CA R D I A C AR R H Y T H M I A S

Transcription

1 1 CA R D I A C AR R H Y T H M I A S Cardiac arrhythmia refers to any irregular heart action caused by physiological or pathological disturbances in the discharge of cardiac impulses from the sinoatrial node or their transmission through the conductive tissue of the heart. This can cause the heart to pump less effectively. Some arrhythmias are so brief (for example, a temporary pause or premature beat) that the overall heart rate or rhythm is not greatly affected. However, if arrhythmias last for some time, they may cause the heart rate to be too slow or too fast or the heart rhythm to be erratic. Because arrhythmias are prominent features of a number of specific cardiac diseases, when a specific Western disease diagnosis is known, practitioners should compare and combine the information in this chapter with that in the relevant following disease chapter. Nosology: Although there are many different subcategories of heart arrhythmia, clinicians usually emphasize five main types: 1. Pre m a t u re beat. The most common arrhythmia, pre m a t u re beats are benign and are often described as flip-flops. Caffeine (including that in colas, chocolate, and tea), decongestants, and stress increase the occurrence of pre m a t u re beats. El e c t rolyte imbalances also are critical. 2. Atrial fibrillation. Doctors estimate that 3-5% of Americans have atrial fibrillation, making it the most common type of problematic card i a c arrhythmia. Atrial fibrillation, which is found most often in people over 65, develops when a disturbance in the electrical signals causes the two upper atrial chambers of the heart to quive r erratically rather than pump corre c t l y. W h e n this quivering occurs, not all the blood is forc e d out of the heart s chambers. The blood pools inside the atrium and sometimes clots. These socalled mural thrombi can cause a stroke if they b reak off (embolize), travel through the body, and block an art e ry in the brain. 3. Br a d yc a rdia. A slowed heartbeat or bradyc a r- dia causes a person to feel fatigued, dizzy, and lightheaded and may trigger fainting spells. Br a d yc a rdia is formally defined as a heart rate of less than 60bpm. Howe ve r, any heart rate in any individual, if it lowers cardiac output, can cause dizziness or other neurological symptoms. 4. Ta c h yc a rdia. Rapid heartbeat or tachyc a rd i a can also cause inefficient blood circ u l a t i o n. 6 5

2 66 The Treatment of Cardiovascular Diseases with Chinese Medicine During an episode of tachyc a rdia, a person may feel palpitations, rapid heart action, dizziness, light-headedness, and may faint. Ta c h yc a rdia is defined as a heart rate of more than 100bpm. 5. Ventricular arrhythmias. This most seve re and only life-threatening of all arrhythmias affects the beating of the ventricles, the main pumping chambers of the heart. Ve n t r i c u l a r t a c h yc a rdia is a rapid heartbeat arising fro m ectopic electrical impulses in the ve n t r i c l e s. Ventricular fibrillation occurs when the ve n t r i- cles go out of control, quivering and beating i n e f f e c t i ve l y, stopping the pumping action. If a m o re normal rhythm is not re s t o red pro m p t- ly within 3-5 minutes the patient will suffer brain oxygen deficiency and heart damage and die. This is the most common cause of mort a l- ity in the first 24 hours of a heart attack. Etiology: Many arrhythmias have no known cause. There are, however, a number of factors that are known to contribute to some arrhythmias. These include coronary artery disease, hypertension, diabetes mellitus, smoking, high cholesterol, obesity, a high fat diet, excessive use of alcohol (or withdrawal from it, i.e., holiday syndrome ), drug abuse, certain substances, including some over-the-counter and prescription medications, dietary supplements, and herbal remedies, electrolyte imbalance (especially sodium, calcium, magnesium, and potassium), stress, a family history of heart disease, and advancing age. Pathophysiology: In tachycardia, the automatic firing rate of secondary or autonomous, ectopic pacemaker tissue may become too fast. If such an abnormal focus fires faster than the sinus node, it may take over control of the heart rhythm and cause tachycardia. In another type of abnormal conduction, impulses get caught in a merrygo-round-like sequence. This process, called circuit re-entry, is a common cause of tachycardias. Sinus bradyc a rdia is a general term that describes a slow heartbeat related to the pace of electrical signals originating in the sinus node. It may be the sign of a well conditioned, healthy heart that can pump the body s necessary supply of blood (or oxygen demand) with fewer beats than ave r- age. Sick sinus syndrome (also called sinus node dysfunction or brady-tachy syndrome) is an arrhythmia related to the sinus node. It may be caused by disease or damage to the heart tissue itself or by outside factors, such as medications, that affect the sinus node. Most commonly it is caused by fibrosis or scar tissue in older patients with no know organic heart disease. He a rt block is a type of bradyc a rdia related to the heart tissues that conduct the electrical signal from the sino atrial (SA) node to the ventricles. He a rt block is often a problem with the atrioventricular (AV) node, a part of the heart s conduction system in the center of the heart. It also may be related to s t ru c t u res called the bundle of His and right and left bundle branches which conduct the electrical impulse so that it spreads like a wave through the ventricles, causing them to contract. Atrial fibrillation can occur as a t a c h y or b r a d y arrhythmia depending upon the re - e n t ry pattern. It is the most intensely irregular and rapid beat known to occur. T h e re are three circumstances in which atrial fibrillation can occur: 1. Primary arrhythmia without any underlying heart disease or structural defects 2. Secondary arrhythmia in the presence of a systemic abnormality, but no structural heart disease (for instance, lung disease with pulmonary hypertension) 3. Secondary arrhythmia in the presence of cardiac disease, usually coronary disease or cardiomyopathy

3 Cardiac Arrhythmias 67 The pathophysiologic changes that occur in patients with heart failure and atrial fibrillation are complex and incompletely understood. Alterations in neurohormonal activation, elect rophysiologic parameters, and mechanical factors related to heart muscle fiber emergencies c o n s p i re to create an environment in which h e a rt failure predisposes to atrial fibrillation and atrial fibrillation exacerbates heart failure (due to the lack of atrial kick to load the ve n- tricles prior to contraction). Me c h a n i s m s include atrial remodeling and tachyc a rd i a - induced myo p a t h y. Epidemiology: The incidence of supraventricular ectopic b e a t s 1 whether simple or complex or whether detected during rest, routine activity, or exercise increases with age, even among persons carefully screened to exclude latent c o ro n a ry art e ry disease (CAD). Is o l a t e d s u p r a ventricular ectopic beats have been detected by exercise ECG in 8% of apparently healthy persons aged but in 76% of those aged Frequent (> 100 in 24 hours) supraventricular ectopic beats have been detected during 24-hour ambulatory ECG monitoring in 26% of healthy persons aged with no evidence of CAD. The incidence of supraventricular tachyc a rd i a s also increases with age. Nonsustained suprave n- tricular tachyc a rdia has been detected by exe r- cise ECG in < 1% of apparently healthy persons aged but in 10% of those aged Risk of developing a spontaneous suprave n t r i c- ular tachyarrhythmia was 2% in the yo u n g e r g roup and 10% in the older gro u p. Howe ve r, the tachyc a rdia was not associated with an i n c reased risk of coro n a ry eve n t s. Likewise, the incidence of ventricular ectopic beats whether simple or complex or detected during rest, routine activity, or exe rc i s e increases with age, even among persons carefully screened to exclude latent CAD. Isolated ventricular ectopic beats have been detected by exercise ECG in 11% of apparently healthy persons aged but in 57% of those aged With 24-hour ambulatory ECG monitoring, isolated ventricular ectopic beats have been detected in 80% of healthy persons aged who had no evidence of CAD. Frequent (> five per minute or 100 in 24 hours) ventricular ectopic beats have been detected in 17%. Ventricular ectopic beats were detected by resting ECG in 8% of randomly selected patients > 70. With 24-hour ambulatory ECG monitoring, ventricular tachycardia has been detected in 4% of women and 10% of men aged Asymptomatic runs of exercise-induced ventricular tachycardia ( 6 beats) have been reported in nearly 4% of apparently healthy persons times the prevalence in younger persons. Signs & symptoms: He a rt rhythm disorders cause many differe n t symptoms or no symptoms at all. When symptomatic, these symptoms fall into two basic categories: 1) palpitations (meaning awareness of the heartbeat), and 2) hemodynamic upset due to either sustained bradyc a rdias or tachyc a rd i a s. Palpitations are often described by patients as skipping, pounding, fluttering, flip-flopping, racing, or sudden stopping of the heart b e a t. Hemodyanamic upset causes fatigue, lightheadedness, dizziness, and syncope. Chest pain and shortness of breath suggests that the arrhythmia may be more serious or associated with an alteration of cardiac output. Diagnosis: The working diagnosis is usually established by the patient s history and the report of palpitations, abnormally slow or rapid heartbeat, and dizziness or syncope. This typically leads

4 68 The Treatment of Cardiovascular Diseases with Chinese Medicine to the administration of the standard 12-lead electrocardiogram (ECG or EKG). However, since this only provides a relatively brief sampling of cardiac rhythm, ambulatory ECG monitoring may also be used. This refers to a continuous 24-hour ECG recorder (such as a Holter monitor) which is more likely to detect an arrhythmic episode. A treadmill test may be used for people whose suspected arrhythmias are clearly exercise-related. This consists of exercising on a treadmill while one s blood pressure and ECG are monitored. El e c t rophysiologic studies are indicated when spontaneous arrhythmias are infrequent and when a serious sustained arrhythmia is suspected. T h e re are two types of electro p h y s i o l o g i c studies: esophageal electrophysiologic pro c e- d u re and intracardiac electrophysiologic pro c e- d u re. In esophageal electrophysiologic studies, a thin, soft, flexible plastic tube is inserted into the patient s nostril and positioned in the esophagus. Because the esophagus is close to the heart s atria, an ECG re c o rding there give s m o re precise information than a regular ECG. An electrical stimulator may be used to make the heart beat faster to try to re s t a rt the p a t i e n t s arrhythmia. During this pro c e d u re, c e rtain medications may be tested to find the most effective one. This pro c e d u re also may be done to temporarily stop certain types of arrhythmias. In intracardiac electro p h y s i o l o g i c p ro c e d u re, one or more catheters are placed into the large blood vessels in the legs, arms, or both. Then the tips of the catheters are move d into the heart. Once there, they re c o rd electrical signals from the normal electrical system. This also gives much more precise information than an ord i n a ry ECG. During these studies, the heart is stimulated to beat rapidly or irre g- u l a r l y. The heart s response to this and the way electricity moves around the heart during a t a c h yc a rdia helps the cardiologist diagnose the nature of an arrhythmia. This is called cardiac electrical mapping. An echocardiogram, an ultasound of the heart, may also be done to clarify the nature of any h e a rt disease present. In patients with arrhythmia accompanied by chest pain or in those patients with two or more coro n a ry disease risk factors, a coro n a ry angiography may be performed. Fi n a l l y, when dizziness or syncope is suspected to be va s ovagal or neuro c a rd i o g e n i c, i. e., a non-intrinsically cardiac reason is suspected, a tilt table test may be performed to make a d i f f e rential diagnosis. 2 This is also re f e r red to as autonomic testing. In these patients, a low blood p re s s u re is found along with bradyc a rd i a, d i a p h o resis, and nausea. Differential diagnosis: Inadequate vasoconstriction Orthostatic reaction Vasovagal syncope (usually familial) Autonomic insufficiency (Shy-Drager s syndrome) C a rotid sinus syndrome (takes only a small amount of pre s s u re to set off baro recept o r s ) Hyperbradykinesia (a congenital anomaly) Hypovolemia Blood loss Addison s disease (loss of sodium) Reduced cardiac output Atrioventricular block Ventricular asystole Sinus bradycardia Sick sinus syndrome Supraventricular tachycardia (second or third degree heart block, i.e., Stokes- Adams syndrome) Ventricular tachycardia Aortic stenosis Hypertrophic subaortic stenosis Pulmonary stenosis Pulmonary embolism Pulmonary hypertension (such as with chronic lung disease or medications such as the infamous phen-fen ) Myocardial infarction

5 Cardiac Arrhythmias 69 Cardiac tamponade Carotid sinus hypersenstivity Heart failure Other vascular causes Subclavian steal syndrome (in which blood is shunted away from the brain) Aortic dissection (due to atherosclerosis or weakening of vessel walls) Arteriosclerosis of the carotid Arteriosclerosis of the cerebral vessels Transient ischemic attacks (TIAs, due to emboli, i.e., clot pieces, or total final blocks by plaques into certain areas of the brain s circulation) Hypertensive encephalopathy Takayasu s arteritis Cervical spine abnormalities (that impinge on autonomic neurons) Anemia Heat Hyperventilation (causes blood vessel dysregulation due to excessive loss of carbon dioxide) Hypoglycemia (so-called neuroglycopenia. The brain is selectively attuned to only glucose for fuel.) Hypoxia Drugs (especially sedatives which impair respiratory drive or autonomic centers) Neurologic/psychiatric diagnoses Seizures Anxiety Panic attack Western medical treatment: T h e re are a number of Western medical tre a t- ments currently available to pre vent or re d u c e the frequency of arrhythmias. Choice of tre a t- ment is dependent on such factors as: 1) the n a t u re and severity of the heart rhythm disord e r and its symptoms, 2) the presence of underlying diseases and other conditions that contribute to the disorder or effect the patient s health or quality of life, 3) the patient s age, overall health, and personal and family medical history, and 4) any medications and/or other therapies that the patient may be taking for other conditions. Treatment options include defibrillation and c a rd i oversion, medications, surgery, and lifestyle changes. Defibrillation and cardioversion are general terms used to describe techniques that administer a controlled or synchro n i zed electric shock to the heart to restore or maintain its normal rhythm. Implantable card i ove rt e r defibrillators (ICDs) are the most successful therapy to treat ventricular fibrillation, the major cause of sudden cardiac death, in certain high-risk patients. Implantable card i ove rt e r defibrillators are 99% effective in stopping life-threatening arrhythmias. They continuously monitor the heart rhythm, automatically function as pacemakers for heart rates that are too slow, and deliver life-saving shocks if a d a n g e rous fast heart rhythm is detected. Pacemakers are implanted devices that monitor and regulate the rhythm of the heart and transmit electrical impulses to stimulate the heart if it is beating too slowly. In addition, the U.S. Food and Drug Administration (FDA) recently approved a special type of pacemaker for use in certain patients with heart failure. This technique, called cardiac resynchronization therapy, the implanted device paces both the left and right ventricles of the heart simultaneously. This resynchronizes muscle contractions and improves the efficiency of the weakened heart by allowing a more controlled flow of blood or improved cardiac output. And finally, in catheter ablation, one or more flexible catheters are introduced under x-ray guidance into the blood vessels and directed to the heart muscle. A burst of radio frequency energy destroys very small areas of tissue that give rise to abnormal electrical signals. These are the so-called aberrant extra pathways, such as in Wolff-Parkinson-White syndrome. Medications are prescribed to control abnormal

6 70 The Treatment of Cardiovascular Diseases with Chinese Medicine h e a rt rhythms or treat related etiologic conditions such as high blood pre s s u re, coro n a ry a rt e ry disease, heart failure and heart attack. Drugs may also be administered to reduce the risk of stroke in patients with certain types of arrhythmias. The classes of drugs typically prescribed to patients with heart arrhythmias include antiarrhythmics used to treat abnormal h e a rt rhythms per se; antihypert e n s i ves to tre a t high blood pre s s u re; diuretics to decrease fluid and salt in the body, thus reducing the heart s w o rkload; inotropic and cardiotonic drugs to stimulate the force of heart muscle contractions; anticlotting agents or anticoagulants to pre ve n t blood clots that can cause heart attack and s t roke; and cholestero l - l owering drugs to pre ve n t high cholesterol. Antiarrhythmics consist of sodium channel blockers, beta-blockers, potassium channel blockers, and calcium channel blockers. Pain re l i e vers may also be pre s c r i b e d after a heart attack to treat angina, and thro m- bolytic therapy is used in the early stages of heart attack or stroke to break up a blood clot and re s t o re blood flow. Medications are often prescribed in tandem with defibrillation and card i oversion or with surgery and lifestyle changes. Surgery is sometimes used as a treatment for abnormal heart rhythms, but it may also be useful for some patients with heart failure, coronary artery disease, and other conditions that increase the risk of arrhythmias. Lifestyle changes, such as better diet, less alcohol, stopping smoking, more exercise, and less stress, may improve the symptoms of arrhythmias and other heart disorders or improve the overall health of the patient. Recent studies in the medical literature indicate that a great percentage of coro n a ry deaths in the c o ro n a ry care setting are associated with low l e vels of magnesium. Although not standard c a re, magnesium supplementation in cert a i n subsets of patients at risk may be warranted. Prognosis: The outcome of arrhythmias is dependent on several factors: 1. The kind of arrhythmia, i.e., whether it is simply an atrial arrhythmia (originating from the atrium) or a more potentially lethal arrhythmia, such as ventricular tachycardia or ventricular fibrillation 2. The ejection fraction of the heart or the overall pumping ability of the heart 3. The individual person s differing response to the same arrhythmia 4. The presence of left ventricular hypertrophy. It is an established fact that any arrhythmia in the presence of left ventricular hypertrophy at least doubles the future probability of sudden death. Un f o rt u n a t e l y, arrhythmias can sometimes cause sudden death. Complications of some of the disorders associated with heart arrhythmias include heart attack, heart failure, and stroke. Chinese medical disease categorization: In Chinese medicine, depending on the main p resenting manifestations, arrhythmias fall under the categories of heart palpitations (xin ji), fright palpitations (jing ji), fearful throbbing (z h e n g c h o n g), vacuity taxation (xu lao), chest impediment (xiong bi), dizziness (xuan yun), and, if ve ry s e ve re, clouding re versal (yun jue), cold re ve r s a l (han jue) and blood re versal (xue jue). 3 Of these Chinese medical disease categories, cardiac arrhythmias predominantly fall under the traditional disease category of heart palpitations. Disease causes & mechanisms: In Chinese medicine, heart palpitations are due to all three categories of disease causes: external

7 Cardiac Arrhythmias 71 contraction of the six environmental exc e s s e s, internal damage by the seven affects, and neither internal nor external causes, such as unre g- ulated stirring and stillness, i. e., activity and rest, unregulated eating and drinking, iatro g e n- esis, poisoning, drugs of abuse, parasites, and traumatic injury. In addition, heart palpitations may also be due to former heaven natural e n d owment, enduring diseases, and aging. In terms of disease mechanisms, heart palpitations are a type of pathological stirring or movement of the heart qi. Therefore, there are only three mechanisms of heart palpitations. First, there is nonconstruction and malnourishment of the heart. In this case, there is either not enough qi and yang to stir or move the blood or not enough blood and yin to nourish and enrich the heart so that the heart qi can perform this function properly. The heart qi and blood are mainly engendered and transformed by the spleen, the latter heaven root. Therefore, if, for any reason, the spleen becomes vacuous and weak, it may fail to upbear the finest essence of food and drink to the heart and lungs. However, the heart is also especially dependent on the former heaven root, the kidneys, for its construction and nourishment. Thus it is said, Former and latter heavens are mutually rooted. Both heart yin and yang are directly linked to the kidneys, the root of yin and yang of the whole body. Therefore, anything resulting in kidney yin or yang vacuity may also cause heart yin or yang vacuity. And finally, the heart and lung qi together form the ancestral, gathered, or chest qi. This means that anything which results in a reduction in lung qi may also cause a vacuity of heart qi and vice versa. The second mechanism of heart palpitations is some sort of heat evils ascending to harass the heart. While insufficiency of qi causes the heart to move the blood too slowly, heat (a pathological form of yang qi) causes it to move frenetically or too rapidly. Such heat can be replete or vacuous and internally engendered or externally contracted. The main types of heat associated with heart palpitations are depressive heat, phlegm heat, stasis heat, and vacuity heat. However, they most commonly begin with depression transforming heat. Because qi is yang and, therefore, warm by nature, if qi becomes stagnant and depressed, it may transform into what is called depressive heat. This tendency for depression to transform heat is directly related to the degree of exuberance of the life-gate fire, and some people constitutionally have a more exuberant lifegate fire than others. Those with more life-gate fire tend to transform heat more quickly. Such depressive heat most commonly arises in the liver and stomach. However, because heat is yang, this heat tends to float upward to accumulate in the lungs and heart in the upper burner. If it combines with phlegm, it creates phlegm heat. If depressive heat endures for a long time, it may consume and damage yin, thus resulting in yin vacuity failing to control and restrain yang. This gives rise to ascendant hyperactivity of yang or internal flaring of vacuity heat. Vacuity heat may also be due to any especially intense or enduring heat evils as well as to former heaven natural endowment insufficiency, overtaxation, and drug use (both certain prescription drugs and drugs of abuse). The third mechanism of heart palpitations is something obstructing the free flow of the heart qi. This causes blockage and impediment to the f l ow of blood and mostly refers to blood stasis and phlegm rheum. Blood stasis causing heart arrhythmias is mainly due to enduring disease, especially enduring qi and yang va c u i t y, qi stagnation, and phlegm obstruction. In Chinese medicine, it is said, If the qi moves, the blood m oves. T h e re f o re, if the qi becomes va c u o u s and weak, it may fail to stir or propel the blood. Because yang is inherently warm, a lack of sufficient yang causes vacuity cold, and cold s nature is constricting and contracting, yang va c u i t y may congeal the blood and lead to blood stasis.

8 72 The Treatment of Cardiovascular Diseases with Chinese Medicine In addition, any evil qi which causes loss of fre e f l ow of the qi may eventually result in the creation of blood stasis. This includes any of Zhu Da n - x i s six depressions but particularly qi stagnation, dampness, and phlegm. It is said, Bl o o d and fluids flow together. T h e re f o re, dampness and phlegm may hinder and obstruct the uninhibited flow of blood, thus leading to blood stasis. If stasis endures for some time, it eve n t u a l l y enters the network vessels. Phlegm rheum refers to thick and thin forms of phlegm fluids. These are due to faulty diet, insufficient exe rcise, certain medications, and enduring disease, especially again qi va c u i t y and/or stagnation, yang va c u i t y, and blood stasis. Phlegm is congealed fluids. T h e re f o re, anything which hinders or negatively affects the m ovement and transformation of water fluids in the body may eventually lead to the cre a t i o n of phlegm. In part i c u l a r, the three viscera which c o n t rol water metabolism in the body are the lungs, spleen, and kidneys. The lung qi in the upper burner must be sufficient and freely flowing in order to depurate and downbear fluids and control the water passageways. Spleen yang qi in the middle burner must be sufficient to upbear clear fluids and downbear turbid fluids in order to pre vent the accumulation of dampness. This is why it is said, The spleen is the root of phlegm engenderment. In addition, the yang qi of the kidneys in the lower burner is responsible for the bladder s qi transformation and the exc retion of turbid liquids from the b o d y. T h e re f o re, the engenderment of phlegm fluids in the body is closely tied to disturbances in the function of these three viscera. Howe ve r, it is important to understand that phlegm can also be engendered by two other mechanisms. First, heat may boil the fluids and cook them into phlegm. This refers mainly to forms of enduring or persistent heat, be they replete or vacuous. The second mechanism of phlegm formation is qi stagnation. Just as it is qi which m oves the blood, qi moves fluids. If the qi stops, fluids stop. In that case, fluids gather and transform into dampness. Over time, damp evils congeal into phlegm. In real life, most patients with heart palpitations suffer from a combination of vacuity and repletion. This is particularly so in the elderly, w h e re vacuity is commonly mixed with phlegm obstruction and blood stasis. Treatment based on pattern discrimination: 1. Heart qi vacuity pattern Main symptoms: Heart palpitations and disquietude which get worse on exertion, shortness of breath, lack of strength, a faint, weak voice and/or disinclination to speak, lassitude of the spirit, a lusterless facial complexion, pale white lips, lack of warmth in the extremities, frequent yawning or sighing, spontaneous perspiration, a pale, enlarged, tender tongue with white fur, and a vacuous, weak pulse Treatment principles: Nourish the heart, boost the qi, and quiet the spirit Rx: Yang Xin Tang Jia Jian (Nourish the Heart Decoction with Additions & Subtractions) Radix Codonopsitis Pilosulae (Dang Sh e n), Radix Di o s c o reae Oppositae (Shan Ya o), and mix-fried Radix Gl ycyrrhizae Uralensis (Ga n Ca o), 9g each, Sclerotium Pararadicis Po r i a e Cocos (Fu Sh e n), Sclerotium Poriae Cocos (Fu Li n g), Semen Nelumbinis Nuciferae (Lian Zi), Semen Biotae Orientalis (Bai Zi Re n), Fru c t u s Schisandrae Chinensis (Wu Wei Zi), Radix Angelicae Sinensis (Dang Gu i), Radix Albus Paeoniae Lactiflorae (Bai Sh a o), and stir-fried Semen Zizyphi Spinosae (Suan Zao Re n), 6g each Formula explanation: Dang Shen, Shan Yao, and the large dose of Gan Cao fortify the mid-

9 Cardiac Arrhythmias 73 dle and supplement the qi. Heart qi has its root in the middle burner. Only if the spleen is strong and fortified can heart qi be full and exuberant. Fu Ling assists in supplementing the spleen but also percolates dampness. Fu Shen has the same functions as Fu Ling, only weaker. In addition, it quiets the heart spirit. This combination of the spleen-supplementing, dampness-percolating, and spirit-quieting medicinals is supported by Lian Zi which eliminates dampness, supplements the spleen, and also quiets the spirit. In addition, Lian Zi supplements the kidneys and astringes to protect the qi. Bai Zi Ren, Dang Gui, Bai Shao, Suan Zao Ren, and Wu Wei Zi all supplement the blood. Spirit qi is nourished and constructed by heart blood. Only if blood is exuberant, can the spirit be strong, secure, and quiet. Bai Zi Ren nourishes heart blood, Suan Zao Rennourishes liver blood, and Wu Wei Zi s five flavors nourish all five viscera. In addition, these three medicinals quiet the spirit. Gan Cao, besides fortifying the middle, also harmonizes all the ingredients in this prescription. Additions & subtractions: For severe heart palpitations, add 12 grams each of Os Draconis (Long Gu) and Concha Ostreae (Mu Li). For disquieted sleep at night or restlessness, add six grams of licorice-processed Radix Polygalae Tenuifoliae (Yuan Zhi) and 12 grams of Caulis Polygoni Multiflori (Ye Jiao Teng). For fatigue, add 15 grams of honey stir-fried Radix Astragali Membranacei (Huang Qi). For spontaneous perspiration, add 12 grams of uncooked Radix Astragali Me m b r a n a c e i (Huang Qi) and nine grams of bran stir-fried R h i zoma Atractylodis Ma c rocephalae (Ba i Zhu). Acumoxa therapy: Xin Shu (Bl 15), Nei Guan (Per 6), Zu San Li (St 36), Dan Zhong (CV 17) Additions & subtractions: For disquieted sleep at night, add Shen Men (Ht 7). For dizziness, add Bai Hui (GV 20). For symptoms of blood stasis, add He Gu (LI 4) and San Yin Jiao (Sp 6). For pain in the chest, add Yu Tang (CV 18). For susceptibility to fright, add Da Ling (Per 7). For profuse sweating, add Gao Huang (Bl 43). 2. Heart yang vacuity pattern Main symptoms: He a rt palpitations and disquietude which get worse on exe rtion, a cold body and limbs or even counterf l ow chilling of the limbs in seve re cases, lassitude of the spirit, a somber white facial complexion, oppre s s i o n (and sometimes pain) in the chest, shortness of b reath, a pale tongue with white fur, and a deep, fine, forceless or vacuous, weak pulse Treatment principles: Warm and supplement heart yang and quiet the spirit Rx: Gui Zhi Gan Cao Long Gu Mu Li Tang (Cinnamon Twig, Licorice, Dragon Bone & Oyster Shell Decoction) Os Draconis (Long Gu) and Concha Ostreae (Mu Li), 12g each, Ramulus Cinnamomi Cassiae (Gui Zhi) and mix-fried Radix Glycyrrhizae Uralensis (Gan Cao), 9g each Formula explanation: Gui Zhi is warm and acrid. It enters and warms the channels and network vessels and activates the movement of qi and yang, in this case heart yang. Sweet and neutral, Gan Cao supplements the middle and boosts the qi, thereby supplementing the heart qi. These governing medicinals are assisted by Long Gu and Mu Li which heavily settle and quiet the spirit, astringe and secure. Heavy settling is necessary in this case to anchor vacuous yang, quiet the heart spirit, and astringe sweat. Additions & subtractions: For severe yang vacuity, add six grams each of Radix Lateralis Praeparatus Aconiti Carmichaeli (Fu Zi) and Radix Rubrus Panacis Ginseng (Hong Shen). For heart qi vacuity, add 12 grams of Radix

10 74 The Treatment of Cardiovascular Diseases with Chinese Medicine Astragali Membranacei (Huang Qi) and nine grams of Radix Codonopsitis Pilosulae (Dang Shen). For reduced food intake and loose stools, add six grams of dry Rhizo m a Zingiberis Officinalis (Gan Jiang) and nine grams of Rhizoma Atractylodis Macrocephalae (Bai Zhu). For cold spontaneous perspiration, add nine grams of Rhizoma At r a c t y l o d i s Macrocephalae (Bai Zhu) and 12 grams of Radix Astragali Membranacei (Huang Qi). Zhi Gan Cao Tang Jia Jian (Mix-fried Licorice Decoction with Additions & Subtractions) mix-fried Radix Gl ycyrrhizae Uralensis (Gan Ca o) and uncooked Radix Rehmanniae Gl u t i n o s a e (Sheng Di), 12g each, Tuber Op h i o p o g o n i s Japonici (Mai Men Do n g) and wine stir-fried Radix Angelicae Sinensis (Dang Gu i), 9g each, Ramulus Cinnamomi Cassiae (Gui Zhi), Gelatinum Corii Asini (E Ji a o), and Radix Lateralis Praeparatus Aconiti Carmichaeli (Fu Zi), 6g each, Semen Cannabis Sa t i vae (Huo Ma Re n), 5g, Fructus Zizyphi Jujubae (Da Za o), 3 pieces, Radix Panacis Ginseng (Ren Sh e n) and uncooked R h i zoma Zingiberis Officinalis (Sheng Ji a n g), 3g e a c h Formula explanation: Besides warming yang, this prescription also nourishes yin and blood. Hence, it is indicated in patients suffering from a combination of yang vacuity with blood and yin damage. Mix-fried Gan Cao and Ren Shen supplement the middle and fortify the spleen. Sheng Di, E Jiao, Dang Gui, and Da Zao supplement the blood. Dang Gui also gently moves and quickens the blood. Sheng Di also clears heart heat which potentially may arise secondary to blood and yin vacuity. Mai Men Dong and Huo Ma Ren nourish yin. They are assisted by Sheng Di. Gui Zhi and Fu Zi are acrid and warm or hot medicinals. They enter and warm the channels and network vessels, scatter cold, and move the qi and blood. Sheng Ji a n g h a r m o n i zes the middle and there by assists mix-fried Gan Cao and Ren Sh e n. Furthermore, the combination of Da Zao and Sheng Jiang harmonizes the constructive and defensive, the qi and blood, and the spleen and stomach. Shen Fu Tang Jia We i (Ginseng & Aconite Decoction with Added Flavors) uncooked Radix Astragali Me m b r a n a c e i (Huang Qi), 18g, Radix Panacis Ginseng (Ren Sh e n), 9-15g, Radix Lateralis Pr a e p a r a t u s Aconiti Carmichaeli (Fu Zi), 9g Formula explanation: This formula is indicated if heart yang is severely depleted and is deserting. This manifests with severe and sudden upset of heart palpitations, cold profuse sweating, shortness and weakness of breath, a white facial complexion with cyanotic lips and mouth, counterf l ow chilling of the limbs, clouded spirit, a pale tongue, and a faint pulse on the verge of expiry. This is an emergency condition and the above formula should only be administered in combination with emergency Western medical treatment. Although the formula is very small and simple if prepared as a bulk herb prescription following the above dosing guidelines, it can have a profound effect on the body. This formula should only be administered for a short time while the patient is presenting with the desertion pattern. As soon as the desertion phase is over, the formula needs to be adjusted. Within this formula, Ren Shen powerfully supplements the source qi and stems desertion. Fu Zi warms, arouses, and moves the yang of the entire body. The combination of Ren Shen and Fu Zi s t rongly warms, supplements, and stems deserting yang qi. Huang Qi fortifies the middle and boosts the qi. It upbears clear yang to the head and upper body. In this prescription, it assists both Ren Shen and Fu Zi. It aids the qi supplementation of Ren Shen and upbears yang qi to the head and upper body.

11 Cardiac Arrhythmias 75 Bu Xin Tong Mai Tang (Supplement the Heart & Free the Vessels Decoction) Radix Astragali Membranacei (Huang Qi) and Radix Angelicae Sinensis (Dang Gui), 12g each, Radix Codonopsitis Pilosulae (Da n g Sh e n), Radix Lateralis Praeparatus Ac o n i t i Carmichaeli (Fu Zi), Tuber Op h i o p o g o n i s Japonici (Mai Men Do n g), Radix Sa l v i a e Miltiorrhizae (Dan Sh e n), mix-fried Radix Glycyrrhizae Uralensis (Gan Cao), and Herba Epimedii (Xian Ling Pi), 9g each, Fructus Schizandrae Chinensis (Wu Wei Zi), 7g, Ramulus Cinnamomi Cassiae (Gui Zhi), 6g Formula explanation: This is a real-life prescription used in the treatment of bradycardia patients presenting with a yang vacuity pattern. It not only warms yang but also boosts the qi and quickens the blood, two very common complications in all yang vacuity patterns. Fu Zi combined with yang-supplementing Xian Ling Pi warms, moves, and frees all 12 channels as well as strongly stimulates and arouses heart and kidney yang. Gui Zhi supports these functions of Fu Zi but also combines with Dan Shen, Dang Gui, and Gan Cao to enrich and construct the heart and quicken the heart blood, thereby regulating and freeing the flow of the heart vessels. Dan Shen has a particularly strong effect in freeing the heart vessels. Gan Cao also has an empirical antiarrhythmia function. The combination of Dang Shenand Huang Qi greatly supplements the original qi and thus aids in moving the blood. If yang is vacuous, the channels and vessels become cold and warming qi is lacking. Only if there is sufficient qi and yang are the channels warm and the blood moved. Hence, the combination of the qi-boosting medicinals with the yang-warming and channel-moving substances is key to effectively treating this disease. Mai Men Dongand Wu Wei Zi nourish the heart and protect yin from damage by the acrid, hot medicinals in this prescription. Additions & subtractions: For pronounced qi vacuity, add 6-9 grams of Radix Panacis Ginseng (Ren Shen). For marked yang vacuity, add nine grams of Cortex Cinnamomi Cassiae (Rou Gui) and six grams of dried Rhizoma Zingiberis Officinalis (Gan Jiang). For yang vacuity cold congelation, add nine grams of Herba Ephedrae (Ma Huang) and 4.5 grams of Herba Asari Cum Radice (Xin Xin). For simultaneous spleen-kidney yang vacuity, add nine grams each of Fructus Psoraleae Corylifoliae (Bu Gu Zhi), Radix Dioscoreae Oppositae (Shan Ya o), and Rhizoma Cu rc u l i g i n i s Orchioidis (Xian Mao). For spleen yang leading to lack of source for transformation, increase the dosage of Dang Gui and add nine grams of Radix Albus Paeoniae Lactiflorae (Bai Shao) and 18 grams of Caulis Milettiae Seu Spatholobi (Ji Xue Teng). For concurrent blood stasis, add nine grams each of Radix Ligustici Wallichii (Chuan Xiong) and Flos Carthami Tinctorii (Hong Hua). For concurrent phlegm obstruction, add nine grams each of Fructus Trichosanthis Kirlowii (Gua Lou), Bulbus Allii (Xie Bai), and Tuber Curcumae (Yu Jin). For rheum accumulation, add 12 grams of Sclerotium Poriae Cocos (Fu Ling) and nine grams of Rhizoma At r a c t y l o d i s Macrocephalae (Bai Zhu). Acumoxa therapy: Xin Shu (Bl 15), Shen Tang (Bl 44), Da Zhui (GV 14), Tao Dao (GV 13) Additions & subtractions: For reduced food intake and loose stools, add Zu San Li (St 36). For dizziness and nausea, add Zhong Wan (CV 12). For heart pain, add Nei Guan (Per 6). For epigastric glomus, add Xia Wan (CV 10). For heart qi vacuity symptoms, add Dan Zhong (CV 17) and Zu San Li (St 36). For inhibited urination and edema, moxa Guan Yuan (CV 4) to warm kidney yang. For dull purple or dark yet pale lips and nails, add He Gu (LI 4) and San Yin Jiao (Sp 6) to quicken the blood and transform stasis.

12 76 The Treatment of Cardiovascular Diseases with Chinese Medicine 3. Heart yin vacuity pattern Main symptoms: Heart palpitations, vexation and agitation, insomnia, impaired memory, malar flushing, a dry mouth, profuse dreaming, low-grade fever, night sweats, dry stools, sores on the tongue, a red tongue with reduced or no fur, and a fine, rapid pulse Treatment principles: Enrich yin and clear heat, nourish the heart and quiet the spirit R x : Tian Wang Bu Xin Da n ( He a venly Em p e ro r Supplement the He a rt El i x i r ) uncooked Radix Rehmanniae Glutinosae (Sh e n g D i), 15g, Radix Codonopsitis Pilosulae (Da n g Sh e n), Tuber Asparagi Cochinensis (Tian Me n Do n g), Tuber Ophiopogonis Japonici (Mai Me n Do n g), Radix Scrophulariae Ningpoensis (Xu a n Sh e n), Radix Salviae Miltiorrhizae (Dan Sh e n), and Sclerotium Poriae Cocos (Fu Li n g), 9g each, Radix Polygalae Tenuifoliae (Yuan Zhi), Radix Angelicae Sinensis (Dang Gu i), Fru c t u s Schisandrae Chinensis (Wu Wei Zi), Se m e n Biotae Orientalis (Bai Zi Re n), stir-fried Se m e n Zizyphi Spinosae (Suan Zao Re n), and Radix Pl a t ycodi Grandiflori (Jie Ge n g), 6g each Fo rmula explanation: Sheng Di, Xuan Sh e n, Mai Men Dong, a n d Tian Men Do n gall nourish and enrich yin and engender fluids. Sheng Di and Xuan Sh e nalso clear heat from the heart and blood. Mai Men Dong nourishes yin in the upper burner, and Tian Men Do n gnourishes yin in the lower burner. Dang Gu i supplements and gently quickens blood. T h e re f o re, in terms of quickening the blood, it assists Dan Sh e n w h i c h s t rongly quickens blood in the heart vessels. Da n Sh e n f u rther clears heat and combines with Sheng Diand Xuan Sh e nto treat heart heat. Da n Shen f o rtifies the spleen and supplements the qi. Fu Li n g supplements the spleen and perc o l a t e s dampness and thus pre vents the accumulation of dampness secondary to a damaged spleen. Fu rt h e r m o re, Fu Li n g has a slight spirit-quieting function. Yuan Zhi, Bai Zi Re n, and Suan Za o Re n calm the spirit and quiet the heart. T h e s e medicinals treat both the disquietude as well as the heart palpitations. Bai Zi Re n s p e c i f i c a l l y nourishes heart blood; Suan Zao Re n s p e c i f i c a l l y nourishes liver blood; Yuan Zhi t r a n s f o r m s phlegm and re s o l ves depression. Wu Wei Zi assists several of the above medicinals. With its f i ve flavors, it supplements all five viscera, i. e., it boosts the qi and nourishes the blood, it enriches yin and it quiets the spirit. Jie Geng s e rves as the envoy which guides the other medicinals to the upper body in general and chest in part i c u- l a r. Howe ve r, Jie Ge n g also diffuses the lung qi. In turn, lung qi is enabled to move all the qi and, t h e re f o re, all the blood of the body. Thus, in this p rescription, Jie Ge n gcan also be seen as an assistant to the blood-moving and ve s s e l - f re e i n g medicinals Dan Sh e n and Dang Gu i. Additions & subtractions For severe heart palpitations and/or insomnia, add 12 grams each of calcined Os Draconis (Long Gu) and calcined Concha Ostreae (Mu Li). For night sweats, add nine grams each of Semen Levis Tritici Aestivi (Fu Xiao Mai) and Radix Albus Paeoniae Lactiflorae (Bai Shao). Acumoxa therapy: Xin Shu(Bl 15), Nei Guan (Per 6), Shen Men(Ht 7), San Yin Jiao (Sp 6), Tai Xi (Ki 3) Additions & subtractions: For low back and knee soreness and limpness, add Ran Gu (Ki 2). For seminal emission, add Shen Shu(Bl 23) and Zhi Shi (Bl 52). For vacuity vexation and insomnia, add Yin Xi (Ht 6). For dry stools, add Zu San Li (St 36). For impaired memory, add Si Shen Cong (N-HN-1). 4. Heart blood vacuity pattern Main symptoms: Heart palpitations, racing heart, insomnia, impaired memory, dizziness, a lusterless facial complexion, heart vexation, lack of strength in the hands and feet, lassitude

13 Cardiac Arrhythmias 77 of the spirit, pale lips and nails, a pale tongue with thin, white fur, and a fine, weak pulse Treatment principles: Nourish the heart, supplement the blood, and quiet the spirit R x : Si Wu Ta n g Jia Wei ( Four Materials Decoction with Added Fl a vo r s ) cooked Radix Rehmanniae Glutinosae (Shu Di) and Radix Albus Paeoniae Lactiflorae (Bai Sh a o), 12g each, Radix Angelicae Sinensis (Dang Gu i), stir-fried Semen Zizyphi Spinosae (Suan Za o Re n), Arillus Eu p h o r i a e Longanae (Long Ya n Ro u), and Radix Salviae Miltiorrhizae (Da n Sh e n), 9g each, Radix Ligustici Wallichii (C h u a n X i o n g) and mix-fried Radix Gl yc y r r h i z a e Uralensis (Gan Ca o), 6g each Fo rmula explanation: Si Wu Ta n g is the basic and most important blood-nourishing p rescription in the Chinese medicine formul a ry. Sweet and warm, Shu Di enriches yin and nourishes the blood. Bai Sh a o a s t r i n g e s, nourishes the blood, emolliates the live r, and re l a xes tension. Dang Gu i enriches the blood but also gently quickens the blood. C h u a n X i o n g m oves the qi of the blood and thus quickens the blood. It also supplements the b l o o d. These four medicinals combine to p owe rfully nourish and supplement the blood but also move the blood. Hence, blood is supplemented without engendering stagnation, and stagnation is re s o l ved without damaging the blood. These four medicinals are then assisted by what is sometimes re f e r red to as the single medicinal which functions like Si Wu Ta n g, Dan Sh e n. It is said to do so because it quickens the blood at the same time as it supplements it. Howe ve r, it quickens blood more strongly than it supplements it. It especially quickens the blood in the h e a rt vessels. It is also, much unlike Si Wu Tang as a whole, cool in nature. In this combination, this is beneficial and keeps the formula from becoming too warm. Suan Za o Re n assists in supplementing the blood. It p a rticularly supplements liver blood and also quiets the spirit. Long Yan Ro u f o rtifies the middle and nourishes heart blood. Only if the spleen is supplemented can it supply cons t ru c t i ve qi to the heart for transformation of the blood. Its spleen-fortifying function is assisted by mix-fried Gan Ca o. In addition, Gan Ca o has an empirical anti-arrhythmic function and also harmonizes all the other i n g redients in this formula. Additions & subtractions: For seve re palpitations, add 12 grams each of calcined Os Dr a c o n i s (Long Gu) and calcined Concha Os t reae (Mu Li). For insomnia, add 12 grams of Caulis Po l y g o n i Multiflori (Ye Jiao Te n g) and nine grams of Semen Biotae Orientalis (Bai Zi Re n). Fo r i m p a i red memory, add six grams of Rhizo m a Acori Graminei (Shi Chang Pu) and 12 grams of Caulis Polygoni Multiflori (Ye Jiao Te n g). Gui Pi Ta n g ( R e t u rn the Spleen D e c o c t i o n ) Radix Astragali Membranacei (Huang Qi), 12g, Rhizoma Atractylodis Ma c ro c e p h a l a e (Bai Zhu), Radix Angelicae Sinensis (Dang Gui), Sclerotium Pararadicis Poriae Cocos (Fu Shen), mix-fried Radix Glycyrrhizae Uralensis (Gan Cao), and Radix Codonopsitis Pilosulae (Dang Sh e n), 9g each, Arillus Eu p h o r i a e Longanae (Long Yan Rou), stir-fried Semen Zizyphi Spinosae (Suan Zao Ren), and licoriceprocessed Radix Polygalae Tenuifoliae (Yuan Zhi), 6g each, Radix Auklandiae Lappae (Mu Xiang), 3g Fo rmula explanation: This prescription not only supplements the blood but also fort i f i e s the spleen. Hence, it is indicated if there is dual vacuity of the heart and spleen with fatigue, reduced food intake, loose stools, and abdominal distention. Within it, Dang Sh e n, Hu a n g Q i, Bai Zhu, and Gan Ca o f o rtify the center and boost the qi. In addition, Bai Zhu d r i e s

14 78 The Treatment of Cardiovascular Diseases with Chinese Medicine dampness and Gan Ca o has an empirical antiarrhythmic function. Huang Qi boosts the qi and upbears clear yang to the chest and heart. Suan Zao Ren and Dang Gu i supplement the blood to nourish the heart and live r. He a rt blood is further supplemented by Long Yan Ro u which fortifies the middle and nourishes the h e a rt. Only if the spleen is supplemented can it supply constru c t i ve qi to the heart for the transformation of blood. In addition, the combination of Suan Zao Ren, Long Yan Ro u, a n d Fu Shen quiets the spirit and calms the mind. Yuan Zhi adds to this combination of spiritquieting medicinals. It also re s o l ves depre s s i o n and transforms phlegm. Mu Xiangm oves the qi and pre vents the more stagnating and enriching medicinals in this prescription fro m o b s t ructing the middle. Gan Ca o also harmon i zes all the other ingredients in this formula. Suan Zao Ren Tang Jia Jian (Zizyphus Spinosa Decoction with Additions & Subtractions) stir-fried Semen Zizyphi Spinosae (Suan Za o Re n), 15g, Radix Albus Paeoniae Lactiflorae (Ba i Sh a o), mix-fried Radix Gl ycyrrhizae Ur a l e n s i s (Gan Ca o), and Sclerotium Pararadicis Po r i a e Cocos (Fu Sh e n), 9g each, Rhizoma Anemarrhenae Asphodeloidis (Zhi Mu) and Radix Ligustici Wallichii (Chuan Xiong), 6g each Formula explanation: This formula is for blood vacuity of the heart and liver. In addition to the above heart blood vacuity symptoms, there are dry, rough eyes, blurred vision, lusterless nails, and numbness of the extremities. Within this formula, Suan Zao Ren, Bai Shao, and Chuan Xiong nourish and supplement the blood. Sweet, neutral, and sour, Suan Zao Ren specifically enriches liver blood and also quiets the spirit. Sour, bitter, and cool, Bai Shao nourishes liver blood and astringes. Acrid, warm Chuan Xiongmoves the qi and blood. Bitter and cold, Zhi Mu enriches yin and clears vacuity heat. Sweet, bland, and neutral, Fu Shen gently supplements the spleen and percolates dampness. Fu rt h e r m o re, it combines with Suan Zao Rento quiet the spirit. Sweet and warm, mix-fried Gan Cao boosts the heart and middle qi and regulates irregular heart rhythm. In addition, Gan Cao harmonizes all the other ingredients in this formula. Additions & subtractions For severe liver blood vacuity with eye or gynecological problems, add nine grams each of Radix Angelicae Sinensis (Dang Gu i) and cooked Radix Rehmanniae Glutinosae (Shu Di). For severe heart palpitations, add nine grams each of Arillus Euphoriae Longanae (Long Yan Rou) and Semen Biotae Orientalis (Bai Zi Ren) and six grams of Radix Salviae Miltiorrhizae (Dan Shen). Acumoxa therapy: Xin Shu (Bl 15), Ge Shu (Bl 17), Pi Shu (Bl 20), Zu San Li (St 36), Nei Guan (Per 6) Additions & subtractions: For impaire d memory, add Si Shen Cong (N-HN-1). For reduced food intake, add Zhong Wan (CV 12). For dizziness, add Gan Shu (Bl 18). For a red tongue and sore throat, add Da Ling (Per 7). For profuse dreaming, add Shen Men (Ht 7). For liver blood vacuity, add Gan Shu (Bl 18). For tremors, add Tai Chong (Liv 3) and San Yin Jiao (Sp 6). For scanty menstruation which is pale in color, add San Yin Jiao (Sp 6). For amenorrhea, add Zhong Ji (CV 3) and Gui Lai (St 29). For night sweats and seminal emission, add Fu Liu (Ki 7) to nourish liver-kidney yin. 5. Qi & yin dual vacuity pattern Main symptoms: He a rt palpitations and racing h e a rt, dull red cheeks, possible hacking of bloody phlegm, chest oppression, shortness of bre a t h, fatigue, a lusterless facial complexion, spontaneous perspiration, a red tongue with re d u c e d f u r, and a fine, rapid or fine, bound pulse