tea leaves during fermentation.
a. Cholesterol
In the investigation of 240 men and women 18 years or older on a low-fat diet with mild to moderate hypercholesterolemia were randomly assigned to receive a daily capsule containing theaflavin-enriched green tea extract (375 mg) or placebo for 12 weeks, found that after 12 weeks, the mean ± SEM changes from baseline in total cholesterol, LDL-C, HDL-C, and triglyceride levels were -11.3% ± 0.9% (P = .01), -16.4% ± 1.1% (P = .01), 2.3% ± 2.1% (P = .27), and 2.6% ± 3.5% (P = .47), respectively, in the tea extract group. The mean levels of total cholesterol, LDL-C, HDL-C, and triglycerides did not change significantly in the placebo group. No significant adverse events were observed, according to "Cholesterol-Lowering Effect of a Theaflavin-Enriched Green Tea Extract" by David J. Maron, MD; Guo Ping Lu, MD; Nai Sheng Cai, MD; Zong Gui Wu, MD; Yue Hua Li, MD; Hui Chen, MD; Jian Qiu Zhu, MD; Xue Juan Jin, MS; Bert C. Wouters, MA; Jian Zhao, PhD.(40)

b. Antioxidant effects
In the investigation of four main TF derivatives (theaflavin (TF(1)), theaflavin-3-gallate (TF(2)A), theaflavin-3'-gallate (TF(2)B), and theaflavin-3,3'-digallate (TF(3))) in scavenging reactive oxygen species (ROS) in vitro, their properties of inhibiting superoxide, singlet oxygen, hydrogen peroxide, and the hydroxyl radical, and their effects on hydroxyl radical-induced DNA oxidative damage, found that compared with (-)-epigallocatechin gallate (EGCG), TF derivatives were good antioxidants for scavenging ROS and preventing the hydroxyl radical-induced DNA damage in vitro. TF(3) was the most positive in scavenging hydrogen peroxide and hydroxyl radical, and TF(1) suppressed superoxide. Positive antioxidant capacities of TF(2)B on singlet oxygen, hydrogen peroxide, hydroxyl radical, and the hydroxyl radical-induced DNA damage in vitro were found, according to "Evaluation of the antioxidant effects of four main theaflavin derivatives through chemiluminescence and DNA damage analyses" by Wu YY, Li W, Xu Y, Jin EH, Tu YY.(41)

c. Cardio-protective activities
In the analyzing the protective effect of theaflavin (TF1) and its underlying mechanism,
found that (1) compared with the control group, TF1 (10, 20, 40 μmol/l) displayed a better recovery of cardiac function after ischemia/reperfusion in a concentration-dependent manner. At 60 min of reperfusion, LVDP, ± LVdP/dt (max) and CF in the TF1 group were much higher than those in the control group, whereas left ventricular end-diastolic pressure (LVEDP) in the TF1 group was lower than that in the control group (P < 0.01). (2) Pretreatment with glibenclamide (10 μmol/l), a K(ATP) antagonist, completely abolished the cardioprotective effects of TF1 (20 μmol/l). Also, most of the effects of TF1 (20 μmol/l) on cardiac function after 60 min of reperfusion were reversed by 5-HD (100 μmol/l), a selective mitochondria K(ATP) antagonist. (3) Atractyloside (20 μmol/l), a mitochondrial permeability transition pore (mPTP) opener, administered at the beginning of 15 min of reperfusion completely abolished the cardioprotection of TF1 (20 μmol/l), according to "ATP-dependent potassium channels and mitochondrial permeability transition pores play roles in the cardioprotection of theaflavin in young rat" by Ma H, Huang X, Li Q, Guan Y, Yuan F, Zhang Y.(42)

4. Resveratrol is a type of natural phenol in the group of Stilbenoids, produced naturally by many plants when under attack by bacteria or fungi. It has been studied by many researchers for it health benefits in treating chronic diaereses, including cancer, diabetes, heart disease, etc.
a. In a study of "Resveratrol: a promising agent in promoting cardioprotection against coronary heart disease." by Penumathsa SV, Maulik N. (Source from Molecular Cardiology and Angiogenesis Laboratory, Department of Surgery, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-1110, USA.), posted in PubMed, researchers indicated in abstract that many studies have provided evidence that resveratrol possesses antioxidant and antiapoptotic effects apart from activation of longevity proteins (such as SIRT-1). We have recently reported the angiogenic, antihypercholesterolemic, and antihypercholesterolemic, antihypercholesterolemic, antidiabetic effects of resveratrol and the mechanisms involved in reduced ventricular remodeling and increased cardiac functions. We have also shown different strategic target molecules involved in resveratrol-mediated.
cardioprotection.

b. Lipid metabolism
in a study of " [Effects of resveratrol on lipid metabolism in C57BL/6J mice]."[Article in Chinese]

by Ren Y, Li Y, Zhao Y, Yu F, Zhan Z, Yuan Y, Yang J. (Source from Department of Nutrition and Food hygiene, School of Public Health, China Medical University, Shenyang 110001, China. renyahao0512@sohu.com) researchers found that The serum TC, LDL-C, HDL-C levels of high-fat diet and resveratrol groups were higher than those of control group (P < 0.05), and the serum TC and LDL-C levels of high-fat diet were also higher than those of resveratrol group (P < 0. 05). But the serum TG levels of high-fat diet and resveratrol groups were lower than those of control group (P < 0.05). The TC content of liver in high-fat diet group were higher than those of control and resveratrol groups (P < 0.05), and concluded that The TC content in C57BL/6J mice can be decreased by resveratrol (22.5 mg/kg BW).

c. Diabetes and Obesity
According to the study of " Resveratrol, obesity and diabetes." by Szkudelska K, Szkudelski T. (Source from Department of Animal Physiology and Biochemistry, Poznan University of Life Sciences, Poznan, Poland. tszkudel@jay.up.poznan.pl) posted in PubMed, researchers found that The accumulating evidence also indicates the benefits of resveratrol in diabetes and diabetic complications. It is known that resveratrol affects insulin secretion and blood insulin concentration. In animals with hyperinsulinemia, resveratrol was found to reduce blood insulin. Moreover, numerous data indicate that in diabetic rats, resveratrol is able to reduce hyperglycemia. The mechanism of resveratrol's action is complex and is demonstrated to involve both insulin-dependent and insulin-independent effects. These data point to the potential possibility of use of resveratrol in preventing and/or treating both obesity and diabetes.

D. Antioxidants to prevent angina

1. Nitric oxide (NO)
Nitric oxide (NO), one of the antioxidant and peroxynitrite can inhibit pathways of oxygen radical generation, and, in turn, oxidants can inhibit NO synthesis from NOS.

2. Glutathione and vitamin E
Reduced form of glutathione may act as a first line of defense against oxidative stress during ischemia–reperfusion while vitamin E may act later on during severe oxidative stress by rendering resistance to the heart against the ischemic–reperfusion injury

3. 2-dithiole-3-thione (D3T)
Researcher found that in rat cardiac H9c2 cells, D3T and time-dependent induction of a number of cellular antioxidants and phase 2 enzymes, including catalase, reduced glutathione (GSH), GSH peroxidase, glutathione reductase (GR), GSH S-transferase (GST), and NADH:quinone oxidoreduc- tase-1 (NQO1) help to protect against H9c2 cell injury caused by various oxidants and simulated ischemia-reperfusion. D3T pretreatment also resulted in decreased intracellular accumulation of reactive oxygen in H9c2 cells after exposure to the oxidants as well as simulated ischemia-reperfusion.

4. Selenium
Deficiency of of a co-enzyme selenium, which is required in maintaining the glutathione redox cycle, also promote more susceptible to oxidative injure.

5. Etc.

Treatments

A. In conventional medicine perspective

In the summation of the evidences of angina pectoris' optimal treatment, Dr. Jánosi A. at the Fovárosi Onkormányzat Szent János Kórház-Rendelointézet III. Belgyógyászat, indicated that the first steps of therapy are - after the diagnosis - the influence of risk factors, life-style changes and optimal medical therapy. The optimal medical therapy consists of statin, aspirin and ACE inhibitor treatment besides antianginal therapy, where the beta blockers are regarded as first drugs of choice. Percutaneous interventions as initial treatment option are not recommended because we have no evidences that this intervention prolongs life and prevents myocardial infarction. If the patient remains symptomatic after medical treatment, it is necessary to perform revascularization(43a).

A.1. Medical treatments
1. 1. Nitroglycerin
a. Nitroglycerin is used to treat ischemic cardiac pain. and improve blood flow to the heart. Transdermal nitrate delivery systems improve the quality of life in ambulant patients: anginal attacks are reduced with a minimum of side effects. The widespread acceptance of this novel form of drug delivery has stimulated its application in other therapeutic avenues. The efficacy of transdermal nitroglycerin in the suppression of silent ischemic attacks has been demonstrated(43)
b. Side effects are not limit to
b.1. Dizziness
b.2. Lightheadedness, or fainting when sitting up or standing
b.3. Flushing of face and neck
b.4. Headache
b.5. Irritation
b.6. Nausea
b.7. Vomiting
b.8. Etc.

1.2. Beta-blockers
a. Beta blocker has been used to lower heart rate, blood pressure, and enhance oxygen to the heart. In the study of The 248 cases presented with new coronary heart disease from 1982 through 1984, and the 737 controls were a probability sample of health maintenance organization patients free of coronary heart disease. A withdrawal syndrome immediately following the cessation of beta-blocker use may be an acute precipitant of angina and myocardial infarction in hypertensive patients who have no prior history of coronary heart disease(44).
b. Side effects are not limit to
b.1. the medicine can cause allergic reaction to certain people, such as: rash, itching, swelling, dizziness, trouble breathing.
b.2. Easy bruising or bleeding,
b.3. Swollen hands or feet,
b.4. Confusion,
b.5. Depression
b.6. Etc.

1.3. Calcium channel blockers
a. The medicine used to relax arteries, lower blood pressure, and reduce strain on the heart. Researchers suggested that Compared with clopidogrel without calcium-channel blockers (CCBs), clopidogrel with CCB does not increase the mortality or composite thromboembolic events in elderly CAD patients, but clopidogrel combined with nondihydropyridine CCB is associated with significantly increased composite thromboembolic events in comparison with dihydropyridine CCB(45).
b. Side effects are not limit to
b.1. Stomach pain
b.2. Constipation
b.3. Drowsiness
b.4. Fatigue Feelings of a rapidly or forcefully beating heart (palpitations)
b.5. Flushing or hot flashes
b.6. Headaches
b.7. Nausea
b.8. Etc.

1.4. Statins
a. The medicine used to lower cholesterol. Dr. Biasucci LM, and the scientists at the Sacro Cuore University, in the study of Statins and coronary artery disease:clinical evidence and future perspective said "The introduction of more powerful statins in the market offered the opportunity to study whether an intensive lipid lowering treatment could yields even better cardiovascular outcomes than a moderate statin therapy and several clinical trial confirmed this hypothesis. Statins have also pleiotropic effect behind their lipid lowering function: they reduce inflammation, which plays an important role in the atherosclerotic process"(46).
b. Side effects are limit to
b.1. Headache
b.2. Nausea
b.3. Vomiting
b.4. Constipation
b.5. Diarrhea
b.6. Weakness
b.7. Muscle pain
b.8. Etc.

1.5. Aspirin
a. Many researchers believe that daily intake aspirin can reduce the risk of blood clots from forming in your arteries. In the study to determine the cardiovascular and coronary risk thresholds at which aspirin for primary prevention of coronary heart disease is safe and worthwhile, Dr. Sanmuganathan PS and the research team at the Royal Hallamshire Hospital, indicated that Aspirin treatment for primary prevention is safe and worthwhile at coronary event risk >/= 1.5%/year; safe but of limited value at coronary risk 1%/year; and unsafe at coronary event risk 0.5%/year. Advice on aspirin for primary prevention requires formal accurate estimation of absolute coronary event risk(47).
b. Side effects are not limit to
b.1. Stomach pains
b.2. Feelings of nausea
b.3. Vomiting.
b.4. Allergic reaction to some people
b.5. Aspirin may interact with other medicine, such as blood thinning medicine
b.6. Etc.

2. If the underline causes of Angina is a result of Ischemic heart disease, then
a. Percutaneous Coronary Intervention (PCI )
Percutaneous Coronary Intervention (PCI ) is one therapeutic treatment used to treat the narrowed coronary arteries of the heart found in coronary heart disease and Ischemic heart disease. In study of a total of 282 patients (74.1% females) with mean age of 57.0±3.2 years were studied. Most of the patients (89.7%) underwent elective PCI. Angiographic and procedure success rates were 95.7% and 94.6%, respectively. In-hospital MACE included two cases of death (0.7%) and one MI (0.3%); 2/29 (6.9%) of the emergent PCI and 1/253 (0.4%) of the elective PCI cases. MACE during follow-up included three cases of death (1.0%) and two MI (0.7%); 2/252 (0.8%) of the elective PCI and 1/28 (3.5%) of the emergent PCI cases. The overall MACE was calculated as 8 cases (2.8%) which included 5/29 (17.2%) of the emergent and 3/253 (1.1%) of the elective cases; P<0.001, concluded that PCI is performed with an acceptable success rate in our center in Isfahan and mortality and complications are within the range reported by other highly specialized centers in IRAN. Further studies with larger sample size are needed to find predictive factors(48).

b. Coronary revascularisation
Coronary artery bypass grafting (CABG)
Coronary artery bypass grafting (CABG) is a surgical procedure performed to reduce the risk of death from coronary artery disease by bypass atherosclerotic narrowings as arteries or veins from elsewhere in the patient's body are grafted to the coronary arteries to improve the blood supply to the heart muscle. some researchers suggested that transthoracic echocardiography(TEE) prior to coronary artery bypass surgery can provides higher resolution images than transthoracic echocardiography (TTE). Therefore one can conclude that TEE is the imaging modality of choice for detecting aortic atheromatous plaques but in patients with low risk for stroke and aortic atheromas, a detailed TTE may be sufficient for the pre-operative assessment(49).

B. In herbal medicine perspective

1. Soybean is the genus Glycine, belonging to the family Fabaceae, one of the legumes that contains twice as much protein per acre as any other major vegetable or grain crop, native to Southeast Asia. Now, it is grown worldwide with suitable climate for commercial profit and a a healthy foods. The herb has been used in traditional medicine for the proper functioning of the bowels, heart, kidney, liver, stomach. etc.
a. Insulin sensitive
Soybean helps to normalize plasma glucose and insulin homeostasis, according to "Increased insulin sensitivity and changes in the expression profile of key insulin regulatory genes and beta cell transcription factors in diabetic KKAy-mice after feeding with a soy bean protein rich diet high in isoflavone content" by Nordentoft I, Jeppesen PB, Hong J, Abudula R, Hermansen K.(50)

b. Cardiovascular diseases
Soy protein reduces reduces the levels of serum lipoprotein, decrease in low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), LDL-C/high-density lipoprotein cholesterol (HDL-C), triacylglycerol/HDL-C and TC/HDL-Cpostmenopausal women are at risk of cardiovascular disease, according to "Effects of soy bean on serum paraoxonase 1 activity and lipoproteins in hyperlipidemic postmenopausal women" by Shidfar F, Ehramphosh E, Heydari I, Haghighi L, Hosseini S, Shidfar S.(51)

2. Garlic (Allium sativum) is a species in the onion genus, belonging to family Amaryllidaceae, native to central Asia. It has been used popularly in traditional and Chinese medicine in treating common cold and flu to the Plague, blood pressure cholesterol levels, natural antibiotic, etc.
a. Cholesterol

Eating 4 cloves of garlic a day can cut total CHOLESTEROL by 70%(Fresh or Supplement). The member of the allium family fights poor circulation.The sulfur compound in garlic keep your platelets from clumping together. It helps UNCLOG your Arteries but check with your Doctor if you are taking Blood thinning medications. Cook with both Garlic and onion to fight high blood pressure effectively. Try to take them everyday if you have high blood pressure and Cholesterol.

b. Blood pressure
In the assessment of garlic extract and its effect of hypertension. found that Aged garlic extract was generally well tolerated and acceptability of trial treatment was high (92%) and aged garlic extract is superior to placebo in lowering systolic blood pressure similarly to current first line medications in patients with treated but uncontrolled hypertension, according to "Aged garlic extract lowers blood pressure in patients with treated but uncontrolled hypertension: a randomised controlled trial" by Ried K, Frank OR, Stocks NP.(52)

7. Atherosclerosis
In the demonstration of aged garlic extract therapy with supplements (AGE+S) and theirs effect on cardiovascular diseases found that CAC progression was significantly lower and TR significantly higher in the AGE+S compared to the placebo group after adjustment of cardiovascular risk factors (p<0.05). Total cholesterol, LDL-C, homocysteine, IgG and IgM autoantibodies to MDA-LDL and apoB-immune complexes were decreased, whereas HDL, OxPL/apoB, and Lp (a) were significantly increased in AGE+S to placebo and concluded that AGE+S is associated with a favorable improvement in oxidative biomarkers, vascular function, and reduced progression of atherosclerosis., according to "Aged garlic extract supplemented with B vitamins, folic acid and L-arginine retards the progression of subclinical atherosclerosis: a randomized clinical trial" by Budoff MJ, Ahmadi N, Gul KM, Liu ST, Flores FR, Tiano J, Takasu J, Miller E, Tsimikas S.(53)

3. Alfalfa
a. Antioxidant
In a study of measurements of pH, water holding capacity, color, oxymyoglobin content, TBARS and oxidation-reduction potential in evaluating the effects of a dietary protein-xanthophylls (PX) concentrate of alfalfa to turkey diets conducted by University of Life Sciences in Lublin, Skromna 8, 20-704 Lublin, (54), researchers found that TBARS and oxidation-reduction potential values suggested that the inclusion of the concentrate to turkey diets acts as an antioxidant in the raw meat.

2. Cholesterol
In a study to test the effect of Alfalfa used in traditional medicine to treat high blood cholesterol conducted by Malinow MR, McLaughlin P, Stafford C.(55), in 3 human volunteers during ingestion of diets containing alfalfa seeds (AS) for 3 weeks, researchers found that Plasma cholesterol concentrations were reduced and No signs of toxicity were detected through serum determinations of multiple parameters. The ingestion of AS in rats decreased the concentration of plasma cholesterol, reduced intestinal absorption of exogenous and endogenous cholesterol, and increased fecal biliary excretion.

3. Hyperlipoproteinemia
In a study of Fifteen patients with hyperlipoproteinemia (HLP), types IIA (n = 8), IIB (n = 3) and IV (n = 4) were given 40 g of heat prepared alfalfa seeds 3 times daily at mealtimes for 8 weeks with otherwise unchanged diet, conducted by Mölgaard J, von Schenck H, Olsson AG.(3), found that patients with type II HLP alfalfa treatment caused after 8 weeks a maximal lowering of pretreatment median values of total plasma cholesterol from 9.58 to 8.00 mmol/l (P less than 0.001) and low density lipoprotein (LDL) cholesterol from 7.69 to 6.33 mmol/l (P less than 0.01), which corresponds to decreases of 17% and 18%, respectively. Maximal decrease was 26% in total cholesterol and 30% in LDL cholesterol. In two patients with hypercholesterolemia the LDL cholesterol decreased less than 5%. Apolipoprotein B decreased in the same period from 2.17 to 1.43 g/l (P less than 0.05) in type II HLP, corresponding to 34% decrease, whereas apolipoprotein A-I did not change. Body weight increased slightly during the first 4 weeks of alfalfa treatment (P less than 0.001) probably because of the caloric content in the alfalfa seeds. After cessation of treatment, all lipoprotein concentrations returned to pretreatment levels. We conclude that alfalfa seeds can be added to the diet to help normalize serum cholesterol concentrations in patients with type II HLP.

4. Ginkgo biloba
a. Hypertension
Ginkgo enhanced endothelium-dependent vasodilation and elevation of the endothelial intracellular Ca(2+) level in SHR, resulting in hypotension, according to the study of "Effects of Ginkgo biloba extract on blood pressure and vascular endothelial response by acetylcholine in spontaneously hypertensive rats" by Kubota Y, Tanaka N, Kagota S, Nakamura K, Kunitomo M, Umegaki K, Shinozuka K.(56)

b. Cardiovascular tissues
Ginkgo biloba extract (EGb) has shown the protection of the cardiovascular tissues against HgCl(2)-induced oxidative damage, according to the study of "Protective effects of Ginkgo biloba extract against mercury(II)-induced cardiovascular oxidative damage in rats" by Tunali-Akbay T, Sener G, Salvarli H, Sehirli O, Yarat A.(57)

c. Hyperlipidemia
Ginkgo biloba leaves (EGB) has demonstrated the activities of limitation of the absorption of cholesterol, inactivation of HMGCoA and favorable regulation of profiles of essential polyunsaturated fatty acid (EFA), according to the study of "Application of GC/MS-based metabonomic profiling in studying the lipid-regulating effects of Ginkgo biloba extract on diet-induced hyperlipidemia in rats" by Zhang Q, Wang GJ, A JY, Wu D, Zhu LL, Ma B,(58)

5. Grape seed extract
Grape Seed Extract is the commercial extracts from whole grape seeds that contains many concentrations, including vitamin E, flavonoids, linoleic acid, oligomeric proanthocyanidins(OPCs), etc..The herb has been used in traditional medicine as antioxidant, anti-inflammatory agents and to treat skin wounds with less scarring, allergies, macular degeneration, arthritis, enhance circulation of blood vessels, lower cholesterol, etc.
a. Antioxidant Activity
in the assessment of phenolic content, antioxidant activity of White and red wines spiked with green tea extract and grape seed extract found that the green tea extract and grape seed extract increased antioxidant activity dose-dependently and the CRTs varied considerably between the Korean and Australian groups, with Koreans preferring wines spiked with green tea extract and Australians showing a preference for wines spiked with grape seed extract, according to "Total Phenolic Content, Antioxidant Activity and Cross-Cultural Consumer Rejection Threshold in White and Red Wines Functionally Enhanced with Catechin-Rich" by Yoo YJ, Saliba A, Prenzler PD, Ryan DM.(59)

b. Atherosclerosis
in the association of consumption of red wine and other polyphenolic compounds and prevention of cardiovascular diseases found that aortic atherosclerosis evaluated as the cholesterol content in aortic tissue was comparable in the control and GSE-dosed females, but it was significantly reduced in the abdominal part of GSE-dosed male compared to the controls (P < 0.05). In conclusion, feeding GSE extract to Watanabe heritable hyperlipidemic (WHHL) rabbits had no significant effects in females but was associated with transient less hypercholesterolemic response to semisynthetic diet, according to "Effects of red grape skin and seed extract supplementation on atherosclerosis in Watanabe heritable hyperlipidemic rabbits" by Frederiksen H, Mortensen A, Schrøder M, Frandsen H, Bysted A, Knuthsen P, Rasmussen SE.(60)

C. In traditional Chinese medicine perspective

Traditional Chinese medicine defines angina as a diseases as a result of Ischemic heart disease (belongs tothe categories of "xiong bi", "xin tong", "xin ji", "jue xin tong" and "zhen xin tong)either caused by Stagnation of Heart Blood of which leads to symptoms of localized stabbing chest pain aggravated at night, palpitation,restlessness, dark purple tongue, etc. in most cases or Heart Yin Deficiency of which lead to symptoms of chest pain and oppression, restlessness, insomnia, palpitation, night sweating, lumbago, weak waist and knees, dizziness, tinnitus. etc., in most cases

C.1. Formula

1. Jing Zhi Guan Xin Pian used for coronary heart disease, angina pectoris due to stagnation of heart blood

2. Ingredients

a. Radix Salviae Miltiorrhizae (Dan Shen)

b. Radix Rubra (Chi Shao)

c. Chuanxiong rhizome (Chuan Xion)

d. Flos Carthami. (Hong Hua)

e. Lignum Dalbergiae Odoriferae (Jiang Xiang0

C.2. Heart Yin Deficiency
1. Tian Wang Bu Xin Wan used for coronary heart disease, angina pectoris due to heart Yin Deficiency
2. Ingredients
a. Radix Salviae Miltiorrhizae (Dan Shen)
b. Rhizoma Acori Tatarinowii (Shi Chang Pu)
c. Radix Rehmanniae Glutinosae (Di Huang)
d. Radix Angelica Sinensis (Dang Gui)
e. Fructus Schisandrae Chinensis (Wu Wei Zi)
f. Tuber Ophiopogonis Japonici (Mai Men Dong)
g. Semen Ziziphi Spinosae (Suan Zao Ren)
h. Semen Biotae Orientalis (Semen Platycladi) (Bai Zi Ren)
i. Radix Codonopsis Pilosulae (Dang Shen)
j. Sclerotium Poriae Cocos (Fu Ling)
k. Radix Scrophulariae Ningpoensis (Xuan Shen)
l. Radix Polygalae Tenuifoliae (Yuan Zhi)
m. Radix Platycodi Grandiflori (Jie Geng)
n. Radix Glycyrrhizae Uralensis (Gan Cao)

Please consult with your doctor or related field specialist before applying

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