Gina: I think this dates back to 2001, when I did the ACNEM course, Australasian College of Nutritional Environmental Medicine. And that was their primary course. And of course there was a lot about magnesium, so that always really, really stayed with me, particularly in the context of heart failure, chronic diseases, hypertension, and arrhythmias. And so, that’s been a real long-term interest.

Andrew: But what piqued your interest to do the ACNEM course? I mean, you know?

Gina: I think I already had a leaning, and I was doing a lot of research into natural medicines, bioidentical hormones. A whole lot of things really grabbed my interest. And…

Andrew: Yeah?

Gina: …that’s kind of when it all started.

Andrew: Gotcha. And tell us a little bit about your history as a registered nurse, working in cardiac wards and intensive care.

Gina: So, most of my career was spent in intensive care, so that was both general and cardiothoracic intensive care, with a little bit of peds in there as well, And I gave that away, probably when I was…I’d been in that for a long time, and I was starting to struggle with the shift work, so that kind of dates back. From there, I went on and did pathology, hospital in the home, and that was where I got my entree into the world of heart failure. And from there, I ended up moving back to Sydney, and got a job there doing heart failure in a major Sydney hospital.

Andrew: Right. A very famous Sydney hospital, I might add.

Gina: Yep.

Andrew: So, you’re working in the wards there. What sort of things did you see? We were talking off air just before, and you surprised me, in that at least one of the specialists there started to use IV magnesium for certain indications.

Gina: Yeah, this was really interesting, Andrew. This was in a post-op neurosurgical intensive care, and the neurosurgeon used to run intravenous magnesium at extremely high, much higher than normal, infusion rates, and he, his aim was to push the serum magnesium, and we know that serum magnesium is pretty useless for assessing magnesium generally, but he’s to push the serum magnesium up to about 2.0 and above, even higher than that, in order to address the vasospasm for patients that had had clipping of subarachnoid hemorrhage aneurysms or yeah, aneurysms.

Andrew: Yeah, yeah. So, just for people who aren’t au fait with this sort of language, the clipping is to stop the aneurysm, the, you know, berry aneurysm or something like that. Correct?

Gina: Yes. Yep.

Andrew: Yeah.

Gina: Interestingly, I was, at a later stage, working in a Melbourne intensive care. I had a while living down there. And I had a patient that went into SVT, otherwise known as supraventricular tachycardia, with a rate, a classic rate of about 180, and he had a history of ischemic heart disease, and I ran to get the intensivist after I flipped him across to a 12-lead ECG on his monitor, and his ST segments had dropped drastically, meaning he was starting to show signs of ischemia at that rapid heart rate, unsurprisingly. The intensivist came up to the patient, drew up a whole ampule of magnesium sulfate, and literally slammed it in…

Andrew: Pushed it.

Gina: …and I went thinking he was going to drop his blood pressure drastically, but in fact, within about 10, 15 seconds, he reverted into sinus.

Andrew: Wow.

Gina: And I was absolutely amazed. And it kind of occurred to me that what had happened there was with him slamming magnesium in as a bolus dose, which you never do…

Andrew: No.

Gina: It’s too vasoactive to do that. This was magnesium sulfate. He got a peak serum level enough to revert him out of that SVT, back into sinus.

Andrew: Into sinus. Wow.

Gina: It was quite astonishing to watch that.

Andrew: Well, that’s experience for you. That’s really interesting, isn’t it?

Gina: Yeah. Interestingly…

Andrew: And yet, you know, some…

Gina: we’re talking about arrhythmias, the post-operative heart bypass, whether that was bypass grafts or valve repairs, used to come out from theatre with magnesium loaded into their maintenance IV, their fluid. And the idea with that was to reduce the risk of post-operative atrial fibrillation, which is a common, common side effect post-operatively. So, that was interesting and…

Andrew: You know, this gels with the work of Professor Frank Rosenfeldt, down at the Alfred, in Victoria, years ago now.

Gina: Yeah. Yeah.

Andrew: And he used…now, he preferred magnesium orotate, and it was actually the orotic acid he was after. But magnesium on its own has this vasodilatory effect, and helps with normal sinus rhythm as well. But very interestingly, the work, like, that he did, it was reducing atrial fib by 50%, reducing hospital stays by 30%, reducing the cost to patient of $2,300, and so the hospital went, “As you were. We like this. Hospital saving. Yes.” Don’t worry about the patient saving. Hospital saving. But I thought it was very interesting, those improvements in patient outcomes.

Gina: Very groundbreaking study, that one.

Andrew: Yeah. So, let’s sort of go into magnesium, and its role in the cardiovascular system. Can you take us through the major points here?

Gina: I think magnesium is the first thing that comes to mind when dealing with any patient with hypertension. And I think the best way for me to, is explain this is, Andrew, if I gave you a balloon, you would just take a big breath and blow it up. No issues at all. However, if I gave you a hot water bottle and asked you to blow it up, you would bust a gut trying to distend the hot water bottle. And that kind of equates to what’s happening to the heart, trying to expel its output into the systemic circulation. And if that circulation is stiff and non-compliant, or left ventricular afterload, then the heart is really gonna struggle to do its job, which is to pump and deliver oxygenated blood out to the tissues. So, magnesium is the missing link here, to help with turning that hot water bottle into a balloon, as it were. In other words, a stiff, non-compliant circulation, trying to help that to relax, as in the account of vasospasm we talked about before, in intensive care, post-op neurosurg patients.

Andrew: So, that afterload is basically back pressure from a non-elastic arterial system, correct?

Gina: Yes. Exactly.

Andrew: Yeah. Yeah.

Gina: So, magnesium is the first thing that comes to mind.

Andrew: What’s interesting to me is that when you look at dietary guidelines, even cardiovascular stuff, they’ll always mention potassium first, and never magnesium. Why? I don’t get it.

Gina: I think it’s a lack of understanding about the level to which magnesium is involved with over 600 different enzyme systems, and its relationship to the ATP pump, calcium, and so forth. And there’s just a lack of recognition there. For example, I had a heart failure patient who, this is going back probably about, oh, nine years or so, she was really struggling, and I recommended a really good-quality magnesium supplement for her, and only to be reported by the cardiac rehab nurse, who put in, actually, a complaint by saying that, “Why is Gina recommending magnesium, because her blood levels are normal?” And I just shook my head and said, “Well, you know, that is completely irrelevant since the vast majority of magnesium is actually intracellular. It’s not within the vascular space or the serum space at all.”

Andrew: This smacks of true ignorance of physiology. And there are certain elements, electrolytes, cations, anions, which just don’t measure well in a serum level. You know, chromium. Zinc. There’s so many. And yet, do you think this might be the issue, about why it’s these nutrients, let’s say, are dismissed? Because if we can’t measure them, it’s not easy. We can’t send them to the pathology lab, so what’s the point? And yet you’ll get every now and again, you’ll get a surgeon like,  every now and again, you’ll get a surgeon like those that you’ve mentioned, who know their physiology, and they know what this important electrolyte can do in acute, you know, emergent situations. So, it’s really funny how people don’t know that.

Gina: Yeah. It’s really important. And it’s, magnesium deficiency, whether it’s significant or relative, is a huge and a widespread issue, particularly since people are dealing with a massive amount of stress, which is going to increase their need for magnesium, not less. So, in fact, they would need more magnesium. And I think, for us as practitioners, we need to take on board the vast and different roles that magnesium plays. For example, I had a child in emergency one time who had severe bronchospasm, refractory to all of the normal things that they do with Ventolin and bronchodilators in general, and there must have been a very astute emergency physician at the time, who organized for that child to have some intravenous magnesium, and that just resolved the bronchospasm. So, it’s far, far broader than we, even as naturopaths, have understood.

Andrew: You know, that was one of the only sort of indications for magnesium sulfate in the old days, was status asthmaticus, not even any cardiac issues. It was only status asthmaticus. And I think maybe preeclampsia. And that’s

Gina: Preeclampsia. Yep.

Andrew: It was never… Yeah. It was never, ever used. Yeah. So, back to cardiovascular disease, let’s talk about magnesium, and what sort of conditions can magnesium help. And then I think we’ll delve into what forms of magnesium, what doses, and, you know, what else you use with it. So, firstly, what sort of conditions do you tend to favor? Does it tend to be useful in?

Gina: Yeah. Number one, hypertension. And I think, without access to adequate testing, we should assume that people are deficient and are going to benefit. So, for example, you might choose a magnesium supplement once, even twice a day. Secondly, for arrhythmias, this is incredibly important, because we are seeing an increase in, particularly, AF now, SVT, and, you know, other cardiac arrhythmias, and magnesium has a powerful role with helping to stabilize the electrical activity in the heart, so that’s one of the first things that I would be thinking along those lines.

Andrew: So, when you’re mentioning AF, atrial fibrillation, and we’ve spoken about supraventricular tachycardia before, SVT, when we’re talking about atrial fib, you know, the standard sort of progression is you’ll get paroxysmal atrial fib, then you’ll have all-the-time atrial fib, or episodes, which, you know, may have to be treated by cardioversion. And what normally happens is the patient then goes on blood thinners, your flecainide sort of thing. And then they’ll look at perhaps cardiac ablation in the atrial, the, what is it, sinoatrial nodes, or the atrium, and then possibly a pacemaker down the track.

Gina: Potentially…

Andrew: When you’re talking about… yeah. Sorry. You go.

Gina: Potentially, if people are cardioverted, which is a fairly standard practice, and they’re not preloaded, and continue their magnesium post-procedure, they are very likely to revert back into atrial fibrillation, which is really disappointing.

Andrew: Right. Right. So, forgive me. So, this is, they continue their magnesium after cardioversion, and it doesn’t work? It doesn’t hold them enough?

Gina: It may not, because there’s some irritation around those electrical pathways in the heart…

Andrew: Yeah, the nodes, yeah.

Gina: …and it is common to revert back, after being cardioverted, back into atrial fibrillation, but I think magnesium, pre and post, would have a really, really important role there.

Andrew: Right. Gotcha. And do you ever combine it with looking for, like, heart muscle damage markers, troponin I, or is it more to do with intracellular issues, like nerve transmission, if you like?

Gina: I’d be probably more likely to try and get a copy of an echocardiogram report, because that’s going to tell a lot about whether the heart is struggling, whether there’s dyssynchrony, all of those sorts of issues within the heart. But, you know, certainly there are lots of specialists, even at the hospital I worked in in Sydney, that specialized in electrical anomalies within the heart, and that was kind of what they did. But for any ablation, any patient that is, has an ablation procedure coming up, the risk is that they can wipe out key electrical pathways, and the patient will end up with a pacemaker or a defibrillator, which is a combined device.

Andrew: Yeah. Yeah. Right. Forgive me for asking, because I’m asking for me here. Is this when we’re talking about that, the central bundle that runs down the intraventricular space?

Gina: Yes. And higher up…

Andrew: That you can damage that? Is that what it is?

Gina: …high up into the atrium…

Andrew: Right.

Gina: …so, before they do an ablation, they have to do really complex and detailed electrical mapping of the heart, to try and identify where is the locus of abnormal activity.

Andrew: Yeah. Right.

Gina: So, this is something that we need to immediately be reaching for if we have patients with any arrhythmias, and go in hard.

Andrew: Yeah. Gotcha. So, forms of magnesium. You and I have spoken about the work of Professor Frank Rosenfeldt, with magnesium orotate, but we’ve had magnesium aspartate. I spoke with Doctor Ross Walker, who uses magnesium orotate aspartate. But we’ve got so many others that are involved in, or the ligands are involved in either helping to transport that electrolyte, or have other functions with, say, nerves, for instance. So, when do you sort of choose different forms, or do you tend to go, nah, we’ll always go with this?

Gina: I often, and I always have prescribed, a glycinated form, because I think that’s generally reasonably bioavailable, and fairly well-tolerated, but I think there’s a lot of evidence now for, I also recommend citrate for some patients as well. I think there’s emerging evidence now for the use of threonate for neurological conditions. And I think we, Andrew, we will see an increase in threonate prescriptions…

Andrew: Oh, for sure. Yeah.

Gina: …now, because there’s so many people now suffering from neurological issues as well. The orotate, I think there is evidence for that as well. I tend to kind of fall back to prescribing patterns, just using something that I know works well, and can trust.

Andrew: What about using glycerophosphate, like, as a phosphate shuttle?

Gina: Yeah. I think there’s going to be glycerophosphate forms, we will see more of now, and that may show enhanced bioavailability and effectiveness as well. So, I think we will now see more of the supplement companies formulating in that form of magnesium as well. So, I think that will become more common now.

Andrew: Yep. And then, you know, we’ve also got accessory nutrients. You know, taurine, zinc, you know, fish oil. Other things, though, of use? What else have you used to help, you know, other cardiac conditions?

Gina: Predominantly magnesium, and, for example, I had a patient that recently had a quadruple bypass, and trying to get him to understand the importance of magnesium, and he’s still actually not back on his magnesium as of now, three weeks post-operatively, but I don’t want him going into atrial fibrillation. And it is important to support the energetics of the heart as well.

Andrew: You know, one of the things that interest me, it piqued my interest, and that was, I’ve got a couple of friends who have got atrial fib, and one’s got a pacemaker. But, the use of quercetin. And there seems to be some evidence here with atrial fib. Have you ever used it?

Gina: I do often use it, and often use it as a zinc ionophore as well.

Andrew: Aha.

Gina: So, that’s also been very useful. I think a lot of people, during COVID, actually got the C, D, zinc message, and…

Andrew: Yeah.

Gina: …it was, I forget his name, he’s passed on now, but he brought to the public’s attention about how quercetin is acting as a zinc ionophore…

Andrew: Right.

Gina: …to get the zinc intracellular, or to enhance intracellular transport of zinc.

Andrew: Right. Now, forgive me. Was this the guy that put a private message to his friends on Facebook, and it got out, and he was a virologist? Is that, was it that guy, or somebody else?

Gina: No, it was…the name will come to me later, but it was…

Andrew: Yeah, yeah.

Gina: …he actually treated… President Trump was in office at that time, and he treated him as well when he got COVID, so, he certainly used all of these, C…C, D and zinc…

Andrew: Yep.

Gina: …with quercetin as an ionophore. So…

Andrew: Gotcha.

Gina: …potentially, it has other roles, with other minerals as well.

Andrew: Gotcha. Okay. And, what other sort of nutrients, what other herbs, in fact, do you use with cardiac conditions, and where? I remember there was a… I keep defaulting, and I don’t think this is right, but it was a trial on Hawthorn leaves, and I keep going DART trials. It wasn’t called the DART trial. That was diet and reinfarction. There was a trial that was done on Hawthorn, but quite some years ago. Do you ever use herbs, and for what?

Gina: Yes. And I do use that with heart failure. It’s particularly useful with heart failure classifications. There’s 1, 2, 3, and 4. Four is, “I cannot get out of the chair or bed. I’m so breathless, even at rest.” Three is breathless on very minimal exertion. Two is where most people with heart failure sit. They’re breathless with exertion, such as going upstairs or an incline, and one is they have heart failure, but they have no symptoms. So, there is good evidence to use Hawthorn in class 2and 3.

Andrew: Right.

Gina: So, sometimes I might even use that as a standalone. For example, I’ve got a patient locally with myocarditis, and post-jab, and she is using the Hawthorn as well, amongst many other supplements.

Andrew: The other thing, of course, the other nutrient I guess we should talk about is ubiquinol. How often do you use it, and do you tend to favor certain conditions? Do you ever use it judiciously? How high do you go?

Gina: Yes. I use 300 milligrams a day of ubiquinol, not ubiquinone, because for most people, you know, once they’re over 40, they’re going to do better on ubiquinol. So, I do use that. In fact, I recommended it for a patient with heart failure I saw yesterday. And it is all, again, about supporting mitochondrial energy production. So, of course we’re thinking magnesium, we’re thinking B vitamins, we’re thinking CoQ10, in this case, ubiquinol, so that is something that I definitely would recommend often. The other thing, Andrew, that comes to mind is, for… So many patients are on proton pump inhibitors now. And obviously, we know that if you change stomach acid, you’re going to impede the absorption of magnesium, zinc, folate, iron, B12, calcium, and so on. So, for those people, there are some that we’re never going to get off PPIs, potentially, those with, Barrett’s esophagus, possibly those with a hiatus hernia. So, I’m kind of leaning more now to trying to bypass that absorption altogether, and putting those people on a topical magnesium as well, so just using a really good-quality magnesium spray.

Andrew: Right. And, clinical effect?

Gina: Clinical effects are seen more rapidly, probably, in kids. So, for kids with anxiety, really difficult to get to sleep, all of those sorts of things. And often, the topical magnesiums are a magnesium chloride, but it seems to get fairly good absorption, and you notice the effects more readily in those people. I’ve got one patient who is using topical magnesium for…he’s got a diabetes-related peripheral neuropathy. His feet are affected. So he’s using that, both feet, and he’s getting really good results with that.

Andrew: Okay. And what about dose…

Gina: So, I think the idea here is to get as much magnesium into the system as people can cope with.

Andrew: Great. Okay. So, that leads on to my next question. That is doses. Like, we’ve gotta obviously circumvent bowel tolerance, which, I’ve had a wide breadth of experience here with different patients, somebody who could tolerate NAFL, and we had to use a really poorly-absorbed lower dose magnesium, and other people that can really, you know, really take a lot of magnesium in, without any effect on their stomach, on their intestines whatsoever. What’s your experience? What does it show you? Is there a sweet spot with dosage with magnesium?

Gina: I think, as you said, it’s very individual. Some people will not even tolerate, you know, like, they might get diarrhea with a sort of a half-decent dose of magnesium glycinate, which, to me, is a very well-tolerated, bioavailable form of magnesium. Other people can soak it up like a sponge.

Andrew: Yeah. Yeah, it’s really amazing. I’ll always remember this, the triathlete from Kilcoy. You know how you remember patients because of some aspect of them? The triathlete from Kilcoy, and he just could not tolerate magnesium. And in the end, we had to use a pretty poorly-absorbed phosphate-type lower-dose thing, and he wasn’t really getting great effect, but it was, like, all that he could handle with bowel tolerance, and that’s when I spoke to him about perhaps find an integrative GP, to do intravenous magnesium. Eventually, I lost contact with him.

The other side of the spectrum is, I’ll always remember this. I did my neck, drying my hair with a towel. I mean, you know, these anecdotes. But I took three teaspoons, three times a day, so a total of nine teaspoons. Like, that’s 2, 4, 6,  1800 milligrams. Massive. And no bowel tolerance whatsoever. And I’ll always remember, a few months later, I related it to somebody who walked in to where I was practicing like this, with tears in her eyes. I said, “What have you done?” “Put my neck out.” I said, “Okay.” Got her booked into somebody that was gonna look after her treatment later on, but for now I said, “Okay, let’s get you on to some magnesium.” And I said, “Now, I’ve taken three, three, and three, total of nine teaspoons.” Right? And two weeks later, she… And I said, “Look, I don’t normally do that. I normally go two and two, for a high dose,” and…as long as their renal function’s okay. But a couple weeks later, she came back, and she said, “I tried that nine teaspoons like you said, but, gee, it cleaned me out.” And I said, “Well, how did you take it? Like, three, three, and three?” She said, “No. No, nine teaspoons. Stat.” I said, “How did you stir it?” But it, to me, it’s, point is, she said “It worked really well, but it cleaned me out.” So, I just thought, “Ohh.” Yeah. It’s a lesson in explaining instructions clearly to patients, I think.

Gina: It is really important to be really specific with dosing. That one guy that I mentioned, that’s recently had a quadruple bypass, he overdosed on his magnesium, and had the same thing. He didn’t follow my explicit instructions, and he was, yeah, he had diarrhea. So, it is something, you know, no matter how explicit I copy their prescription into their plan, so that they know exactly what they should be doing, and some people just, maybe they don’t follow instructions well, and they can overdo it. And the other thing of concern is, too, if people, obviously, when I was a heart failure nurse, I had a lot of patients with very, very reduced, renal function. And once you get to an eGFR of less than 30, you’ve really, really gotta be cautious, as with any medicines, and supplements. Some supplements, not all. But magnesium is one of them where you really need to back off on that dosing, because you don’t want to cause them any issues. Because, obviously, magnesium levels are controlled by the kidneys, to some extent.

Andrew: Yeah. What was your level of cutoff? What was your level of, woo, back off? Forty?

Gina: eGFR of 30 or less.

Andrew: Thirty or less. Gotcha.

Gina: So, often, as naturopaths, we’re panicking about slightly reduced eGFR, but for many patients, it’s not really an issue, and they can tolerate most meds, and most supplements, until their renal function is really markedly reduced.

Andrew: Yeah.

Gina: So, I’d wanna become cautious at that level.

Andrew: Just a last question, Gina. How could we encourage patients, and what can we recommend, with regards to lifestyle factors, to help with their cardiovascular health?

Gina: I think all the things that we do well as naturopaths, which is transitioning people to a whole foods diet, rich in vegetables, particularly the dark green and leafy, nuts and seeds, really good-quality protein, moving away from sugar, which is going to deplete people’s magnesium, chromium, and, and, and. So, stress management is always going to be a big part of what we look at as naturopaths. And for example, exercise, being outside, in nature, grounding, all the things that we want to encourage people to do to manage their stress, but I can say that stress is rampant right now, and that’s something, as naturopaths, I think that we do really well. And whilst magnesium, zinc, all of those B vitamins are going to help with a stress response, we still need to come in with dietary modifications, and all of those lifestyle things, stress management. You know, for some people, it’ll be meditation. For other people, exercise, grounding, all of those sorts of things that we normally would do in a consult.

Andrew: Gina, there’s obviously a wealth of expertise there through, and I’m gonna say it without fear, but many, many years of practice. So, thank you so much for taking us through, not just magnesium, but everything else that we can use to help our patients with cardiovascular issues. Thank you so much for taking us through these today, Gina.

Gina: Yeah. You’re very welcome.

Andrew: And thank you, everyone, for joining us. Remember, you can catch up on today’s show notes and the other podcasts on the Designs for Health website. I’m Andrew Whitfield-Cook. This is “Wellness by Designs.”