Palpitation of the heart refers to the subjective sensation of the heart beating fast and vigorously, and its associated symptoms of anxiety and restlessness. Its severity and its cause both vary.
Etiology and Pathology
Palpitation occurs principally when the body’s constitution is weak, when stimulated by strong passions, or when certain exogenous pathogenic evils invade the body. A weak constitution may be due to its inherent weakness, chronic illness, various conditions of blood loss or excessive fatigue, or excessive sexual activity. These conditions may lead to deficiency of Qi, blood, Yin or Yang, so that the heart loses its nourishment. The effects of the passions are mainly the result of prolonged brooding or fear, which depletes heart-Qi and makes it insecure. When heart-Qi is deficient and insecure, Yin-blood also becomes insufficient and unable to nourish the heart. Alternately, heart-Qi may become gelled, thereby allowing Phlegm to form and Fire to blaze. Disturbance of the heart by Phlegm and Fire leads to disturbance of the mind and palpitation of the heart. Certain illnesses of Heat or rheumatism due to exogenous evils may injure the heart channels or block the heart meridians and vessels. This causes stasis of heart-blood.
In addition to these three categories, palpitation of the heart can also occur when the patient overindulges in smoking, alcohol or greasy foods. Such overindulgence can also lead to the generation of endogenous Phlegm and Heat, which can in turn cause disturbance of the mind and palpitation of the heart.
Thus, though the heart is the principal organ affected in palpitation, the spleen and the kidney are often also intimately involved in the causation of palpitations.
Overall, the pathology of palpitations may be of deficiency or of strength. Deficiency type of palpitation includes deficiency of Qi, blood, Yin or Yang, which leads to the heart losing its nourishment; while strength type includes strength of Phlegm and Fire that disturb the heart, or heart-blood gelling and stagnating so that Qi and blood cannot circulation smoothly. Such deficiency and strength may be mixed, and one condition can transform into the other. If a condition of strength becomes prolonged it can damage genuine Qi and lead to its deficiency. And a condition of deficiency often enables attack by exogenous factors and concomitant symptoms. Moreover, in certain severe illnesses, deficiency of Qi or Yin can injure Yang so that heart-Yang becomes depleted, sometimes so severely that it collapses.
Palpitation is characterized by the subjective sensation of the heart beating rapidly, with anxiety, restlessness and the feeling of having lost control over oneself. It is often accompanied by shortness of breath, weakness, fatigue, and disinclination to speak.
During the attack there may be abnormalities of the pulse, so that palpation of the pulse is of exceedingly important significance during an attack. Depending on its cause palpitation may be associated with a pulse that is hurried, hesitant, intermittent, rapid, swift, impeded or threadlike. In some patients with more severe cases the beating of the heart may be so pronounced that it moves the clothing overlying the apex of the heart.
Palpitations may be intermittent or sustained. Depending upon the cause intermittent palpitations may occur once in several days or several times in 1 day. It may be quite intense during the attack but the patient may be without discomfort during remission. With sustained palpitation, on the other hand, the patient may be continually restless and anxious, with loss of self-control.
Key Points of Analysis
The causes of palpitation are complex, and its differential diagnosis is therefore also complex. Broadly speaking, the following are key.
First differentiate between strength and deficiency of the illness. In palpitation due to a deficiency state, differentiate between deficiency of Qi and blood of the zang organs and that of Yin-Yang. In strength type of palpitations, differentiate between Phlegm-Rheum, blood stasis and Fire. Palpitations most commonly occur in a deficiency state, but the symptoms often show a mixture of deficiency and strength. Hence in diagnosis attention must be paid to both and to their relative degrees.
The degree of deficiency of the genuine is affected by the degree of injury to the visceral organs. In general, if only one visceral organ is involved the palpitation tends to be mild, whereas if several visceral organs are involved it tends to be severe. The visceral organs are interrelated through several types of interactions. Heart illnesses can induce impairment or injury of the other zang-fu organs; similarly, illnesses of other organs can directly or indirectly affect the heart. In ordinary circumstances, if palpitation is due to only the heart itself being diseased it tends to be mild with few mixed symptoms. Clinically, the main symptoms are limited to palpitation, anxiety, chest tightness and insomnia. But if other organs are involved then additional symptoms become apparent. For example, if kidney-Yang or kidney-Yin is deficient, there may be such additional symptoms as aching pains in the waist, Yin-deficiency Cold, impotence, polyuria, cold limbs with cold-aversion and hotness in the palms and soles. If Liver-Fire is active or liver-Yin deficient, there may be dizziness, tinnitus, blurred vision, a bitter taste in the mouth, agitation and flank pains. If the spleen is insufficient, there may be nausea, epigastric distention, fatigue, weakness and a white and greasy tongue coating. In these more complex situations the condition is more severe.
Deficiency of Heart-Qi
Main Symptoms. Palpitation with shortness of breath; dizziness with weakness; and spontaneous sweating. Activity tends to aggravate while quiescence to ameliorate the palpitation. The tongue coating is thin and white and the tongue red. The pulse is threadlike and feeble.
Therapeutic Principle. Replenish heart-Qi.
Treatment. Modified Wuweizi Tang (Schisandra Decoction). Its composition is as follows: renshen (Panax) 15 g, huangqi (Astragalus) 15 g, wuweizi (Schisandra) 10 g, maimendong (Ophiopogon) 12 g and fried gancao (Glycyrrhiza) 6g.
If deficiency of heart-Qi progresses to deficiency of heart-Yang, with associated cold limbs and cold-aversion, use Bao Yuan Tang instead to augment heart-Qi and support heart-Yang.
If Yin deficiency has caused impairment of Qi and water movement so that Rheum accumulates beneath the heart, there may be shortness of breath, thirst without desire to drink and decreased urine output. In this case use Ling Gui Zhu Gan Tang (Poria-Cinnamomum-Atractylodes-Glycyrrhiza Decoction) to warm Yang, dissipate Rheum, strengthen the spleen and promote water movement. The composition of Ling Gui Zhu Gan Tang is as follows: fuling (Poria) 12 g, guizhi (Cinnamomum) 9 g, baizhu (Atractylodes) 9 g, and fried gancao (Glycyrrhiza) 6g.
Deficiency of Heart-Yin
Main Symptoms. Palpitation with fearfulness; restlessness with insomnia; thirst; mild fever; hotness in the five centers; and night sweats. The tongue is red with little moisture, and the pulse is threadlike and rapid.
Therapeutic Principle. Nourish Yin, generate blood and calm the heart and the mind.
Treatment. Tian Wang Bu Xin Dan or Zhusha An Shen Wan (Cinnabar Tranquilizer Pill). The composition of Zhusha An Shen Wan is as follows: shengdi-huang (Rehmannia) 20 g, xuanshen (Scrophularia) 15 g, danshen (Salvia) 15 g, danggui (Angelica) 10 g, wuweizi (Schisandra) 10 g, maimendong (Ophiopogon) 10 g, yuzhu (Polygonatum) 10 g, baiziren (Biota) 10 g, suanzaoren (Ziziphus) 10 g, cishi (magnetite) 25 g, zhenzhumu (Pteria magaritifera) 25 g, and fried gancao (Glycyrrhiza) 6g. Hence it has a different composition.)
Both formulas are designed to nourish Yin, generate blood and calm the heart and the mind. Tian Wang Bu Xin Dan is stronger in restoration and weaker in calming the heart and the mind; it is more suitable for treating deficiency of heart-Qi or Yin deficiency with fever. Zhusha An Shen Wan is stronger in calming the heart and the mind and is relatively weak in restoration; it is more suitable when Yin deficiency is mild but Heart-Fire is blazing.
If heart-Yin and kidney-Yin are both deficient, with stirring of deficiency-Fire and spermatorrhea, add guiban (Chinemys), huangbai (Phellodendron) and zhimu (Anemarrhena) as appropriate.
If restlessness and dizziness are prominent, add baishaoyao (Paeonia), heshouwu (Polygonum) and gouqizi (Lycium).
Insufficiency of Both Heart and Spleen
Main Symptoms. Palpitation; shortness of breath; dizziness; lusterless complexion; lassitude and weakness; and abdominal distention with anorexia. The tongue is red and the pulse threadlike and feeble.
Therapeutic Principle. Strengthen the spleen, nourish the heart and replenish Qi and blood.
Treatment. Gui Pi Tang (Spleen-Restoring Decoction).
However, if heart-blood is insufficient and heart-Qi deficient, giving rise to palpitation with a hesitant and intermittent pulse, use Zhi Gancao Tang to augment Qi, generate blood, nourish Yin and restore the pulse.
Yin Deficiency of Liver and Kidney
Main Symptoms. Palpitation; insomnia; hotness in the five centers; dizziness with tinnitus; irascibility; and spermatorrhea with lumbago. The tongue is red with slight moisture, and the pulse is rapid.
Therapeutic Principle. Nourish the liver and the kidney, and nourish the heart to calm the mind.
Treatment. Yi Guan Jian combined with Suanzaoren Tang. Using these two formulas together can achieve the effect of nourishing both the liver and the kidney, generating blood and tranquilizing the mind.
If there is constipation as well, add gualou seed (Trichosanthes) and increase the amount of shengdihuang.
For recurrent fever in Yin deficiency, with hotness in the palms and soles, add digupi (Lycium) and baiwei (Cynanchum atratum, versicolor).
If there is thirst as well, add shihu (Dendrobium) and yuzhu (Polygonatum).
In Yin deficiency of both the liver and the kidney, if deficiency-Fire blazes internally so that strong Fire disturbs the heart and the liver and produces such symptoms as agitation, irascibility and a red tongue, add huanglian (Coptis) and zhizi (Gardenia jasminoides) to clear the heart and purge Fire.
Yang Deficiency of Spleen and Kidney
Main Symptoms. Palpitation; lassitude; shortness of breath with disinclination to speak; watery feces; abdominal distention with anorexia; lumbago; cold-aversion with cold limbs; and dysuria. The tongue is pale, with white and greasy coating, and the pulse is deep, threadlike and slow or hesitant and intermittent. (Note that the pulse may be objectively slow despite the subjective sensation of palpitation.)
Therapeutic Principle. Warm restoration of the spleen and the kidney; mobilization of water; and calming of the heart.
Treatment. Li Zhong Tang combined with Zhen Wu Tang. (Li Zhong Tang has the same composition as Li Zhong Wan, but prepared as a decoction.)
If urine output is reduced, with edema in the limbs, add zhuling (Polyporus), fangji (Stephania), dafupi (Areca catechu, peel) and tinglizi (Lepidium).
If water and Dampness accumulate in the middle-jiao, preventing stomach-Qi from descending normally and inducing nausea, vomiting and epigastric discomfort, add processed banxia (Pinellia) and chenpi (Citrus tangerina) to regulate Qi and lower the abnormally ascent.
Heart Insufficiency with Timidity
Main Symptoms. Palpitation; fearfulness; restlessness with fidgeting; fitful sleep with excessive dreaming; anorexia with nausea; and aversion to noise. The tongue and its coating are generally normal. The pulse is threadlike and somewhat rapid, or threadlike and taut.
Therapeutic Principle. Replenish Qi, nourish the heart, relieve convulsions and tranquilize the mind.
Treatment. An Shen Ding Zhi Wan (Mind-Calming Pill). Its composition is as follows: dangshen (Codonopsis) 12 g, wuweizi (Schisandra) 10 g, shanyao (Dioscorea) 10 g, fuling (Poria) 12 g, tianmendong (Asparagus chochinchinensis) 10 g, shudi-huang (Rehmannia) 10 g, suanzaoren ((Ziziphus) 10 g, longchi (fossil teeth) 20 g, cishi (magnetite) 20 g, shichangpu (Acorus) 10 g, yuanzhi (Polygala) 6 g and fried gancao (Glycyrrhiza) 5 g.
If there is spontaneous sweating as well, add fuxiaomai (Triticum), shanzhuyu (Cornus) and meihua (Armeniaca mume).
If heart deficiency is accompanied by blood stasis, add danshen (Salvia), taoren (Prunus persica) and honghua (Carthamus).
If heart insufficiency is accompanied by stagnation of heart-Qi, manifesting as palpitation, restlessness, depression and intermittent chest and subcostal distention and pain, add chaihu (Bupleurum), yujin (Curcuma), hehuanpi (Albizia julibrissin) and white wumei (Prunus mume).
Blockage by Retained Turbid Phlegm
Main Symptoms. Palpitation with shortness of breath; heart and chest tightness and distention; much sputum; and abdominal distention with anorexia or nausea. The tongue coating is white and greasy or smooth and greasy, and the pulse is taut and slippery.
Therapeutic Principle. Regulate Qi, dissipate Phlegm, calm the heart and tran-quilize the mind.
Treatment. Dao Tan Tang (Phlegm-Dissipating Decoction). Its composition is as follows: processed banxia (Pinellia) 10 g, bile-treated nanxing (Arisaema consanguineum, erubescens) 10 g, chenpi (Citrus tangerina) 10 g, zhishi (Citrus aurantium) 10 g, fuling (Poria) 15 g and gancao (Glycyrrhiza) 5 g.
For stronger action to calm the heart and the mind add suanzaoren (Ziziphus), baiziren (Biota) and yuanzhi (Polygala).
Chronic accumulation of turbid Phlegm can transform into Heat. Phlegm-Heat disturbing the interior can lead to palpitations, insomnia, chest tightness, restlessness, a dry and bitter mouth, yellow and greasy tongue coating and slippery and rapid pulse. In this case the therapeutic principle is to clear Heat, dissipate Phlegm and calm the heart and the mind. Use augmented Huanglian Wen Dan Tang (Coptis Gallbladder-Warming Decoction). The composition is as follows: huanglian (Coptis) 5 g, chenpi (Citrus tangerina) 10 g, zhuli (Phyllostachys nigra) 10 g, processed banxia (Pinellia) 10 g, fuling (Poria) 10 g, zhuru (Phyllostachys nigra) 10 g, zhizi (Gardenia jasminoides) 10 g, bile-treated nanxing (Arisaema consanguineum, erubescens) 10 g, danshen (Salvia) 10 g, yuanzhi (Polygala) 6g, suanzaoren (Ziziphus) 10 g, dazao (Ziziphus) six pieces, and gancao (Glycyrrhiza) 5 g.
If palpitation and restlessness are prominent, add zhenzhumu (Pteria magaritifera, martensii) and muli (Ostrea).
Obstruction of Blood Vessels
Though palpitation is mostly due to deficiency of genuine Qi, obstruction of blood vessels by stasis is also common.
Main Symptoms. Palpitation; frequent heart pain; shortness of breath with wheezing and chest tightness; or cold body and limbs. The tongue is dark or has petechiae. The pulse is depletive, or hesitant and intermittent.
Therapeutic Principle. Promote blood circulation and remove blood stasis.
Treatment. Xue Fu Zhu Yu Tang (Decoction for Releasing Blood Stasis).
If there is Qi deficiency as well, remove chaihu, zhiqiao and jiegeng, but add huangqi (Astragalus), dangshen (Codonopsis) and huangjing (Polygonatum) to replenish Qi.
If there is blood insufficiency as well, add shudihuang (Rehmannia), gouqizi (Lycium) and prepared heshouwu (Polygonum multiflorum) to nourish blood.
If there is Yin deficiency as well, remove chaihu, zhiqiao, jiegeng and chuanxiong, but add maimendong (Ophiopogon), yuzhu (Polygonatum), nuzhenzi (Ligustrum), moliancao (Eclipta) and other herbs that nourish Yin and generate fluids.
If there is Yang deficiency as well, remove chaihu and jiegeng, but add fuzi (Aconitum), rougui (Cinnamomum), yinyanghuo (Epimedium), bajitian (Morinda) and other herbs that warm the channels and augment Yang.
If there is turbid Phlegm as well, add gualou (Trichosanthes), xiebai (Allium macrostemon) and processed banxia (Pinellia).
If chest pain is prominent, add ruxiang (Boswellia), moyao (Commiphora), puhuang (Typha angustifolia) and wulingzhi (Pleropus pselaphon).
The principal acupoints to select are Xinshu (BL-15), Jueyinshu (BL-14), Tanzhong (RN-17), Juque (CV-14), Shenmen (HT-7), andNeiguan (PC-6).
If Fire blazes in Yin deficiency, add Taixi (KI-3) and Sanyinjiao (SP-6).
If Phlegm-Fire moves internally, add Zhongwan (CV-12) and Fenglong (ST-40). If there is blockage by retained water, add Zhongwan (CV-12), Yinlingquan (SP-9) and Zusanli (ST-36).
If there are shortness of breath and wheezing in addition to palpitation, add Feishu (BL-13), Chize (LU-5) and Taiyuan (LU-9).
If there is edema, add Shuifen (CV-9), Yinlingquan (SP-9) and Sanyinjiao (SP-6). In general, apply the reinforcing method. Moxibustion may be added.
Case Study 1
The patient was an adult female. She had palpitation with chest tightness and shortness of breath for over a year. At the time of admission to hospital, she felt tightness and pressure in her chest and precordial pain. Any physical activity precipitated palpitation with panic and shortness of breath, alleviated by sighing. For about a month she also had mild fever and three episodes of heavy menstruation within the month.
The tongue was tender, red and purple, with a thin coating, and the pulse was rapid, at a rate of 160 beats per minute. The heart was slightly enlarged, with the point of maximal impulse in the fifth intercostal space and 1 cm lateral of the nipple line. On auscultation there was a grade 2-3 systolic murmur over the apex. The electrocardiogram showed an inverted T-wave in all leads, indicating strain of the heart muscle.
Diagnosis. Palpitation due to deficiency of both Qi and Yin, resulting in disharmony among the vessels, stasis of heart-blood and failure of nourishment for the heart.
Therapeutic Principle. Replenish Qi and Yin, mobilize blood and harmonize the vessels, and calm the heart and the mind.
Treatment and Course. The prescribed formula had the following composition: dangshen (Codonopsis) 12 g, danshen (Salvia) 12 g, longchi (fossil teeth) 15 g, shudihuang (Rehmannia) 10 g, maimendong (Ophiopogon) 10 g, honghua (Carthamus) 10 g, chuanxiong (Ligusticum) 10 g, guizhi (Cinnamomum) 5g, wuweizi (Schisandra) 5 g, calcined muli (Ostrea) 30 g, huzhang (Polygonum cuspi-datum) 30 g and fried gancao (Glycyrrhiza) 6g.
After five daily doses, the mild fever abated. The formula was continued. Over a period of over 70 days treatment all symptoms, including chest tightness and pressure and palpitation, gradually subsided with only occasional precordial aching. The cardiac murmur disappeared and the electrocardiogram also showed marked improvement.
Case Study 2
The patient was an adult male with a medical history of palpitations, accompanied by a sensation of chest pressure and tightness. During an attack he also had panic, restlessness and a dry and sticky mouth.
The tongue coating was yellow and sticky, and the pulse was threadlike, rapid but irregular. Auscultation of the heart confirmed an irregular heart rhythm with an overall rate of 200 beats per minute. The electrocardiogram showed supraventricular tachycardia.
Diagnosis. Palpitation due to Phlegm-Fire disturbing the heart and causing panic.
Therapeutic Principle. PurgeFire, dissipatePhlegmandcalmtheheartandthemind.
Treatment. The prescribed formula had the following composition: huanglian (Coptis) 3g, shichangpu (Acorus) 3g, zhizi (Gardenia jasminoides) 10 g, ginger-treated zhuru (Phyllostachys nigra) 10 g, processed banxia (Pinellia) 10 g, fuling (Poria) 10 g, juhong (Citrus tangerina) 6g, yujin (Curcuma) 6g, roasted yuanzhi (Polygala) 5 g, and hupo powder (amber) 2 g. The hupo was taken separately.
After two doses the palpitation was relieved. After other five doses, the tongue coating returned to normal. The pulse remained threadlike but was now normal in rate and rhythm.