Case 1
A male, 60 years old, was admitted to the Guangdong Provincial Hospital of Chinese Medicine-Zhuhai Hospital on May 31, 2019, because of recurrent shortness of breath for over one month, that had aggravated for two days. Present medical history: Shortness of breath at rest and aggravation after activities with a little chest tightness, difficulty in lying horizontally, edema of both lower limbs, insomnia, and loss of appetite. His past medical history showed heart failure, atrial fibrillation, and an enlarged heart without any family history. Physical examinations showed weak respiratory sounds of both lungs, extended cardiac dullness, and a low and blunt heart sound. The tongue was pale and dark with a white and greasy coating, and the pulse was string-like and slippery. Laboratory examinations indicated aspartate aminotransferase of 70.0 U/L, lactate dehydrogenase (LDH) of 1,114 U/L, creatine kinase (CK) of 241.6 U/L brain natriuretic peptide (BNP) of 6,785 pg/mL, myoglobin of 99.48 ng/mL, cTnT of 816.3 pg/mL, INR of 1.3, D-dimer of 8.35 mg/L, HbA1c of 6.8%, CHOL of 4.79 mmol/L, TG of 1.78 mmol/L, LDL-C of 3.55 mmol/L, and HDL-C of 0.76 mmol/L. The results of the electrocardiogram (ECG): Left atrium hypertrophy, left ventricular hypertrophy, T wave change, and left axis deviation. UCG: EF of 35%, enlargement of the heart, general decline in the wall activity, a change of dilated cardiomyopathy was considered, left heart insufficiency (severe), right heart insufficiency (mild), multiple solid masses in the left ventricular, multiple hypoechoic and hyperechoic masses in the left ventricular apex (41 × 17 mm, 33 × 12 mm, and 36 × 12 mm) (high likelihood of thrombosis), aortic and mitral regurgitation (mild), tricuspid regurgitation (moderate), pulmonary hypertension (mild), and pericardial effusion (small amount) (Fig. 1). Chest X-ray: 1. Increased bronchovascular shadows, 2. enlarged heart shadow, widened right lower pulmonary trunk, aortic tortuosity, and calcification, and 3. bilateral costophrenic angles becoming blunt, and pleura thickening. Color doppler ultrasound of the cervical and vertebral arteries: Slight incrassation of the intima-media membrane of the bilateral carotid arteries, plaque in the right side, slight tortuosity of the bilateral vertebral arteries, and reduction of the diameter and blood flow of the right side. Color doppler ultrasonography of the veins of both lower extremities: Dysfunction with regurgitation (severe) of the bilateral femoral-saphenous vein valves and great saphenous vein valves, and varicosis of the great saphenous vein.
Western medicine diagnosis: 1. Acute left heart failure, 2. suspected coronary heart disease, 3. dilated cardiomyopathy, 4. left ventricular thrombus, 5. non-rheumatic tricuspid regurgitation (moderate), 6. hyperlipidemia, 7. carotid arteriosclerosis (with plaque), and 8. varicosity (lower limbs). Western medicine treatment: Aspirin (100 mg, qd, po) and clopidogrel (75 mg, qd, po) for antiplatelet aggregation, rivaroxaban (15 mg, qd, po) to prevent aggravation of the ventricular thrombus, enoxaparin (0.4 ml, qd) for anticoagulation; digoxin tablets (0.125 mg, qd, po) for the cardiotonic effect, metoprolol (12.5 mg, bid, po) to control the blood pressure and heart rate, furosemide (20 mg, bid, and po) and spironolactone (20mg, bid, po) for diuresis and improving myocardial remodeling, benazepril (5 mg, qd, po) or valsartan (80 mg, qd, po) to reduce blood pressure, isosorbide mononitrate (20 mg, qd, po) to expand the coronary arteries, rosuvastatin calcium tablets (20 mg, qd, po) to reduce the lipid level and plaque, potassium chloride (1 g, qd, po) sustained release tablets as a supplement, and oxygen inhalation for life support.
Chinese medical diagnosis: Heart failure disease (syndrome of Yang deficiency and flooding). Etiology and pathogenesis: The patient’s chest tightness and shortness of breath were caused by the damage of Yang Qi for a long time, and the Yang could not spread water for usage but accumulated in the heart and lungs. The tongue was dull, the coating was white and greasy, and the pulse was stringy and slippery; thus, the syndrome was characterized as a Yang deficiency and flooding. Chinese medicine treatment: To address both symptoms and root causes, modified Zhenwu decoction (ZWD) was given to the patient. Prescription: Radix Aconiti Lateralis Praeparata 15 g, Radix Paeoniae Alba 15 g, Rhizoma Zingiberis Recens 10 g, Rhizoma Atractylodis Macrocephalae 15 g, Poria 20 g, Semen Lepidii 10 g, Fructus Jujubae 10 g, and Bulbus Fritillariae Thunbergii 10 g. These herbs were boiled in water for decoction usage, po, and qd. Prescription analysis: In the ZWD, Radix Aconiti Lateralis Praeparata was the monarch drug to warm the Yang of the kidney and spleen to promote the circulation of Qi and body fluid, Rhizoma Atractylodis Macrocephalae and Poria were minister drugs to tonify the spleen to promote urination and draining, Rhizoma Zingiberis Recens was the assistant drug to warm the Yang for dispelling cold and dampness, Radix Paeoniae Alba was the guide drug to promote urination and nourish the Yin. This traditional Chinese decoction treated both the symptoms and causes as the principle, and took the method of benefiting the Qi and Yang in order to evacuate the water and dredge the collaterals.
Reexamination after a week: LDH: 668.0 U/L, CK: 46.2 U/L, BNP: 1,246.0 pg/ml, cTnT: 193.8 pg/ml, INR: 1.2, D-dimer: 0.7 mg/L, UCG: EF 34%, a change of dilated cardiomyopathy was considered, general decline and desynchrony in the left ventricular wall activity, reduction of the left ventricular systolic and diastolic function, thrombus in the left ventricular apical (18 × 10 mm), aortic, mitral and tricuspid regurgitation (mild), and pericardial effusion (small amount) (Fig. 2). The patient’s condition improved after treatment, and he was discharged on June 12, 2019. The patient’s spirit had improved with no obvious shortness of breath at rest, no chest pain and radiating pain, and no edema in both lower extremities. The tongue was dull, the coating was white and greasy, and the pulse was stringy and slippery. Physical examination: The breath sounds of both lungs were better, the heart rhythm was uniform, and no pathological murmur was heard in the auscultation area of each valve. The diagnosis and treatment from June 12, 2019 to July 9, 2019 were similar to that in hospital, except the enoxaparin, and decreased dosage of furosemide (10 mg, qd, po) and spironolactone (10 mg, qd, po). Rechecked UCG on July 9 showed an EF of 37% with no abnormal mass in the left ventricle.
Case 2
A male, 37 years old, was admitted to Guangdong Provincial Hospital of Chinese Medicine-Zhuhai Hospital on February 10, 2018, because of chest distress and shortness of breath for two weeks, and edema of both lower limbs for one week. Present medical history: Shortness of breath and chest tightness that was aggravated after activities, unable to be supine, severe edema from the lower extremities to the thighs, cough, and sputum with blood. The past medical history showed heart failure and hypertension without any family history. Physical examinations showed weak respiratory sounds and moist rales of both lungs, extended cardiac dullness, diffuse apex beats, and weak heart sounds. The tongue was pale and dark with a white coating, and the pulse was rapid. Laboratory examinations: WBC 13.37 10E9/L, NEUT% of 81.1%, GLU of 7.6 mmol/L, D-dimer of 2.18 mg/L, PT of 13 s, INR of 1.16, FIB of 6.13 g/L, PCT of 1.5 ng/ml, BNP of 13,988 pg/ml, cTnT of 73.12 pg/ml, and LDH of 835 U/L. ECG: Nodal tachycardia, T wave changes, and left atrial enlargement. UCG: EF of 24%, whole heart enlargement, combined bi-side cardiac dysfunction, left ventricular mural thrombus (43 × 22 mm), ultrasound changes of hypertension and coronary heart disease, mitral regurgitation (mild), tricuspid regurgitation (moderate), pulmonary hypertension (mild), and pericardial effusion (small-medium amount) (Fig. 3).
Western diagnosis: 1. Heart failure, 2. Grade 3 hypertension (very high-risk group), 3. hypertensive heart disease, 4. left ventricular thrombus, 5. alcoholic cardiomyopathy, 6. suspicious coronary heart disease, 7. tricuspid regurgitation (moderate), and 8. pericardial effusion (non-inflammatory) (small-medium amount). Western medicine treatment: Aspirin (100 mg, qd, po) and clopidogrel (75 mg, qd, po) for antiplatelet aggregation, rivaroxaban (15 mg, qd, po) for anticoagulation, cedilan (0.2 mg, prn, iv) and digoxin (0.125 mg, qd, po) for a cardiotonic effect, sodium nitroprusside (50 mg + 5% GS 250 ml, prn, ivd) to expand the coronary arteries and reduce the blood pressure, metoprolol (12.5 mg, bid, po) to control the heart rate, furosemide (40 mg, qd, po) and spironolactone (20 mg, bid, po) for diuresis and preventing myocardial fibrosis, benazepril (5 mg, qd, po) to reduce blood pressure and prevent myocardial remodeling, and rosuvastatin calcium (20 mg, qd, po) tablets to reduce the lipid level and plaque.
Chinese medical diagnosis: Heart failure (syndrome of the Yang deficiency and water stasis, and blood stasis blocking collaterals). Etiology and pathogenesis: The patient’s chest tightness and shortness of breath were caused by the damage of the Yang Qi for a long time, and the Yang could not spread water for usage but accumulated it in the heart and lungs with blood stasis. The tongue was pale and dark with a white coating, and the pulse was rapid; thus, the syndrome was characterized as a Yang deficiency and water stasis with blood stasis blocking the collaterals. Chinese medicine treatment: To address both symptoms and root causes, modified Wuling decoction was given to the patient. Prescription: Pericarpium Trichosanthis 10 g, Semen Lepidii 10 g, Ramulus Cinnamomi 15 g, Poria 20 g, Polyporus 20 g, Rhizoma Atractylodis Macrocephalae 30 g, and Radix Pseudostellariae 15 g. These herbs were boiled in water for decoction usage, po, and qd. Prescription analysis: In the Wuling powder, Rhizoma Alismatis was the monarch drug for clearing dampness and promoting dieresis, Poria, Polyporus, and Rhizoma Atractylodis Macrocephalae were the minister drugs to strengthen the effect of the monarch drug, Ramulus Cinnamomi was the guide drug to warm the Yang to promote the circulation of Qi and body fluid, and dispelling external pathogens. This traditional Chinese decoction treated both the symptoms and causes as the principle, consequently benefiting the Qi and Yang in order to activate the blood and invigorate the water.
Recheck of the UCG on February 13: EF of 41%, changes in hypertension, left ventricular dysfunction, left ventricular mural thrombus (41 × 18 mm), mitral and tricuspid regurgitation (mild), and pericardial effusion (small amount). Ambulatory blood pressure: 1. The 24-h ambulatory blood pressure curve showed a non-spoon shape distribution and 2. blood pressure increased in the morning. Dynamic ECG: Sinus rhythm, ST-T changes, and a 24-h heart rate variability analysis showed a decrease. The patient was discharged after the symptoms improved. The patient’s spirit was good, the shortness of breath and chest tightness were relieved, there was no cough and phlegm, no chest pain, slept well, and had normal bowel movements. Physical examination: The breath sounds in both lungs were slightly thicker, and no wet rales were heard. The cardiac dullness circle expanded to the left, the rhythm was uniform, and no pathological murmur was heard in the auscultation area of each valve. Diagnosis and treatment from June 13, 2018 to July 21, 2018 were similar to that in hospital, except the cedilan and sodium nitroprusside, and decreased dosage of furosemide (10 mg, qd, po) and spironolactone (10 mg, qd, po). Reexamination of the UCG on February 21: EF of 49%, cardiac changes of hypertension and alcoholic cardiomyopathy, left ventricular dysfunction (mild), left ventricular mural thrombus (22 × 12 mm), and mitral regurgitation (mild) (Fig. 4).