TCM Case Work-Up

This page may be removed from patient intake form in order to work on. Work must be completed and returned before the
second visit. Patient name, first or last, should not be written anywhere on this page. All reference to the patient is by assigned
file number located on the patient’s folder.

Patient File Number: 019 Intern Name: Huiying Chin

Date of Treatment: Jan 12, 2022 Clinic Day/Time Mon: 2pm Supervisor: Jennifer Vogels
71 M

MC 1: Cold hands and feet, Raynaud’s syndrome diagnosed. Chronic 15 years condition, always triggered
in early winter when he works outside. Fingers will get cold and after going inside, turns red, swollen,
itchy with cold sores. Prefers to keep the skin cool, heat would trigger itch and redness. The condition
goes on for a few weeks and by mid-Winter it’s gone. No joint pain or connective issue inflammation after
various examinations. Feet are cold, no swelling or redness. Sleep without socks at night

MC2: Atrial fibrillation diagnosed during colonoscopy 4 years ago. Irregular heartbeat without
palpitations or any symptoms.

HEENT: No HA, a few times a year rare clammy hands and dizziness (maybe dehydration). Floaters.
Itchy ear canal. History of eczema on forehead and ears (worse in dry season or sun). Occasional phlegm
in throat, needs to expectorate after exercise. Runny nose and post nasal drip when in cold exposure.

No SOB or Chest issues.

Appetite: Good, mostly 2 meals and a lot of snacks, sometimes light breakfast. Likes to snack late at night
on crunchy or sweets. Try to eat healthy.

Thirst: Drinks a lot (prefers cold), wakes up to pee a few times at night.
BM: 1-2x a day, sometimes skip a day, nore regular in winter, formed, no pain, easy to wipe. Sometimes
soft.

Sleep: Easy to fall asleep, a lot of sleep after retirement, well rested. Half the time wakes up to pee around
3-4am and difficult to fall back asleep (1 hour or so).

Energy: Consistent Good 8/10, no dips, tired if exerted physically

Stress: 6/10 – ended a Covid eviction of squatter
No medication or known allergies. Uses cortisone cream for itchy and swollen fingers.
No musculoskeletal issues.

Pulse: Good width and strength, regular, 78 bpm, weaker lung and left side stronger overall than right.
Inspection: Patient is lean, fit, average height and weight, good shen. Overall complexion (bright white)
Diagnosis: Lung Qi deficiency, yin deficiency heat, KD yang deficiency

MC1 – cold hands and feet – tonify yang and improve overall circulation
MC2 – Atrial fibrillation – tonify heart and lungs
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Pool of points:
LU7+KD6 – Ren to support insomnia, tonify lungs and kidneys
SI3+BL62 – Du to regulate water passageways and support circulation
BL13 – tonify LU
BL15 – tonify HT
BL18 – Tonify LV
BL20 – tonify SP
BL23 – Tonify KD
BL24 – Qi Hai Shu – tonify Qi for lung and heart
CV4 – tonify yang and qi
CV6 – tonify qi
DU20 – raise clear yang
Yin tang – calm shen
HT 7 – tonify HT and calm shen
SP6 – tonify yin and blood, supports sleep

Prognosis: Good, patient is active, open to herbal formulas and eats healthy.
Treatment plan: Weekly treatments for 5-6 sessions and evaluate

Diagnostic categories with signs and symptoms to support each category:

Yang deficiency – cold hands and feet
Deficient heat – red and swollen hands, prefers cold drinks and huge appetite for snacks
LU qi deficiency – runny nose in cold exposure, irregular heartbeat (A-fib)

Diagnosis based directly on above diagnostic categories (include a diagnosis for each MC/SC):
Cold hands and feet – KD yang deficiency, LU qi deficiency, HT yang deficiency
Atrial fibrillation – HT qi and HT yang deficiency, LU qi deficiency

Explanation of Diagnosis:
Patient is active, in his 70s and has a long history of working with his hands and being outside. Long term
exposure to the elements makes the hands more sensitive to temperature changes. Old age also tends to
cause long term yin and yang deficiency. Patient has a habit of drinking cold drinks year round. There is
some deficient heat that he copes with drinking cold water and snacking.

The atrial fibrillation could be related to Lung qi and heart qi deficiency. Patient is not aware of
palpitations. So the heart qi and lung qi deficiency is still mild. There might be patterns in the Heart and
Pericardium channel related to the irregular heartbeat.

World Century Compendium passage:

Pattern of the (hand–shaoyin) heart meridian Overview This pattern manifests conditions along
the pathway of the heart meridian as well as heart-related problems. Clinical manifestations A
dry throat, thirst with a desire to drink water, pain in the axillary or along the medial aspect of
the arm, warmth and pain of the palms, cardiac pain, palpitations, insomnia and abnormal
mental activities. Analysis Since a branch of the heart meridian travels along the throat, heat in

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the heart meridian may cause a dry throat. Heat consuming yin fluids may cause thirst with a
desire to drink water.

Pattern of the (hand–jueyin) pericardium meridian Overview This pattern manifests conditions
along the pathway of the pericardium meridian as well as pericardium-related problems. Clinical
manifestations A warm sensation on the palms, spasm of the arms and elbows, swelling of the
axilla (armpit), chest fullness, cardia pain, palpitations, a red face, restlessness and mania.
Analysis The pericardium meridian starts from the chest, leaves the pericardium and travels
upward to the axilla, then runs along the midline of the medial aspect of the upper limbs to the
palms; disorder of this meridian may therefore causes a warm sensation on the palms, spasm of
the arms and elbows, swelling of the axilla (armpit) and chest fullness. A problem of the
pericardium may obstruct the heart vessels, leading to cardiac pain and palpitations. The luster
of the heart shows in the face, and heat in the pericardium may cause a red face. Since the heart
dominates the mind (spirit), a disordered pericardium may cause restlessness and mania.

Treatment Principle based directly on above diagnosis (include a treatment principle for each MC/SC):
Cold hands and feet – Tonify KD yang, LU qi, HT qi
Atrial fibrillation – Tonify HT qi and HT yang, LU qi, course qi through HT and PC channel

Pool of points, adjunctive techniques: with clear reasons for using each, what method and what adjunctive
techniques will be used:
BL23 – tonify KD
BL13- Tonify LU
BL15 – tonify HT
BL14 – tonify PC
CV17 – local point for heart issues
CV4 – tonify qi and yang
CV6 – tonify qi
LU7+KD6 – Ren channel treatment
SP4+PC6 – Chong channel treatment
DU20 – raise clear yang
Ear points – hand, fingers, toes, based on sensitivity, pt zero, sympathetic, endocrine
ST36 – tonify ST qi and blood
SP6 – tonify Yin and blood
HT7 – tonify HT and calm the shen

Citation in support of diagnosis:

Information/quote, Author, Book Title (italics), Edition (if applicable), City of Publisher: Name of Publisher; Year of
Publication, (page numbers)
Chen Ping, Diagnosis in Traditional Chinese Medicine, Taos, New Mexico, Complementary Medicine Press,
2004 (220-223 Heart deficiency patterns) (70-73 pain)
Hong-zhou Wu, Zhao-qin Fang, Pan-ji Cheng, Chou-ping Han, Introduction to Diagnosis in Traditional
Chinese Medicine, Hackensack NJ, World Century Publishing Corporation, 2013 (271 Palpitations)

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Xue-mei Li, Jingyi Zhao, Acupuncture Patterns and Practice, Seattle, WA, Eastland Press, 2012, (169,
Palpitations)

Treatment Plan: #_5_of treatments for #5 of weeks, then re-evaluate.

Prognosis: Good, patient is active and motivated to eat healthy and try herbal formulas. But the
conditions are both chronic and will take longer to see clear results.

Research Article Summary (Article 1)

Title How Do You Treat Raynaud's Syndrome in Your Practice?

Author/s Poovadan Sudhakaran, MBBS, PhD

Journal Medical Acupuncture

Publication Date 2019 Jun 1; 31(3): 193–199.

Raynaud's Disease in Chinese Medicine

Chinese Medicine attributes this condition to Stagnation of Qi and Blood in the channels due to
invasion of Cold and Dampness. Alcohol and tobacco use can generate Internal Fire, which
aggravates the Stagnation.
The points commonly recommended are: LI 11 and ST 36, the Homeostatic points; and LU 9, the
Grand Point for blood vessels. These points are used in all cases. In addition, for the upper
extremities, use HT 3, TB 5, PC 6, and the Jiaji Points from C-6 to T-3, as well as the Baxie Extra
Points. For the lower extremities, use GB 34, SP 9, GB 39, ST 32, SP 6, and the Jiaji Points, from LI
to LI II, and the Bafeng Extra Points.
In addition to the above points that are usually recommended, the author has found that using
the Yin Linking Vessel (Extra Meridian) boosts the effects of the treatment by promoting the
circulation of Qi and Blood in the channels. This is done by using PC 6 right and SP 4 left, in that
order in women (in men the sides are reversed), and KI 9 (where the channel enters the surface)
bilaterally.
Treatment is given daily, and 16–20 treatments constitute a course. Subsequent monthly
treatments will be needed for maintenance.
Auricular points used are the Sympathetic Autonomic Point, Endocrine Point, Adrenal Gland C,
Adrenal Gland E, Heart C1, Heart C2, Heart E, Heat Point, Lesser Occipital Nerve, Liver, Spleen
C, Shenmen, Thalamus Point, Occiput, and Sympathetic Chain. Select according to tenderness.
Chinese herbal formulas used are: Si Ni Tang, if the person has features of Cold syndrome with a
slow pulse, a pale tongue, and a desire for hot drinks; and Si Ni San, if the person has signs of
Stagnation such as irritability, muscular tension, and alternating calmness and agitation.
The Evidence for Acupuncture
Very few research reports are available on the efficacy of acupuncture for treating Raynaud's
disease. Those that exist include:
 A controlled randomized prospective study involving 33 patients (17 treated patients and
16 controls) showed an overall reduction of attacks by 63% in the acupuncture group and
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 27% in the control group.6
 Auricular electroacupuncture (EA) reduced the frequency and severity of attacks in PRD
but had no influence on skin perfusion and skin temperature.7
 Acupuncture and phototherapy were directly confirmed to increase the diameter and
blood flow velocity in peripheral arterioles.8
 EA regulated the balance of endothelium-derived vasoconstrictors and vasodilators in
rats.9
Illustrative Case
A 24-year-old female presented with a history of intermittent numbness, tingling, coldness, and
color changes (pallor, blue, and red in that order), involving her index, middle, and ring fingers
on both hands, for more than 4 years. Initially, her symptoms developed only in Winter months,
but, later on, the symptoms occurred throughout the year, mostly on cold days. She was well
otherwise. A clinical examination did not reveal any other abnormality. Laboratory investigations
—including ESR, cRP, RA factor, anti-centromere antibody, and scleroderma (SCL 70) antibody
tests—yielded negative results. However, her ANF was raised (> 1280).
Because of this raised ANF, 200 mg of hydroxychloroquine per day was prescribed and her
Raynaud's disease was treated with acupuncture. The points used were:
 PC 6 right, SP 4 left and KI 9 bilaterally to open the Yin Linking Vessel
 LI 11, ST 36, the Homeostatic Points
 LU 9, the Grand Point for blood vessels
 HT 3, TB 5, and Baxie Extra Points
 LR 3 to promote the flow of Qi.
Treatment was given twice per week for 8 weeks and then once per month for 2 years. The
patient's symptoms gradually reduced in severity and frequency; for complete disappearance of
symptoms, it took 4 years of monthly treatments. At that point, the treatments were stopped
with advice to return if there were any recurrences. That was 5 years ago; she has not been
heard from since.

Case 2:
A 48-year-old female, residing in a northern state of India, presented with a complaint of pain
and stiffness in both of her hands from the past six months, and symptoms were more
lateralized to her right hand. Her pain worsened in the early mornings and when she would put
food in and out of her refrigerator. Pallor at the finger tips was noticed whenever she was
exposed to the cold climate.
Complete blood count, erythrocyte sedimentation rate, and antinuclear antibody laboratory
tests were performed to rule out any other underlying disorders. Infrared thermal imaging
showed colder areas distally in both hands. In the context of Traditional Chinese Medicine, this
condition is referred as Cold syndrome arising from dysfunction of the Liver, with Stasis of Qi
and Blood. This condition also indicates that there is a Yang Deficiency.
Thus, this patient's therapy was aimed at regulating her flow of Qi, and improving the energy in
her Liver meridian to balance the Yin and Yang. The points chosen to treat this case were GV 20,
LR 3, LI 4, SI 3, LU 9, ST 36, UB 15, and PC 8. The needling details are shown in Table 1.5 A De Qi
sensation was achieved following needling. Each acupuncture session was for 30 minutes, 6
times per week, for 3 weeks.

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Application to your case (Article 1)

How might you incorporate the information in this article into your care of the patient? (at least
300 words)

The Ancient Medical Texts describe physiology and health as an equilibrium of Yin and Yang (hot
and cold) maintained throughout the body, otherwise there is risk of pathology. The pathologic flow
of Cold (Kidney Yin) into the hands and feet is due to a Deficiency of Kidney Yang, which can trigger
an afflux of Kidney Yin (Cold) to the organs or extremities.

To treat Raynaud's disease, first tonify Kidney Yang and Yin to reestablish internal homeostasis. For
Kidney Yang, needle/moxa GV 4 and CV 4. For Kidney Yin, tonify KI 3, the Source point (being careful
not to cause bleeding); KI 7–KI 8, the Tonification point, touching the bone; and CV 4, the “Barrier of
the Source” deeply; and apply moxa to BL 23 and BL 52, the Shu and outside Shu points. Once
restored, the Kidney Yang must be distributed to warm the hands and feet. The ancient texts offer
ways to distribute Kidney Yang, Mingmen, throughout the body, namely the San Jiao (TE). To help it
perform this role, needle CV 17, CV 12, ST 25, CV 7, and C V5, and warm BL 22.

The technique Mobilize Ministerial Fire (MMF) directs Kidney Yang to the hands through the San
Jiao's intermediaries of the Heart and its messenger, the Pericardium, from CV 17 to PC 8, where
the Kidney Yang polarizes to TE 1 and travels up the TE meridian internally throughout the body to
induce metabolic and cellular activity. To MMF with moxa, have the patient sit upright with each
hand resting on the opposite knee, head bent forward, and shoulders relaxed to open the thoracic
vertebrae. With a moxa stick heat BL 13, BL 42, BL 14, BL 43, BL 15, and BL 44 to a pink color until
the patient feels warmth travel down the arms all the way to the hands. The points should be given
moxa until this sensation is felt. It is also helpful to heat GV 14, BL 11, GV 4, BL 23 and BL 52. This
technique not only warms the hands, but also enables Mingmen distribution throughout the entire
body to replenish energy and prevent certain afflux pathologies.

Another Mingmen distribution pathway is the Yin Curious meridians, which carry Fire, specifically
the Chongmai. The Chongmai distributes the innate procreative Fire of Kidney Yang via its
ascending branch to all the organs and bowels supporting their functions, and via its descending
branch to warm the feet, facilitating polarization of the meridians and preventing many afflux
pathologies. As with all Curious meridians, the Chongmai begins with the Kidneys. From the Kidneys
it descends along the Renmai and Dumai through the uterus/prostate, then branching toward the
pubic region merging with CV 4. From CV 4, the Chongmai travels to the point “Pubic Bone” (KI 11)
superficially; from which the ascending branch rises, and the descending branch continues through
ST 30, ST 36, KI 4, and ST 42; ending at the Jing Well points LR 1 and KI 1.

To treat cold feet with the descending branch, needle SP 4 deeply to open the Chongmai; CV 4
deeply perpendicularly; KI 11 superficially perpendicularly; ST 30 from above to below superficially;
ST 36, SP 6, KI4, and ST 42 over the pedal pulse proximal to the distal, “Antique LV 1” at the level of
3 hairs (and KI 1), and PC 6 to open the coupled Curious meridian.

As the hands relate to Heaven/Yang and the feet relate to Earth/Yin, a symptomatic treatment for
cold hands and feet uses the Jing River Shu Antique points corresponding to Fire on the Yang

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meridians of the hands (SI 5, TE 6, and LI 5) with the Source points to augment SI 4, TE 4, and LI 4;
and the Ying Spring Shu Antique points corresponding to Fire on the Yin meridians of the feet (LR2,
SP2, KD2) with the Source points to augment LR 3, SP 3, and KI 3.

For all Blood-circulation conditions, open the 4 Barriers with LI 4 and LR 3. Circulate the energy that
leads the Blood (Ying Qi) in the principal channels with LU 7 (in the direction of LI 4), LI 4
(perpendicularly), TE 5, SI 3, HT 7, and PC 6 for the hands; ST 36, SP 2, LR 2, KI 2 (the three leg Yin
points can be replaced with SP 6), GB 41, and BL 60 for the feet.

The texts suggest cold hands may be due to Deficient Wei Qi circulating in the upper region and
cold feet to Deficient Wei Qi in the lower region. There are many methods offered to build,
strengthen, and circulate Wei Qi. Minimally, one can tonify the formation of Wei with CV 5 and CV
7, the Lower Jaio Mu points, acting on the Kidneys and Liver, the final stage in the formation of Wei
Qi. When treating any arteriole problem—as the Blood relates to the Heart, and the Heart relates
to the Mental—Calming the Mind and reducing stress is essential. Basic points include GV 20, HT 7,
CV 17 and YinTang, and one can add Shenmen and Kidney Yin in the ear. Consider SP 10 and BL 17
when treating the Blood, and tonify the SP/ST system, as the Ying and Blood correspond to acquired
energy.

Choosing appropriate points from the above tools, according to the energetic state of the patient, a
needle duration of 20–30 minutes, with lifestyle recommendations to keep the extremities warm,
will produce gradual results.

As Raynaud's disease is most often a chronic Empty–Cold condition, an initial frequency of

treatments 2–3 times per week for at least 12–15 sessions until lasting results are produced, then
reducing to weekly treatments for a total of 15–20 sessions is ideal, basing each treatment on how
the patient presents at the time. For example, if symptoms are not present, tonifying Kidney Yin
and Yang, Calming the Mind, and circulating the Ying may be the focus for prevention; whereas,
when symptoms are present, the Fire, Source, and circulation points—and distribution of Mingmen
to the extremities with MMF and Chongmai descending branch—can produce immediate relief.
Observation (tongue, complexion, morphotype, and extremities) and Palpation (radial pulses,
extremities, and pedal pulse) contribute to deciding the focus of each treatment. For example,
when the pedal pulse is absent or deficient, utilizing the Chongmai descending branch is essential;
when a pale tongue and complexion are observed, building the energy/Blood and helping it
circulate are key; and with a rapid pulse and a red crevassed tongue, Calming the Mind, circulating
the Ying, and treating the Blood will be the priority.

Less-chronic cases of cold limbs can resolve with 1–6 treatments, using the Fire and Source points,
circulating Ying, distributing Mingmen, and Calming the Mind. In my experience, most people
present with more-aggravating afflux pathologies, so treatments alternate between resolving afflux
when present and treating the cause (cold hands and feet) for prevention. Despite the limited
number of patients presenting specifically for Raynaud's disease, the texts teach that the
conscientious energetic doctor treats cold hands and feet daily in practice to prevent all sorts of
pathologies.

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 Research Article Summary (Article 2)

Title Acupuncture for paroxysmal and persistent atrial fibrillation: An effective non-
pharmacological tool?
Author/s Federico Lombardi, Sebastiano Belletti, Pier Maria Battezzati, and Alberto Lomuscio

Journal World J Cardiol. 2012 Mar 26; 4(3): 60–65.

Publication Date 2012 Mar 26

Key Findings (at least 200 words)

Abstract
In Traditional Chinese Medicine, stimulation of the Neiguan spot has been utilized to treat
palpitations and symptoms related to different cardiovascular diseases. We evaluated whether
acupuncture might exert an antiarrhythmic effect on patients with paroxysmal or persistent
atrial fibrillation (AF). Two sets of data are reviewed. The first included patients with persistent
AF who underwent electrical cardioversion to restore sinus rhythm. The second included
patients with symptomatic paroxysmal AF. All subjects had normal ventricular function.
Acupuncture treatment consisted of 10 acupuncture sessions on a once a week basis with
puncturing of the Neiguan, Shenmen and Xinshu spots. In patients with persistent AF, the
recurrence rate after acupuncture treatment was similar to that observed in patients on
amiodarone, but significantly smaller than that measured after sham acupuncture treatment or
in the absence of any antiarrhythmic drugs. In a small group of patients with paroxysmal AF,
acupuncture resulted in a significant reduction in the number and duration of symptomatic AF
episodes. In conclusion, we observed that acupuncture of the Neiguan spot was associated with
an antiarrhythmic effect, which was evident in patients with both persistent and paroxysmal AF.
These preliminary data, observed in 2 small groups of AF patients, need to be validated in a
larger population but strongly suggest that acupuncture may be an effective non-invasive and
safe antiarrhythmic tool in the management of these patients.

Keywords: Chinese medicine, Antiarrhythmic drugs, Autonomic mechanisms, Atrial arrhythmias

Application to your case (Article 2)

How might you incorporate the information in this article into your care of the patient? (at least
300 words)

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Possible effects of Neiguan puncturing
These findings indicate that acupuncture of the Neiguan spot exerts an antiarrhythmic
effect similar to that of amiodarone in patients with persistent AF and is additive to
common antiarrhythmic drugs in patients with symptomatic paroxysmal AF. Although
these results deserve confirmation in a larger patient population, they are, in our opinion, of
relevant physiopathological and clinical interest and open new perspectives in the
management of AF patients in relation to traditional and Western medicine.

In the Traditional Chinese Medical Doctrine[11,21], AF, like most supraventricular

arrhythmias, is related to Heart Yin deficiency in the absence of structural disorders or to
Heart Yang deficiency in the presence of a cardiac disease. The Neiguan spot is located in
the portion of the heart meridian situated in the forearm and is responsible for blood flow
and pulse rate control. Its malfunction has been associated with anxiety and restlessness
and cardiac pain.

In the Western world, puncturing of the Neiguan spot has been used to treat chest pain,
sickness and vomiting during chemo-embolization procedures[22] and to limit the
symptoms related to fullness-tension in the chest and palpitations[23]. Reductions in the
electrocardiographic signs of myocardial ischemia and plasma levels of endothelin have
also been reported[23,24].

Electroacupuncture of the Neiguan spot has also been associated with an effect on the
autonomic nervous system and, in particular on the sympatho-vagal interaction[25,26]. In
one of the first studies, Kong et al[27] was able to restore a more physiological sympatho-
vagal balance after acupuncture by measuring heart rate variability. More recently,
however, in a systematic review[28] in which the effects of acupuncture on heart rate
variability were studied in different patient populations and experimental conditions,
contrasting results were observed. For example in healthy subjects, acupuncture
determined a significant attenuation of signs of sympathetic activation and reduced vagal
modulation induced by a stress state in comparison to sham acupuncture[29]. Other

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studies, however, failed to detect similar changes in heart rate variability parameters when
subjects were exposed to mental stress testing or other stressors[28]. On the other hand,
Flachskampf et al[12], reported that 6 wk of acupuncture significantly lowered median 24-h
ambulatory blood pressure and that the effect was no longer present after cessation of
acupuncture treatment.

The possibility that acupuncture may exert its antiarrhythmic effect through an action on
the autonomic nervous system is therefore a plausible hypothesis although not tested in our
studies. Indeed, several clinical and experimental reports have indicated that an imbalance
of autonomic control mechanisms due to either an increase in vagal or sympathetic neural
activity directed to the heart may favor the initiation and maintenance of AF episodes[1,2].
In patients who developed AF during Holter recordings[30,31], signs of either an increased
vagal or sympathetic modulation of the sinus node were commonly detected in the minutes
preceding AF initiation: a finding that in our opinion, suggests that an imbalance between
the two branches of the autonomic nervous system rather than a specific predominance of
one component is the most important pro-arrhythmic factor.

The possibility that the antiarrhythmic effect of acupuncture might be related to a

stabilization of sympathetic and vagal control mechanisms rather than to a direct
antiadrenergic or vagomimetic effect is therefore appealing and is substantiated by recent
experimental findings. In fact, whereas direct high threshold cardiac vagal ganglia
stimulation has been associated with a pro-fibrillatory effect[32,33], bilateral low-level vago-
sympathetic nerve stimulation has been found to suppress effectively high-frequency
stimulation-induced focal AF at atrial and pulmonary vein sites[34-36]. Whether
acupuncture of Neiguan spot might exert similar effects on cardiac autonomic ganglia
remains to be determined and at the moment it is an interesting hypothesis.

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Research Article Summary (Article 3)

Title Acupuncture on Neiguan spot: A promising therapeutic approach for atrial fibrillation by
modulating autonomic nerves?

Author/s Ling Zhang*, Zhen Yu Dong, Mei Ma, Baopeng Tang

*Corresponding author: Ling Zhang, Xinjiang Medical University, Urumuqi, Xinjiang, China.

Journal American Journal of Biomedical Science and Research

Publication Date April 10, 2019

Key Findings (at least 200 words)

Atrial fibrillation (AF) is one of the most common arrhythmias with high morbidity and mortality
[2]. AF is frequently associated with heart diseases, autonomous nerve imbalance, hypertension,
obstructive sleep apnea, inflammation, oxidative stress, and with a high prevalence in the
elderly. Previous clinical and experimental researches have confirmed that cardiac autonomic
imbalance plays a predominant role in the initiation and maintenance of AF [2-4].

In traditional Chinese medicine, Neiguan acupuncture has been used to treat cardiac arrhythmia
and ischemia [5]. Multiple clinical evidences have demonstrated that Neiguan-acupuncture may
be an effective approach for AF patients who underwent electrical cardioversion to restore sinus
rhythm. The study by Federico Lombardi and his group [6] indicated that acupuncture of
Neiguan has unequivocal effects in patients with persistent and paroxysmal AF.

The recurrence rate with acupuncture is similar with oral or intravenous amiodarone on
persistent AF patient, but markedly lower than the sham group. In patients with paroxysmal AF,
acupuncture significantly reduce the number and duration of episodes of AF. In Chinese
researches, meta-analysis of two studies [7,8] showed that for individuals with AF, acupuncture
on Neiguan point was shown to be as effective as intravenous amiodarone in conversion from
AF to sinus rate. Another individual study has demonstrated that acupuncture on Neiguan spot
plus intravenous deslanoside had better effect on response rate than intravenous deslanoside
alone [9]. FAM Jonkmant’s case report [10] favored the effectiveness of acupuncture on
reducing the recurrence of AF, acupuncture could be a novel approach to treatment resistant
AF. But the mechanism behind acupuncture on Neiguan spot needs further elucidation.

Autonomic nerve regulation may be one of the mechanisms of acupuncture on Neiguan spot in
the attenuation of AF. Multiple clinical studies have illustrated that acupuncture of Neiguan spot
has been shown to lessen nausea and vomiting which are related to vagal modulation,
acupuncture of Neiguan spot could be a vagal enhancer in healthy subjects [11]. Joanne W. Y.
Chung’s meta-analysis [12] supported the possible role of acupuncture on modulating the
autonomic she found that LF, HF and LF/HF ratio of HRV significantly decreased. Tatsuo et al.
[13] demonstrated that acupuncture on Neiguan spot reduced cardiac excitability and corrected
the imbalance between cardiac sympathetic and vagal nerve activity during left stellate ganglion
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(LSG) stimulation in Yorkshire pigs. Anatomically, Neiguan spot is located on the nerve
originating from LSG, the same ganglia that innervate the heart.

Stimulation of Neiguan spot may exert the function of regulating autonomic nerve. Another
potential mechanism is about the central nervous system. Acupuncture of Neiguan elicits its
cardiac effects by reducing the cardiovascular sympathoexcitatory reflex response. This effect is
primarily achieved by inhibiting the rostral ventrolateral medulla to up-regulate inhibitory
neurotransmitters such as GABA, opioids, 5-HT, NO and NOS [14].

Acupuncture’s anti-AF effect may be related to the stabilizing sympathetic and vagus nerve
control mechanisms, rather than direct anti-adrenergic or vagus nerve effects. Although the
mechanism is not clear, it does not prevent us from applying it to the clinic. Our team is working
on a bracelet that can continuously produce electrical stimulation to the Neiguan spot, which we
hope can be used to treat AF. Therefore, we think that acupuncture on Neiguan spot could be a
minimally invasive, economic and safe approach to attenuate AF.

References

Application to your case (Article 3)

How might you incorporate the information in this article into your care of the patient? (at least
300 words)

Biomedica How does the patient’s biomedical diagnosis inform your approach to treatment?
l Diagnosis
(For example, are there any points or herbs you are avoiding? Are there ways in which the
patient is limited in the types of treatment they can receive? Are there ways in which you are
coordinating care with other treatment providers?) (at least 200 words)
NA No biomedical diagnosis for patient.

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