In modern China, the two medical systems of Western allopathic medicine and traditional Chinese medicine (TCM) are integrated and operate side by side. Many conventional allopathic doctors now recognize that a combination of Western therapy and TCM has shown better results in improving overall health in patients with cardiovascular conditions than have drugs or surgery alone. Use of traditional Chinese medicine has led to a reduction in total mortality, an increase in the therapeutic effectiveness of drugs, and a decrease in severity of drug side effects, as well as an improvement in quality of life (as a result of smoking cessation, weight control, diet modification, exercise, etc).
Numerous studies have shown that traditional Chinese medicine significantly helps patients with cardiac insufficiency, hyperlipidemia, hypertension, pericarditis, angina pectoris, tachycardia, atherosclerosis, congestive heart failure, and other circulatory conditions. One or more of the following changes have been reported: improved blood circulation, increased oxygen flow and intake, decreased edema and fluid accumulation in tissues, greater cardiac muscle strength, decreased myocardial hypertrophy or enlargement, decreased blockage in arteries, regulation of heart rhythm, lower serum cholesterol and triglycerides, and normal or near normal blood pressure. In holistic medicine and TCM, these effects are described differently: improved qi and blood flow; decrease in blood stasis and qi stagnation; decreased stagnation of cold in the chest; decreased phlegm, fluid, and damp accumulation; supplemented and nourished heart yin; strengthened heart qi; draining of heart fire; harmonized heart connections to other organs (not just anatomically speaking) such as kidneys, lung, pericardium, spleen, gallbladder, and small intestine; and reinforced and invigorated heart yang.
Traditional Chinese medicine has shown promise in surgical patients following coronary bypass, stent, or angioplasty by decreasing pain and promoting relaxation, thus allowing a faster recovery. Additionally, TCM can help relieve many of the adverse effects of cardiovascular drugs. The adverse effects from drugs most commonly seen in our clinic are fatigue, lowered libido, drowsiness, muscle weakness and numbness, liver damage from cholesterol/lipid-lowering drugs, nutritional disturbance and general asthenia from diuretics, headache, dizziness, constipation from calcium channel blockers, rash, gastrointestinal disturbances, and insomnia from antiarrhythmic drugs. Switching drugs may or may not stop these effects. However, adverse effects can become an everyday nuisance to patients, which ultimately decreases compliance to pharmacotherapy.
Physiology and Pathologies of the Heart According to traditional Chinese medicine
In traditional Chinese medicine, the emphasis is placed on a holistic landscape with a mind, body, and spirit interconnection. The Xin, or heart, in TCM is not equal to the heart in Western medicine. The physiological functions of the heart extend beyond those of its anatomical structure. In the ancient Chinese text on internal medicine Nei Jing, the heart is considered the “king” or “monarch” of the body. It is the most important of all the internal organs and is described as the “ruler” of the internal organs. The Nei Jing says, “All the blood is under the control of the heart … the heart governs the blood and the blood vessels, and dominates blood circulation …the blood current flows continuously in a circle and never stops.” These medical thoughts were documented in Chinese texts thousands of years before William Harvey (1573-1657) described the theory of blood circulation.
The above physiological functions are the same as in Western medicine. However, in traditional Chinese medicine the heart has a number of additional interdependent functions.
Heart Qi
Refers to the energetic forces of the heart, and it is this qi that makes the blood flow. Heart qi is the driving force of the heart’s strength, rate, and rhythm and keeps it beating. According to a Chinese medical text, Simple Questions, “If heart qi is strong, the blood vessels will be in a good state and the pulse will be full and regular.”
Heart Yin
Refers to the vital essence and material structures of the heart, including the heart blood. The heart yin is the calming, passive aspect and is the opposite of heart yang. However, it counterbalances the heart yang to ensure proper heart function.
Refers not only to the western meaning of blood but includes nutrition and nourishment. The outward manifestation of this is the face, particularly the complexion. The heart distributes blood to the entire body, especially to the face, since the face is rich in blood vessels. As mentioned in Nei Jing, “If the heart blood is abundant, the face will have a normal reddish (rosy) complexion and will be moist and bright. If the heart blood is insufficient, the face will be pale and without luster. If the heart blood is stagnant and blocked, the face may be purplish with blue lips.”
Heart Yang
Refers to its vital and dynamic function, the lively and expansive aspect of the heart which includes the heart qi. Heart yang complements heart yin and leads to a healthy heart. Heart yang is prone to coldness, especially in the elderly, and explains why elderly cardiac patients tend not to do well in colder climates. External cold can invade the chest, obstructing the circulation of yang. Patients with weak hearts are more likely to experience cold invading the body and causing chest pain. It is said in another Chinese medical text titled Methods and Rules of Medicine that “In chest obstruction pain of the heart region is caused by yang deficiency and invasion of cold.”
Other Functions of the Heart
Heart opens into the tongue
The tongue is considered to be the “offshoot, sprout, or window” of the heart. The heart controls the color, body, and appearance of the tongue since the tongue is closely related to heart qi and heart blood. This means that if there are pathologies of the heart, they are sometimes discernible in the tongue. In clinical practice, the tongue is a more accurate diagnostic tool than the complexion in women. Most women wear some form of face makeup when they come for an office visit. According to traditional Chinese medicine, the condition of the heart also affects the taste and the speech. Abnormalities of the heart may cause talking excessively, laughing inappropriately, stuttering, or speaking difficulties.
Heart houses the mind and stores the spirit (Shen)
The ancient text Spiritual Axis states, “The heart is the Monarch of the five yin organs and the six yang organs and it is the residence of the Mind….” It is said that the brain controls intelligence and memory, but it is the heart that reflects the inner consciousness, emotions, and the spiritual aspects of a human being. If one’s heart functions normally, then there will be healthy consciousness and sound mental activities. On the other hand, if the heart is diseased, there is a tendency for the Mind not to be rooted and the Shen or spirit is disturbed; then there will be mental restlessness, depression, anxiety, and insomnia and/or disturbed sleep and excessive dreaming.
There is a Chinese phrase known as Jing Shen which I use quite often when teaching at colleges. It is translated as vitality (Jing) and spirit (Shen). I have joked in the classroom that a student with good Jing Shen is alert, energetic, and enthusiastic and has a bright complexion and a twinkle in his/her eyes. This student has the heart for learning.
Heart is related to joy in human emotion
Joy or happiness is beneficial to the heart and improves blood flow. Joy makes the heart qi harmonize, leading to the proper nourishment by the blood to the heart muscles. But if a person is overjoyed, manic, or overly excited, the heart is excessively stimulated. This type of damage to the heart due to an impairment of heart spirit is seen with addicts who take recreational drugs. Similarly, overexcitement can trigger chest pains in a heart attack victim.
Heart meridian and channel system
A text on acupuncture used at the Shanghai College of Traditional Chinese Medicine states that the heart “channel begins in its associated organ, the heart, then emerges through the blood vessel system surrounding the heart, and travels downward across the diaphragm where it connects with the small intestine. A branch of the channel separates the heart and ascends alongside the esophagus to the face where it joins the tissues surrounding the eye. Another branch goes directly from the heart to the lung, then slants downward to emerge below the axilla. From here, the channel descends along the medial border of the anterior aspect of the upper arm, behind the lung and pericardium channels, to the antecubital fossa, where it continues downward to the capitate bone proximal to the palm. It then enters the palm and follows the medial side of the little finger to the finger tip.”
The heart meridian is directly joined to the lungs, small intestine, and kidneys. An example of pathology of heart and lung is congestive heart failure (CHF). The lungs, according to traditional Chinese medicine, are responsible not only for respiration but also for dispersing and descending water and other functions of water/fluid metabolism. In CHF, there is inadequate pumping of the heart due to fluid buildup in the lungs and edema in other tissues. Examples of pathology of the heart and small intestine are intestinal and urinary disorders that can arise from a stressful heart. In my clinical experience, patients often complain about constipation or urinary frequencies after their coronary bypass or angioplasty operations compared to other types of surgery. An example of pathology of heart and kidneys is harder to explain. The TCM concept is that the kidneys are the basic constitution or gate of vitality and the motivating force of all functional activities of the internal organs. When the kidney is weak due to overwork, late nights, inadequate sleep, excessive drug use, frequent pregnancy, febrile illness, bad diet, etc, it cannot support the heart yin. Because of the imbalance, the yin of the kidney is not able to nourish the heart, causing the heart to be stressed and agitated (heart fire). This leads to added pressure to the systemic arterial blood circuit, as in the case of hypertension.
The following two case studies explore treatment strategies in traditional Chinese medicine. Note that the following data are based on Oriental medical theories and reflect traditional Chinese medicine diagnosis and treatment.
Case study 1
Clinic: Center for Integrated Medicine, Visalia, California
Attending doctor: Dr. Kwong
Patient: Mrs. E. is a 48-year-old high school teacher. Ht: 5’8″, Wt: 140 lb
Chief complaints: Dizziness, vertigo, high blood pressure
Medical history: A relatively healthy female with no history of heart, cholesterol, or other circulatory problems was referred by one of her fellow teachers to our clinic. Approximately two months ago, she began to experience daily dizzy spells, chest stuffiness, and frontal headaches. She went to her allopathic physician (Dr. M.) a week later, and he determined that her blood pressure at that time was 165/101. He gave her samples of a blood pressure medication (she did not tell us the specific name). Mrs. E. made a decision not to take the drug. According to Mrs. E., “I was in the doctor’s office no more than seven minutes and he proceeded to write me a prescription and give me a drug. I don’t want anything just to cover my symptom like a bandage. I am more interested in treating the whole body and getting to the root of the problem.”
History of present illness: Patient admits to being under extreme stress the last three months. She was suddenly responsible for her baby granddaughter, whom her drug-addicted son had abandoned. This had drained her both financially and emotionally.
Subjective findings: Her symptoms were fullness/stuffiness of the chest, dizziness, vertigo, distending pain of the head and eyes, disturbed sleep (tossing and turning), night sweat, irritability, dark urine, and sweating palms and feet.
Objective findings: Both arms had wiry and slightly rapid pulse in cun, guan, and chi positions. Tongue showed a red body with red tip, midline vertical crack, and dark engorgement underneath. Eyes were slightly bloodshot. Complexion had a mallor flush. High blood pressure, taken twice in our office (159/100 and one hour later, 156/100). Soreness, tightness, and pain on acupressure points upon palpation of the neck and shoulder, with pain partially relieved upon pressure. Palpation of the abdomen indicated tightness on left side. Other findings were normal.
Western allopathic diagnosis:
1. High blood pressure
2. Essential hypertension
TCM holistic diagnosis:
1. Heart and kidney disharmony
2. Liver yang rising
3. Upward disturbance of liver wind
Treatment plan:
1. Acupuncture twice a week and reevaluate in two weeks. Needle with draining technique. Acupuncture prescription consisted of the following acupoints:
• Nei guan (Pericardium6) located 2 cun above the transverse crease of the wrist, between the tendons m. palmaris longus and m. flexor radialis. I punctured perpendicularly 0.5 to 0.8 inch.
• Shen men (Heart7) located at the ulnar end of the transverse crease of the wrist, in the depression on the radial side of the tendon m. flexor carpi ulnaris. Needle punctured perpendicularly 0.3 to 0.5 inch.
• Feng chi (gallbladder20) located in the depression between the upper portion of m. sternocleidomastoideus and m. trapezius directly below the external occipital protuberance. I angled needle towards nose and punctured 0.5 to 1 inch.
• San yin jiao (spleen6) located 3 cun directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibia. Punctured perpendicularly 1 inch.
• Tai xi (kidney3) located in the depression between the medical malleolus and tendo calcaneus at the level with the tip of the medical malleolus. Punctured perpendicularly 0.5 inch.
• Xing jian (liver2) located on the dorsum of the foot between the first and second toes, proximal to the margin of the web. I punctured obliquely 0.3 to 0.5 inch.
• Yintang located midway between the medial ends of the two eyebrows under the glabella. Punctured subcutaneously downward 0.3 to 0.5 inch.
• Qu chi (large intest.11) located when elbow is flexed, in the point at the lateral end of the transverse cubital crease, midway between the radial side of crease and lateral epicondyle of the humerus. I punctured perpendicularly 1 to 1.5 inch.
2. Herbal tea with two doses daily (1 cup PO bid). Modification of the classical prescription Tianma Gouteng yin which consisted of the following herbs: tian ma (3 qian); gou teng (4 qian); zhu ru (3 qian); zhi zi (3 qian); chi shao (3 qian); sang ji sheng (4 qian); fu ling (3 qian); dan shen (4 qian); mu li (5 qian); mudan pi (3 qian); gui ban (5 qian); and xiaku cao (3 qian).
3. Chinese culinary recipes were given along with nutritional guidelines to decrease blood pressure.
4. Auricular herb seed in acupoint, shenmen twice a week.
5. Tai chi and qigong exercises to decrease emotional stress. I recommended these exercises be done daily, but patient was not motivated and did not adhere to the exercise and meditation.
6. Other guidelines: Patient is to take blood pressure readings several times daily and bring her chart to each office visit for evaluation.
Progress notes after two weeks: Her average daily blood pressure was 142/96. She had fewer headaches and only three episodes of dizziness and vertigo. Her chest fullness lessened in intensity, and there was an improvement in sleep. All other symptoms remained the same. We used the same treatment protocol for the next two weeks.
Progress notes after one month: Mrs. E.’s average daily blood pressure was 138/89. A full follow-up evaluation was done at this time. Pulse condition was slippery, wiry in all three positions of her left and right arm. Tongue body was red, and had cracks with no coat. Eyes and complexion were clear. There was less pain upon palpation of shoulder and abdomen. Urine was clear and her overall disposition was improved. I decreased the dosage of the herbal prescription but kept her acupuncture and food therapy at the same level.
Progress notes after two months: Patient was compliant with treatment program. Her average daily blood pressure was 133/82. We tapered her office visits to once a week. Overall, this patient has improved remarkably, and she was switched to herbal pills for blood pressure maintenance. I also instructed her to continue to pay attention to her diet and find ways to relieve her stress. We will follow up in one month. At that time I will refer her to an allopathic physician (not her previous MD) for physical examination.
Angina Pectoris and traditional Chinese medicine
A study in Denmark in 1996 found that the combination of acupuncture, shiatsu and lifestyle changes was helpful in the treatment of patients with angina pectoris. Sixty-nine patients with severe angina pectoris were followed for two years during their treatment period. Forty-nine of these patients were candidates for coronary artery bypass grafting. Treatment with these elements of TCM led to one third fewer deaths in these patients compared to a similar group of patients. Invasive treatment was postponed in 61% of the study patients due to clinical improvement, and there was a reduction of 90% in the annual number of in-hospital days. The researchers concluded that, “The combined treatment with acupuncture, shiatsu, and lifestyle adjustment may be highly cost effective for patients with advanced angina pectoris.”
According to Soren Ballegaard, Director of the Acupuncture Center in Denmark, and lead investigator in the study reported above, there are potential gains to be made when Western medicine is integrated with traditional Chinese medicine. “Within the framework of Western medicine, intervention occurs in the case of disruption, and little emphasis is placed on prevention. By contrast, the overall purpose of traditional Chinese medicine is a life in balance with nature. Traditional Chinese doctors are paid according to their ability to help patients stay healthy. The focus of health care should be on preventive methods, such as diet and exercise.”
Case study 2
Clinic: Center for Integrated Medicine, Hanford, California
Attending doctor: Frank Robbins, LAc
Patient: Mr. R. is a 52-year-old air-conditioning mechanic. Ht: 6’0″, Wt: 220 lb
Chief complaint: High cholesterol
Medical history: Mr. R. has multiple health problems, which are degenerative disk of neck and lower back, hypertension for 15 years, mild arthrosclerosis, sinus allergies, tension headaches (4x/week), and smoked for 30 years (stopped for five years). His drug profile indicates the following medications: Prinivil 20 mg, Soma 350 mg, Vioxx 50 mg, ASA, Flonase NS, and Allegra D. His last office visit to allopathic doctor resulted in a lab test, which included a lipid panel. The following are his results:
• Triglycerides: 129
• Cholesterol: 232
• HDL: 40
• LDL: 166.5
• Chol/HDL ratio: 5.8 (average risk)
His allopathic doctor said he needed to be put on a cholesterol-lowering drug. Mr. R. has some reservation about adding another drug to his regimen. He said that drugs may control his diseases but have done nothing to cure him. Instead they led to fatigue and numbness in his upper extremities; therefore, he decided to try alternative/complementary medicine. Besides this, he was worried about the side effects of a cholesterol-lowering drug. We mentioned that the new-generation drugs may have fewer side effects. Anyhow, he was not satisfied with our answer.
Objective findings: Tongue: thin body with white coat; pulse: thin, weak, slippery; complexion: pale; sweat: spontaneous; diet: poor.
All other TCM systems were normal.
Western allopathic diagnosis:
1. High cholesterol
2. Mild arthrosclerosis
TCM holistic diagnosis:
1. Damp and phlegm accumulation in blood
2. Qi deficiency with blood stasis
3. Kidney yang deficiency
Treatment plan:
1. Herbal medicine prescription consisted of the following herbs: shan zha, gou qi zi, ju hua, ji nei jin, yi mu cao, ze xie, dang gui, chuan xiong, jue ming zi, he shou wu, and hong hua. All were 1.5 qian in strength except for hong hua 0.5 qian to be prepared in tea form.
2. Acupuncture prescription: fenglong (st40), qihai (sp10), zusanli (st36), ren9 (st25).
3. Diet therapy: We recommended that he keep a food diary, and we instructed him on correcting his eating habits. In addition, we gave him Chinese herbal soups to help him lose weight and to lower his cholesterol levels.
4. Daily taoyin exercises that included stretching and walking.
Follow-up: Mr. R. went back to his allopathic physician four months later for another lipid panel. Here are the data: triglycerides, 95; cholesterol total, 179; HDL cholesterol, 55; LDL cholesterol, 107; cholesterol/HDL ratio of 3.3 (less than the average risk).
After reviewing the results, his allopathic physician indicated that Mr. R.’s levels were excellent. Mr. R. now weighs 168 lb and is continuing to lose weight. His diet has also improved. We are now working to improve his back pain.
Clarifying the Treatment Points
1. An aspect of a traditional Chinese medicine physical examination is palpating the pulse on various positions on the wrist. Cun positions reflect the uppermost organ systems such as the heart and lung (the crown to the diaphragm). Guan positions reflect the middle part of the body such as the liver, stomach, and spleen (diaphragm to the navel) whereas the chi positions of the pulse reflect that of the lower part of the body as the kidney (navel to the feet). The nature of the imbalance in a patient’s condition/illness, the area, and the nature of the disease can be determined from the wrist pulse. In Western medicine the pulse reflects the heart’s rate and regularity. In TCM, the pulse reflects not just the heart but can assess the overall condition of the body: the depth, rate, strength, width, rhythm, and other qualities.
2. The dosage or strength of an herb is weighed out on the scale. 1 qian is approximately equal to 3.2 grams. The strength is usually written after the herb’s name (ie, hong hua 0.5 qian). In the herbal prescription, some herbs have a higher strength than others depending on the holistic diagnosis. I like to start with lower doses of certain herbs if patients are on a drug regimen so that it prevents any potential interactions.
3. Acupoints can be written two ways. The name of the acupoints, such as zusanli, or the number st36; st refers to the meridian (stomach in this case) and 36 refers to the 36th acupoint on that meridian. Number 36 means that it follows acupoint number 35 and falls between 35 and 37 along the meridian channel. Some meridians have few acupoints (9 acupoints in the heart meridian as in the diagram) whereas some meridians have many (the urinary bladder has 67 acupoints).
4. Herbal pills are usually used for maintenance therapy. These are small pills that look like the homeopathic remedies and are not taken as a tea. For those individuals who cannot swallow pills (eg, babies and small children) the pills are crushed or dissolved in water. Herbal pills come in a standard formulation and the ingredients cannot be modified. On the other hand, a tea from raw herbs (plant form) used in an herbal prescription is much easier to modify and can be easily changed/adjusted to suit the patient’s specific needs.
5. Chinese nutrition/foods/recipes vary depending on the traditional Chinese medicine diagnosis. Two cardiac patients with the same Western diagnosis may not have the same TCM diagnosis. So the herbs, acupuncture, and food prescription may be different for the two cardiac patients with the same Western diagnosis because their holistic diagnosis is not the same. In general, some foods that I recommend to help blood pressure are tomatoes, celery, shitake and other mushrooms, blueberries, cranberries, lotus root, seaweed, kelp, barley, and aduki beans.