2nd The Milner Place Protocol (MAP) for Management of Cardiac Dysrhythmias Jeremy Mikolai, ND, and Martin Milner, ND Background and Innovation this is achieved through a prolonged neurotransmitter which agonizes the “There are no naturally occurring refractory period that results from beta-1 adrenergic receptors of the heart; beta blockers,” Dr. Milner often says in increased cell permeability to , it increases automaticity and contractility reference to the use of beta-1 adrenergic which increases the phase 4 portion of the by increasing the permeability of the receptor blockers (beta blockers) in the cardiac action potential. cells to calcium. Release of ACh in the treatment of arrhythmias and in control The ventricles of the heart are also supraventricular myocardium and from of the heart rate. “Nature doesn’t block affected by ACh, though the vagal the few parasympathetic fibers in the receptors,” Milner asserts. “It augments innervation of the ventricles is sparse. ventricles inhibits the release of NE from antagonist pathways. Acetylcholine is This occurs by virtue of the antagonistic sympathetic fibers. That NE inhibition ‘nature’s beta blocker.’” relationship between the sympathetic and prevents increased automaticity by the There are moments in a physician’s parasympathetic halves of the ANS. sympathetic ANS.3 career when he sees the biochemistry of Ventricular myocardium is heavily ACh in the body is synthe­sized a disease process in a whole new way. innervated by the sympathetic ANS. from acetyl- (acetyl-CoA) and Beginning in 2008, Dr. Milner revisited Norepinephrine (NE) is the dominant ➤ his study of the autonomic nervous system (ANS) control of heart rate; he considered the actions of beta blockers which inhibit sympathetic ANS stimulation of the heart. He considered acetylcholine (ACh), the neurotransmitter of the parasympathetic ANS, and its action on heart rate inhibition. He then developed an approach for using oral supplements to augment ACh production and release. This evolved into the Milner Acetylcholine Protocol (MAP) for management of cardiac dysrhythmias.1

Biochemical Plausibility The biochemical plausibility of the MAP is based on the ACh inhibitory effect on cardiac rate and dysrhythmias through several mechanisms. The sinoatrial (SA) node, the normal pacemaker of the heart, receives input from the 10th cranial nerve (CN X), the vagus nerve, via ACh. That effect on the SA node inhibits automaticity and slows the heart rate. This is achieved by hyperpolarization of the cells through increased potassium permeability, result­ ing in slower spontaneous depolarization.2 The atrioventricular (AV) node of the heart also receives input from the vagus nerve via ACh. The effect slows or blocks conduction through the node. Again, Figure 1: Biosynthesis of ACh and Immediate Precursors

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➤ in a reaction catalyzed by the Choline deficient states may play can raise endogenous neurotransmitter enzyme choline acetyl transferase (CAT; a part in diseases and conditions levels. His work pertains primarily to Figure 1, p. 73). including liver disease and fatty serotonin and catecholamines, but Acetyl-CoA comes from any of several liver infiltration, neural tube defects, is applicable to ACh via analogous sources, including dehydrogenation methylation defects, hypertension, mechanisms. More importantly, the work of pyruvate, end products of , neurological disorders, of Hinz et al. has established that oral , or production of coenzyme inflammatory disorders, and cancer.7 precursor dosing leads to demonstrable A (CoA) from B5 which is then Population research has demonstrated clinical effects and improved patient acetylated before interacting with choline. that many groups do not achieve their outcomes.19–22 Pyruvate is the end product of aerobic AI of choline.6,8–11 For instance, there is The half-life of ACh is very short glycolysis. It can also be converted from evidence that only 2% of postmenopausal at 2 minutes. To ensure fidelity in lactate, the end product of anaerobic women reach their choline AI on a daily neuromuscular transmission, the body glycolysis. Pyruvate can then be converted basis.11 further enhances this breakdown of ACh to acetyl-CoA through the action of the Research has established that genetic enzymatically through acetylcholine pyruvate dehydrogenase complex. Acetyl- polymorphisms which alter choline esterase enzymes. While ACh is CoA then has several potential fates, all of or metabolism may increase reclaimed by reuptake at the synaptic which demand the transfer of acyl groups, an individual’s dietary requirement cleft, augmenting production and release including participation in the Krebs cycle, for choline. For instance, when to the extent necessary to inhibit cardiac in fatty acid synthesis, in the production of 5-methyltetrahydrofolate (5-MTHF) is automaticity will require the persistent ACh, and others.4 deficient due to a polymorphism (or availability of substrates for ACh (PA), vitamin B5, other reasons), the body depends on production, a problem that we will need is the initial substrate for de novo CoA betaine from choline for the conversion to address. synthesis. This five-step process requires of homocysteine to .12 While we can find no evidence in the both pantothenate (ionized PA) and the Methionine is then converted to medical literature for the use of choline containing . S-adenosyl-methionine (SAMe), the major to address cardiac dysrhythmias, we can is a derivative of PA and is methyl donor for one- transfers in establish that the biochemical action the functional component of CoA in the the body.13 When choline is required as of ACh exerts control over the cardiac carrying of acyl groups. Pantethine is a methyl donor it is shunted away from rate and depolarization. The fact that composed of two pantethine molecules other biochemical processes. Therefore, supplementing oral choline raises levels of joined by a bond.5 greater demand for dietary choline may ACh in the CNS is long established in the Choline is an essential . be prevalent in the population based medical literature, as cited.17,18 Therefore, reutilize choline and synthesize on genetic polymorphisms that are the biochemical and therapeutic it de novo, but in quantities insufficient prevalent.14–16 plausibility for the choline aspect of MAP to meet metabolic demand. Therefore, an is present. adequate intake of choline is necessary Therapeutic Plausibility Pantethine has been reported to have for health.6 The established adequate The therapeutic plausibility of utilizing antiarrhythmic action on experimental intake (AI) in adult men is 550 mg/day the ACh pathway in the treatment models of cardiac arrhythmias. In a and in adult women is 425 mg/day unless of cardiac dysrhythmias through study of a dog model of hypoxic cardiac pregnant (450 mg/d) or breast-feeding (550 supplementing oral precursors requires perfusion, administration of pantethine mg/d). Eggs are the richest dietary sources both that (1) oral supplementation be able was shown to significantly prolong the of choline, followed by animal to raise ACh levels in the neurons; and cardiac action potential and refractory sources, leaving vegans and several other (2) those increases demonstrate clinical period.23 While the mechanism of that groups at routinely inadequate daily effects. effect was not described, it is noteworthy intakes.7–10 A list of choline content in It is well established that the amount that this is the same action which ACh has foods can be found in the Micronutrient of ACh in the central nervous system on the supraventricular myocardial cells, Information Center article on choline from is directly affected by the oral intake as described above. the Linus Pauling Institute, Oregon State of choline. Studies and reviews which Research on rate models of cardiac University.7 date back to the late 1970s establish that function has demonstrated that the Choline is an essential substrate in the the synthesis of ACh in the brain (CNS) intravenous (IV) administration of CoA synthesis of the neurotransmitter ACh, responds to the availability of choline in results in a transient decrease in the heart but is also vital in several other bodily the blood and that the ability of neurons rate. These studies make it appear that processes. Choline is necessary: as a to make and release neurotransmitters, it is the adenosine portion of the CoA component of cell membranes, in cell including ACh, depends directly on the molecule which may be responsible for signaling molecules, in metabolism concentration of amino acids and choline the decrease in heart rate rather than the and transportation, and as a major in the blood.17,18 pantethine, pantothenic acid, or cysteine source of methyl groups. Methylation Excellent research has been produced constituents of the molecule.24 reactions turn body processes on and by Marty Hinz, MD, and his groups over The accumulation of long chain off and activate and inactivate metabolic the recent decades substantiating that oral acyl fatty acid intermediates promotes intermediates.7 supplementation of amino acid precursors cardiac arrhythmias. This has been

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demonstrated in several respects. Cardiac and pantothenic acid or pantethine. At We instruct patients to mix their arrhythmia may be the first clinical various times we have preferred various in a 32 fluid ounce (fl. oz.), presentation in children with fatty acid forms of these two essential ingredients. drinking bottle with water at the beginning oxidation disorders.25 Experimental Our current preference is to implement of the day. Assuming that the patient is models have demonstrated that buildup the protocol using choline bitartrate and awake for 16 hours per day, we divide the of acylcarnitines and other intermediates pantethine. day into 4-hour segments. During the first promote dysregulation of calcium Our preference for choline bitartrate 4 hours of the day the patient drinks 4 fl. resulting in dysrhythmias.26 Ischemic developed due to its high in oz. of the beverage, between hours 5 to injury in myocardial infarction has water, its potency, and the challenges 8 they drink 8 fl. oz., during hours 8 to also been associated with the buildup in sourcing a product that is not 12 they drink another 8 fl. oz., and during of these intermediates promoting genetically modified. Furthermore, a their final 4 hours awake they drink 12 fl. arrhythmogenesis. Meanwhile, shorter significant number of patients are soy or oz., ensuring adequate levels overnight chain metabolites such as acetyl-CoA egg sensitive and most lecithin products (Table 1). and palmitoyl-CoA do not promote in the marketplace are soy or egg derived. The MAP dosing works in a three- arrhythmogenesis.26,27 Our preference for pantethine over stage dose escalation (Table 1). At stage The potential for statin drugs (HMG- pantothenic acid (PA) comes from our 1 we deliver 500 mg of pantethine and CoA reductase inhibitors) to exert an observation that some patients do not 2000 mg of choline per day. Due to the antiarrhythmic effect on the heart has respond to PA, though they do respond to very short half-life of ACh we are able to been an area of research interest. Statins pantethine. tell within one week whether this dose is reduce recurrences of supraventricular We used to begin the protocol with PA adequate. If the patient achieves complete and ventricular arrhythmias in patients due to the fact that it is considerably less symptomatic or objective improvement with and without coronary artery disease. expensive than pantethine; if a patient did over the course of the first week then Several mechanisms have been proposed not respond to PA, we would then switch the MAP is maintained at stage 1; if not, for this antiarrhythmic effect, yet none to pantethine. We now tend to work in we escalate to stage 2. Stage 2 dosing have been proved. Hypotheses include: the reverse. We know that if we escalate is 1000 mg of pantethine and 4000 mg lowering of LDL , improved through the dosing stages of MAP using of choline; after one week we reassess. endothelial function, stabilization of pantethine and the arrhythmia does not If resolution of symptoms or objective atherosclerosis, anti-inflammatory come under control, MAP will not likely findings is complete or near complete effects, modulation of membrane ion work for that patient. Conversely, if we we stop at stage 2, otherwise we escalate flux, and improvement of autonomic can gain control of the arrhythmia using to stage 3. Stage 3 dosing is 1500 mg function.28,29 Experiments using other pantethine and choline, we can then try a of pantethine and 6000 mg of choline. antilipidemic agents have not shown switch to PA if the patient desires a lower Reassessment is made after one week in similar antiarrhythmic effects; therefore cost option. the same manner as previous stages. It is something unique about statins must Achieving a delivery system which rare that more than 1500 mg of pantethine give them their antiarrhythmic properties, keeps the substrates at constant blood will demonstrate further benefit, though rather than their LDL lowering or levels is a challenge. As discussed, if we we have had patients who needed to atherosclerosis stabilizing effects. want to ensure that adequate levels of escalate the initial dose of choline up to Statin drugs inhibit the effect of the precursors are available to be therapeutic, 10 grams before coming under rhythm HMG-CoA reductase enzyme, leading they must persist at reasonable blood control. After several weeks of a persistent to an upstream increase in metabolic concentrations at all times. We have symptom-free/arrhythmia-free period, a substrates, especially CoA. It may be found only one way to provide this type down titration can be attempted to find that buildup of CoA is responsible, in of steady state and that is to dose the the lowest effective dose that maintains whole or in part, for the antiarrhythmic nutrients in a beverage which the patient the arrhythmia resolution. When PA is effects of statins or for an improvement in can drink continuously throughout the substituted for pantethine, it is used at autonomic function. day. ➤ Therapeutic plausibility for the effect of CoA/pantethine/PA on cardiac Table 1: MAP Dosage Forms, Dose Escalation, and Delivery Method dysrhythmias is present in the medical literature. Since biochemical and Pantothenic acid/Pantethine Lecithin/Choline Bitartrate therapeutic plausibility exists for use of Stage 1 1000 mg/500 mg 2 Tablespoons/2000 mg either PA/pantethine or choline singly, the Stage 2 2000 mg/1000 mg 4 Tablespoons/4000 mg potential exists for their combined effect Stage 3 3000 mg/1500 mg 6 Tablespoons/6000 mg to be greater than the sum of its parts. This *** Mixed with a sufficient quantity of water to make 32 fluid ounces (fl. oz.). is the principle of the MAP. This beverage is drunk throughout the day according to the follow schedule: Protocol, Materials, and Dose Escalation Awake Hours Drink this Amount The principle of the MAP treatment Hours 1–4 4 fl. oz. is to give the two essential nutrient Hours 5–8 8 fl. oz. precursors for the endogenous production Hours 9–12 8 fl. oz. of ACh. These two nutrients are choline Hours 13–16 12 fl. oz.

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➤ double the dose of pantethine used for methotrexate or who have defects in folate Contraindications and Side Effects that stage: 1000 mg at stage 1, 2000 mg at or choline metabolism are known to have It is theoretically contraindicated to stage 2, 3000 mg at stage 3. When lecithin a higher dietary requirement for choline.7 use MAP in cases of bradycardia and is substituted for choline bitartrate we use Those who take oral contraception, bradydysrhythmias or in conditions a non-GMO soy lecithin which contains estrogen, or progestin may have an in which increasing the refractory 1000 mg of choline per tablespoon (Table increased requirement for pantothenic period of the SA or AV node would be 1). acid.5 contraindicated such as first, second, or Choline is important in several aspects third degree AV heart blocks, SA node Indications of cardiovascular health. It is vital in exit blocks, sinus pauses, and sinus arrest. MAP is indicated for any the endothelial functions that regulate There are no known interactions between tachyarrhythmia, including sinus blood pressure; choline insufficiency choline and other supplements, drugs, tachycardia, atrial tachycardia, supra­ has been implicated in atherosclerosis, diseases, conditions, or lab tests.52 The ventricular tachycardia, atrial fibrillation, and it has been shown to lower levels most concerning possibility for interac­ atrial flutter, and accelerated ventricular of homocysteine.8,30–32 It may help to tions between pantethine or PA and other rhythms, provided there are no control severity and need for medication drugs, supplements, and conditions is in contraindications with other aspects in asthma.33,34 Choline may lower the anticoagulation/antiplatelet therapy and of treatment. MAP is also indicated for incidence of neural tube defects.14,35 It bleeding disorders.53,54 Extreme caution ectopic arrhythmias such as premature may have a positive effect on several should be used in these circumstances and atrial contractions (PACs) and premature neurological conditions and processes, best practices would dictate counseling ventricular contractions (PVCs). MAP including psychiatric disorders, , patients to discontinue use of pantethine is appropriate as adjuvant therapy in memory, and cognition.36–39 Diets two weeks before surgery.53 the vast majority of circumstances; deficient in choline induce fatty liver Choline can cause adverse reactions however, potential interactions with other disease, and oral consumption of choline including sweating, gastrointestinal treatments and medications should always has been shown to help reverse fatty liver distress, nausea, vomiting, diarrhea, and a be scrutinized. Patients should be closely disease in several studies.40–42 Therefore, fishy body odor.7 Guidelines indicate that monitored for adverse events during it is an important therapy in patients daily choline doses should not exceed initiation and dose escalation. Several with this condition or at risk for it due 3500 mg per day in adults; however, doses noncardiac indications for MAP also to other conditions such as metabolic of 12,000 to 16,000 mg/day have been exist, including anxiety, hyperactivity, syndrome. Several studies have linked used in a study on seizure disorders and reactive attachment disorder, PTSD, and the importance of dietary choline to the doses of 7500 mg/day in a study on high other deficits of neurotransmitter and ANS prevention of colon, breast, and other blood pressure, both without significant balance. cancers.43–45 Pantethine may improve adverse events.7,55 A single prospective responses to stress.46 Pantethine has been investigation found an association Side Benefits shown to improve LDL cholesterol and between high choline diets and colorectal There are several potential side levels in repeated research at adenomas in women, though this benefits to supplementation with choline doses of at least 600 to 900 mg/day.47–51 observation may have been attributable and pantethine or PA. Patients who take to any of several other factors.56 People

Table 2: MAP – Summary of Cases 1–3 Patient Presentation Objective Findings Final MAP Dose Other Treatments Final Outcome on Stable MAP 44 yo Ten years of ECG: accelerated Stage 1: PA 1000 mg/ None After one week: normal ECG. female palpitations, two junctional rhythm with Lecithin 2000 mg After one month: only a single week exacerbation nonspecific ST changes. episode of palpitations over the palpitations, occurring previous two-week period. every 30 seconds.

29 yo Ten month history Exercise stress test: Stage 2: Pantethine B complex vitamin 2/d, After one month: no palpitations male of palpitations, 30 atrial bigeminy and 1000 mg / Choline glycinate or arrhythmic beats, no seconds in duration, quadrigeminy, up to 13 bitartrate 4000 mg 480 mg/d, botanical complaints or symptoms up to three times daily, PACs/min, ectopic atrial formula 2 mL, 3×/d; all postexercise, before or during worse post-exercise, pacemaker, inappropriate of these unchanged stressful events or exams. worse anxiety, blood pressure response since MAP stage 1. especially test anxiety. to exercise.

59 yo 3 months of ECG: persistent ectopic Stage 2: Pantethine 12.5 mg/d, After two weeks: self report of female palpitations, “flutters” rhythm. Holter monitor: 1000 mg/Choline tyrosine 1000 mg/d “significant improvements” in lasting up to a week atrial tachycardia, bitartrate 4000 mg 5-HTP 300 mg/d, palpitations and symptomatic or more. premature atrial and methylfolate 3.75 mg/d; heartbeats. ventricular beats. all since before MAP initiation.

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with liver or disease, Parkinson’s Her physical exam was normal across The patient reported daily use of a B disease, depression, or seven systems. Her electrocardiogram vitamin complex and 1 gram of essential may be at an increased risk of adverse (ECG) revealed an accelerated junctional fatty acids. The MAP stage 1 was initiated events when consuming choline at a rhythm, diffuse nonspecific ST segment using pantethine 500 mg and choline level up to or near the upper limit, though changes, and no arrhythmic beats (Figure bitartrate 2000 mg along with B complex otherwise there is no known of 2A). Blood chemistries and thyroid lab twice daily, a botanical formula (two parts choline to humans.7,57 It is regarded as tests were within normal limits. MAP was each Passiflora incarnata and Crataegus likely to be safe in pregnancy and lactation initiated at 1000 mg of pantothenic acid oxycantha, one part each of Valeriana when the upper limit is not exceeded.52 and two tablespoons soy lecithin mixed in officinalis and Leonorus cardiaca), 2 mL Pantethine is exceptionally well water and used daily. three times/day, and magnesium glycinate tolerated at doses up to 1200 mg.5,47– One week later, the patient reported 480 mg/day. 51,53,54 The most common side effects noticing a reduction in heart rate within One week later, he reported noticing are gastrointestinal in nature and three minutes of her initial use of the improvements after the first three days include nausea, diarrhea, and epigastric MAP. She was still having occasional of treatment. He was feeling fewer discomfort. When using doses in excess palpitations but much less frequently palpitations and less anxiety in stressful of 1200 mg, monitor closely and down and lasting only 10 seconds; she had not situations, but was still having 1 or 2 titrate or discontinue when necessary for been using the MAP daily. Her ECG on symptomatic palpitations after daily side effect control. There is insufficient that date was normal, demonstrating a exercise. The MAP was increased to stage evidence to support the safety of its use sinus rhythm at a rate of 60 bpm and no 2 and no other changes were made to the in pregnancy and lactation and should ST changes (Figure 2B). The patient was treatment plan. therefore be avoided.53 There is no known reminded to use the MAP on a daily basis At two-week follow up, the patient toxicity to humans even at very high levels and was maintained at stage 1. reported that his palpitations had of intake.5,53 One month after the initial visit, the improved further, but were not yet patient reported only one episode of completely gone. He still noticed Patient Data palpitations over the previous two week palpitations if he did not get enough rest. We have used the MAP protocol period which lasted less than one minute Their quality and severity had decreased; to address tachyarrhythmias, including in duration. Overall, she was pleased and he now reported them as “very subtle.” atrial fibrillation, ectopic rhythms, and thought that the treatment plan had been Stage 2 MAP was maintained. palpitations. In the upcoming months, effective. At follow-up two weeks later, the we will publish a peer-reviewed case patient reported that he had not been series on the success of the use of MAP Case 2 having palpitations. Cardiac monitoring in patients with these conditions. A small X. C., a 29-year-old male, presented for heart rate variability revealed no sampling of successful case data will be with complaints of palpitations lasting arrhythmic beats. discussed here and is summarized in approximately 30 seconds and occurring Table 2. every other day up to 2 to 3 times daily Case 3 for the previous 10 months. They felt G. S., a 59-year-old female, presented Case 1 like early, strong, or pounding beats with “flutters” after receiving “a lot of C. F., a 44-year-old female, presented in his chest and neck that gave him epinephrine” during a dental procedure to clinic with complaints of palpitations, a “dropping” feeling in his chest. An 3 months prior. Immediately after the pounding heart, and rapid heart rate. exercise stress test revealed premature procedure she began experiencing “strong Occasional “flip-flop” sensations in her atrial contractions (PACs) in patterns of and weak flutters” that could last a week heart had occurred for more than 10 years, bigeminy and quadrigeminy,13 PACs per or more. The severity of her palpitations but had increased in frequency to every minute, an ectopic atrial pacemaker, and had decreased somewhat over the three 30 seconds over the previous two weeks. inappropriate blood pressure response to ➤ exercise.

(A) 12 lead ECG demonstrating accelerated junctional rhythm with ST changes. (B) Normal 12 lead ECG demonstrating normal sinus rhythm and resolution of ST changes.

FigureFigure 2: 12 2: Lead 12 lead electrocardiograms electrocardiograms for forCase Case 1 - 144 – year44-year-old old female female before before (A) (A) and and after after (B) (B) MAP MAP treatment. treatment.

TOWNSEND LETTER – FEB/MARCH 2013 BEST OF NATUROPATHIC MEDICINE 77 Management of Cardiac Dysrhythmias

➤

months, but they persisted and were Conclusion with an upcoming peer-reviewed case worse at night. She had an irregularly MAP therapy has been successful series. Following that, we intend to irregular pulse in a recent past visit with in many patients with varying types begin comparative effectiveness trials of her PCP. She presented to us for a resting of tachycardia and dysrhythmias over MAP plus usual therapy (conventional ECG which demonstrated persistent its years of use. We have successfully pharmaceutical rate and rhythm control nonsinus rhythm, nonspecific ST changes, combined it with other natural, medical, agents) versus usual therapy plus placebo. no arrhythmic beats. Follow-up 24-hour and surgical interventions to equal The MAP is a promising treatment option Holter monitoring revealed PACs, PVCs, success. There are patients who are that warrants further investigation. and short periods of atrial tachycardia. Her nonresponders to MAP, but they can history was significant for PTSD treated be identified and redirected to other To contact the authors or for further with quetiapine 12.5 mg, L-tyrosine 1000 therapies within a few weeks of MAP trial. information: mg, 5-HTP 300 mg, and methylfolate 3.75 MAP is our first line natural treatment Dr. Martin Milner and Dr. Jeremy Mikolai mg, daily. MAP was initiated at stage 2 for tachydysrhythmias, especially when Heart & Lung Wellness Program using 1000 mg pantethine and 4000 mg comorbidities such as dyslipidemia or Center for Natural Medicine Inc. (CNM) choline bitartrate. metabolic syndrome exist. 1330 SE Cesar E Chavez Blvd. Two weeks later, at the first follow- We have presented only a small sample Portland, Oregon 97214 up visit, the patient reported “significant of straightforward case data here. We will 503-232-1100 improvements” in her palpitations and her continue to publish on the successful use CNMWellness.com experience of discernible heartbeats. of MAP in more complex cases beginning [email protected]

These authors have no financial conflicts of interest to declare.

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Jeremy Mikolai, ND, is the cofounder of the Naturopathic Institute of Cardiovascular and Pulmonary Medicine (NICVM). He is the attending physician in cardiovascular and pulmonary medicine at the National College of Natural Medicine (NCNM) and co-attending physician in the Heart & Lung Wellness program at the Center for Natural Medicine (CNM), both in Portland, OR. He is in his third year as the Heart & Lung Resident under the mentorship of Dr. Martin Milner at CNM and is the chief resident for 2012–2013 at NCNM. Dr. Mikolai is active in research and is an adjunct faculty member in the Masters of Science in Integrative Medicine Research (MSiMR) program at the Helfgott Research Institute at NCNM. He is actively working to create the first ND fellowship in cardiology.

Martin Milner, ND, has been in private practice since 1983 and is the medical director of the Center for Natural Medicine, Inc. CNM functions both as an integrated group medical practice and as a teaching clinic of NCNM. CNM is also active in clinical trials and research. Dr. Milner is the professor of cardiovascular and pulmonary medicine at NCNM and has been since 1986. He continues to supervise and mentor 48 ND student interns per year in the Heart & Lung Wellness Program, which he has maintained since 1999. He trains two ND residents each year, one who assists him in the Heart & Lung Wellness Program and one in his private practice. Dr. Milner is actively pursuing, with Dr. Mikolai, the creation of the first board certification program for NDs in Naturopathic Cardiology. In this regard, Dr. Milner and Dr. Mikolai cofounded the Naturopathic Institute of Cardiovascular and Pulmonary Medicine (NICVM.com), offering a rigorous curriculum of postgraduate education in naturopathic cardiovascular and pulmonary medicine.

Joseph DelGrosso, RD, (illustrator) is currently in his fourth year as a naturopathic medical student at the National College of Natural Medicine and a registered dietitian. He graduated magna cum laude in 2008 with a bachelor of science in dietetics from the State University of New York College at Oneonta, where he received the distinction of most outstanding dietetic student. He completed his dietetic internship at Queens College, New York.

TOWNSEND LETTER – FEB/MARCH 2013 BEST OF NATUROPATHIC MEDICINE 79