Slow heart rate with premature beats refers to a pathological change characterized by a slow heartbeat accompanied by premature beats, known in modern medicine as bradyarrhythmia. In Traditional Chinese Medicine (TCM), it falls under the categories of “chest obstruction” (胸痹), “palpitations” (惊悸), and “sudden fainting” (怔忡). Clinically, it is primarily manifested by symptoms such as chest tightness, shortness of breath, palpitations, fear of cold, and a pulse that is thin or intermittent, indicating a deficiency of Yang and coldness. This condition is often caused by a weak constitution, insufficient Qi and blood, Yang deficiency of the heart, invasion of external pathogens, and obstruction of the heart meridian. Professor Liu Qiting has treated dozens of cases of slow heart rate and premature beats with his self-formulated formula, the “Tiaobo Zenglv Decoction,” achieving significant efficacy, which is introduced below.
Pathogenesis: Invasion of cold and dampness, obstruction of the heart orifice
From a large amount of clinical data, the formation of slow heart rate with premature beats is often caused by factors such as aging, weakness, and external invasion of cold and dampness. The pathogenesis can be divided into two extremes: deficiency and excess. The deficiency type is Yang deficiency, specifically heart and kidney Yang deficiency, while the excess type is characterized by excessive Yin, leading to cold dampness and blood stasis. Yang deficiency is the root cause, while excessive Yin is the manifestation.
The beating of the heart, the pulsation of the pulse, and the circulation of blood all rely on the warming and promoting effects of heart Yang and Qi. As stated in the “Treatise on Blood Disorders”: “Qi is the commander of blood” (气为血帅); when Qi flows, blood flows; when Qi stagnates, blood stasis occurs. Heart Yang is rooted in the kidneys, and its function must be warmed by the fire of the kidney Yang to exert its role in “governing blood vessels”. If there is heart and kidney Yang deficiency, it leads to internal cold; or if there is a weak constitution with external invasion of cold and dampness, cold, as a Yin pathogen, easily harms the body’s Yang Qi; or if there is excessive Yin and declining Yang, water Qi can invade the heart; or if there is pre-existing phlegm and stasis, obstructing the heart orifice. The interaction between internal and external pathogens leads to obstruction of the heart orifice, combined with insufficient heart Qi, resulting in slower blood flow and causing bradycardia and arrhythmia.
Treatment: Warming Yang, benefiting Qi, dispelling cold, and restoring pulse
Slow heart rate with premature beats is characterized by a weak constitution, invasion of cold and dampness, and obstruction of the heart orifice, leading to insufficient heart Yang, weak propulsion, and arrhythmia with a slow pulse rate. The root cause is heart and kidney Yang deficiency, while the manifestation is excessive cold and dampness. The relationship between root and manifestation is reciprocal; Yang deficiency leads to cold, and excessive cold harms Yang. Therefore, treatment should focus on warming Yang and benefiting Qi to address the root cause, while dispelling cold and resolving dampness to treat the manifestation, achieving the effect of restoring Yang, dispelling cold, and restoring the pulse. The formula used is Liu Qiting’s experience formula, the Tiaobo Zenglv Decoction.
Formula composition: Prepared Aconite (制附子) 10g, Red Ginseng (红参) 15g, Cinnamon Twig (桂枝) 15g, Poria (茯苓) 30g, Ephedra (麻黄) 10g, Asarum (细辛) 3g, Sophora Root (苦参) 15g, Licorice (甘草) 10g.
Dosage: Soak the above herbs for 2 hours, first decoct the prepared Aconite for 1 hour, then add the other herbs, decoct for 30-40 minutes each time, decoct three times, mix the juices, and take in 4 doses warm, each after meals and before sleep.
Function: Warming Yang, benefiting Qi, dispelling cold, and restoring pulse.
Indications: Slow heart rate with premature beats.
Formula basis: Slow heart rate with premature beats is often caused by a weak constitution and external invasion of pathogens. Clinically, it is primarily characterized by symptoms of chest tightness, shortness of breath, palpitations, and fear of cold, indicating a deficiency of cold. Cold pathogens obstruct the heart orifice, leading to insufficient heart Yang, weak propulsion, arrhythmia, and a slow pulse rate.
The treatment should focus on benefiting Qi and warming Yang, dispelling cold and transforming dampness, and promoting heart Qi. Aconite is effective in supplementing the Mingmen fire, assisting Yang, and invigorating heart Yang to expel cold; Red Ginseng greatly tonifies the Yuan Qi, serving as a powerful Qi and blood tonic, ensuring sufficient Qi in the spleen and lungs, thus invigorating the heart vessels; Cinnamon Twig and Poria assist Yang, transform dampness, and promote water metabolism, specifically treating water Qi invading the heart and dampness obstructing the heart orifice; Ephedra and Asarum are key herbs for dispelling cold, with Ephedra dispersing cold and opening the pores, expelling pathogens from the surface, while Asarum dispels Yin cold pathogens. Together, they treat both internal and external cold pathogens, enhancing the ability to expel cold and also having a constrictive effect on blood vessels, which helps to increase heart rate, thus complementing each other; Sophora Root dries dampness and eliminates turbidity, effectively treating arrhythmias; Licorice harmonizes the properties of the herbs. The combination of these herbs works together to benefit Qi, strengthen the spleen, warm and transform water dampness, and invigorate heart Yang.
Modification and application: For those with heart deficiency and fearfulness, add Sour Jujube Seed (酸枣仁) and Amber (琥珀) to nourish blood and calm the spirit; for those with deficiency of both heart and spleen, add Astragalus (黄芪) and Longan Flesh (龙眼肉) to tonify the heart and spleen, benefiting Qi and nourishing blood; for those with blood stasis, add Chuanxiong (川芎) and Danshen (丹参) to invigorate blood and alleviate pain, transforming stasis and unblocking obstruction; for those with water Qi invading the heart, add Dried Ginger (干姜) and Bai Zhu (白术) to restore Yang and unblock the pulse, drying dampness and resolving phlegm; for those with weak heart Yang, increase the dosage of Cinnamon Twig and Aconite to warm the meridians and unblock the pulse, restoring Yang and rescuing from reversal.
Case Study
Patient Zhang, female, 51 years old, first diagnosed on December 1, 2011.
The patient complained of chest tightness, chest pain, palpitations, and shortness of breath for three years, worsening over the past half month. She had a history of bradycardia, feeling chest tightness and shortness of breath during fatigue or emotional instability, with multiple ECGs showing sinus bradycardia (around 50 beats/min), and second-degree atrioventricular block. She had been treated with various Chinese and Western medicines for coronary heart disease locally. Half a month ago, due to busy household chores and poor mood, she experienced aggravated chest tightness and shortness of breath, accompanied by fearfulness and palpitations, frequent sighing, fatigue, cold limbs, worsening symptoms with exertion and in the afternoon, occasional insomnia, poor appetite, feeling of fullness in the stomach, prone to colds, frequent urination, normal bowel movements, and delayed menstruation by 3-5 days, with cold pain in the lower abdomen during menstruation, scanty dark flow, and two days of menstruation. A re-examination of the ECG and 24-hour dynamic ECG indicated sinus bradycardia (49 beats/min), ST segment elevation and downward shift, frequent premature beats, and the Western diagnosis was coronary heart disease.
Upon examination, the patient appeared pale, with cold limbs, a tense expression, and anxiety, often taking deep breaths to relieve chest tightness and shortness of breath. The tongue was pale with a white coating, and the pulse was thin and slow. Based on the tongue and pulse diagnosis, the pattern was identified as insufficient Yang Qi and obstruction of the heart orifice. Due to Yang Qi deficiency, there was weak propulsion, poor blood circulation, and blood stasis, leading to chest tightness and shortness of breath, palpitations, and frequent sighing; Yang deficiency resulted in excessive internal cold, hence the cold limbs, fatigue, and poor appetite, with a thin pulse. The treatment should focus on warming Yang, benefiting Qi, dispelling cold, and restoring the pulse, using the modified Tiaobo Zenglv Decoction.
Prescription: Prepared Aconite (制附子) 10g (to be decocted first), Red Ginseng (红参) 15g, Cinnamon Twig (桂枝) 15g, Poria (茯苓) 30g, Ephedra (麻黄) 10g, Asarum (细辛) 3g, Sophora Root (苦参) 15g, Sour Jujube Seed (酸枣仁) 30g, Amber Powder (琥珀粉) 3g (to be taken in water), Licorice (甘草) 10g. One dose per day, decocted three times, mixed with Amber powder, taken in 4 doses, each after meals and before sleep. As the patient was in the menopausal stage, she was advised to avoid unnecessary worries, maintain a positive mindset, and avoid emotional stress, with regular sleep and a light diet, balancing work and rest.
On December 12, 2011, during the second visit, after taking 3 doses, there was no significant change in the condition. After taking 6 more doses, the patient felt slight relief in chest tightness, shortness of breath, palpitations, and coldness, with improved spirit and increased appetite. The complexion showed slight improvement, with cold limbs, heart rate at 52 beats/min, and occasional premature beats. The dosage of prepared Aconite was increased to 15g (to be decocted first) to enhance the warming and Yang-boosting effect, and 10 more doses were prescribed, with instructions to use the leftover herbs to make foot baths every night before sleep, fully utilizing the effective components of the herbs.
On December 23, 2011, during the third visit, the patient reported significant improvement in chest tightness and shortness of breath, disappearance of palpitations, and normal sleep, appetite, and bowel movements, but still felt fatigued, cold limbs, delayed menstruation, scanty light flow, heart rate at 58 beats/min, and disappearance of premature beats. The tongue was pale, with a thin white coating, and the pulse was deep and slow. The Amber powder was removed from the prescription, and the previous method of administration was continued.
On January 12, 2012, during the follow-up visit, after taking 30 doses continuously, the condition was basically stable, with a heart rate around 60 beats/min and disappearance of premature beats. Considering the patient’s Yang deficiency constitution, prone to cold and easy to catch colds, a formula combining Yao Ping Feng San and Gui Zhi Tang was prescribed, using Astragalus (黄芪) 30g, Fried Bai Zhu (炒白术) 30g, Fang Feng (防风) 15g, Cinnamon Twig (桂枝) 15g, Fried Bai Shao (炒白芍) 15g, and Honey-fried Licorice (炙甘草) 10g, one dose per day, decocted in water to benefit Qi, consolidate the exterior, regulate the Ying and Wei, enhance immunity, and strengthen the constitution. A month later, the patient reported stable condition with no significant discomfort and stopped taking the medicine on her own.
Note: Liu Qiting’s use of the modified Tiaobo Zenglv Decoction to treat slow heart rate with premature beats has achieved good clinical efficacy, especially in alleviating symptoms, improving prognosis, and ensuring safe medication, fully demonstrating the great potential and unique advantages of TCM in treating this condition. There have been some objections regarding the use of Sophora Root for treating arrhythmias; however, the basis for the Tiaobo Zenglv Decoction comes from pharmacological experiments and years of clinical experience. Pharmacological studies have shown that the alkaloid in Sophora Root has a quinidine-like effect, influencing the potassium and sodium ion transport systems in myocardial cells, reducing myocardial excitability, thus having an anti-arrhythmic effect, and showing good efficacy for tachycardia, bradycardia, premature atrial contractions, premature ventricular contractions, and atrial fibrillation.
Attention should be paid to the decoction and administration methods; Aconite should be decocted first, boiled for 1 hour on low heat after boiling. Prolonged decoction can reduce its toxicity and increase calcium content. Pharmacological research has proven that the active component of Aconite, racemic dehydroaconitine, has a rapid effect on increasing heart rate and improving sinoatrial and atrioventricular conduction in cases of bradyarrhythmia, thus having a certain cardiotonic effect. Each dose should be decocted three times and mixed, taken in 4 doses to maintain the continuity of the medicinal effect. The leftover herbs can be decocted again for foot baths before sleep, fully utilizing the effective components of the herbs, and also encouraging the patient to develop the habit of foot baths before sleep, as foot baths have multiple benefits such as promoting circulation, improving blood flow, consolidating the foundation, dispelling cold, and nourishing and protecting the kidneys.
Additionally, clinical observations have found that cases triggered by fatigue and invasion of cold and dampness respond well to treatment once the causative factors are eliminated. However, cases caused by elderly coronary heart disease and cardiomyopathy show poorer results. There are also some younger cases, initially often due to external heat pathogens, who, in their eagerness to recover, excessively used hormones. Although the heat subsided, the pathogens penetrated inward, leading to symptoms such as palpitations, chest tightness, shortness of breath, and spontaneous sweating, with ECGs often indicating myocarditis, atrioventricular block, and premature beats. These patients recover more slowly, which is related to a sudden decline in the body’s immune mechanism and the inability to overcome the pathogens, also reminding us to be cautious with or avoid hormone treatment for externally contracted febrile diseases.
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