What are palpitations? Palpitations are a subjective symptom characterized by abnormal heartbeats or a sensation of restlessness in the chest—and in severe cases, a loss of control over the heartbeat—that occurs when the heart is subjected to strenuous physical activity, emotional excitement, or the effects of disease. They are commonly known as “heart fluttering.” Here, palpitations refer specifically to irregular heart rhythms caused by disease.
Palpitations include “jingji” and “zhecong.” “Jingji” is triggered by external factors such as fear or shock; once the triggering factor is eliminated, the palpitations disappear. “Zhecong,” on the other hand, is not caused by external factors; it manifests as a constant, restless fluttering that comes and goes, with no respite. The two differ in etiology, clinical presentation, and severity, yet they are closely related. Prolonged jingji can develop into zhecong; conversely, patients with zhecong are prone to having their palpitations exacerbated by external shocks. Due to this close relationship, later generations often combined the two under the collective term “palpitations.”
Palpitations are similar to what modern medicine refers to as autonomic nervous system dysfunction, as well as arrhythmias caused by various heart diseases. Arrhythmias occur when the discharge of cardiac excitation waves is disrupted or their conduction is obstructed, causing the heartbeat to lose its normal rhythm. Common arrhythmias include: sinus tachycardia, sinus bradycardia, sinus arrhythmia, sinus arrest, premature beats, paroxysmal tachycardia, atrial fibrillation, and atrioventricular block. The normal sinus heart rate for adults is 60–100 beats per minute.
I. Etiology and Pathogenesis of Palpitations
According to Traditional Chinese Medicine, the development of palpitations is often associated with psychological factors, deficiency of heart blood, weakness of heart yang, retention of fluid, and blood stasis obstructing the meridians.
1. Restless Mind: Individuals who are generally timid and easily frightened may, upon suddenly experiencing shock or terror, become so startled and disoriented that they lose self-control; over time, even minor startles can trigger persistent palpitations. Alternatively, intense anger may injure the liver, and extreme fear may injure the kidneys, causing qi to rise in reverse and essence to retreat. This results in yin deficiency below and fire rising above, which agitates the heart spirit and leads to palpitations. Furthermore, when phlegm-heat is internally retained and, following suppressed anger, the stomach loses its harmonious descending function, phlegm and fire become intertwined, disturbing the mind and causing palpitations.
2. Insufficiency of Heart Blood: Prolonged illness leading to physical weakness, excessive blood loss, excessive worry, or overwork damaging the heart and spleen can deplete heart blood and impair the spleen and stomach’s ability to generate and transform nutrients. Over time, this leads to a deficiency of both qi and blood, depriving the heart of its nourishment, resulting in restlessness of the mind and spirit, and the onset of this condition.
3. Yin Deficiency with Excessive Fire: Due to chronic illness and debility, excessive sexual activity, or frequent seminal emission, which injure kidney yin; or in individuals with an inherent deficiency of kidney yin, where yin fails to control fire, leading to uncontrolled “empty fire” that ascends to disturb the mind and cause palpitations.
4. Insufficiency of Heart Yang: Following a severe or prolonged illness, yang qi becomes deficient and unable to warm and nourish the heart meridians, thus leading to palpitations and restlessness.
5. Stagnant Blood Obstructing the Meridians: This results from deficient heart yang causing impaired blood circulation, or may develop from a syndrome of bi (obstruction). If pathogenic factors of wind, cold, and dampness invade the blood vessels and penetrate the heart, they obstruct the heart meridians, impair the circulation of nutritive blood, and lead to palpitations.
6. Ascending Pathogenic Fluids: Yang deficiency in the spleen and kidneys impairs the ability to transform and metabolize body fluids, causing them to accumulate as pathogenic fluids. When these fluids ascend and suppress heart yang, this condition develops.
Modern medicine recognizes that there are many causes of arrhythmias. Some may be neurogenic, primarily involving the influence of the autonomic nervous system on heart rhythm—such as sympathetic nervous system excitation or reduced or excessive vagal tone. However, more commonly, arrhythmias result from various heart diseases, myocarditis, massive blood loss, shock, drug poisoning, electrolyte imbalances, and endocrine disorders, which cause myocardial damage, leading to myocardial ischemia and lesions in the blood vessels supplying the cardiac conduction system, thereby triggering arrhythmias.
II. Manifestations and Treatment of Palpitations
1. Differential Diagnosis and Treatment in Traditional Chinese Medicine
This syndrome is classified into deficiency and excess patterns, with the excess pattern being the most common. It is further subdivided into six subtypes.
(1) Restless Heart Spirit Type: Since fright disrupts the flow of qi, the heart spirit loses its autonomy, and the heart fails to contain the spirit, leading to a state of constant anxiety. Patients thus exhibit symptoms such as being easily startled and fearful, restlessness whether sitting or lying down, insomnia with frequent dreaming, a thin white tongue coating, and a weak and rapid pulse or a pulse with pauses and irregular beats. The treatment principle is to calm the mind, stabilize the spirit, nourish the blood, and soothe the spirit. The formula “An Shen Ding Zhi Wan” (Calm the Spirit and Stabilize the Mind Pills), with appropriate modifications, may be used for treatment.
(2) Insufficiency of Heart Blood Type: Since the heart governs the blood vessels and its radiance manifests on the face, blood deficiency fails to nourish the heart and cannot ascend to nourish the brain. As the tongue is the “sprout” of the heart, insufficiency of heart blood leads to blood deficiency and qi deficiency. Consequently, patients present with palpitations, dizziness, a lackluster complexion, fatigue and weakness, a pale-red tongue, and a fine, weak pulse. The treatment principle should be to tonify blood and nourish the heart, as well as to invigorate qi and calm the spirit. Treatment may involve the use of Gui Pi Decoction or Sheng Mai Powder combined with Suan Zao Ren Decoction, with appropriate modifications.
(3) Yin Deficiency with Excessive Fire Pattern: Due to insufficiency of kidney yin, which fails to support the heart, heart fire becomes agitated internally, disturbing the mind. Furthermore, yin deficiency below leads to yang disturbance above. Consequently, patients present with palpitations and restlessness, irritability and insomnia, dizziness and vertigo, heat in the palms and soles, lower back soreness, and tinnitus, along with a red tongue and a fine, rapid pulse. The treatment principle is to nourish yin, clear fire, nourish the heart, and calm the spirit. Tianwang Buxin Dan may be used with modifications based on the specific symptoms. For instance, in cases of predominantly excessive heart fire, Coptis, Bamboo Leaf, and Forsythia Fruit may be added; if accompanied by heat in the palms, soles, and chest, as well as nocturnal emissions and lower back pain, Anemarrhena, Polygonatum, Cornus Fruit, and Phellodendron may be added to the formula.
(4) Heart Yang Deficiency Type: Due to physical debility resulting from severe or chronic illness, heart yang is depleted, the heart lacks warmth and nourishment, and there is a deficiency of yang qi in the chest. Consequently, the patient experiences a sensation of emptiness in the heart, restlessness and palpitations, a pale complexion, chest tightness and shortness of breath, aversion to cold and cold extremities, a pale tongue, and a weak pulse or a deep, fine, and rapid pulse. The treatment principle is to warm and tonify Heart Yang, calm the spirit, and alleviate palpitations. The Guizhi Gancao Longgu Muli Decoction, with appropriate modifications, may be used for treatment.
(5) Blood Stasis Obstructing the Meridians Pattern: Since the heart governs the blood vessels, obstruction in the heart meridians deprives the heart of its proper nourishment. Blood stasis and qi stagnation suppress heart yang, causing the heart meridians to contract and the blood vessels to become obstructed. Consequently, patients present with palpitations and restlessness, chest tightness and discomfort, intermittent chest pain, and may exhibit cyanosis of the lips and nails, a dark purple tongue with ecchymoses, and a涩 or intermittent pulse. The treatment principle should be to promote blood circulation and resolve stasis, as well as regulate qi and unblock the meridians. The Decoction of Peach Kernel and Safflower, with appropriate modifications, may be used for treatment.
(6) Pattern of Damp-Phlegm Invading the Heart: Since water is a yin pathogen that relies on yang qi for transformation, yang deficiency prevents the proper transformation of water. As a result, damp-phlegm accumulates internally and ascends to overwhelm the heart. Yang qi fails to reach the limbs or nourish the muscles and skin, and the accumulation of damp-phlegm in the middle jiao obstructs the ascension of clear yang. Consequently, patients may experience palpitations and dizziness, fullness and distension in the chest and epigastrium, aversion to cold with cold limbs, scanty urine, or edema in the lower limbs, thirst without desire to drink, or accompanied by nausea and salivation. The tongue coating is white and slippery, and the pulse is string-like and slippery. The treatment principle is to invigorate heart yang, transform qi, and promote the flow of fluids. Ling Gui Zhu Gan Decoction may be used for treatment.
2. Modern Medical Perspectives on the Manifestations and Treatment of Arrhythmias
(1) Sinus Tachycardia: Aside from palpitations and restlessness, and a heart rate of 100–140 beats per minute, patients have no other symptoms.
(2) Sinus Bradycardia: The ventricular rate is typically 40–60 beats per minute. When the heart rate is too slow, patients often experience fatigue, dizziness, palpitations, shortness of breath, chest tightness, chest pain, and low blood pressure.
(3) Sinus Arrhythmia: Patients may experience dizziness, palpitations, and other symptoms.
(4) Sinus Arrest: If the arrest lasts for a prolonged period, patients may experience syncope.
(5) Premature beats: Also known as premature contractions, extrasystoles, or simply “premature beats.” Patients often experience a sensation of the heart “thumping” in the chest or a feeling that the heart has stopped beating; the pulse may be intermittently absent, and the pulse rate is lower than the heart rate. This condition is commonly seen in cases of mental stress, excessive smoking or alcohol consumption, as well as in patients with coronary heart disease, cardiomyopathy, and atrial disorders.
(6) Paroxysmal tachycardia: This is a paroxysmal, rapid, and regular heart rhythm characterized by sudden onset and sudden cessation. It is commonly seen in patients with coronary heart disease, myocarditis, hypertensive heart disease, and drug poisoning. During an episode, the heart rate can reach 150–200 beats per minute, accompanied by palpitations, discomfort in the precordial region, and dizziness; episodes may last from several minutes to several hours, or even several days.
(7) Atrial Fibrillation: This condition involves irregular electrical impulses in the atria at a rate of 350–600 beats per minute, causing the muscle fibers in various parts of the atria to quiver in a highly uncoordinated manner, resulting in the loss of effective mechanical contraction of the atria. The vast majority of cases occur in individuals with significant cardiac pathology. The most common causes include rheumatic heart disease, coronary heart disease, and hypertensive heart disease. Patients typically present with pronounced symptoms such as rapid heart rate, palpitations, chest tightness, and anxiety. The heartbeat is irregular, and the pulse varies in speed and strength, with the pulse rate being lower than the heart rate.
(8) Atrioventricular Block: This condition refers to the obstruction of electrical impulses during atrioventricular conduction. It is classified as incomplete (including first- and second-degree atrioventricular block) and complete (third-degree atrioventricular block). Causes include vagal nerve stimulation, coronary heart disease, hypertension, myocardial disease, and certain medications. Patients often present with fatigue, dizziness, syncope, and convulsions; skipped beats, a slowed heart rate, or cardiac arrest may occur, with severe cases reaching 20–40 beats per minute.
In modern medicine, the treatment of arrhythmias is based on their type and cause, as well as the severity of symptoms they produce, with different treatments administered accordingly or targeted at the underlying cause. Mild cases do not require special treatment, while severe cases necessitate emergency intervention. Treatment methods for arrhythmias primarily include antiarrhythmic medication, electrical therapies such as defibrillation, electrical cardioversion, and electrical pacing, as well as various procedures to stimulate the vagus nerve. Concurrently, effective measures should be taken to control the underlying disease and contributing factors as much as possible.