Inspired by the idea of combining Chinese and Western medicine, Western medicine pathophysiology, Chinese medicine evidence, and modern Chinese medicine pharmacology by Prof. Ding-Ya Fang, I have made some exploration on the Chinese medicine treatment of heart failure by combining Western medicine’s understanding of the pathophysiological mechanism of heart failure. Modern medicine believes that heart failure is due to various causes of myocardial contraction and/or diastolic dysfunction, and the heart cannot pump enough blood to meet the needs of tissue metabolism. Heart failure is a progressive change that, once initiated, activates neurohumoral compensatory mechanisms, including increased sympathetic nervous system excitability and renin-angiotensin system (RAS) activation. Increased sympathetic excitability and increased blood norepinephrine levels can increase myocardial contractility and heart rate to increase cardiac blood output, but at the same time, it can also cause peripheral vasoconstriction, reducing tissue blood supply and increasing cardiac afterload; RAS activation has the advantage of increasing myocardial contractility and peripheral vasoconstriction to maintain blood pressure, regulate blood redistribution, and ensure blood supply to the heart, brain and other important organs. However, it also promotes aldosterone secretion, which causes water and sodium retention and increases volume load. Prolonged activation of the sympathetic nervous system, RAS, and increased secretion of aldosterone can also cause a series of changes in the myocardium, vascular smooth muscle, and vascular endothelium. In the myocardium angiotensin II increases the synthesis of new contractile proteins through various pathways; extracellular aldosterone stimulates the conversion of fibroblasts into collagen fibers, which increases collagen fibers and contributes to myocardial interstitial fibrosis. In the vasculature, vascular smooth muscle proliferation and luminal narrowing are caused, while the ability of vascular endothelial cells to secrete nitric oxide is reduced, so that vasodilation is affected. The long-term effect of these unfavorable factors eventually leads to further deterioration of cardiac function, tissue ischemia and stasis, and water and sodium retention, which can be seen as wheezing and shortness of breath, weakness and dizziness, palpitations, oliguria, edema, liver stasis, ascites, cyanosis, coughing up sputum, and coughing up blood. This pathophysiological mechanism is understood from a TCM perspective: the heart is deficient in qi, which is unable to move blood, and blood is not conducive to water, so that qi is deficient, blood is stagnant, and water stops and develops. Western medicine treatment emphasizes antagonizing the sympathetic nervous system and the renin-angiotensin-aldosterone system; Chinese medicine treatment involves benefiting Qi, invigorating Blood, and promoting water. It is composed of Fu Ling, Gui Zhi, Ze Di, Bai Zhu, and Pig Ling, which can resolve Qi and promote water retention, and is used to treat the evidence of water retention in the bladder, such as thirst and urinary discomfort. The author treated a patient with coronary heart failure, who was in his seventies, when he was first admitted to the hospital, he was unable to lie down, his lips and nails were cyanotic, he had a lot of white foamy sputum, both lower limbs had severe concave edema, his tongue was pale and dark, with teeth marks on the side, and his coating was white and slippery. He was treated with intravenous and oral diuretics, angiotensin-converting enzyme inhibitors, nitrates, and cardiac drugs according to western medical guidelines for the treatment of heart failure, and could lie down intermittently. Considering that the excessive amount of diuretic would lead to the increase of blood uric acid level and trigger the attack of gouty arthritis, and also affect the blood sugar level, we did not increase the dose of western diuretic, but took the diuretic effect of Wu Ling San and used Wu Ling San to reduce the dose. Considering that blood stasis is one of the basic pathological mechanisms of heart failure, and the patient has signs of blood stasis such as venous thrombosis, cyanosis of lips and nails, and dark tongue, we used Ze Lan instead of Ze Xie to promote blood circulation and water circulation, and added Mao Dong Qing to activate blood circulation and open the blood vessels; and because the patient has signs of yin injury such as thirst, red tongue and less fluid after diuresis with western medicine, and qi leaks with fluid, the patient also has signs of qi deficiency such as weakness of limbs, so we added Aconite to nourish yin and raw Astragalus to benefit qi. After one dose of medicine (the dose of western medicine remained unchanged), the next day the patient was pleased to say that the volume of urine increased greatly last night, “Wow, it’s never been so painful before”. Inspired by this, in the subsequent clinical practice, this method and formula (named Dong Qi Wu Ling Tang) was flexibly applied in the treatment of heart failure in coronary artery disease and dilated heart disease, with repeated success, fully appreciating the advantages of Chinese medicine in the treatment of heart failure, i.e. diuretic without harming Yin and depleting Qi. The whole formula of Dong Qi Wu Ling Tang is composed of eight herbs: Astragalus, Mao Dong Qing, Poria, Gui Zhi, Pig Ling, Zelen, Atractylodes, and Agaricus, which have the effect of benefiting Qi, invigorating blood and promoting water retention, and at the same time, diuretic does not harm Yin and consume Qi. The author’s experience is that raw astragalus and mao dongqing should be used heavily, 30g-50g each. raw astragalus is the only herb written into the treatment of dilated cardiomyopathy in Western medicine’s “Practical Internal Medicine”. Raw Astragalus tonifies Qi and has a cardiotonic effect, which enhances myocardial contractility and increases cardiac output, and is more pronounced in poisoned or fatigued failing hearts. In cardiomyocytes cultured with Astragalus, the cytoplasm is rich in mitochondria and glycogen granules, which are the energy source of the cells. Therefore, Astragalus can improve the energy metabolism of cardiomyocytes and strengthen their functions, which is one of the manifestations of its beneficial effect on Qi and muscle production. Astragalus polysaccharide can counteract acute myocardial ischemia caused by the posterior pituitary cord. Astragalus also has diuretic and swelling effect, can reduce the volume load in heart failure. Mao Dongqing blood circulation power is strong, folk commonly used to treat thrombo-occlusive vasculitis. Pharmacological studies have confirmed that Maodongqing has a clear release of vascular smooth muscle spasm, antithrombotic effect. It can counteract the contraction effect of epinephrine and posterior pituitary hormone on peripheral blood vessels. Ilexonin ( IA) is a physiologically active pentacyclic triterpenoid extracted from Mao Dongqing and chemically modified, which can increase the production of prostacyclin (PGI2), reduce the production of thromboxane (TXA2) by arterial endothelial cells [59], inhibit platelet aggregation induced by adenosine diphosphate (ADP) [26], and has a clear antithrombotic effect [ 60]; in platelet aggregation assay, the percentage of platelet aggregation at 30 min was (11.0±8.24)%, and the inhibition rate was 74.4%; trichostatin also reduced the levels of inflammatory factors IL-6 and serum macrophage colony-stimulating factor (M-CSF) after intimal balloon injury, and inhibited the proliferation of smooth muscle cells in the damaged intimal vessels. In clinical practice, special attention should be paid to the strong vasodilating power of Mao Dongqing, which can easily lead to hypotension at high doses. For patients with heart failure and hypotension, the dosage should be reduced and the dosage of raw Astragalus should be increased appropriately. Studies have shown that the addition of five Ling San (Poria, Atractylodes, Zelen, Poria, Gui Zhi, Chuanxiong, Astragalus) can increase renal blood flow, inhibit the reabsorption of sodium ions in the renal tubules, so that the 24-hour urine volume and sodium excretion increased, with a significant diuretic effect on swelling; on growth, water metabolism, renal function, better than the western drugs, and thiazide and other western drugs compared with the systemic state better than the western drug group. Zeilan not only has diuretic effect, but also has strong blood-activating effect, and its effective part L.F04 can significantly inhibit platelet aggregation and the formation of thrombus in vivo and in vitro [61], so it is used instead of Zeilan. The addition of Agaricus blazei is to imitate the intention of pig-ling soup and to prevent the disadvantages of diuretic injury to yin. In conclusion, “myocardial diastolic dysfunction → sympathetic nervous system and RAAS activation → vasoconstriction, blood circulation stasis, sodium and water retention” is the basic pathophysiological characteristic of heart failure, which is throughout the development of heart failure. The above pathophysiological mechanism determines that “qi deficiency, blood stasis and water stagnation” is the basic type of heart failure, which is the fundamental contradiction of the disease, and determines that “benefitting qi, activating blood and promoting water retention” is the basic treatment method. Of course, for each patient, due to the different primary causes of heart failure, physical constitution, season of onset, and stage of development of the disease, there will be a variety of concurrent symptoms, including yin deficiency, phlegm deficiency, yang deficiency, and blood stasis and heat, etc. Therefore, it is necessary to combine Chinese medicine to identify the symptoms, activate the method, and add and subtract according to the symptoms. This formula not only enhances myocardial contractility, but also dilates blood vessels, reduces peripheral resistance, diuresis and swelling, and reduces volume load. Appendix: Dongqi Wuling Tang for heart failure medical case Liu Moumou, male, 73 years old Initial diagnosis: 2010-1-1 Complaint: intermittent episodes of chest tightness and breathlessness for more than 19 years, aggravated for half a day. History: Intermittent episodes of chest tightness and breathlessness for more than 19 years, treated in an outside hospital, details unknown. 2 years ago, the patient was diagnosed with dilated cardiomyopathy when he was hospitalized in our hospital due to chest tightness and palpitations, and was treated with symptomatic support. In the past two years, he had recurrent episodes of chest tightness, wheezing, shortness of breath, and paroxysmal dyspnea at night, and was repeatedly hospitalized in our hospital. The patient has been taking Conco 2.5mg qd, Coxua 50mg qd, aspirin 0.1g qd, etc. regularly for a long time. In the past week, the patient had insomnia, no palpitation and chest tightness, no cough and sputum, no dizziness and headache, and came to our hospital for emergency treatment yesterday night due to insomnia. The patient was admitted to our ward for further treatment. The patient’s symptoms were: wheezing, inability to lie down, chest tightness, shortness of breath, poor sleep, low urine and stool once a day in recent days. Past history: history of hypertension for more than 2 years, the highest blood pressure 160/100 mmHg, usually taking Coxsackia 50mg qd, Bisoprolol fumarate 5mg qd, etc., self-reported good blood pressure control. He had a history of gout for 9 years and was taking allopurinol 0.1g bid orally. chronic renal insufficiency for 10 years and was taking piperazine ferulate tablets 50mg tid orally and Jin Shui Bao capsule 0.99g tid. hyperlipidemia for 10 years and was taking simvastatin 20mg qd orally. On examination: coarse breath sounds in both lungs, small amount of wet woven P mu 110 beats/min in both lower lungs, arrhythmia, enlargement of the heart border to the left, no murmur heard in each valve auscultation. No murmur could be heard in each valve auscultation area. The tongue is pale and dark with petechiae, the tongue is fat, the moss is thin and yellow, the pulse is weak in inches and slippery in the two guan feet. Ancillary tests: BNP: 15880pg/ml. three infarcts (-). Biochemical heptad showed: CREA 149.52umol/L, K: 4.62mmol/L GLU 7.53mmol/L. Blood count: WBC: 6.03×109/L, N%: 53.6%. Blood gas analysis: PH: 7.374, PCO2: 30.3mmHg, PO2: 110mmHg, BE: -6.3mmol/L, HCO3-: 19.4. Cardiac ultrasound: right atrial internal diameter 52*36mm, left ventricular ejection fraction 30%. Western medical diagnosis: 1, acute exacerbation of chronic congestive heart failure 2, dilated cardiomyopathy, enlarged heart borders, arrhythmia, complete left bundle branch block, frequent ventricular asystole, paroxysmal atrial fibrillation, cardiac function grade IV 3, hypertension grade II (very high risk) 4, pulmonary infection 5, gout 6, chronic renal insufficiency Treatment: Western medicine was given Irbesartan 150mg qd to lower blood pressure, Isosorbide nitrate pumped 4mg/h To dilate blood vessels, tolathiamil 20mg into the pot once/day, bumetanide 1mg into the pot once/day, diuretic to reduce the load. Administered sildiran 0.2mg for cardiac strengthening, atorvastatin 20mg qd for lipid adjustment, trimetazidine 20mg tid. administered ceftriaxone for anti-infection. Chinese medicine not prescribed yet. Second consultation: 2010-1-4 After 2 days of western medicine treatment, wheezing was relieved, but the patient complained of obvious weakness, dry mouth but did not want to drink, poor sleep, difficulty in sleeping, and nasal discharge. The second stool was regulated. The tongue is pale and fat, with petechiae and white, watery coating. Biochemistry 7: K: 3.62 mmol/L, Na: 139.07 mmol/L, CL: 96.39 mmol/L, TCO2: 32.82 mmol/L, UREA: 10.71 mmol/L, CREA: 186.72 mmol/L, GLU: 6.98 mmol/L. Evidence: Qi deficiency, blood stasis, water retention. Legislation: Benefit Qi Prescription: Fu Ling 15g Poria 15g Poria 15g Ze Lan 15g Atractylodes 15g Lily 30g Mao Dong Qing 30g Astragalus 30g Formula analysis: adding Lily can prevent diuretic injury to Yin, and can calm the mind and help sleep. Also advised to stop Bumetanide. Third consultation: 2010-1-11 Weakness slightly relieved compared with before, no breathlessness. Dry mouth relieved. Pain in the shoulders and back is often uncomfortable. Restless sleep at night, dreaming a lot, urination, red tongue, thin yellow coating, slightly greasy, fat tongue, sunken and slippery pulse. Prescription: Dong Qi Wu Ling Tang. Poria 15g Poria 15g Zeilan 15g Atractylodes 15g Lily 30g Mao Dongqing 30g Astragalus 30g Yujin 15g Mulberry 20g Gui Zhi 10g Radix Codonopsis 20g Formula Analysis: Qi deficiency, poor blood flow, limb meridian paralysis, so feel pain in the shoulder and back. The red tongue, thin yellow fur and slight greasiness are considered to be dampness and stagnation of blood and heat, which disturbs the heart and mind, thus causing insomnia. Another advice to stop torasemide, change furosemide 20mg po bid four diagnosis: 2010-1-14 take the above 3 doses, weakness significantly improved, no shortness of breath, shoulder and back pain stop, night sleep is also better than before, urine volume can be, stool once a day, soft quality forming, tongue tip red, thin yellow moss, tongue body fat, smooth pulse. Prescription: The above is effective, so make slight adjustments on its basis. Tongue tip red, thin yellow moss, consider still have heart fire, add light bamboo leaf to clear heart fire, and also has a diuretic effect. Add ginger to rejuvenate water drink. Fifth consultation: 2010-01-18 The patient has no complaints, no fatigue, no chest tightness, no shortness of breath, sleep, food, bowel movement, red tongue, thin yellow moss, fat tongue, smooth pulse. Prescription: The current condition is more stable than before, followed by Dong Qi Wu Ling Tang. Poria 15g, Poria 15g, Zelen 15g, Atractylodes 15g, Lily 30g, Cordyceps 30g, Mulberry 20g, Ulmus 15, Radix Codonopsis 20g, Cinnamomum 10g, discharged from hospital on January 20, 2008. He can go fishing by car. The diagnosis of “dilated cardiomyopathy and heart failure” is clear, and for the basic contradiction of Qi deficiency, blood stasis and water stagnation, Dong Qi Wu Ling Tang has been used as a remedy. During diuretic treatment with western medicine, the patient experienced side effects of decreased blood potassium and injury to both qi and yin, manifesting as obvious weakness, dry mouth but no desire to drink, poor sleep, and excessive dreaming, etc. After combining the TCM diagnosis with Dong Qi Wu Ling Tang with western medicine, the symptoms of weakness and dry mouth were completely relieved and sleep also turned better. The above results showed that the treatment of heart failure with the Chinese herbal medicine Dong Qi Wu Ling Tang can not only reduce the dosage of diuretics, but also alleviate the side effects of Yin and Qi depletion, and improve cardiac function and increase the activity tolerance.