Chest+Bi+(Xiong+Bi)

Chest Painful Obstruction/Xiōng Bì
A condition characterized by oppression in the chest with chest pain. Mild cases manifest with simple stuffiness and discomfort in the chest.

Severe cases manifest with crushing pain in the chest accompanied by shortness of breath and dyspnea. In some cases, the pain will radiate to the left upper back or into the left shoulder and down the left arm with shortness of breath, dyspnea, and difficulty breathing while lying flat.

Relevant Biomedical Disorders
-Angina pectoris -Coronary artery disease -Ischemic heart disease -Myocardial infarction -Rheumatic heart disease -Intercostal neuralgia -Costochondritis -Bronchitis -Pneumonia -Pleurisy -Emphysema -Carcinoma of the lung

TCM Etiology and Pathogenesis
Invasion by exogenous Cold: exogenous Cold can directly invade the chest and obstructive circulation of Yang Qi. Pre-existing yang deficiency, especially of the chest, create susceptibility to invasion by exogenous Cold. These factors lead to inadequate warming and circulation of Qi and Blood, resulted in Qi stagnation and Blood stasis, obstruction in the chest, and chest pain.

Improper diet: excessive consumption of greasy, raw and cold food impairs the function of the Spleen and Stomach leading to pathogenic Dampness and Phlegm accumulation. Phlegm blocks circulation of Qi and Blood in the channels and vessels causing chest pain.

Emotional stress: the Spleen is weakened by excessive pensiveness and worry which can cause inadequate production of Qi and Blood. Insufficient Qi fails to circulate the Blood, and efficient Blood fails to properly nourish the Heart. Additionally, anger and frustration can cause Liver Qi stagnation, which can lead to Blood stasis, resulting in chest pain.

Constitutional vacuity, aging: decline of the Kidneys due to aging as well as constitutional vacuity are both potential causes of Chest Bi. Kidney Yang is the foundation of Yang Qi for the entire body; when Kidney Yang declines, Heart Yang becomes sluggish. Lack of warming by Heart Yang and poor circulation in the Heart vessels can cause chest pain. Likewise, when Kidney Yin deteriorates, Heart Yin and Blood deficiency ensue. Consequently, circulation in the Heart vessels become sluggish due to lack of nourishment from Yin, causing pain.

Chest Painful Obstruction/Xiōng Bì is always a combination of deficiency and excess. The Root usually involves a deficiency of one or more of the following organs: the Spleen, Heart, and Kidneys. The Branch manifestations are related to excess resulting from Blood stasis, congealed Cold, Qi Stagnation and/or Phlegm Accumulation.

Diagnosis by Nature of Pain Symptoms
Chest stuffiness or oppression that: changes in severity depending on emotional stress = Qi stagnation is aggravated by exertion, accompanied by SOB, fatigue, spontaneous sweating = HT Qi vacuity is accompanied by obesity, cough with copious sputum, and greasy tongue coat = Phlegm Accumulation

Stabbing, throbbing, and crushing pain at fixed location with purple tongue with petechiae and engorged sublingual veins = Blood Stasis

Spasmodic pain with: sudden onset of excruciating pain accompanied by cold limbs, the sensation of suffocation and symptoms aggravated by cold = Cold in the Heart Vessels cold intolerance, lying in fetal position, and a puffy, pale tongue = Yang vacuity with empty Cold

Complications
Irregular pulse (arrhythmias): paroxysmal Chest Painful Obstruction/Xiōng Bì may give rise to an irregular pulse. This is caused by pathogenic factors obstructing the free flow of Heart Yang Qi and impeding blood circulation. Irregular polls manifested as subjective palpitations or a palpable knotted, intermittent pulse.

Cold congested Fluids Overflowing to the Heart (Heart failure): extreme deficiency of Heart and Kidney Yang causes water to spill over to the Heart and further deplete Heart Yang. Clinical manifestations include cough, wheezing with copious, watery sputum, palpitations and systemic pitting edema.

Differential Diagnosis
Chest Bi: pain is characteristically stabbing, with a sensation of oppression in the chest, and possible radiating paint the left shoulder and arm. The pain is accompanied by palpitations, SOB, cold limbs, perspiration, and a knotted, intermittent pulse. It is more commonly seen in the middle-aged and elderly population with a history of heart disease or hyperlipidemia.

Zhēn xīn tòng (True Cardiac Pain): a severe complication of Chest Bi, zhēn xīn tòng (True Cardiac Pain) is critical and fatal. This type of chest pain is constant, severe and stabbing; it is usually accompanied by profuse perspiration, clammy, cold extremities, pale complexion, faint and thin pulse or knotted and intermittent pulse and cyanotic lips, hands and feet.

Epigastric pain (Wèi Tòng): atypical Chest Bi may present as pain in the epigastrium, and can easily be confused with Epigastric pain (Wèi Tòng). True Epigastric pain (Wèi Tòng) is a distending pain located in the epigastrium that may sometimes radiate to the corresponding region in the back. Other symptoms include nausea, vomiting, belching or acid regurgitation. The onset of Epigastric pain (Wèi Tòng) is not age-specific and is usually caused by improper diet.

Treatment Principles
Chest Bi is characterized by root deficiency with branch excess. In critical conditions, the first priority is to treat the branch by eliminating pathogenic factors; once the patient is stabilized, the focus turns to supplementing zheng qi.
 * Excess patterns**: dispel Cold, quicken the Blood to eliminate stasis, transform Phlegm, relieve pain
 * Deficiency patterns:** warm and supplement Yang Qi, nourish Yin or Blood, relieve pain

Qi Stagnation in the Chest
[Chai hu (Bupleurum root) 10g, Xiang fu (Cyperus rhizome) 10g, Zhi ke (Mature Bitter Orange) 10g, Chen pi (Tangerine peel) 10g, Bai shao (White Peony root) 10g, Chuan xiong (Ligusticum root)10g, Zhi gan cao (Honey-fried Licorice root) 3g]
 * Main Symptoms:** stuffiness or distending, wandering pain in the chest that increases with emotional stress
 * Secondary symptoms**: irritability, frustration, anger, depression, sighing, abdominal distention or pain, breast tenderness, dysmenorrhea, irregular menstruation
 * Tongue:** normal or possibly slightly purple, thin, white coat
 * Pulse:** wiry
 * Treatment Principles:** Course the Liver, rectify the Qi, relieve pain
 * Herbal Treatment:** Chai Hu Shu Gan San (Bupleurum Course the Liver Decoction)

Obstruction of the Heart by Blood Stasis
[Tao Ren (Peach kernel) 12g, Hong Hua (Carthamus) 9g, Chuan Xiong (Ligusticum root) 4.5g, Chi Shao (Red Peony root) 6g, Chuan Niu Xi (Cyathula root) 9g, Chai Hu (Bupleurum root) 3g, Sheng Di Huang (Fresh Rehmannia root) 9g, Jie Geng (Platycodon root) 4.5g, Zhi Ke (Bitter Orange) 6g, Dang Gui (Tangkuei) 9g, Gan Cao (Licorice root) 3g]
 * Main Symptoms:** palpitations with chest stuffiness and intermittent stabbing chest pain
 * Secondary Symptoms:** cyanotic lips and nails
 * Tongue:** purple with stasis macules
 * Pulse:** choppy, knotted or intermittent
 * Treatment Principles:** Quicken the Blood, dissolve stasis, rectify Qi, open the channels and collaterals, relieve pain
 * Herbal Treatment:** Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction)

Turbid Phlegm Stagnating in the Chest
[Gua Lou (Trichosanthes fruit) 12g, Xie Bai (Chinese chive) 9 -12g, Fa Ban Xia (Processed Pinellia tuber) 12g, Bai Jiu (White liquor) 50cc]
 * Main Symptoms:** sensation of congestion and pain in the chest; possible radiation of pain to the upper back, left shoulder, and into left arm; pain worse during cloudy weather
 * Secondary Symptoms:** obesity, sensation of heaviness, shortness of breath or rapid breathing, copious sputum
 * Tongue:** white, greasy coat
 * Pulse:** slippery
 * Treatment Principles:** Unblock the Yang, dispel Turbid Phlegm, relieve pain
 * Herbal Treatment:** Gua Lou Xie Bai Ban Xia Tang(Trichosanthes Fruit, Chinese Chive, and Pinellia Decoction)

Congealed Cold
[Gua Lou (Trichosanthes fruit) 12g, Xie Bai (Chinese chive) 12g, Bai Jiu (White liquor) 50cc]
 * Main Symptoms:** severe chest pain that increases with exposure to cold; possible radiation of pain to the upper back, left shoulder, and into left arm
 * Secondary Symptoms:** oppression in the chest, shortness of breath, palpitations, dyspnea, inability to lie flat, pale complexion, cold extremities
 * Tongue:** white coat
 * Pulse:** deep, thin or slow, tight
 * Treatment Principles:** Unblock the Yang, scatter Cold, relieve pain
 * Herbal Treatment:** Gua Lou Xie Bai Bai Jiu Tang(Trichosanthes Fruit, Chinese Chive, and Wine Decoction)

Qi and Yin Vacuity
Herbal Treatment: Sheng Mai San (Generate the Pulse Powder) [Ren Shen (Ginseng root) 9g, Mai Men Dong (Ophiopogon tuber) 15g, Wu Wei Zi (Schisandra fruit) 6g] + rén shēn yǎng yíng tāng(Ginseng Decoction to Nourish the Nutritive Qi) [Ren Shen (Ginseng root) 9g, Bai Zhu (White Atratylodes root) 9g, Fu Ling (Poria) 12g, Huang Qi (Astragalus root) 12g, Shu Di Huang (Cooked Rehmannia root) 9g, Dang Gui (Tangkuei root) 9g, Bai Shao (White Peony root) 12g, Chen Pi (Aged Tangerine peel) 9g, Rou Gui (Cinnamon bark) 3g, Wu Wei Zi (Schisandra fruit) 6g, Yuan Zhi (Polygala root) 6g, Sheng Jiang (Fresh Ginger rhizome) 3g, Zhi Gan Cao (Honey-fried Licorice root) 6g, Da Zao (Jujube) 2 pcs.]
 * Main Symptoms:** intermittent chest stuffiness and dull pain that is aggravated by exertion, applications, shortness of breath
 * Secondary Symptoms:** fatigue, disinclination to speak, dizziness, vertigo, lusterless complexion
 * Tongue:** slightly red; possibly scalloped
 * Pulse:** thin and weak, knotted or intermittent
 * Treatment Principles:** Supplement Qi, nourish Yin, relieve pain

HT and KI Yin Vacuity
[Shu di huang (Cooked Rehmannia root) 24g, Shan yao (Dioscorea root) 12g, Shan zhu yu (Cornus fruit) 12g, Gou Qi Zi (Lycium berry) 12g, Fu Ling (Poria) 9g, Zhi Gan Cao (Honey-Fried Licorice) 6g
 * Main Symptoms:** intermittent chest stuffiness or dull pain, palpitations
 * Secondary Symptoms:** insomnia, irritability, restlessness, 5 Centers Heat, dizziness, tinnitus, forgetfulness, dry mouth, night sweats, sore low back
 * Tongue**: red with scanty or no coating
 * Pulse:** rapid, thin or choppy
 * Treatment Principles:** Nourish Heart and Kidney Yin, calm the Shen, relieve pain
 * Herbal Treatment:** Zuo Gui Yin

Tian Wang Bu Xin Dan (Emperor of Heaven's Special Pill to Tonify the Heart) [Sheng Di Huang (Fresh Rehmannia root) 120g, Fu Ling (Poria)15g, Dan Shen (Salvia root) 15g, Ren Shen (Ginseng root) 15g, Dang Gui (Tangkuei) 30g, Bai Zi Ren (Arborvitae seed) 30g, Yuan Zhi (Polygala root) 15g, Suan Zao Ren (Zizyphus seed) 30g, Tian Men Dong (Asparagus tuber) 30g, Mai Men Dong (Ophiopogon tuber) 30g, Wu Wei Zi (Schisandra fruit) 30g, Xuan Shen (Scrophularia root) 15g, Jie Geng (Platycodon root) 15 g, Zhu Sha (Cinnabar) 15g]

Heart and Kidney Yang Vacuity
[Shu di huang (Cooked Rehmannia root) 24g, Shan yao (Dioscorea root) 12g, Shan zhu yu (Cornus fruit) 12g, Gou Qi Zi (Lycium berry) 12g, Du Zhong (Eucommia bark) 9g, Zhi Gan Cao (Honey-Fried Licorice) 6g, Zhi Fu Zi (Prepared Aconite tuber) 9g, Rou Gui (Cinnamon bark) 6g] + Shen Fu Tang(Ginseng and Aconite Decoction) [Ren Shen (Ginseng root) 30g, Zhi Fu Zi (Processed Aconite tuber) 15g]
 * Main Symptoms:** chest oppression and shortness of breath, dull or colicky pain that may radiate to the upper back and shoulder in severe cases
 * Secondary Symptoms:** palpitations, sweating, cold extremities and torso, fatigue, sore low back and knees, pale complexion, pale or cyanotic lips and nails
 * Tongue:** pale or dark purple
 * Pulse:** deep, thin or deep, minute
 * Treatment Principles:** Warm the Yang, boost Qi, relieve pain
 * Herbal Treatment:** You Gui Yin (Right-Restoring Beverage)

Acupuncture for Chest Painful Obstruction/Xiōng Bì

 * Basic points:** PC6, CV17, BL15, CV14
 * Qi stagnation:** LI4, LV3, BL14
 * HT Blood Stasis:** BL17, SP10, HT6
 * Turbid Phlegm:** ST40, LU9, PC4
 * Congealed Cold:** BL14, HT5, CV4, CV6
 * Qi and Yin xu:** ST36, CV6, BL17, SP6
 * HT/KI Yin xu:** HT6, KI3, BL23
 * HT/KI Yang xu:** CV4, CV6, CV8, BL23, HT5, GV4, GV14 + moxa

Clinical Tips
Use herbs that are acrid, warm and drying in nature with caution and ovoid overuse of rich and cloying herbs. Chest Painful Obstruction/Xiōng Bì is a complicated disorder of excess and deficiency; pure excess or deficiency patterns are rarely seen. Herbs that are acrid, warm and drying should be used to treat excess patterns of Qi stagnation, Blood stasis, Cold pathogenic invasion or turbid Phlegm accumulation. However, overuse of these herbs may injure body fluids, damage Blood and exacerbate deficiency.

Sweet, rich and cloying herbs are needed to replenish vital substances in patterns of Heart Qi deficiency and Heart and Kidney Yin or Yang deficiency. However, overuse of these herbs may contribute to or exacerbate Qi stagnation, Damp accumulation or Blood stasis.

Carefully differentiate excess and efficient Cold. Both excess and deficient Cold share similar article presentations; however, they have different courses and prognoses. Excess Cold is characterized by chest pain that radiates through the back, inability to lie flat, difficulty in breathing, cold limbs, and a deep, tight pulse. It can progress into zhēn xīn tòng (True Cardiac Pain) with constant, severe chest pain. The progression of Chest Painful Obstruction/Xiōng Bì into zhēn xīn tòng (True Cardiac Pain) is similar to that of angina pectoris developing into myocardial infarction. Treatment is focused on dispersing the Cold pathogen.

Deficient Cold is characterized by chest pain that radiates to the back, profuse sweating, clammy cold extremities, and a thin, deep pulse. It can progress into Heart Yang collapse with profuse sweating, just oppression, shortness of breath, cyanotic lips, nails and complexion, and a minute pulse. The development of Chest Painful Obstruction/Xiōng Bì into Heart Yang collapse is similar to that of angina pectoris developing into cardiogenic shock or heart failure. Treatment is focused on tonifying and rescuing collapsed Heart Yang.

Manage diet appropriately. It is essential for patients with Chest Painful Obstruction/Xiōng Bì to maintain a low-sodium diet and eat a well-balanced diet rich in vegetables, whole grains, healthy protein and fats. Preventing constipation is necessary because straining with bowel movements can elicit chest pain.