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Heart pattern identification

心病辨证 〔心病辨證〕xīn bìng biàn zhèng

The process of diagnosing a morbid condition as a disease pattern of the heart.

Physiology Recap

The heart has the functions of storing the spirit and governing the blood and vessels.

The heart stores the spirit: The spirit, which resides in the heart, is that which enables the individual to be conscious, respond effectively to stimuli and think clearly during waking time, and to rest when necessary and sleep easily at night.

Disturbances of the spirit are closely related to the heart. The spirit is nourished by the heart’s yīn blood; it is warmed and animated by the heart’s yáng qì.

The heart governs the blood and vessels: The heart, by its yáng qì, propels the blood through the vessels; hence conditions of the blood and vessels are understood to reflect the state of the heart.

Yīn-blood and yáng qì: Yīn-blood (yīn and blood) is the substantial aspect of the heart and its tendency to quiescence; the yáng qì of the heart is the heart’s active aspect.

Pathomechanical Features

Disease of the heart is attributed to either insufficiency of the qì, blood, yīn or yáng of the heart or to evils largely of internal origin.

It manifests essentially in disturbances of the spirit of the heart’s governance of the blood vessels.

Insufficiency of Qì, Blood, Yīn, and Yáng

The heart is susceptible to insufficiency of its qì, blood, yīn, and yáng resulting mostly from damage to right qì through enduring illness, constitutional insufficiency, and taxation of the spirit through excessive preoccupation. The patterns can be summarized as follows:

Insufficiencies of the heart’s yáng qì or yīn blood may be caused or exacerbated by insufficiencies in other viscera. Since the heart and lung are both powered by ancestral qì, qì vacuity often affects them both at the same time.

Susceptibility to Evils

The heart is susceptible to fire, phlegm, and blood stasis, mostly arising internally.

Cold: The heart is susceptible to insufficiency of yáng qì (vacuity cold), which makes it further susceptible to externally contracted cold evil. These factors appear in heart yáng vacuity and heart vessel obstruction.

Fire: Hyperactive heart fire arises when depressed qì transforms into fire, when excessive consumption of rich, fatty, and hot-spicy foods engenders heat, or when external fire invades the interior.

Fire manifests in general repletion heat signs (heat effusion, desire for cold drinks, short voidings of reddish urine), in addition to the heat-specific signs:

In warm-heat disease, heat entering the pericardium is effectively heat affecting the heart, since the distinguishing signs are manic agitation, clouded spirit, and delirious speech. Conventionally, however, it is discussed under warm disease rather than under heart disease.

Phlegm: Factors contributing to phlegm in heart disease include inability of the spleen to warm and transform water-damp, heat concentrating fluids, and qì depression. It is seen in phlegm clouding the heart spirit and phlegm-fire harassing the spirit. The main manifestations in these patterns are:

Stasis: Blood stasis affecting the heart develops under the influence of cold, qì depression, and phlegm. It is seen in heart vessel obstruction patterns.

Combinations: Fire, phlegm, and stasis often occur in combination because they share common causes.

In addition, although cold does not appear in the name of any heart pattern, it nevertheless figures in heart disease. Vacuity cold and externally contracted cold evil may cause or exacerbate static blood and/or phlegm.

Heart Spirit

Disturbances of the heart spirit occur in any disease of the heart and are attributed to exuberance or debilitation of the heart’s yáng qì or to phlegm.

Exuberance of the heart’s yáng qì stemming from insufficiency of yīn blood or repletion fire causes the heart spirit to become agitated, causing heart vexation, insomnia, profuse dreaming, talkativeness, and even manic raving. Such conditions are often described as the disquieted heart spirit (心神不安 xīn shén bù ān, 心神不宁 xīn shén bù níng) or spirit failing to keep to its abode (神不守舍 shén bù shǒu shè). In some cases, there may be susceptibility to fright.

Exuberant heart yáng qì stemming from insufficiency of yīn blood or repletion fire remains strong at night, and hence often causes insomnia and profuse dreaming. The body’s yáng qì is naturally stronger in the daytime to support our daily activities. At night it normally grows weaker, as yīn qì becomes stronger. When excessively exuberant, yáng fails to enter yīn (阳不入阴 yáng bù rù yīn), that is, it fails to be constrained by yīn. This is why insomnia and profuse dreaming figure prominently in heart disease.

Debilitation of the heart’s yáng qì deprives the heart spirit of animation, causing lassitude of spirit laziness to speak or, in more severe cases, listlessness of essence-spirit with dull reactions and reduced thinking activity.

Phlegm clouds the spirit (also described as phlegm clouding the orifices of the heart). When this occurs in external contractions, it causes partial or total loss of consciousness. When it occurs in illness of internal origin, it causes mental disturbances.

Blood and Vessels

The effect of heart disease on the heart’s governing the vessels occurs in exuberance and debilitation of yáng qì and in static blood.

Exuberance of the heart’s yáng qì forces the blood to move more rapidly. This causes heart palpitation, a red or crimson tongue, and a rapid pulse. In severe cases, it causes frenetic movement of hot blood, which manifests in bleeding.

Debilitation of the heart’s yáng qì prevents it from moving freely. This causes heart palpitation, oppression in the chest, chest pain (pain in the anterior of the chest), a bright-white complexion, and a slow pulse, a bound pulse, or an intermittent pulse. Here, heart palpitation is caused by debilitated yáng qì laboring to move the blood.

Cold, static blood, phlegm: Debilitation of the heart’s yáng qì fosters and is exacerbated by cold, static blood, and phlegm. These evils add to yáng qì’s burden and exacerbate oppression in the chest. Static blood can cause stabbing chest pain.

Relationship to Other Viscera

Pathomechanical relationships exist between the heart and the other four viscera, as well as with its paired bowel, the small intestine.

Heart Signs

Heart signs include heart and chest discomforts, including heart palpitation, pain in the chest, and oppression in the chest and by heart spirit signs, such as forgetfulness, heart vexation, insomnia, delirious speech, mania, and clouded spirit.

Heart and Chest

Heart palpitation (心悸 xīn jì); fright palpitation (惊悸 jīng jì); fearful throbbing (怔忡 zhēng chōng): Heart palpitation is a forceful or rapid heartbeat that is felt by the patient, associated with fright and flusteredness. When triggered by emotional stimulus, it is sometimes referred to as fright palpitation. Severe heart palpitation arising spontaneously without emotional stimulus and affecting a greater area (even stretching as far as the umbilicus) is called fearful throbbing, since it causes fear and panic. All three signs result from:

Note that although heart palpitation is traditionally described as being a disturbance of the spirit rather than the vessels, modern pathomechanical descriptions explain it in terms of movement of qì and blood. Also, all three signs are traditionally considered to be diseases.

Chest pain (胸痛 xiōng tòng): Also called pain in the chest. Pain anywhere in the chest. It occurs in heart disease, lung disease, and liver disease. In heart disease, chest pain is in the anterior of the chest at the position of the heart. The pain can radiate into the shoulder and along the medial side of the left arm. It is attributed to chest yáng failing to move or to the obstructive effect of phlegm, stasis, and cold in heart vessel obstruction.

Note that heart pain (心痛 xīn tòng) refers to pain in the heart or pain in the region of the heart, which includes the pit of the stomach. The term true heart pain (真心痛 zhēn xīn tòng) refers to pain in the heart itself (cardiodynia as in myocardial infarction), but this is a disease name rather than a symptom name.

Oppression in the chest (胸闷 xiōng mèn): A feeling of constriction and discomfort in the chest. Often called chest tightness in biomedicine. It indicates that yáng qì is failing to move or that evils are causing obstruction. Oppression in the chest occurs in heart disease, notably heart yáng vacuity and heart vessel obstruction, and in lung patterns involving phlegm, such as cold phlegm obstructing the lung or phlegm-heat congesting the lung. Less commonly, it occurs in spleen patterns involving dampness and in depressed liver qì.

In heart disease, oppression in the chest in severe cases is accompanied by pain and shares the same pathomechanisms as pain in the chest (see previous item). The two occurring together are often referred to as stifling oppression and pain in the heart and chest. (心胸憋闷疼痛 xīn xiōng bié mèn téng tòng).

Heart Spirit

Forgetfulness (健忘 jiàn wàng); abstraction (恍惚 huǎng hū): Forgetfulness is poor memory. It is often accompanied by abstraction, which is absentmindedness and inability to focus attention. It is mostly caused by heart blood depriving the heart spirit of nourishment or insufficiency of kidney essence, and less commonly by phlegm turbidity harassing the upper body or static blood attacking the heart. It mostly occurs in heart blood vacuity; dual vacuity of the heart and spleen; insufficiency of kidney essence; kidney yīn vacuity; and heart-liver blood vacuity.

Susceptibility to fright (易惊 yì jīng); flusteredness (心慌 xīn huāng): Susceptibility to fright is the tendency to be frightened or shocked easily. It is often associated with flusteredness (a feeling of nervousness and lack of composure) and with heart palpitation. It results from insufficiency of qì and blood failing to nourish the heart, from fire or phlegm-fire harassing the heart spirit, or from failure of the gallbladder’s governing of decision-making that results in lack of self-confidence. It occurs in heart blood vacuity, hyperactive heart fire, phlegm-fire harassing the spirit, in gallbladder qì vacuity, and dual vacuity of qì and blood.

Insomnia (失眠 shī mián): Also called sleeplessness (不寐 bù mèi). Difficulty getting to sleep, a tendency to wake with difficulty falling asleep again, or poor sleep that leaves the patient unrefreshed. It is considered a disease as well as a symptom. It is often associated with profuse dreaming, the tendency to dream more than usual. The main pathomechanisms are:

Insomnia occurs in heart blood vacuity; heart yīn vacuity; dual vacuity of the heart and spleen (insufficiency of heart blood and spleen qì vacuity); intense heart fire; phlegm-fire harassing the heart; noninteraction of the heart and kidney; ascendant hyperactivity of liver yáng; gallbladder qì vacuity; residual heat in the final stages of warm disease; and stomach patterns involving severe disharmony of stomach qì.

Profuse dreaming (多梦 duō mèng): A tendency to dream more often than normal. It often accompanies insomnia. When dreaming is profuse, it is often confused, hence the term profuse confused dreaming (多梦纷纭 duō mèng fēn yún) is a commonly used synonym. It occurs in heart blood vacuity and heart yīn vacuity. It can also occur in intense heart fire or phlegm-fire harassing the spirit, as well as in heart-gallbladder qì vacuity.

Heart vexation (心烦 xīn fán): A feeling of unrest in the heart. It arises when intense heart repletion fire or vacuity fire stemming from heart yīn vacuity harasses the heart spirit.

Spirit abnormalities (神的异常 shén de yì cháng): Also called spirit-mind abnormalities (神志异常 shén zhì yì cháng). Any state of the spirit, temporary or lasting, in which the patient does not react normally to stimulus and does not think or speak coherently or has abnormal moods (chronic emotional states) and difficulty relating to others or coping with daily life. The term includes clouding collapse (sudden clouding of the spirit during active life that causes a standing patient to fall), which occurs in epilepsy; manic agitation and delirious speech occurring in febrile disease; and mental abnormalities, such as occur in mania and withdrawal and in feeble-mindedness. Spirit abnormalities are explained in terms of various vacuities, qì depression, phlegm, and fire, but in all cases, they involve disturbances of the heart spirit. The main categories of mental disease are mania and withdrawal, which are described under Heart-Related Diseases.

Deranged spirit (神乱 shén luàn): Severe abnormality of the spirit. See previous.

Clouded spirit (神昏 shén hūn): Partial or total loss of consciousness that in heart disease arises when:

Clouded spirit can occur in vacuity and repletion patterns: Vacuity patterns include desertion patterns, notably fulminant desertion of heart yáng. Repletion patterns include heat entering the pericardium, intestinal heat bowel repletion patterns, heat toxin attacking the heart, summerheat patterns, phlegm-fire clouding the spirit, extreme heat engendering wind, wind-phlegm internal block patterns (as in wind stroke).

Clouding collapse (昏倒 hūn dǎo): Sudden loss of consciousness that causes a standing patient to fall to the ground. It occurs in epilepsy and wind stroke. In wind stroke, consciousness is not always regained.

Mania (发狂 fā kuáng): (1) Manic agitation (see next); (2) a disease characterized by the same signs (狂 kuáng). See mania and withdrawal.

Manic agitation (狂躁 kuáng zào): Also called manic derangement (狂乱 kuáng luàn). A condition marked by pronounced physical movements (agitation), in severe cases with flailing of the arms and legs (扬手掷足 yáng shǒu zhī zú) and deranged spirit sometimes with shouting, singing, and cursing. It is attributed to hyperactive heart fire, phlegm-fire harassing the heart spirit, or blood stasis. It may occur in externally contracted disease, such as yáng míng (yáng míng) patterns.

Delirious speech (谵语 zhān yǔ): Incoherent speech in a state of unclear spirit-mind, usually in high fever. It mostly occurs in repletion patterns. It is seen in intense heart or phlegm-fire harassing the heart spirit, which are mostly attributable to internal evils, although external heat may play a role. In febrile disease, delirious speech can occur in yáng míng (yáng míng) patterns and in heat entering the provisioning aspect (or the pericardium). It occurs in desertion patterns when the heart-spirit is deprived of nourishment, but with less stridor (see Muttering below).

Muttering (郑声 zhèng shēng): Also called mussitation. The act of mumbling to oneself haltingly and with frequent repetitions. Mussitation is a sign of dissipation of essence-spirit and is observed in yīn or yáng collapse patterns, when the heart spirit is clouded. Muttering is like delirious speech but only occurs in severe vacuity patterns.

Talking to self (独语 dú yǔ): Also called soliloquy. Talking when nobody else is present but ceasing when anybody approaches. It is a sign of a deranged spirit.

Tongue

Most pathological conditions of the body are reflected in the tongue. Hyperactive heart fire is associated with the following specific tongue conditions.

Mouth and tongue sores (口舌生疮 kǒu shé shēng chuāng): Ulcerations of the tongue or other parts of the oral cavity. These are associated with hyperactive heart fire.

Red-tipped tongue (舌尖红 shé jiān hóng): A tongue that is redder at the tip than in other parts. It is most commonly associated with hyperactive heart fire.

Pulse

Numerous pulses characterize heart disease. Many of them are the basic pulses associated with insufficiency of qì, blood, yīn, and yáng and of the evils that affect the heart

Often seen in heart disease are bound and intermittent pulses (collectively called bound-intermittent) in which beats are skipped. They reflect either insufficiency of its yáng qì or blood stasis.

Bound pulse (结脉 jié mài): A bound pulse is a slow, irregularly interrupted pulse. It is the result of cold, phlegm, or static blood obstructing the vessels. It is seen in heart vessel obstruction and in concretions, conglomerations, accumulations, and gatherings.

Intermittent pulse (代脉 dài mài): An intermittent pulse is a regularly interrupted pulse. It results from insufficiency of original qì and debilitation of the viscera. It is also seen in wind patterns, cold patterns, conditions resulting from fear and fright, and in injuries from knocks and falls.

Heart-Related Diseases

Heart-related diseases include palpitation and insomnia, traditionally regarded as diseases as well as symptoms, are described under Heart Signs above.

Epilepsy and mania and withdrawal are heart-related diseases but involve disturbances of other viscera.

Chest impediment (胸痹 xiōng bì): A disease characterized by stifling oppression in the anterior chest, in severe cases with pain that stretches into the back and in some cases panting that prevents the patient from lying down. It is caused by yáng vacuity, static blood, phlegm, and cold and takes the form of heart yáng vacuity, fulminant desertion of heart yáng, or heart vessel obstruction.

Chest impediment is a traditional disease category that is broad in scope, corresponding to what modern biomedicine classes as cardiovascular disease, pulmonary emphysema, and pleurisy.

True heart pain (真心痛 zhēn xīn tòng): A disease characterized by pain in the heart accompanied by heart palpitation, water swelling, cold limbs, hasty panting, sweating, and a somber-white facial complexion. The Líng Shū states, In true heart pain, the arms and legs and feet turn cold up to the joints and heart pain is severe. If it occurs at dawn, death ensues in the evening; if it occurs in the evening, death ensues at dawn (真心痛，手足清至节，心痛甚，旦发夕死，夕发旦死 zhēn xīn tòng, shǒu zú qīng zhì jié, xīn tòng shén, dàn fā xī sǐ, xī fā dàn sǐ). According to this description, true heart pain corresponds to cardiodynia caused by acute myocardial infarction with circulatory failure in biomedicine. See also chest impediment above. Note that the term true heart pain is derived by contrast to heart pain, a traditional term denoting any pain in the region of the heart, i.e., in the heart or the pit of the stomach (the two being sometimes poorly distinguishable).

Mania and withdrawal (癫狂 diān kuáng): Mania and withdrawal is a generic term for all conditions marked by mental derangement manifesting in disorganized behavior and speech and inability to cope with the demands of everyday life.

Mania (狂 kuáng) is characterized by manic agitation, shouting, violent behavior, and abusive speech. It is mostly attributed to phlegm-fire harassing the spirit or exuberant fire damaging yīn.

Withdrawal (癫 diān) is marked by signs such as mental depression, taciturnity, talking to self (soliloquy), and feeble-mindedness. It is mostly attributed to binding depression of phlegm and qì or to dual vacuity of the heart and spleen. Note that withdrawal here has nothing to do with the action associated with autumn in the five phases (the Chinese terms are different) or withdrawal associated with detox. Rather it refers to the withdrawn mental state of the patient.

Mania and withdrawal are not entirely distinct. In enduring withdrawal, depressed phlegm can transform into fire, causing mania. In prolonged mania, depressed fire can diffuse and discharge to leave stagnant phlegm and qì, causing withdrawal.

The term mania and withdrawal is a generic term for different types of mental illness. Although it is reminiscent of manic depression, it does not necessarily denote a bipolar condition. It includes depression, manic depression, schizophrenia, and delusional disorders.

Mania and withdrawal disease is to be distinguished from depression patterns, discussed below under Liver and Gallbladder Diseases.

Feeble-mindedness (痴呆 chī dāi): Dementia; a condition manifesting in dull facial expression, indifference of spirit-affect, dull reactions, and strange behavior. It is caused by congenital insufficiency, or by phlegm turbidity clouding the heart, which arises through such factors as depressed liver qì and spleen-stomach vacuity. Feeble-mindedness is poorly distinguishable from withdrawal in mania and withdrawal disease (癫狂 diān kuáng).

Heart Patterns

Below is a brief description of the major heart disease patterns, with links to entries that provide more detail.

Simple Patterns

Heart qì vacuity (心气虚 xīn qì xū): Heart palpitation; lassitude of spirit; qì vacuity signs. Results from constitutional weakness; enduring illness; decline in visceral qì in advancing years.

Heart yáng vacuity (心阳虚 xīn yáng xū): Heart palpitation or fearful throbbing; stifling oppression and possibly pain in the chest; yáng vacuity signs (vacuity cold). Develops from heart qì vacuity.

Vacuity desertion of heart yáng (心阳暴脱 xīn yàng bào tuō): Sudden development of heart palpitation, stifling oppression and pain in the chest, cold sweating, reversal cold of the limbs, clouded spirit, and a faint pulse in patients suffering from heart yáng vacuity.

Heart blood vacuity (心血虚 xīn xuè xū): Heart palpitation; insomnia; profuse dreaming; forgetfulness; blood vacuity signs. Results from blood loss; excessive taxation of the spirit; enduring illness; insufficient blood production resulting from spleen qì vacuity.

Heart yīn vacuity (心阴虚 xīn yīn xū): Heart palpitation; heart vexation; insomnia; profuse dreaming; yīn vacuity signs (vacuity heat). Results from enduring illness; excessive sweating, vomiting, or diarrhea; damage by fire resulting from depressed qì; lung, liver, and/or kidney yīn vacuity causing damage to heart yīn.

Hyperactive heart fire (心火亢盛 xīn huǒ kàng shèng): Vexation and agitation (or even manic agitation and delirious speech); mouth and tongue sores; repletion heat signs (e.g., heat effusion). Develops from excesses among the seven affects, causing qì to become depressed and transform into fire; excessive consumption of rich, fatty, and hot spicy foods; external fire invading the interior.

Heart vessel obstruction (心脉痹阻 xīn mài bì zǔ): Heart palpitation; intermittent stifling oppression and pain in the chest; blood stasis signs. Factors: insufficiency of yáng qì; blood stasis; phlegm turbidity; externally contracted cold or exuberant cold arising from yáng vacuity; qì depression resulting from affect damage.

Phlegm clouding the heart spirit (痰蒙心神 tán méng xīn shén): A repletion pattern marked by deranged spirit with signs of phlegm turbidity. Seen in epilepsy, withdrawal, and external contractions. Develops from qì depression resulting from affect damage and causing phlegm to accumulate and bind with qì and/or conversely from phlegm causing qì stagnation.

Phlegm-fire harassing the spirit (痰火扰心 tán huǒ rǎo xīn): A repletion pattern. Signs: deranged spirit; phlegm-heat signs. Seen in mania (mental illness with manic agitation) or externally contracted disease (clouded spirit with delirious speech). Develops by concentration of fluids either by externally contracted heat evil or by fire resulting from transformation of depressed qì.

Combined Patterns

Heart-lung qì vacuity (心肺气虚 xīn fèi qì xū): A forceless cough and shortness of breath or panting; heart palpitation; oppression in the chest; qì vacuity signs. It develops when cough and panting damage lung qì and further affects the heart or when vacuity in advancing age and/or excessive taxation damage heart and lung qì.

Dual vacuity of the heart and spleen (心脾两虚 xīn pí liǎng xū): Heart palpitation; insomnia; reduced eating; sloppy stool; signs of qì and blood vacuity. It results from enduring illness or excessive thought and preoccupation damaging the heart and spleen, or from chronic bleeding.

Heart-liver blood vacuity (心肝血虚 xīn gān xuè xū): Heart palpitation; insomnia; eyes and sinews deprived of nourishment; blood vacuity signs. It is caused by excessive thought and preoccupation damaging yīn blood, by excessive bleeding, or by enduring illness.

Effulgent heart-liver fire (心肝火旺 xīn gān huǒ wàng): Insomnia; distension and fullness in the chest and rib-side; and generalized heat effusion. Attributed to impaired free coursing stemming from excesses among the seven affects, giving rise to depressed liver qì that transforms into fire.

Noninteraction of the heart and kidney (心肾不交 xīn shèn bù jiāo): Heart vexation; heart palpitation; insomnia; limp aching lumbus and knees; seminal emission; profuse dreaming; and yīn vacuity signs. It is caused by excessive thought and preoccupation, by damage to yīn through enduring illness, or by sexual intemperance (excessive sexual activity).

Heart-kidney yáng vacuity (心肾阳虚 xīn shèn yáng xū): Heart palpitation or fearful throbbing; puffy swelling; scant urine; vacuity cold signs. It develops when heart yáng vacuity affects the kidney or when kidney yáng vacuity water flood intimidates the heart. Compare water qì intimidating the heart.

Water qì intimidating the heart (水气凌心 shuǐ qì líng xīn): A heart-kidney yáng vacuity pattern (See preceding item), in which the heart is affected by water qì resulting from kidney yáng vacuity. This is a vacuity-repletion complex and is marked by heart palpitation, rapid breathing, and a skipping pulse.

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