How Do You Treat Stable Angina in Your Practice?

Abstract

William Heberden, MD, in 1768, gave the first description of angina pectoris (stable angina) and called it a “breast disorder,” (reported by Hessian et al.)¹ It is estimated that ∼9,000,000 people in the United States have chronic angina.² It is a clinical syndrome of precordial discomfort or pain, due to transient myocardial ischemia without infarction. Typically, it is brought on by exertion or psychologic stress and relieved by rest or sublingual nitroglycerin.

Diagnosis is clinical, made by the typical history and electrocardiogram (ECG)—if done during the attack—which usually shows ST depression and, in some cases, ST elevation, decreased R-wave height, bundle branch conduction disturbances, and arrhythmias, most commonly ventricular ectopics. Between attacks the ECG tracing is normal in 30% of cases, in the other 70%, it may show nonspecific T- and ST-segment changes. Stress ECG has a sensitivity of 90% in both men and women. An echocardiogram is used if the patient cannot do a stress test. Available imaging techniques include electron-beam computed tomography (CT), multidetector row CT, coronary angiography, cardiac magnetic resonance imaging, intravascular ultra sonography, and the nuclear stress test. Modern biomedicine treatment involves antiplatelet drugs, beta blockers and statins; a calcium-channel blocker is then added if necessary. Revascularization is considered in intractable cases.

Unstable angina occurs even at rest; usually, it is more severe, lasts longer (> 30 minutes), does not disappear with rest, and might signal a heart attack.

Prinzmetal angina (angina inversa) often happens in the late part of the night, is more painful, occurs in younger patients, and is due to spasm of the coronary arteries.

In women, angina pectoris is often due to microvascular disease as opposed to reduction of flow in the coronary arteries that occurs in men. Symptoms are usually atypical in the form of fatigue, nausea, dyspnea, abdominal pain, and discomfort in the neck, with or without chest pain.

Angina Pectoris in Chinese Medicine

In Chinese Medicine, angina pectoris is essentially Heart Blood Stasis. Of the various Heart Disharmony patterns, Heart Blood Stasis is the only pattern that causes chest pain. Pericardium patterns produce more chest pain than Heart patterns. This is because the Pericardium channel goes to the center of the chest and influences both the Heart and the Lungs. In this location, the channel acts as an agent for propulsion of Qi and Blood for both Heart and Lungs. Hence, involvement of the Pericardium channel causes pain, tightness, oppression, and distension in the chest. The Heart channel and the Pericardium channel can be involved together. If the pathology is Qi Stasis, the feeling is “distending” pain; if the pathology is Blood Stasis, the pain is often described as “stabbing.” A purple tongue indicates Heart Blood Stasis, as the Heart “opens” to the tongue, while purple lips would indicate Stasis of Blood in the Pericardium channel.

Hence, in addition to HT 7, Pericardium points PC 6, PC 4 (Accumulation point), BL 14, and CV 17 (Back Shu point and front MU point of the Pericardium), BL 15 and CV 14 (Back Shu point and front MU point of the Heart) are of utmost importance in the treatment of angina pectoris.

BL 13 (the Back Shu point of the Lungs) resolves both Qi and Blood Stagnation in the chest.

As the Stagnation continues, it affects other body fluids, and they condense to form Phlegm, and this aggravates the pathology further. ST 40, supported by ST 36, is the most useful point to treat Phlegm.

The Great Connecting channel of the Stomach goes from the Stomach to the ventricle of the Heart, and ST 36 exerts its effect on the Heart through this pathway.

SP 10, BL 17, GV 10, GV 11, and GV 12 relieve Stagnation of the Blood in general.

Bipay is an Extra point situated at the uppermost tip of the anterior axillary crease and is highly effective for addressing cardiac pain and arrhythmias.

LU 9 is the Influential point for blood vessels.

Because Stasis is an Excess condition, all of these points are stimulated by the reduction method. Stimulation of the above points would provide relief in almost all cases of angina pectoris similar to the effect of nitroglycerin, but at a slower pace; the absence of side-effects would be a distinct advantage.

Underlying Blood Stasis, there are almost always some Deficiency states, especially Yang Deficiencies related to the Kidney, Spleen, and Heart. I always look for such underlying patterns. Correcting them takes the treatment to a higher level not usually achieved with modern biomedicine treatments. This is reflected in the sense of well-being patients experience and by reduction in the frequency and severity of attacks. Physical exercise, correction of lipid abnormalities and other conditions such as diabetes mellitus and obesity should be adjuvants to acupuncture.

Chinese herbal remedies. These include Xue Fu Zhu Tang (Blood Mansion Eliminating Stasis decoction) and Red Stirring (Three Treasures Remedy).

Auricular points. These points include Heart E, Heart C1, Heart C2, Sympathetic Autonomic Point, Point Zero, Shen Men, Thalamus Point, Vagus Nerve, Lung 1, Lung 2, and Stomach. Choose points according to tenderness.

Illustrative Case

A 54-year-old overweight woman (98 kg) presented with a history of the following:
• Recurrent angina pectoris for 2½ years

• Recurrent palpitations (paroxysmal atrial tachycardia)

• Gastroesophageal reflux disease (GERD; associated with hiatus hernia) for 4 years.

This patient's angina was associated with a feeling of tightness and oppression in the chest, and the pain often radiated to the entire chest, more to the left. Chest pain, with a purple tongue pointed to Heart Blood Stasis (as previously mentioned, the Heart opens to the tongue). The presence of this patient's pain radiating to all over her chest with a feeling of oppression and her purple lips pointed to Blood Stasis in the Pericardium channel. Her tongue was purple, and her pulse was choppy. The tongue also had raised purple spots on the sides, pointing to Liver Blood Stasis. Palpitations, her hiatus hernia, and resultant GERD, associated with her cold feet and a warm face were due to Rebellious Qi of the Penetrating vessel. I have discussed this in detail elsewhere.³

She was treated with nitroglycerin spray because it was impossible to administer acupuncture every time she had chest pain; thus she needed to have some medication available for use when she experienced pain. Acupuncture was given, using CV 17, BL 15, PC 6, HT 7, Bipay, and LU 9 to address chest pain; and using SP 4 (Rt), PC 6 (Lt), LI 4 (Rt), LR 3 (Lt), ST 30, and KI 21 bilaterally. SP 4 is the Opening point, PC 6 is the Coupled point, ST 30 is the Entry point, and KI 21 is the Exit point of the Penetrating vessel. LR 3 and LI 4 were used to facilitate Qi movement to reduce Stagnation. PC 6, when used as an individual point, has its own actions, but, when used as a Coupled point immediately following SP 4, PC 6 acts as a point for the Penetrating vessel. This group of points balances Yin and Yang, back and front, left and right, and above and below.

Treatment was given twice weekly for 8 weeks and then once per month for maintenance, and she had near total symptom relief.

In longstanding cases needing long-term treatment, acupuncture needs support from herbal medicines to reduce the frequency and duration of treatments. The Chinese herbal medicines mentioned above will support acupuncture, but, in this case, I used:
• Latrodectus Mactans (homeopathic 30c), 5 drops twice per week. This was chosen due to its ease of administration. Being a bioenergy medicine, it would complement acupuncture better as both act through the Life Force (Qi).

• Silybum Marianum, 7 g, twice daily, was given to address Liver Qi and Blood Stagnation.

Evidence

Richter et al. reported beneficial effects of acupuncture in a randomized clinical trial (RCT). In this trial, frequency of attacks were reduced from 10.6 to 6.1 per week, performance before the onset of pain increased from 82 to 96, intensity of pain reduced from 1.4 to 0.8 (scale: 0–4). This was associated with improvements in ST depression from 1.03 mm to 0.71 mm.⁴

Xu et al. reported effectiveness of between 80% and 96.2% with acupuncture for addressing angina pectoris symptoms with no side-effects.⁵

In a review involving 16 individual studies, Chen et al. reported that acupuncture combined with conventional drugs was superior to conventional drugs alone for addressing angina.⁶ Acupuncture alone was superior to conventional drugs, but the onset of action was slower than with nitroglycerin.

Zhang et al. reviewed 8 RCTs, including 640 angina pectoris cases, involving 372 patients receiving acupuncture and 268 receiving conventional drugs. Results showed that acupuncture was superior to conventional drugs for relieving symptoms and reversing ECG changes, with no adverse side-effects. However, the time of onset of action was longer for acupuncture therapy.⁷

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