Can We Use Terminalia Arjuna (Roxb.) Wight and Arn in Place of Novel Oral Anticoagulants (NOACs) in Post-COVID-19Cardiac Conditions?

Dear Editor,

COVID-19 is known to cause several cardiac disorders such as pancarditis, coronary artery disease (CAD), arrhythmias, cardiomyopathy, and stroke during and after the active stage of the COVID-19 infection, even when the subjects turn to be real-time polymerase chain reaction (RT-PCR) negative. Factors like age above 45 years and comorbidities such as diabetes, hypertension, CAD, and/or thyroid disorders increase the risk of post-COVID-19 complications. In such post-COVID-19 patients, novel oral anticoagulants (NOACs) and beta-blockers are prescribed as preventive measures.

We recently had a 47–year–old post-COVID-19 male who developed a severe episode of palpitation after six weeks of infection subsidence. He had a history of suffering from atrial fibrillation about 10 years back, which had responded to Cordarone. He was off Cordarone for the last eight years. An electrocardiogram (ECG) was taken which revealed the recent atrial fibrillation. Holter monitoring showed an episode of ventricular tachycardia. Echo was unremarkable without any valvular or regional wall motion abnormalities. Considering his recent COVID-19 and recurrence of atrial fibrillation, he had been put on Cordarone, beta-blocker, and aspirin. With regard to using a NOAC in this case, we decided to administer bark powder of the Indian medicinal plant Terminalia arjuna (Roxb.) Wight & Arn (Arjuna) 500 mg three times a day (TID) instead, which has been demonstrated to have antiarrhythmic, anti-inflammatory, anti-ischemic, and antioxidant properties. The patient reported relief in palpitation following above drugs within 48 h of the drug intake.

Such use of Arjuna can be supported by considering the prior preclinical and clinical trials.^{1, 2} The in vitro antithrombotic effects of Arjuna are reported in 20 patients with CAD. This effect was attributed to the desensitization of platelets and/or transduction mechanisms involved in thrombosis. ³ Another randomized controlled clinical trial in diabetic patients has revealed significant inhibition of platelet aggregation induced by Arjuna. In the CAD patients, one-month administration of Arjuna significantly reduced the platelet count. This may have therapeutic significance in preventing post-COVID-19 thrombotic events. ⁴ As estimated in a randomized controlled clinical trial (n = 105) in CAD patients, the antioxidant effect of Arjuna (500 mg) was found to be comparable to Vitamin E (400 IU). ⁵

The evidence of the efficacy of Arjuna is found also in the preclinical investigations. Arjuna contains triterpenoids, flavonoids, and glycosides, known to interact with the angiotensin converting enzyme-2 (ACE2), which plays a crucial role not only in the SARS-CoV2 infection but also in the post-COVID-19 complications. The Arjuna bark extract contains 1.08% quercetin and 0.16% rutin along with β-sitosterol.^{6, 7} All these compounds interact with the ACE2 and modulate it. In the rat model of myocardial ischemia/reperfusion injury-induced arrhythmias, quercetin is proved to exert protective effect.

Arjuna bark extract also contains potent antioxidant polyphenols such as gallic acid, gallocatechin, epigallocatechin, catechin, and epicatechin. The antioxidant effects of these constituents may provide protection against the oxidative stress associated with the post-COVID-19 complications.

All these evidences and our case report strongly suggest that Arjuna bark extract may provide therapeutic benefits as an adjuvant to the ongoing therapy. It may be considered in place of the NOACs as a well-proven alternative, providing multiple therapeutic advantages rather than just anticoagulating effects.