Palpitations

Palpitations/Xīn Jì
refers to a condition in which a person’s heart rate becomes so irregular, accelerated, or forceful that she is aware of it, experiencing sensations of nervousness, anxiety, or terror.

Relevant Biomedical Conditions
-Neurosis -Tachycardia -Arrhythmias -Hyperthyroidism -Heart failure -Menopause

TCM Etiology and Pathogenesis

 * Exogenous pathogenic factors:** Wind, Cold, and Damp pathogens may invade and obstruct the channels and collaterals; over time, this obstruction may progress to the Heart, causing Heart Blood stasis with palpitations.
 * Severe blood loss:** hemorrhage from any cause –if significant – will fail to nourish the Heart and deprive the Spirit of its residence, leading to palpitations.


 * Improper diet or over thinking:** overeating or excessive consumption of cold, raw, or extremely rich foods can overburden the Spleen, resulting in the production of pathogenic Dampness and Phlegm. Spleen Qi vacuity that results from improper diet or over thinking impacts the Heart in the form of Heart Qi or Heart Blood vacuity. Blood stasis may also result from any of the above causes.


 * Emotional stress:** Liver Qi stagnation resulting from frustration, anger, or depression may, over time, lead to Blood stasis and Phlegm accumulation. Both can obstruct the Heart vessels, causing palpitations. Liver Qi stagnation can also generate Heat, which accelerates the heart rate and causes palpitations. Finally, Liver Qi stagnation can result in Spleen Qi vacuity which results in decreased Blood production and lack of nourishment to the Heart.


 * Constitutional vacuity, aging, chronic or severe illness, excessive sexual activity:**
 * HT/GB Qi xu:** constitutional Qi vacuity of the Heart and the Gallbladder manifests in lack of self-confidence, timidity, and indecisive behavior. The Heart is malnourished and the Shen is easily disturbed by sudden, frightening events.
 * KI Yin xu:** if Kidney Yin (Water) cannot nourish the Heart (Fire), loss of communication between the Kidney and Heart ensues, Heart Fire becomes hyperactive, and palpitations result.
 * HT Yang xu:** when chronic or severe illness exhausts Heart Yang, the vessels of the Heart cannot be sufficiently warmed; poor circulation results in Blood stasis, leading to palpitations.
 * KI Yang xu:** when Kidney Yang fails to warm and steam water, fluids will overflow and block the Heart Yang, causing palpitations.

**// Jing Jì //** ** (Fright Palpitations) ** || **// Zhēng chōng //** ** (Fearful Throbbing) ** || Etiology || Triggered by sudden fear, anger, or exertion || Occurs with dysfunction of zang-fu, triggered by exhaustion || Condition || = Mild; intermittent, temporary, rapid onset; responds quickly to treatment = || Relatively severe with poor prognosis; gradual onset; constant palpitations with irregular or accelerated heart rate || Chief Complaint || Palpitations || Palpitations with systemic deficiency || Nature || Excess, or mixed excess/deficiency patterns; functional disorder; patient’s condition is generally good || Primarily deficiency patterns (though may have excess overlay); organic disorder; patient’s condition is relatively poor ||

**Excess vs. Deficiency**
Irritability, warm sensation in the chest, insomnia or dream-disturbed sleep, nausea and lack of appetite = Phlegm-Fire Harassing the Heart Dizziness, stifling sensation in the chest, shortness of breath or dyspnea, edema = Congested Fluids Overflowing to the Heart
 * Excess**

Agitation, stabbing chest pain, cyanotic lips, purple spots on tongue (petechiae), irregular pulse = Heart Blood Stasis Rapid, slippery, forceful pulse = Phlegm-Fire Slow pulse = pathogenic Cold

Empty feeling in the heart, shortness of breath, fatigue, dizziness, aggravated by exertion = Heart Qi Deficiency Weakness, irritability, aggravated by mental strain = Heart Blood or Yin Deficiency Thin, weak, rapid pulse = Yin Deficiency with Empty Fire Deep, slow pulse = Yang Deficiency with Empty Cold
 * Deficiency**

Mild vs. Severe Cases

 * Mild cases:** palpitations are triggered by emotional factors; occurrences are paroxysmal and of short duration; remission is spontaneous
 * Severe cases:** no emotional factors involved; symptoms include persistent palpitations aggravated by exertion, breathlessness, dyspnea, edema, stabbing chest pain, cold extremities
 * Critical situation:** when palpitations are accompanied by profuse sweating, frigid extremities, shallow breathing, cyanotic lips and tongue, faint pulse, and possible loss of consciousness, collapse of Heart Yang is imminent

Heart and Spleen Vacuity

 * Main Symptoms:** palpitations that are worse with exertion and better with rest, dizziness, pale complexion
 * Secondary Symptoms:** forgetfulness, dizziness, fatigue, poor appetite, insomnia with difficulty falling asleep, light sleep, frequent and vivid dreams
 * Tongue:** pale with thin coat
 * Pulse:** thin, weak
 * Treatment Principles:** Supplement the Heart and Spleen to promote the production of Qi and Blood, calm the Spirit
 * Acupuncture Treatment:** BL17, BL20, ST36
 * Herbal Treatment:**Gui Pi Tang (Spleen-Returning Decoction)

Heart and Gallbladder Qi Vacuity
[Fu Ling (Poria) 9g, Fu Shen (Poria root) 9g, Yuan Zhi (Polygala root) 6g, Ren Shen (Ginseng Root) 9g, Long Gu (Dragon Bone) 30g, Shi Chang Pu (Acorus rhizome) 6g]
 * Main Symptoms:** palpitations, timidity, easily frightened or startled
 * Secondary** Symptoms: insomnia with light sleep, frequent and vivid (sometimes disturbing) dreams, tendency to wake with a start shortness of breath, fatigue, copious, clear urine
 * Tongue**: thin, white coat
 * Pulse:** slightly rapid, weak in left cun position
 * Treatment Principles:** Supplement Qi, stop fright, calm the Spirit
 * Acupuncture Treatment:** HT5, GB40
 * Herbal Treatment**: An Shen Ding Zhi Wan (Spirit-Quieting Mind-Stabilizing Pill)

HT and KI Yin Vacuity with Effulgent Fire

 * Main Symptoms**: palpitations, insomnia, irritability, restlessness, 5 Centers Heat
 * Secondary Symptoms:** dizziness, tinnitus, forgetfulness, dry mouth, night sweats, sore low back
 * Tongue**: red with scanty or no coating
 * Pulse:** rapid, thin
 * Acupuncture Treatment:** BL14, KI3, SP6, BL23
 * Herbal Treatment:** Tian Wang Bu Xin Dan (Emperor of Heaven's Special Pill to Tonify the Heart)

Heart Qi, Blood, and Yin Vacuity

 * Main Symptoms**: palpitations
 * Secondary Symptoms:** shortness of breath, fatigue, pale complexion, spontaneous sweating or night sweats
 * Tongue:** read with scanty or no coat
 * Pulse:** knotted or intermittent
 * Treatment Principles:** Boost Qi, nourish Blood and Yin, calm the Spirit
 * Acupuncture Treatment:** BL14, KI3, SP6, BL23
 * Herbal Treatment:** zhì gān cǎo tāng (Honey-Fried Licorice Decoction)

Phlegm-Fire Harassing the Heart
+ Yuan Zhi (Polygala root) 15g, Suan Zao Ren (Zizyphus seed) 30g
 * Main Symptoms:** palpitations with irritability or restlessness, susceptibility to fright, insomnia, dream-disturbed sleep, chest fullness with expectoration of copious phlegm, heaviness of the head
 * Secondary Symptoms:** aversion to eating, belching, acid regurgitation, nausea or vomiting, distention in the epigastrium, bitter taste in the mouth, dizziness
 * Tongue:** yellow, greasy coat
 * Pulse:** rapid, slippery
 * Treatment Principles:** Clear Heat, transform Phlegm, harmonize the Stomach, calm the Spirit
 * Acupuncture Treatment:** ST40, ST36, LI11, BL19
 * Herbal Treatment:** Huang Lian Wen Dan Tang (Coptis Warm the Gallbladder Decoction)

Heart Yang Vacuity
+ guì zhī gān cǎo lóng gǔ mǔ lì tāng (Cinnamon Twig, Licorice, Dragon Bone and Oyster Shell Decoction)
 * Main Symptoms:** palpitations with chest stuffiness or pain, shortness of breath
 * Secondary Symptoms**: pale complexion, cold extremities and torso
 * Tongue:** pale
 * Pulse:** weak, deep, thin, slow
 * Treatment Principles:** Warm and supplement the Heart Yang, calm the Spirit
 * Acupuncture Treatment:** CV6, CV4, CV8 + moxa
 * Herbal Treatment:** Shen Fu Tang (Ginseng and Aconite Decoction)

Oppression of the Heart by Water and Phlegm-Fluids

 * Main Symptoms:** palpitations with dizziness, fullness in discomfort of the chest and epigastrium, scanty urination, edema of the lower limbs in some cases
 * Secondary Symptoms:** cold extremities and torso, thirst with no desire to drink, expectoration of phlegm and mucus, nausea and vomiting
 * Tongue:** pale, puffy with white, moist/slippery coat
 * Pulse:** slippery, wiry or deep, wiry
 * Treatment Principles:** Warm Heart Yang, transform Phlegm-Fluids, calm the Spirit
 * Acupuncture Treatment:** CV9, SP9, CV4, CV8, CV14
 * Herbal treatment:** líng guì zhú gān tāng (Poria, Cinnamon Twig, Atractylodis Macrocephalae, and Licorice Decoction)

Obstruction of the Heart by Blood Stasis

 * 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, calm the spirit
 * Acupuncture Treatment:** SP10, CV6, BL17, CV17
 * Herbal Treatment:** Xue Fu Zhu Yu Tang (Drive Out Stasis in the Mansion of Blood Decoction)

Acupuncture for Palpitations/Xīn Jì

 * Basic points:** PC6, HT7, BL15, CV14
 * HT/GB Qi xu:** HT5, GB40
 * HT/SP xu:** BL17, BL20, ST36
 * Empty Fire:** BL14, KI3, SP6, BL23
 * Phlegm-Heat:** ST40, ST36, LI11, BL19
 * Heart Yang xu:** CV6, CV4, CV8 + moxa
 * Phlegm-Fluids:** CV9, SP9, CV4, CV8, CV14
 * Blood stasis:** SP10, CV6, BL17, CV17

Auricular: Shen Men, Heart, Sympathetic, Subcortex

Clinical Tips
Metal, shell and mineral substances tend to injure the Spleen and Stomach if used for long periods of time. While appropriate for anchoring and sedating the Heart Spirit, they’re not to be used for long periods of time. The addition of Shen Qu in such cases can help protect the Middle Jiao from damage by the substances.

Palpitations are generally subjective, and an irregular pulse may not be detected on palpation. When present, hasty, knotted, and intermittent are the most common irregular pulses. They can appear alone or in combination. Occasionally, an irregular pulse will be found in a patient who has experienced emotional trauma or extreme sadness. However, this will usually not persist. Palpitations accompanied by an irregular pulse can sometimes indicate severe or critical depletion of Heart Qi or Heart Yang.