© Springer International Publishing Switzerland 2017
Massimo Fioranelli (ed.)Integrative Cardiology10.1007/978-3-319-40010-5_44. Acupuncture in Cardiovascular Diseases
(1)
Zhejiang Chinese Medical University, Hangzhou, China
(2)
Centro Medico di Agopuntura, Corso Dante 126, 10126 Torino, Italy
4.1 Historical Background, the Beginning and the Diffusion
Acupuncture is one of the traditional Chinese medicine (TCM) techniques, with at least a 3,000-years history. It originated in China and the Chinese name is Zhenjiu, meaning needle and moxa, the two methods used to stimulate the acupoint. The occidental word “acupuncture” comes from the Latin words acu (needle) and punctura. Acupuncture is the treatment of illness by sticking needles in the skin at particular points on the body’s surface, called acupoints. These points, described for the first time in a book in the second century BC, the Huang-di Nei-jing (the Emperor Huangdi’s Canon of Medicine), are the same as those used today for medical treatments [1].
The West had already encountered acupuncture and TCM in ancient times, since the third century AD, even if, in the Middle Ages, the exchange of knowledge was limited because of the impossibility of meeting and comparing ideas. Only with the discovery of the Indies did direct trade with China favor closer relations, bringing to Europe the echoes of some of the TCM doctrines, such as the theory of the canals/meridians and the acupuncture points, along with other TCM techniques such as phytotherapy, diet therapy, and gymnastics. There were two reasons for this limited initial knowledge: first, the difficulties in translating a doctrine that was widely different from ours and in addition written in Chinese ideographs; the second reason was the scarce scientific and medical preparation of the diplomats and priests, above all Jesuits, who carried out these first translations. Later, during the seventeenth century, European doctors, particularly Dutch and German, who had had direct contact with China through the Dutch East Indies Company, translated Chinese medical texts. In the eighteenth century, more information reached Europe, mostly from French doctors and diplomats who had lived in the Far East. In the USA, news of this medicine arrived later: the first English translation of a French text on acupuncture was only published in 1826. All these contacts, although fascinating from a cultural point of view, did not, however, lead to a real comparison between the Western medical and academic world and the cultural and scientific heritage of acupuncture and TCM, which, in fact, tended to create ethnographical and anthropological rather than medical and scientific interest.
It was only in the twentieth century, after the First World War, that western countries began to show a serious interest in acupuncture: the first real treatise on acupuncture in the West was the Précis de la Vrai Acupuncture Chinoise by George Soulié de Morant, the first volume of which was published in 1939. Interest grew after World War II and increased in the 1970s, at the end of the Cultural Revolution and the renewal of closer relations between China and the West.
In the USA, the beginning of greater awareness is usually considered to date from 1973, the year of Richard Nixon’s visit to China, when one of the accompanying journalists underwent acupuncture treatment. As the news spread, it aroused a good deal of interest. In Europe, this process had already begun some years earlier, although its diffusion was slower and more gradual than in North America. However, the real spread of acupuncture in the West only began in the 1970s. At first acupuncture grew in popularity, but during the 1980s, this gradually extended to all the disciplines of TCM: massage and physiokinesiotherapy, dietetics and pharmacology, and psycho-corporal and medical gymnastics. In Italy, acupuncture was introduced slightly later than in other western countries; it began to spread from the 1960s/1970s, consolidating its expansion in the 1980s and becoming a deep-rooted medical practice by the 1990s. This diffusion began within small restricted groups of pioneers and interested persons linked mainly to the French Schools of Acupuncture. France, as we have already seen, thanks to its colonies, had scientific and cultural channels open with Vietnam and was certainly a leading nation in the early spread of acupuncture in continental Western Europe [2].
4.2 Acupuncture in Cardiovascular Diseases
4.2.1 Introduction
In the TCM, the heart is the most important organ and is described as the “Emperor” of all the internal organs. It is the seat of the mind, the ruler of blood circulation, and the source of the vascular system. Covered by the pericardium for protection, it is regarded as the “monarch organ” and the “supreme ruler of the Zang-Fu organs,” which in TCM is the collective name for all internal organs. There are five Zang organs (heart, lung, spleen, liver, and kidney) and six Fu organs (gallbladder, stomach, small intestine, large intestine, bladder, and triple energizer). The Zang organs are mostly solid organs, characterized functionally as transforming, producing, and storing essential substances, but not discharging them; the Fu organs are characterized functionally by transforming and digesting food and drink and discharging metabolites.
The five Zang organs are regarded as the core structure and functions of the human body. Each organ is related to certain sense organs and tissues and is named based on the anatomy, but is not confined to anatomical entities; in fact, each can be regarded as a functional system.
The heart is described in The Canon of Medicine and the Classic of Difficulties (first or second century B.C.) as an organ “situated in the thorax” with its “apex contacting the diaphragm and the lung and its beat can be seen or felt under the left nipple, serving as the source of the pulse beat.” In the Yi Xue Ru Men or The ABC of Medicine (1575), the authors wrote: “the Heart looks like a lotus in bud, below the Lungs and above the Liver.” From this description, made many years ago, the heart in Chinese Medicine apparently refers to the same organ as in Western medicine [3, 4].
4.2.2 Physiology and Pathology
In TCM, the main physiological functions of the heart are to rule the blood and vessels and house the mind (Shen). The heartbeats drive blood to circulate through vessels to nourish the body, and this concept is similar to that of Western Medicine. To make this physiological function possible, two basic factors are necessary: a normal quantity of blood in the heart and vessels and a dynamic force that drives blood to circulate (Heart Qi). This is a very important aspect because normal heartbeats depend on adequate Heart Qi; only when Heart Qi is abundant can the Heart beat at a normal rate, rhythm, and strength, maintaining a normal blood circulation. On the other hand, a normal blood circulation also depends on the appropriate volume of heart blood. Thus, in the TCM, heart pathology, if Heart Qi is insufficient, there will be cardiac palpitations, shortness of breath, and a weak pulse. In severe cases, the patient can show precordial pain and a rapid and irregular or hesitant pulse. All these symptoms can be treated with acupuncture in a plan of integrative medicine: when the acupuncturist is a medical doctor, he uses western drugs along with all the tools of TCM.
In TCM, the heart is the “house of the mind”; it governs mental activities including consciousness, thinking, expression, and behavior. According to this function, the “heart,” in Chinese medicine, refers to a part of the central nervous system, particularly the cerebral cortex. This concept seems to be entirely different from that of modern Western medicine. As previously mentioned, in TCM, different organs are not confined to anatomical entities; thus, not only the heart but also all the Zang organs take charge of mental activities and emotions. This is one of the holistic views of Chinese medicine, that all mental activities are reflections of the physiological functions of the organs.
Among the Zang-Fu organs, the heart is the supreme ruler; thus, as it is the commander of all Zang-Fu organs, the heart controls all the mental activities pertaining to the other organs. It can therefore be concluded that the Heart plays the most important role in higher nervous activity. The heart is the house of “Shen”; Shen means the comprehensive manifestation of life activities especially the spirit, consciousness, and thinking. This explains why in TCM the correct functioning of all the Zang-Fu organs is so important for preventing and curing cardiovascular diseases, and why it is fundamental to control different etiological factors such as joy, sadness, anger, the correct diet, the quality of life, etc. [3].
The same is the case in Western medicine: heart diseases constitute an essential problem of contemporary, developed societies. Despite continual progress being made in pharmacotherapy and in invasive cardiology, the number of heart disease cases has been systematically increasing and heart disease remains the world’s number one killer [5]. The reason could be the complex etiology of these diseases; thus, to try to reduce the incidence of pathological heart conditions we must use different treatments. This is possible with integrative medicine, such as acupuncture; conventional medical treatment including lifestyle changes (stopping smoking, modifying diet, and increasing exercise); western drugs such as statins, nitrates, angiotensin-converting-enzyme (ACE) inhibitors, angiotensin II receptor blockers, calcium channel blockers, beta blockers, and antiplatelet drugs; and surgery such as coronary artery bypass grafts [6].
4.2.3 Cardiovascular Pathological Conditions: Evidence
As one of the oldest healing practices in the world, acupuncture has been used for several thousand years to treat many illnesses. In 2003, the World Health Organization (WHO) published a list of evidence-based conditions for which acupuncture could be used [7]. Specific to cardiology, angina pectoris, hypotension, and hypertension were listed. In recent years, however, the effectiveness of acupuncture in the treatment of these and other manifestations of cardiovascular diseases, such as ischemia, arrhythmias, and heart failure, and its effect on heart rate variability (HRV), have been studied and a large number of randomized controlled trials (RCTs) have been published [8].
4.3 Hypertension
Since the 1980s, various authors have demonstrated that several types of experimental hypertension, arrhythmias, and the defense reaction-induced pressure responses can be inhibited by electroacupuncture (EA), whereas hypotension and bradycardia can be alleviated by EA. Several experimental studies have been performed on this subject, from the vast epidemiological impact, above all to clarify the mechanisms of action of acupuncture on the control of the whole cardiovascular function and the possibility of influencing the autonomous nervous system.
Since 1984, numerous works provided by the Russian school have been published and even if planned otherwise, show the effectiveness of acupuncture in the control of light and modest hypertension, underlining at the same time the immediate effect of acupuncture on the pressure values and on the normalization of other parameters inherent to the neurovegetative and psychic functions [2].
A work in which the authors used real acupuncture versus sham acupuncture in ten patients suffering from hypertension revealed, in the group treated with real acupuncture, an immediate reduction of the diastolic pressure values. The acupoints used were Taichong LR3, Zusanli ST36, Quchi LI11, and the auricular point of hypertension [9].
In a controlled study, published in 1997, the authors have documented the increase in the systolic and diastolic pressure values in 50 patients not undergoing drug treatment. The authors also reported a significant decrease in renin activity, whereas the values of vasopressin and cortisol remained unchanged [10].
Thanks to the large number of studies published, in 2002, the WHO reported that acupuncture is suitable for treating primary hypotension and early essential hypertension. It has been reported that the influence of acupuncture on hypertension may be related to its regulatory effect on the level of serum nitrogen monoxide. For primary hypotension, acupuncture seems to be more effective than general tonics. For mild and moderate essential hypertension, the hypotensive effect of acupuncture is much more potent than that of placebos and is comparable with that of certain conventional hypotensive agents [11]. The importance of the integrative treatment has been shown in a recent meta-analysis; in fact, the authors’s results were consistent with the notion that acupuncture significantly lowers blood pressure in patients taking antihypertesive medications [12]. In addition, acupuncture is often effective for relieving subjective symptoms, and it has no side effects. The long history of clinical practice has proven that acupuncture has curative effects, but the physiological basis requires more scientific study. In a recent systematic review, the authors explored the clinical evidence for or against acupuncture as a treatment of various types of cardiac arrhythmias, concluding that several studies demonstrated that acupuncture may be an effective treatment [13].
We know that overactivity of the sympathetic nervous system commonly initiates and sustains blood pressure (BP) elevation in patients with essential hypertension [14], but also the overactivity of the renin–angiotensin–aldosterone system can cause BP elevation [15]. From the beginning, the pharmacological approach to hypertension has been the regulation of one or both of these systems that are responsible for regulating BP and fluid balance in the body; however, from the clinic, we know that unfortunately, many patients require two or more drugs for optimal control [16]. Another problem due to the Western medicine is the difficulty of providing a safe therapy with fewer adverse side effects [17]. Yin et al. [18] examined the use of individualized manual acupuncture (different acupoints in different patients after syndrome differentiation) versus noninvasive sham as an add-on therapy for hypertensive patients concurrently treated with various antihypertensive medications. A significant reduction in both systolic and diastolic BP was observed in the acupuncture compared with the sham group. A preliminary study examining point-specific responses such as hypertension control found that applying EA at Jianshi PC5–Neiguan PC6 and Zusanli ST36–Shangjuxu ST37 once weekly for 8 weeks reduced peak and average systolic and peak diastolic BP by 5 mmHg or more in 70% of patients, whereas EA at Pianli LI6–Wenliu LI7 and Guangming GB37–Xuanzhong GB39 did not consistently lower BP [19]. EA reinforcement treatment at Jianshi PC5–Neiguan PC6 and Zusanli ST36–Shangjuxu ST37 once a month maintained the reduction in BP over the 6-month period. In a meta-analysis published in 2014, examining RCTs using real versus sham acupuncture for the treatment of hypertension, four trials qualified for the analysis. This meta-analysis suggested that acupuncture might significantly lower systolic BP and diastolic BP in patients taking antihypertensive medications, but only lower diastolic BP in unmedicated patients. Most of these patients received individualized manual acupuncture treatment using TCM principles to guide the selection of acupoints [12].
4.3.1 Hypertension in TCM
Acupuncture generally works by harmonizing the body’s energy balance: in parts of the body where there is too much energy, the needles help to remove the excess and bring the body back into balance. From the TCM perspective, hypertension is a disorder of the yin–yang balance, and the treatment is aimed at restoring this balance. It is usually caused by emotional factors, diet, and constitutional defects that lead to an imbalance of yin and yang in the liver, spleen, and kidneys. Since balance restoration takes a considerable period of time, from the beginning an integrative therapy is needed, but once there is a therapeutic effect, this can often last for a long period. In addition, during Chinese medical treatment, the patient’s general condition improves first and the blood pressure lowers later [3, 20].
- 1.
Hyperactivity of liver yang and up-flaming of liver fire. The liver is closely related to psychic and emotional activities: mental stress or anger may cause hyperactivity of the liver yang, resulting in irritability, headache, dizziness, flushing face and red eyes, bitterness in the mouth, tinnitus, aversion to heat, insomnia, and constipation.
- 2.
Yin deficiency of the liver and kidneys and a deficiency of yin with exuberant yang. The kidneys use their essence to produce marrow, and the brain is the “sea of marrow.” In kidney yin deficiency, nourishment of the brain is often impaired and dizziness occurs. There may be other symptoms, such as a hot sensation in the palms and pain in the heels, tinnitus, and insomnia. Kidney yin deficiency is usually accompanied by deficiency of all the body’s yin, in particular, liver yin, with the consequent exuberant liver yang. In this case, the relative excessiveness of yang may still lead to irritability, headache, and aggravate dizziness.
- 3.
Deficiency of both yin and yang. Protracted yin deficiency may involve yang; besides dizziness, there may be symptoms such as cool limbs and an aversion to coldness, palpitations, nocturia, and edema.
- 4.
Internal retention of phlegm-damp. Improper diet, overwork, and stress may damage the transporting and transforming functions of the spleen, resulting in the production of damp and phlegm. Retained phlegm-damp gives rise not only to dizziness, but sometimes numbness of the limbs, headache with the sensation of pressure in the head, a sensation of oppression in the chest, and hypertension [3, 20].
4.3.2 Acupuncture
Baihui (GV20), Fengchi (GB20), Zusanli (ST36), Quchi (LI11), Taichong (LR3), auricular point of hypertension
Additional points are:
- 1.
Hyperactivity of liver yang and up-flaming of liver fire: Xingjian (LR2)
- 2.
Yin deficiency of liver and kidneys and deficiency of yin with exuberant yang: Sanyinjiao (SP6), Taixi (KI 3)
- 3.
Deficiency of both yin and yang: Zhaohai (KI6), Qihai (CV6), Guanyuan (CV4)
- 4.
Interior retention of phlegm-damp: Jianshi PC5, Neiguan (PC6), Shangjuxu (ST37), Fenglong (ST40)
4.4 Myocardial Infarction and Coronary Heart Disease
We know that the autonomic nervous system plays an important role in the modulation of cardiac electrophysiology and arrhythmogenesis [21]. In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules; the resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being.
Acupuncture therapy has been confirmed to be effective in treating cardiovascular diseases in clinical practice, and the acupuncture-induced balance of the autonomic nervous system activities is one of its key mechanisms [22]. Several randomized controlled trials show evidence for acupuncture in the treatment of coronary heart disease, including angina pectoris and myocardial infarction.
Myocardial ischemia and the consequent cardiac damage resulting from a lack of blood flow to the heart muscle can lead to cell death or infarction [23]. The severity and duration of post-ischemic changes depend on the length and intensity of the ischemia and can ultimately lead to heart failure [24]. Norepinephrine, a neurotransmitter released by the sympathetic nervous system, can increase the extent of ischemia by increasing demand for myocardial oxygen and causing coronary vasoconstriction [25], and the increases in sympathetic activation during myocardial ischemia can also lead to arrhythmias and increase infarct size [26].
Since the 1980s, various studies have been published to evaluate the effects of acupuncture on myocardial ischemia. Chen et al. [27] showed that the stimulation of the acupoint Neiguan PC6 increases myocardial contractility in congestive cardiomyopathy; the stimulation of the acupoint Shaofu HT8 instead decreases the contractive force of the myocardium and turns out to be positive in patients with hypertrophic cardiomyopathy. Li et al. [28] described the positive effects of acupuncture on cardiovascular function in patients with acute myocardial infarction. In this study, the authors compared the clinical and instrumental data of a group of patients treated only using drug therapy with those obtained in another group subjected to acupuncture and drug therapy combined.
Liu et al. [29] studied the effects of acupuncture on 100 patients suffering from coronary heart disease in a blinded controlled study. The authors used an acupuncture group and two control groups, one composed of healthy volunteers treated as patients, the other of subjects suffering from coronary heart disease treated with sham acupuncture at non-acupuncture points. In the subjects treated with true acupuncture, a significant increase in the contractility of the rear ventricular wall and an increase in the volume of the cardiac output, in contrast to the trend of the control group. It is interesting to note that in healthy subjects, significant variations in the cardio-circulatory function have not been highlighted.
In a study performed by Ballegaard et al. [30] on 49 patients with angina (two groups: real acupuncture vs sham acupuncture), the authors showed a reduction of 50% in the angina attacks and in the use of nitro-derivative medicines in both groups, the patients who underwent the real acupuncture also showed significant changes in resistance to stress (+9%) and timing of onset of angina pain (+10%) compared with the sham group.
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