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Chronic congestive heart failure, or chronic cardiac insufficiency, abbrevi- ated as heart failure, is an inevitable consequence in the late stage of almost every organic heart disease. It is clinically marked by symptoms or signs of left heart failure (due to pulmonary congestion) or right heart failure (due to venous congestion in systemic circulation). Cardiac insuf- ficiency is divided into two phases: compensation phase and decompensa- tion phase. Heart failure occurs in the decompensation phase and there are three degrees of severity (I~III). It is often triggered or aggravated by physical overstrain or emotional stimulation. This disease is generally poor in prognosis. In TCM, heart failure is closely associated with “fright with severe palpitations”, “chest bi-syndrome”, “dyspnea with cough”, “edema” and “deficiency-consumption”.

Etiology and Pathology

Heart failure is often caused by chronic heart diseases or long-term debilitation of other organs involving the heart, with insufficiency of qi, blood, yin and yang of the viscera, as well as visceral dysfunction; if at this time the disease is coupled with invasion of exogenous pathogenic factors, overstrain, improper after-care, or emotional stimulation, the healthy qi may be further damaged and the heart can become more insuf- ficient in capacity.

The pathological changes of heart failure are discussed as follows: Deficiency of heart qi and lung qi leads to stagnation of phlegm and blood, marked by chest distress, shortness of breath and cough with spu- tum or even blood. Deficiency of qi and yin results in obstruction of blood in the heart which drives out the heart spirit, causing palpitations aggra- vated upon physical exertion. Exuberance of deficient heat in the interior brings about night sweats, vexation, insomnia and flushed cheeks. Deficiency of heart yang and kidney yang causes an overflow of water and body fluid which attack the heart and lungs in the upper body (with such signs as palpitations and shortness of breath) and the bladder in the lower

body (with such signs as scanty urine and edema). Prolonged affliction debilitates the healthy qi, as well as yin and yang, leading to extreme depletion of heart yang with a stuffy sensation in the heart or chest, sweat- ing, cold limbs and an extremely feeble, faint pulse.

Diagnostic Key Points

1. Chief clinical manifestations of left heart failure:

(1) Symptoms (acute pulmonary edema): Exertional dyspnea, parox- ysmal nocturnal dyspnea, orthopnea, weariness, or even cough, shortness of breath and expectoration of pink, frothy sputum. (2) Physical signs: Enlarged left ventricle, diastolic gallop in the apical

region, fine rales in the two lung bases and retention of fluid in the chest.

(3) X-ray examination: Enlarged heart and pulmonary congestion. 2. Chief clinical manifestations of right heart failure:

(1) Symptoms: Abdominal distension, reduced appetite, scanty urine, profuse nocturnal urine and edema in the lower limbs.

(2) Physical signs: Enlarged heart. If it involves primarily the right ventricle, there are accompanying symptoms such as heaving apex impulse, protodiastolic gallop near the left sternal border, fine rales in the two lung bases, hepatomegalia, engorgement of the jugular vein, positive hepatojugular reflux, edema in the lower limbs, retention of fluid in the chest and abdomen and cyanosis.

(3) X-ray examination: Enlargement of heart shadow, superior vena cava and the right atrium and ventricle.

3. NYHA (New York Heart Association) cardiac functional grading. Grade I: Unrestricted physical activities.

Grade II: Mild restriction of physical activities.

Grade III: Obvious restriction of physical activities, which is lower than the normal volume, with signs of weariness, panting, palpitations or angina.

Grade IV: Symptoms of restricted physical activities in any type or at any time, even when at rest.

Syndrome Differentiation

1. Qi defi ciency of the heart and lungs with blood stasis

and phlegm

Symptoms: Palpitations, chest distress, shortness of breath aggravated upon physical exertion, cough, expectoration of white sputum or bloody sputum and lassitude; a dark red tongue with thin coating and a knotted, intermittent pulse.

Analysis of symptoms : The heart controls blood and the lungs govern qi, so if the heart and lungs are deficient, the qi fails to promote blood, leading to obstruction of heart vessels marked by palpitations, chest distress, shortness of breath and cyanosed lips and nails; physical exer- tion consumes qi, leading to exacerbation of symptoms upon exertion; the lungs fail in their dispersing and descending functions, leading to phlegm and retained fluid in the lungs, marked by cough with white sputum; blood stasis in the lung vessels is responsible for expectoration of bloody sputum; disorder of the child organ involves the mother organ, leading to deficiency of lung qi and spleen qi, marked by lassitude; the dark red tongue with thin coating and the knotted, intermittent pulse are both due to deficiency of heart qi and lung qi with retention of phlegm and blood.

2. Defi ciency of qi and yin with internal obstruction

of heart blood

Symptoms: Palpitations aggravated upon physical exertion, lassitude, diz- ziness, night sweats, red cheeks, vexation and insomnia; a slightly red tongue and a knotted, intermittent pulse or thin, rapid pulse.

Analysis of symptoms: Deficiency of qi and yin leads to obstruction of blood in the heart, as well as malnutrition of the heart, resulting in palpita- tions aggravated upon physical exertion and lassitude; malnutrition of the clear orifices brings about dizziness; deficiency of yin produces internal heat, leading to night sweats and red cheeks; heat disturbs the heart spirit, with such signs as vexation and insomnia.

3. Yang defi ciency of the heart and kidneys with retention

of blood stasis and fl uid

Symptoms: Palpitations, chest distress, shortness of breath, cough with white frothy sputum, intolerance of cold, cold limbs, sore waist, scanty urine, pale or cyanosed complexion and general dropsy; a dark purple tongue with white coating and a thin, deep pulse or knotted, intermittent pulse.

Analysis of symptoms: Deficiency of heart yang brings about obstruction of heart vessels, marked by palpitations, chest distress and cyanosed com- plexion; deficiency of kidney yang leads to malnutrition of the kidneys, causing waist soreness; cold congeals the blood vessels, marked by intol- erance of cold with cold limbs; internal accumulation of water and fluid affects the heart and lungs, resulting in shortness of breath and cough with white frothy sputum; retention of water and fluid in the bladder results in dysfunction of qi transformation, with scanty urine; retention of water and fluid in the skin and muscles is responsible for general dropsy; the dark purple tongue with white coating and a thin, deep pulse or knotted, inter- mittent pulse are attributable to deficiency of heart yang and kidney yang with blood stasis and edema.