Angina pectoris (angina for short) refers to tightness and suffocating pain in the chest and dyspnea. In mild cases, there may be only chest tightness with dyspnea. In severe cases, chest pain penetrates to the back, back pain penetrates to the chest, and the dyspnea is accompanied by orthopnea (inability to breathe except in an upright position).
Etiology and Pathology
In angina pectoris the main pathogenic agents are Yin-Cold and turbid Phlegm. Its primary location of illness is the heart; but the liver, the spleen and the kidney may also be involved. The pathology is that of chronic deficiency of chest-Yang complicated by opportunistic attack by pathogenic evils of Yin and cold nature, which results in blockage and stagnation of chest-Yang and disharmony of the meridians. The causes of the chronic deficiency of chest-Yang are often closely related to the body’s constitution, old age and the aftermath of illnesses. The precipitating agents may be exogenous Cold, intemperate diet, excessive brooding, or habitual lack of physical activity.
Angina often results from attack by exogenous Cold evil in a patient with chronic deficiency of heart-Qi or ineffective heart-Yang. Exogenous Cold gels inside the chest and prevents chest-Yang from acting, resulting in blockage of the heart vessels and sudden appearance of angina.
Anxiety, brooding rage and fright can impede the movement of heart and lung Qi, leading to impaired circulation of blood. This can also lead to angina. When there is excessive brooding, spleen insufficiency or Qi stagnation, turbid Phlegm can easily form; and turbid Phlegm contributes to the blockage of chest-Yang.
A diet rich in spices and fats or irregular satiation and hunger, if continued for a long time, can injure the spleen and the stomach, disrupting digestion, transportation and transformation. The essence from the foods and drinks cannot be efficiently extracted and cannot support the generation of Qi and blood. In such circumstances, Dampness can accumulate and transform into Phlegm. Dampness and Phlegm can attack upward and invade the clear and hollow areas of the heart and the chest, so that Qi movement is disrupted and the heart vessels obstructed. Angina develops as a result. If turbid Phlegm persists for a long time, the condition may become one of intermixing of Phlegm and static blood. In that case, the illness becomes difficult to treat.
Chronic fatigue, internal injury or prolonged illness can all impair the functions of the spleen and the stomach and lead to their insufficiency. Qi and blood then lose the source of their generation and become deficient in the visceral organs. Similarly, if there has been significant blood loss, the blood vessels become depleted of blood and the heart also loses its nourishment. Deficiency of heart-Qi in turn leads to deficiency of heart-Yang. Deficiency of both Yang and Qi in the heart deprives the heart of its motive force, causing failure of Yang action and impeding Qi and blood circulation. Angina then results.
In the elderly, the body constitution may become weak or there may be deficiency of both heart-Yin and heart-Yang. After a long time this may affect the kidney. When kidney-Yang becomes deficient it fails to invigorate heart-Yang. Debility of heart-Yang leads to failure to warm the blood vessels, which then fail in their function of transportation. This can also lead to angina. At the same time, deficiency of kidney-Yin means failure of the Water Element to stimulate the Wood Element and inability to aid the heart. Fire then blazes in the heart and the liver, which can not only scorch the fluids and transform them into Phlegm, causing angina, but also can injure Yin-blood and disrupt the nourishment of the heart vessels. With both deficiency of heart-Yin and poor nourishment of the heart vessels, Heart-Fire flares up and injures kidney-Yin. Deficiency of heart and kidney Yang permits Yin-Cold and Phlegm-Rheum to occupy Yang’s place, causing obstruction of the heart vessels. This further aggravates angina.
In habitual physical inactivity the movement of Qi may become impaired, and this can lead to impaired activity of chest-Yang. This is the reason why obese persons beyond middle age are quite susceptible to angina.
Angina is characterized by suffocating pain in the chest. The pain characteristically appears suddenly, but may be intermittent. It is frequently accompanied by chest tightness, shortness of breath and palpitation of the heart. The heart pain is usually located in the precordial area, and may be suffocating, vague, stabbing, colicky or burning in quality. Sometimes the pain radiates to the shoulders, the back or the inner aspect of the left arm.
In mild cases, there may not be significant heart pain, but only chest tightness as though being suffocated, palpitation of the heart and anxiety. In severe cases, chest pain may penetrate to the back and back pain to the chest. It is intense and unrelenting. There may be accompanying sweating, cold limbs, pallid complexion, cyanotic lips and dusky hands and feet. In the gravest cases, angina may develop suddenly in the morning and result in death by evening, or begin in the evening and result in death by morning.
Key Points of Analysis
Quality of Pain. The chief characteristic of angina is suffocating pain in the chest. The quality of the pain may vary according to the relative degrees of deficiency and strength.
The most common syndrome is pain with an oppressive quality, with more oppression than pain and without a fixed location. The chest pain is usually accompanied by rib pain and distention and by frequent sighing. This is mainly due to Qi impedance.
If there is much sputum and salivary drool, pain that comes mostly during damp or overcast days, and tongue coating is greasy, it is mainly due to disturbance by turbid Phlegm.
If the chest pain is vague but suffocating, is precipitated by activity and is accompanied by shortness of breath and anxiety, it is mainly due to deficiency of heart-Qi.
If the pain is stabbing or cutting and has a fixed location, or is accompanied by a tongue that is cyanotic and has petechiae, it is mainly due to blood stasis.
If the pain is colicky and is precipitated by Cold, tends to be aggravated by exposure to cold temperatures and is accompanied by cold-intolerance and cold limbs, it is due mainly to gelling of Yin-Cold in the interior so that the heart vessels are obstructed by the gelled Cold.
If the pain is accompanied by symptoms of Yang deficiency, it is mainly due to strong Yin-Cold in the interior and occupying the place of Yang.
Deficiency versus Strength. Angina is principally a condition of root-deficiency and appearance-strength – that is, deficiency is the “root cause” and the “appearance” is largely that of the symptoms of strength. Therefore the first step in diagnosis is to ascertain what is deficient and what is strong, and what is root and what is appearance. In general, appearance-strength is primary during an attack while root-deficiency is primary during remission.
Appearance-strength is mostly Yin-Cold gelling in the interior, turbid Phlegm causing blockage, blood stasis with Qi impedance, or accumulated Phlegm blocking Qi movement. Root-deficiency is mostly deficiency of heart-Qi, deficiency of both Qi and Yin, deficiency of heart and kidney (and spleen) Yang, deficiency of liver and kidney Yin, deficiency of heart and kidney Yin, or Qi deficiency with Yang collapse.
Occasionally, root-deficiency and appearance-strength are equally prominent. This is mostly Qi deficiency with blood stasis, or Yang deficiency with turbid Phlegm.
Severity of Illness. The severity of angina can be assessed on the basis of several analyses. These include frequency of attack, the duration of each attack, the location of the pain and whether it is fixed or not, whether the symptoms are primarily of deficiency or of strength, and the overall duration of the course of illness.
The more frequent the attacks the more severe is the illness. Short duration of an attack indicates a mild illness and long duration a severe illness. Duration of several hours, even several days, indicates the most serious illness. Pain with a fixed location indicates a more severe illness and pain without a fixed location a milder illness.
If the main symptoms reflect strength the illness is relatively mild; if they reflect deficiency it is relatively severe. Recent onset indicates a relatively mild illness, but persistence indicates a relatively severe illness.
In general, to assess the severity of the condition, it is essential to analyze the symptoms of the entire body as well as the local symptoms in order to arrive at an accurate diagnosis.
The first decision the physician must make in the treatment of angina is whether to treat the root or the appearance first. In general, if the apparent symptoms are urgent it is acceptable to treat mainly the appearance; if not urgent then treat both the appearance and the root.
Blood Stasis and Qi Stagnation
Main Symptoms. Chest tightness as though being suffocated, and stabbing or intermittent colicky chest pain with fixed location. In severe cases, chest pain penetrating to the back and back pain penetrating to the chest, or pain radiating to the shoulders; and dusky hands and feet. The tongue is cyanotic or speckled with petechiae. The tongue coating is thin and white. The pulse is taut or shows missing beats.
Therapeutic Principle. Promote blood circulation to remove stasis and activate Qi to remove stagnation.
Treatment. Xue Fu Zhu Yu Tang (Decoction for Releasing Blood Stasis).
If the chest pain is especially severe, remove shengdihuang and niuxi and add jiangxiang (Dalbergia odorifera), yujin (Curcuma), yanhusuo (Corydalis) and danshen (Salvia) to mobilize blood and regulate Qi in order to stop the pain.
If blood stasis and Qi stagnation are equally severe, with strong chest pain, add chenxiang (Aquilaria), tanxiang (Santalum album), bibo (Piper longum) and other acrid and aromatic herbs to regulate Qi and stop pain. Also take sanQi power (Panax pseudoginseng) separately.
If cold-intolerance and cold limbs accompany the acute pain, add xixin (Asarum), guizhi or rougui (Cinnamomum), gaoliangjiang (Alpinia officinarum) and other herbs that warm meridians and disperse Cold.
If the patient sweats, has cold limbs and a pallid complexion, the pulse is threadlike and feeble and Yang-Qi is on the verge of collapse, treat immediately with Si Ni Tang with added renshen (Panax), longgu (fossil bone) and muli (Ostrea) to rescue Yang and reverse collapse. Alternately, administer renshen powder or Du Shen Tang (Lone Ginseng Decoction) and infuse a solution of Sheng Mai San (Pulse-Generating Powder) intravenously.
If chest tightness and pain are due to blood stasis and Qi stagnation complicated by Phlegm and Dampness, use Xuanfuhua Tang (Inula Decoction) augmented with yujin (Curcuma), danggui whiskers (Angelica), taoren (Prunus persica), honghua (Carthamus), guizhi (Cinnamomum), gualou (Trichosanthes) and xiebai (Allium).
Gelling of Yin-Cold in Interior
Main Symptoms. Chest tightness with shortness of breath and palpitation; or, chest pain penetrating to the back, aggravated by cold, and cold body and limbs. The tongue coating is white and smooth or white and greasy. The pulse is deep and slow.
Therapeutic Principle. Activate Yang with acrid and warm herbs, and release obstruction and disperse accumulations.
Treatment. Gualou Xiebai Baijiu Tang (Trichosanthes-Allium Wine Decoction). Its composition is as follows: gualou (Trichosanthes) 10 g, xiebai (Allium) 10 g, zhishi (Citrus aurantium) 10 g, guizhi (Cinnamomum) 10 g, processed fuzi (Aconitum) 10 g, danshen (Salvia) 15 g, and gancao (Glycyrrhiza) 5 g.
If the pain is especially acute, add xixin (Asarum).
If the pain is unrelenting and interpenetrates the chest and back, with cold body and limbs, orthopnea and a deep pulse that is tight or indistinct, the condition is due to extreme Yin-Cold. For such severe angina, add one pill of Suhexiang Wan (Storax pills) to be taken orally in order to resolve turbidity with fragrant herbs, and to warm, dredge and open the orifices to stop the pain.
If the pain is intermittent, accompanied by chest tightness and a sensation of suffocation, and there are other concomitant symptoms of Dampness, the condition is due to Yang deficiency with Cold and Dampness lodging in the interior. Use Yiyi Fuzi San (Coix-Aconitum Powder) to warm and eliminate Cold-Dampness.
Obstruction by Turbid Phlegm
Main Symptoms. Chest tightness with the sensation of being suffocated, or pain penetrating to the back; shortness of breath with dyspnea; and cough producing much white viscid sputum. The tongue coating is dirty and greasy, and the pulse is soft and slow.
Therapeutic Principle. Activate Yang, purge the turbid and eliminate Phlegm.
Treatment. Gualou Xiebai Banxia Tang (Trichosanthes-Allium-Pinellia Decoction). It has the following composition: gualou (Trichosanthes) 10 g, xiebai (Allium) 10 g, prepared banxia (Pinellia) 10 g, chenpi (Citrus tangerina) 10 g, shichangpu (Acorus) 10 g, yujin (Curcuma) 10 g, ganjiang (Zingiber) 5 g, baidoukou (Amomum cardamomum) 5 g and gancao (Glycyrrhiza) 6 g.
For especially strong turbid Phlegm, with suffocating chest tightness and epigastric distention, add zhishi (Citrus aurantium) and houpo (Magnolia) to loosen the chest and suppress abnormally risen Qi.
If cough produces copious sputum, add xingren (Prunus armeniaca), chenpi (Citrus tangerina) and fuling (Poria).
If in addition the tongue coating is yellow and greasing, the sputum is yellow and the pulse is slippery and rapid, these indicate that turbid Phlegm has transformed into Heat. For treatment, remove guizhi and xiebai and add zhuru (Phyllostachys nigra), bile-treated nanxing (Arisaema consanguineum, erubescens), huangqin (Scutellaria), huanglian (Coptis) and tianzhuhuang (Bambusa textilis) to dissipate Phlegm and cool Heat.
If chest tightness with a suffocating sensation is especially prominent, accompanied by Qi stagnation, add jiegeng (Platycodon), zisu stem (Perilla), xiangfu (Cyperus) and meihua (Armeniaca mume).
If there is blood stasis as well, Phlegm and blood stasis can obstruct each other. In such an illness the tongue is dark purple or is speckled with petechiae. Treat with Gualou Xiebai Banxia Tang augmented with taoren (Prunus persica), honghua (Carthamus), danggui (Angelica), chuanxiong (Ligusticum), chishaoyao (Paeonia) and shudihuang (Rehmannia). Taoren and honghua act to remove stasis and mobilize blood, and the others to nourish and harmonize blood in order to unblock the meridians.
Deficiency of Heart and Kidney Yin
Main Symptoms. Cardiac pain or chest tightness; dizziness with tinnitus; fever with a dry mouth and restlessness; and lumbar aches. The tongue is red or dark purple, or speckled with petechiae. The pulse is threadlike and taut.
Therapeutic Principle. Nourish Yin, strengthen the kidney, promote blood circulation and unblock meridians.
Treatment. Zuo Gui Yin (kidney-Yin-Augmenting Drink). It has the following composition: shudihuang (Rehmannia) 15 g, gouqizi (Lycium) 10 g, shanzhuyu (Cornus) 10 g, danshen (Salvia) 10 g, fuling (Poria) 10 g, shanyao (Dioscorea) 15 g, wuweizi (Schisandra) 5 g and fried gancao (Glycyrrhiza) 6 g.
If insufficiency of the heart and the kidney is primary, with palpitation, shortness of breath, restlessness, insomnia and a threadlike and rapid pulse, add yuzhu (Polygonatum odoratum), huangjing (Polygonatum sibiricum), maimen-dong (Ophiopogon), wuweizi (Schisandra), baiziren (Biota), suanzaoren (Ziziphus), longgu (fossil bone) and muli (Ostrea).
If Yin is deficiency and Yang hyperactive, so that Yang and Wind attack upward and give rise to such symptoms as dizziness, headache, blurred vision, numbness in the tongue and limbs, feverish face or flushed face and eyes, and a taut pulse, use Lingjiao Gouteng Tang. Depending on the clinical circumstances tianma (Gastrodia), chouwutong (Clerodendron trichotomum), mudanpi (Paeonia suffruticosa), xiakucao (Prunella) and shijueming (Haliotis) may be added.
Deficiency of Both Qi and Yin
Main Symptoms. Chest tightness or intermittent cardiac pain; palpitation, shortness of breath; dizziness, weakness; insomnia; and lusterless complexion. The sides of the tongue are red or dentate, or there may be petechiae. The pulse is threadlike or hesitant and intermittent.
Therapeutic Principle. Augment Qi, nourish Yin, promote blood circulation and unblock meridians.
Treatment. Combined Sheng Mai San and Gui Pi Tang.
If Yin deficiency is relatively more severe, add yuzhu (Polygonatum odoratum), shengdihuang (Rehmannia) and heshouwu (Polygonum).
If Qi deficiency is relatively more severe, with spontaneous sweating, anorexia, loose feces and malaise, remove maimendong and danggui and add baizhu (Atractylodes) and shanyao (Dioscorea).
If heart pain and cyanotic tongue are prominent, add danshen (Salvia), chishaoyao (Paeonia), yujin (Curcuma), honghua (Carthamus) and sanQi powder (Panax pseudoginseng).
If the pulse is hesitant, slow and regularly intermittent, use Zhi Gancao Tang instead.
Deficiency of Yang-Qi
Main Symptoms. Chest tightness or intermittent heart pain, palpitation; shortness of breath or rapid breathing; lumbar aches; cold-aversion, cold limbs; and a pallid complexion, with pale lips and nail beds. The tongue is blue purple or dusky purple, or pale with a white coating. The pulse is deep and threadlike or hesitant and intermittent.
Therapeutic Principle. Augment Qi, warm Yang, promote blood circulation and unblock meridians.
Treatment. Shen Fu Tang (Ginseng-Aconitum Decoction) combined with Guizhi Qu Shaoyao Tang (Cinnamomum Without Paeonia Decoction). The combined formulas has the following composition: red renshen (Panax) 5g, processed fuzi (Aconitum) 10 g, rougui (Cinnamomum) 10 g, duzhong (Eucommia) 10 g, shanzhuyu (Cornus) 10 g, ganjiang (Zingiber) 6 g and fried gancao (Glycyrrhiza) 6 g. The red renshen should be decocted alone, and the rougui decocted after the rest.
If kidney-Yang is more severely deficient, causing nocturia and spermatorrhea, add kidney-warming herbs such as suoyang (Cynomorium songaricum), lujiao slices (Cervus nippon) and bajitian (Morinda).
If heart-Yang is more severely deficient, causing a hesitant and intermittent or slow and even pulse, increase the amount of renshen and gancao and add xixin (Asarum).
If deficient kidney-Yang is unable to control water, so that Rheum overflows and affects the heart, causing dyspnea, palpitation and edema, use Zhen Wu Tang with added fangji (Stephania), zhuling (Polyporus) and cheqianzi (Plantago) to warm Yang and excrete water.
Heart-Yang on Verge of Collapse
Main Symptoms. All four limbs cold; cold sweat; severe palpitation and dyspnea; dull or confused mental state; and dusky complexion, with cyanotic lips and nail beds. The pulse is deep, indistinct and on the verge of disappearing.
Therapeutic Principle. Rescue Yang, reverse collapse, augment Qi and restore the pulse.
Treatment. Combined Si Ni Tang (Frigid-Extremities Decoction), Shen Fu Tang (Ginseng-Aconitum Decoction) and Sheng Mai San (Pulse-Generating Powder).
If the condition is particularly urgent, administer red renshen powder in water, or Du Shen Tang (Lone Ginseng Decoction).
If palpitation and neurasthenia are prominent, add longgu (fossil bone) and muli (Ostrea).
If the condition is critical, with orthopnea, cold sweat on the limbs and cyanosis, increase the amounts of renshen and fuzi.
Qi Deficiency and Blood Stasis
Main Symptoms. Chest tightness, heart pain, palpitation; shortness of breath; spontaneous sweating; and fatigue. The pulse is threadlike and even or hesitant and intermittent.
Therapeutic Principle. Augment Qi and mobilize blood.
Treatment. Renshen Yang Ying Tang (Ginseng Nutritive-Supporting Decoction) combined with Tao Hong Si Wu Tang (Prunus-Peony Four-Ingredient Decoction). The combined composition is as follows: dangshen (Codonopsis) 15 g, huangqi (Astragalus) 15, danggui (Angelica) 10 g, shudihuang (Rehmannia) 10 g, taoren (Prunus persica) 10 g, chuanxiong (Ligusticum) 10 g, chishaoyao (Paeonia) 10 g, baizhu (Atractylodes) 10 g, chenpi (Citrus tangerina) 10 g, fuling (Poria) 10 g, honghua (Carthamus) 6 g, shengjiang (Zingiber) 5 g, dazao (Ziziphus) five pieces, and fried gancao (Glycyrrhiza) 6 g.
If Qi deficiency is relatively more severe, change dangshen to renshen powder (taken separately) and increase the amount of huangqi.
If chest pain is especially severe, add rougui (Cinnamomum), danshen (Salvia), sanQi powder (Panaxpseudoginseng) and yanhusuo (Corydalis).
If Yin is deficient as well, add yuzhu (Polygonatum) and maimendong (Ophiopogon).
If there is turbid Phlegm as well, add gualou (Trichosanthes), xiebai (Allium macrostemon), processed banxia (Pinellia) and shichangpu (Acorus).
In the acupuncture treatment of angina pectoris, the main acupoints selected are Xinshu (BL-15), Jueyinshu (BL-14), Juque (CV-14), Tanzhong (CV-17), Neiguan (PC-6), Tongli (HT-5), and Ximen (PC-4).
If the condition is due to obstruction by exogenous Cold evil, it is appropriate to apply moxibustion to Juque (CV-14) and Tanzhong (CV-17). Moxibustion may be applied to Guanyuan (CV-4) also.
If it is due to the accumulation of turbid Phlegm, add Fenglong (ST-40), Zusanli (ST-36) and Sanyinjiao (SP-6). Use filiform needles and apply the reducing method, retained the needles for 20 min.
Case Study 1
The patient was a 55-year old male. He had a history of hardening of the arteries and neurasthenia. His sleep was restless, and he had vague chest pains. At presentation he had chest tightness with a feeling of suffocation, difficulty with breathing, and dizziness with headache. On examination his tongue coating was white and his pulse threadlike and slippery.
Diagnosis. Angina pectoris due to turbid Phlegm causing blockage of chest-Yang.
Treatment and Course. Modified Gualou Xiebai Banxia Tang, with the following composition: gualou (Trichosanthes) 20 g, taizishen (Pseudostellaria heterophylla) 10 g, xiebai (Allium macrostemon) 10 g, processed banxia (Pinellia) 10 g, yujin (Curcuma) 10 g, guizhi (Cinnamomum) 5 g, chenpi (Citrus tangerina) 5 g and yuanzhi (Polygala) 5 g.
After five daily doses, chest tightness, difficulty with breathing and headache all diminished. The formula was continued until all symptoms resolved.
Case Study 2
The patient was an 81-year old male with a 15-year history of high blood pressure. For the past 8 years he was also diagnosed to have coronary artery disease. He presented with suffocating chest tightness, as though a heavy stone is pressing on his precordium. He also had intermittent colicky precordial pain, difficulty with breathing, and trance-like sleep at night from which he wakened with difficulty.
His pulse was slow and irregular, with an overall rate of 30 beats per minute. His tongue coating was a dirty white and greasy. His blood pressure was 150/100 mmHg.
Diagnosis. Angina pectoris due to gelling of turbid Yin inactivating heart-Yang, obstructing the meridians and impeding the movement of Qi and blood.
Therapeutic Principle. Activate Yang, eliminate the turbid, mobilize blood and open orifices.
Treatment and Course. The patient was prescribed a formula with the following composition: processed fuzi (Aconitum) 6 g, xiebai (Allium macrostemon) 10 g, alum-treated yujin (Curcuma) 10 g, taoren (Prunus persica) 10 g, honghua (Carthamus) 10 g, parched dangshen (Codonopsis) 12 g, gualou peel (Trichosanthes) 12 g, xingren (Prunus armeniaca) 12 g, guizhi (Cinnamomum) 5g, jiujiechangpu (Anemone altaica) 5 g and fried gancao (Glycyrrhiza) 5 g.
After three daily doses, the patient gained in spirit and chest felt less suffocating. Treatment was modified as follows. The processed fuzi in the formula was increased to 10 g. Sanqi powder was administered at the dosage of 1.5 g twice daily. After 20 daily treatment, chest tightness and suffocation were completely resolved and the pulse rate increased from 30 to 40 beats per minute. The greasiness of the tongue coating also resolved. The treatment, with modifications as appropriate for the changing status, was continued and the patient continued to show improvement.