| Max +ve Delta ST of 3.44 mm at 2.27 hrs in Ch3 | |
|---|
| Max -ve Delta ST of 0.00 mm at 0.00 hrs in Ch1 | |
| Total analysed minute :1439 | Rejected minutes: 1 |
| % of rejected minutes: 0.07 | |
24 hr Holter shows basic sinus rhythm, no supra ventricular tachycardia, no sustained ventricular tachycardia or tachycardia, occasional supra ventricular ectopic’s and ventricular premature contractions. Intermittent 1o AV block and sinus pause noted. Suspecting of Sick Sinus Syndrome.
Therapeutic Intervention
The patient was treated with monotherapy of Nagarjunabhra Rasa (21 Bhavna) 1 tab (125 mg) with lukewarm water for 3 months.
Follow-up and Outcome
Table 3: 24-hour Holter test (after treatment) 19/03/22
| Rate dependent events | | | Conduction | |
|---|
| Avg. heart rate | 07 bpm | | Pause >2.5 sec | Nil |
| Min heart rate | 47 bpm at 11.59hrs | | Longest pause | Nil |
| Max heart rate | 96 bpm at 14.33 hrs | | | |
| Total beats | 100200 | | | |
| Ventricular events | | | Supra ventricular events | |
| VE total | 2 | | SVE total | 79 |
| VE pair total | 0 | | SVE pair total | 2 |
| Longest V -Tach | Nil | | Longest SV-Tach | Nil |
| | ST Analysis | | |
| Ch1 | Ch2 | Ch3 | |
| Total ST minutes | 0 | 0 | 1139 | |
| Longest ST Episodes | Nil | | | |
| Max -ve Delta ST of 0.00 mm at 0.00 hrs in Ch1 | |
|---|
| Total analysed minute :1440 | Rejected minutes: 18 |
| % of rejected minutes: 1.25 | |
24 hr Holter shows basic sinus rhythm, no supra ventricular tachycardia, no sustained ventricular tachycardia or tachycardia, no atrio-ventricular block or sinus pause noted, Occasional supra ventricular ectopic’s and ventricular premature contractions.
Discussion
The American Heart Association (AHA)/American College of Cardiology (ACC) guidelines typically do not recommend permanent pacemakers for first-degree AV block unless the P-R interval exceeds 0.30 seconds with symptoms.
Despite being considered benign, studies show patients with this block face higher rates of atrial fibrillation, pacemaker placement, and all-cause mortality compared to those with normal intervals.[1]
Ayurvedic assessment of the patient was identified as an imbalance in Vyana Vayu, contributing to the patient's symptoms.[5] Nagarjunabhra Rasa has an extensive use in Ayurveda for conditions like all types of cardiac disorders, traditionally composed of 100 Puti Abhraka Bhasma, smeared and triturated with Terminalia arjuna bark’s decoction seven times till dryness, is said to be a Rasayana (anti-oxidant) drug having property of Shula (pain) and Tridosha pacification.[6]
It has got anti-anginal, anti-ischemic, anti-platelet aggregating, antihypertensive, anti- hypercholesterolemic and anti-atherosclerotic properties.[7,10] Various modern studies too suggested Terminalia arjuna bark’s effectiveness in stable angina.[8]
Abhraka Bhasma is a calcium, potassium, magnesium, iron, silicates etc. multi-mineral compound having Yogavahi (bio-activity enhancer) characteristic and is said to be Hridya (cardio-protective) itself.[9]
The initial Holter monitor showed basic sinus rhythm with intermittent first-degree AV block and sinus pauses, indicating possible Sick Sinus Syndrome. After an unsatisfactory 90-day treatment with Nagarjunabhra Rasa, the formulation was enhanced with 21 Bhavna using Arjuna bark, aligning with Chakrapani's principle that "Samskara transforms the quality of the drug.[11]"A follow-up showed no AV block or sinus pauses.
Conclusion
From the above case study, it can be observed that Nagarjunabhra Rasa wit 21 Bhavna can be an excellent alternative to a patient of AV block with long sinus pause, where pacemaker is the only permanent placement. However, it is also to be noteworthy that, since, the preparation of Nagarjunabhra Rasa with 21 Bhavna instead of 7, is an Anabhuta Yoga (experiential knowledge) rather than the classical standard practice, it needs further research and recognition both from Ayurvedic fraternity as well as in the parlance of modern system of medicine.
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