Medical Acupuncture
A Journal For Physicians By Physicians

Spring / Summer 2000- Volume 12 / Number 2
"Aurum Nostrum Non Est Aurum Vulgi"

CASE REPORT

Acupuncture Treatment
Of Post-MI Angina
Alison Lee, MD
Kevin Lee, MD

ABSTRACT
    Post-myocardial infarction (MI) angina is a source of significant morbidity and mortality despite a wide range of standard and experimental therapies. The following case report describes a patient with post-MI angina that responded to treatment with acupuncture. Points used included those from evidence-based selection as well as individual energetics.

KEY WORDS
    Angina Pectoris, Unstable Angina, Acupuncture, Myocardial Infarction, Case Report, Receptors, Opioid

INTRODUCTION
    Despite medical advances, cardiac disease continues to be a major source of morbidity and mortality. Patients whose symptoms do not respond fully to maximal medical management and/or who are not candidates for surgery present a challenge. Previously studied modalities for these patients have included thoracic epidural infusion and spinal cord stimulation. Research supports the use of acupuncture for chronic stable angina. In this case report, acupuncture was shown to be effective in management of refractory post- myocardial infarction (MI) angina. The case demonstrates a combination of evidence-based point selection with point selection based on principles of acupuncture energetics.

Case Report
    A 68-year-old Asian man with a previous cardiac history, 9 days status-post inferior wall MI, presented with the chief complaint of chest pain 6 times a night since MI.
    The patient's chest pain was pressing and radiating; it started in the chest and spread to the throat, jaw, lateral nose, and under each eye. Episodes lasted 5-15 minutes, hourly between midnight and 6 am. Previously active, the man now spent most of his time in bed. His medical history was significant for coronary artery bypass graft surgery twice, 5 and 12 years ago. He denied any arrhythmias or congestive heart failure.
    The review of systems was notable only for skin allergies. Several teeth were lost due to gingival disease. There were no indications of diabetes.
The patient's family history was positive for cardiovascular disease and cutaneous allergies.
    His medications included nitroglycerin, nitroglycerin patch 0.4, 9 am to 11 pm, lansoprazole qHS, atorvastatin 10 mg/d, atenelol 15 mg/d, vitamin C 500 mg/d, and a Chinese herbal formula containing Dan Shen.
Physical Examination
    The patient's blood pressure was 114/69 mm Hg. He was 5'7" and weighed 185 lbs. His skin showed evidence of excoriation, a few ecchymoses, and cherry angiomata. On his chest was a well-healed sternotomy scar with a purple area at the inferior aspect, and mild tenderness especially at CV 17. On the medial aspects of both legs were slightly red, thick saphenous graft site scars, overlying several points on the KI meridian. Lungs and heart were normal; most of the patient's overweight was in the abdomen. Lower extremities were cool with venous stasis; tongue body was large, muscular, and slightly purple, with a thin white coat, slightly shiny laterally. Pulses were pipelike, soft in the SP position and diminished in the KI position.
Diagnostic Studies
    The patient's family reported that his electrocardiogram was changed from previously, reflecting an acute MI. Cardiac enzymes confirmed this. Hypercholesterolemia was also noted. Angiography demonstrated multiple vessel occlusion and good motility.
Treatment and Follow-up
    The patient lived in another state; consequently, treatments were performed when travel times permitted. The family requested treatments similar in schedule to what he would typically receive in China: daily or twice daily. Nutritional/herbal recommendations and visualization exercises were given. Acupuncture treatments were provided as follows:
    At the 1st treatment, research-based points were determined, and sternotomy scar deactivated. The patient remained pain-free until 7 am the following morning.
    The next day, leg scars were deactivated, especially those overlying KI points, and in foci of redness or less vital healing. Pain returned the following morning at 6 am, with chest pain radiating to the sides of the nose and under the eyes. The 3rd day of initial treatment centered on the Tai Yin/Yang Ming circuit with focus on transition between LI 20 and ST 1. The patient was symptom-free.
    Two weeks later, the patient returned for further treatment. He awoke with brief throat pain not long after arrival. Daily treatments included combining points selected on the basis of research, in consideration of his Yang Ming constitution, scar deactivation, and to move blood stasis. The patient's morning pain discontinued, his walking increased, and he stated that he had been delaying his application of the nitroglycerin patch until progressively later in the day. The patient had no symptoms until several days after this cycle. Then, he experienced throat pain 1 hour after eating a sandwich to which mayonnaise had been accidentally applied, suggestive of acute occlusion of coronary microvasculature. Several days after that incident, LI Heat was cleared following ingestion of fat with development of symptoms, and warmth palpated over the LI area. The patient casually discussed the mayonnaise-related episode, but developed acute warmth over the LI area. Treatment was also directed to the throat, including energetics aspects of expression.
    After that, the patient obtained further care from a Chinese- trained physician near his home. His last treatment was Fall 1999. He was seen at 15 months follow-up after his initial treatment; he described full activity, free of cardiac symptoms. His only prescription medication was atenelol.
Summary of Points Treated and Stimulation Methods
    The major points used are listed, with primary rationales for use, in the Table. Treatments were generally performed using needles ranging from 0.5-1 in long, 32-34 gauge, with retention times of 15-20 minutes.

Table. Major Points Used, Rationale, and Literature Citations

DISCUSSION
    Post-infarction angina occurs in 10%-15% of patients and is associated with risk for infarct extension, repeat infarction, or sudden death. Despite numerous therapies including intra-aortic balloon angioplasty, this condition remains associated with a poor prognosis.18,19
    Decreasing sympathetic tone is a major component of cardiovascular therapy. Studies have been done on the effect of acupuncture on heart rate, cardiac output, electrocardiography, vectorcardiography, and vascular studies.8 Like other interventions that favorably affect cardiac disease, acupuncture is associated with sympatholytic effects,20 and effects on endorphins and other neurotransmitters.21 Opiate receptors are found on the vagus nerve,22 arterial tissue,23 and cardiac tissue. The latter play a role in protection against ischemic injury.24 Opiate receptors have also been identified in sympathetic ganglia.25
    European literature has demonstrated beneficial effects of acupuncture in the treatment of chronic stable angina.3,26,27 Both patient reports and exercise testing have been evaluated. When standard point formulas were studied, the greatest improvements occurred in less severely affected patients.26 Improvements in patients with more significant disease were associated with treatments that allowed more individualization.3
    Acupuncture practitioners frequently criticize point formulas for presumed failure to respect energetic theories and patient individuality. The value of formulas is that they lend themselves to research in today's medical environments, and they can serve as a basis for treatments in selected patients. Evaluation of formulas demonstrates the energetic theories underlying their use. Further application of energetic theories to formulas allows modification for individual patients and improved results.
    In terms of TCM and energetics, our patient experienced Stagnation of Heart Blood,7,28 against background susceptibility in Yang Ming. The heart's role in the sustenance of life is well-recognized not only in Western physiologic terms but in a variety of cultures. Before contemporary understanding of the heart and circulation was described by Vesalius, the heart was understood as a housing for emotion and the soul. Chinese medicine describes the heart in myriad relationships.
    The heart is physically located in the Upper Heater, along with the lungs. These organs share a Husband-Wife relationship.29 In the language of TCM, Heart functions include domination of the blood and vessels and housing the Shen. The Heart opens to the tongue. The Heart relies on adequate supply of blood from the Spleen, where blood is derived from nutritional matter; the Spleen controls the flesh and muscles. The heart is a muscle, and intact Spleen function can support the physical integrity of the heart.30 Study point HT 7, the Earth Point on the HT meridian, allows influence of the relationship between Spleen and Heart. Dermatomal back Shu points for Master of the Heart, Heart, and Spleen add reinforcement to this aspect of treatment.
    The patient's persistent throat discomfort drew attention to this area's energetic qualities relating to communication. The relationship between the Chakras of Heart, Throat, and Third Eye follows the branching from the Heart meridian to the throat and eye,7 and can be seen as a pathway for acting on internal changes through insight and clear communication. HT 5 can impact communication, affecting the Heart through its historically noted action on the tongue.
    The Liver30,31 contributes to cardiac activity by its Ko cycle and relationship with the Spleen in governing the amount of blood in the circulation, and by facilitating the smooth flow of rhythmic, flowing activity (cardiac pumping and blood flow through patent, relaxed vessels). The Liver helps provide a smooth path for the blood through its physiologic function in regulating lipid metabolism. Fatty foods are thought to contribute to Liver Stagnation and consumption of Liver Yin. A vicious cycle occurs wherein fats impair the Liver function and fat metabolism is altered. Anger, the emotion of the Liver, has also been associated with type A personality and predisposition to cardiovascular disease or hypertension.32 Through its relationship to Yang Jue Yin, abnormal Liver function may hinder the protective abilities of the Master of the Heart. Affected patients may develop above-average sensitivity to joyful emotional stimuli, with increased susceptibility to adverse effects of overexcitement. Activation of point MH 6 acts on the chest, as well as protection of the Heart. LR 3 can be used to reinforce the Jue Yin effect, and smooth Liver when indicated.
    The patient's constitution and symptoms related according to the inverse/contrary relationship between the trigrams for Shao Yin and Yang Ming.14 The relationship between Yang Ming predisposition and cardiac disease comes together in considering 1 particular manifestation of the Yang Ming constitution, gingival disease. This disturbance is related both to the system's management of sugar and the linearity of the Yang Ming meridian.33 Epidemiological studies show correlation between periodontal disease and coronary artery disease.32 Organisms associated with periodontitis have been identified in atherosclerotic plaque.34 Invasion of coronary artery cells by oral bacteria has been shown to provoke inflammatory changes consistent with atherosclerotic disease.35 ST 36, the Earth Point, may allow drainage of Fire, including inflammation, in Yang Ming. Linear and energetic Yang Ming may additionally be modulated through LI 4 and LI 11. The long circulation between LI and ST can further be affected through these 2 components of Yang Ming.
    Consideration of point combinations adds further dimension to the treatment approach. In addition to heart disease, postoperative changes can reflect disruption of the structural and energetic pericardium, meridians Master of the Heart and CV, zones of Curious Meridians Tchong Mo, Yin Keo, Yin Oe, and the anterior branch of GV. Through these channels, the heart is related to life on many levels. In a broader sense, these relationships can be considered in terms of the Heart Chakra.4,5,7,11 The patient was actively healing his family of their concerns, but there was little left for his own healing. This patient's illness provided an opportunity for family members to develop their own self-reliance and lighten the patient's burden. The patient's unstable angina led the way for a new, more balanced stability in his life.

CONCLUSION
    Acupuncture has a long history of use based on multiple converging logical theories, even when not supported by contemporary English-language research. The literature on acupuncture treatment of cardiac disease is beginning to confirm historical approaches from several traditions.
    Consideration of this particular patient's needs, i.e., treatment individualization, allowed effective application of research to a patient whose pathology was more severe than that of study populations. This case demonstrates that acupuncture can be useful in the treatment of post-MI angina.

ACKNOWLEDGMENT
    Thanks to Kathy Mullins-Engelhardt, LPN, for thoughtful refinements of the manuscript.

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AUTHORS' INFORMATION
Dr Alison Lee is Board-certified in Anesthesiology with certification in Pain Management. She is the Medical Director of Barefoot Doctors, an acupuncture and natural medicine resource center in Walled, Michigan. Dr Lee is actively involved in teaching acupuncture-related subjects to medical groups, including the University of Michigan Medical School. She is the Founding President of Acupuncture Society of Michigan.

Alison Lee, MD
Barefoot Doctors
136 So Pontiac Tr
Walled, MI 48390
Phone/Fax: 248-926-4292

Dr Kevin Lee is a Neurological Surgeon with subspecialty in Pain and Parkinson's disease, in private practice at Barefoot Doctors, an acupuncture and natural medicine resource center in Walled, Michigan. Dr Lee's special interest is in cerebral hemorrhage research at Meridian Biotechnologies, Inc., Walled, Michigan. He is Founding Vice-President of Acupuncture Society of Michigan.

Kevin Lee, MD
Barefoot Doctors
136 So Pontiac Tr
Walled, MI 48390
Phone/Fax: 248-926-4292

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