Overcoming Heart Failure: Combining Eastern And Western Approaches
Overview
Heart failure (HF) stands as a significant global health challenge, markedly affecting prognosis. While conventional medical approaches are prominent in HF management, there is an emerging emphasis on integrating traditional Chinese medicine (TCM). With a rich history spanning over two millennia, TCM offers a holistic approach to addressing various pathogenic aspects of HF. This review provides a comprehensive overview of HF classification, pathophysiology, and treatment, examining it through the lenses of Western medicine, TCM, and integrated traditional Chinese and Western medicine (ITCWM).
Drawing from the latest evidence, the review synthesizes knowledge on ITCWM interventions for HF, considering diverse TCM syndromes. It explores the efficacy of various TCM modalities, including decoctions, oral patent Chinese medicine, injections, acupuncture, and moxibustion. Furthermore, the review investigates TCM-based preventive strategies for HF, such as tai chi, Baduanjin exercise, and Sanfu acupoint herbal patching.
The findings underscore the potential of ITCWM in HF management and rehabilitation. However, the review underscores the need for further research to elucidate the underlying mechanisms and optimize treatment strategies. By bridging the realms of Western medicine and TCM, ITCWM holds promise for enhancing HF care.
Introduction
Heart failure (HF) poses a significant healthcare challenge globally, characterized by impaired ventricular function and a range of symptoms. Its prevalence is on the rise, affecting over 64 million individuals worldwide, with an estimated prevalence of 1%–2% in developed countries. Despite medical advancements, HF remains associated with high mortality and rehospitalization rates. In China, for instance, HF accounts for substantial healthcare costs and demands for services.
Traditional Chinese medicine (TCM) offers a holistic approach to HF treatment, drawing from centuries-old practices. Initially, HF was described in ancient texts using various terms like “heart impediment” and “heart water.” However, in modern TCM, HF is classified based on syndrome differentiation, with qi deficiency with blood stasis being a fundamental syndrome. This classification system helps tailor treatments to individual patients’ presentations.
In Western medicine (WM), HF is categorized based on structural and functional impairments, often involving echocardiography to assess left ventricular ejection fraction (LVEF). The recent standardized classification includes HF with reduced, preserved, or mid-range ejection fraction, reflecting advancements in understanding HF pathophysiology.
Integrated traditional Chinese and Western medicine (ITCWM) approaches combine TCM’s holistic perspective with WM’s objective assessments. By integrating both systems, clinicians can develop individualized treatment plans based on patients’ overall condition and specific HF syndromes.
In conclusion, a comprehensive understanding of HF from both TCM and WM perspectives allows for more personalized and effective management strategies. Integrating these approaches holds promise for optimizing HF treatment outcomes and addressing the complex needs of patients with this condition.
Treating heart failure with Western Medicine (WM)
Heart failure with reduced ejection fraction (HFrEF)
The current approach to managing heart failure with reduced ejection fraction (HFrEF) revolves around contemporary guideline-directed medical therapy (GDMT), consisting of four key drug classes: renin–angiotensin–aldosterone system (RAAS) inhibitors or angiotensin receptor-neprilysin inhibitors (ARNI), beta-blockers (BBs), mineralocorticoid-receptor antagonists (MRAs), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Recent advancements in pharmacological research have introduced promising treatment options targeting the pathophysiology of HF.
One notable addition to GDMT is sacubitril–valsartan, an ARNI that has demonstrated significant improvements in cardiac remodeling and reductions in cardiovascular mortality and HF hospitalization rates. Similarly, SGLT2 inhibitors have shown promising outcomes in reducing HF hospitalizations and mortality rates, independent of diabetes status, as demonstrated by landmark trials such as DAPA-HF and EMPEROR-Reduced.
In addition to these foundational therapies, several pharmacological interventions are being explored, including ivabradine, vericiguat, digoxin, polyunsaturated fatty acids, and intravenous iron therapy. Intravenous iron supplementation, in particular, has shown promise in improving quality of life and functional capacity in HFrEF patients, along with a reduction in HF-related hospitalizations.
Device-based therapies have also revolutionized HF management, targeting specific pathophysiological processes to enhance patient prognosis and quality of life. These therapies include implantable cardioverter defibrillators, cardiac resynchronization therapy, left ventricular assist devices (LVADs), transcatheter interventions for valve lesions, and innovative approaches like cardiac contractility modulation and baroreflex activation therapy.
The MOMENTUM 3 trial highlighted the efficacy of LVAD implantation in mitigating hemodynamic damage and providing a viable alternative for patients with advanced HF. Other interventions such as transcatheter aortic valve replacement and transcatheter edge-to-edge repair address valve lesions, aiming to improve hemodynamics and alleviate symptoms.
Overall, the integration of pharmacological and device-based therapies has transformed the landscape of HF management in western medicine, offering a comprehensive approach to improving outcomes and enhancing the quality of life for patients with HFrEF. Ongoing research and technological advancements continue to expand treatment options, providing hope for further advancements in HF care.
Heart failure with preserved ejection fraction (HFpEF)
As of now, an effective treatment for Heart Failure with Preserved Ejection Fraction (HFpEF) remains elusive, despite advancements in managing Heart Failure with Reduced Ejection Fraction (HFrEF). Current therapeutic approaches primarily target congestion reduction using diuretics like MRAs. Lifestyle modifications such as exercise and caloric restriction for weight loss have shown promise in alleviating symptoms.
Recent studies have examined the efficacy of sacubitril–valsartan in HFpEF patients, with results indicating no overall prognosis improvement but potential benefits in specific subgroups, particularly women and those with LVEF <57%. Additionally, SGLT2 inhibitors (SGLT2i) have emerged as a significant breakthrough, demonstrating a notable reduction in cardiovascular death or hospitalization in HFpEF patients, irrespective of diabetic status.
Both SGLT2 inhibitors and glucagon-like peptide receptor agonists (GLP-1 RAs) originally developed as antidiabetic medications, have shown positive effects on heart and kidney diseases. Notably, SGLT2 inhibitors exhibit precise evidence supporting their efficacy in both HFrEF and HFpEF. The STEP-HFpEF trial, highlighted at ESC Congress 2023 and published in the New England Journal of Medicine, showcased the benefits of semaglutide, a GLP-1 RA, in improving HF-related symptoms and physical function, alongside inducing weight loss, particularly beneficial for HFpEF patients with obesity.
These findings mark significant progress in the medical management of HFpEF, offering promising avenues for targeted treatments and improved outcomes. Further research and clinical trials are warranted to explore the full potential of these therapies and refine treatment strategies for HFpEF patients.
Treating heart failure with Traditional Chinese Medicine (TCM)
Tai chi
Tai chi, originating from ancient Chinese martial arts, offers a holistic approach to wellness by integrating mind and body practices. Through a combination of gentle movements, meditation, and breathing techniques, tai chi facilitates the harmonious flow of qi, or vital energy, throughout the body. Recent research has highlighted its potential benefits for individuals with heart failure (HF). A systematic review of 15 studies revealed promising outcomes, indicating that incorporating tai chi into standard care regimens resulted in improved left ventricular ejection fraction (LVEF) and reduced levels of NT‐proBNP, a biomarker for HF severity. Additionally, patients experienced enhanced quality of life, reduced symptoms, and decreased risk of hospitalization for HF, as evidenced by lower scores on the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Moreover, tai chi has shown efficacy in alleviating depression symptoms and enhancing both quality of life and exercise capacity, as demonstrated by improvements in the 6-minute walk test (6MWT). These findings underscore the potential of tai chi as a complementary therapy for managing HF and improving overall well-being in affected individuals.
Baduanjin
Baduanjin, a form of traditional Chinese Qigong, is widely practiced and emphasizes the harmonization of mind and body. It comprises eight sections of gentle, slow movements combined with muscle stretching and mental focus. A meta-analysis encompassing eight Randomized Controlled Trials (RCTs) involving 648 participants revealed that Baduanjin led to enhancements in both overall quality of life and exercise capacity. This was evidenced by a decrease in the MHFLQ (Minnesota Living with Heart Failure Questionnaire) score, indicating improved quality of life, and an increase in the distance covered during the 6-minute walk test (6MWT), suggesting enhanced exercise capacity.
Sanfu acupoint herbal patching
Sanfu acupoint herbal patching, a therapeutic modality traditionally practiced during the hottest period of the year, utilizes herbal patches applied directly onto specific acupuncture points on the skin. This treatment integrates the percutaneous absorption of herbal extracts with the stimulation and regulation of meridians and acupoints. A study involving 160 chronic heart failure (HF) patients demonstrated the efficacy of Sanfu acupoint herbal patching in enhancing cardiac function, improving quality of life, and reducing the rate of readmissions. This approach presents a holistic and promising intervention for managing chronic HF, offering potential benefits beyond conventional treatments.
Treating heart failure with Integrated Traditional Chinese and Western Medicine (ITCWM)
Traditional Chinese Medicine (TCM) has a rich history spanning thousands of years and has been a cornerstone in treating various ailments across Asia. Drawing from a wealth of clinical trials and TCM-related guidelines and expert consensus, this review highlights the latest progressions in the Integrative Traditional Chinese and Western Medicine (ITCWM) approach for managing Heart Failure (HF). By synthesizing evidence from clinical trials and incorporating insights from TCM experts, this review aims to provide a comprehensive overview of the advancements in ITCWM therapy for HF.
TCM decoction
In a rigorous multicenter, double-blind, randomized controlled trial (RCT), 80 patients with left ventricular ejection fraction (LVEF) of 45% or lower were subjected to a three-month intervention with either Buyang Huanwu decoction or a placebo, alongside standardized Western medication therapy. The study’s primary endpoints encompassed New York Heart Association (NYHA) classification, Traditional Chinese Medicine (TCM) syndrome scores, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels.
The findings revealed that participants receiving Buyang Huanwu decoction exhibited a nearly 1.5-fold increase in the effective rate of NYHA classification and TCM syndrome scores compared to those in the placebo group. Moreover, a higher proportion of individuals in the Buyang Huanwu decoction cohort achieved at least a 30% reduction in NT-proBNP levels compared to the placebo group. However, no significant disparities were observed between the two groups concerning NT-proBNP levels, six-minute walk test (6MWT) distance, or LVEF.
Subsequent analysis of additional RCTs corroborated the potential benefits of Buyang Huanwu decoction in improving LVEF and reducing NT-proBNP levels. Nonetheless, the disparate outcomes observed across studies may stem from varying factors. Notably, the absence of a placebo control in some trials raises concerns about potential psychological influences on treatment outcomes. Moreover, differences in the formulation of herbal treatments, as well as individualized therapy approaches, could contribute to discrepancies in results.
Buyang Huanwu decoction has demonstrated efficacy in ameliorating Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores and various echocardiography parameters in smaller-scale studies. The underlying mechanisms of action may involve the regulation of energy metabolism and coagulation function through diverse targets and pathways.
In the context of heart failure with preserved ejection fraction (HFpEF), Yangyin Shuxin decoction emerged as a promising therapeutic option. Clinical trials have shown that its adjunctive use alongside conventional Western treatment led to improvements in cardiopulmonary function, quality of life, and various diagnostic scores. Mechanistically, Yangyin Shuxin decoction may enhance energy metabolism and reduce oxidative stress-related injuries.
Similarly, Zhenwu decoction has shown favorable outcomes when combined with Western medication in treating chronic heart failure. Its potential mechanisms of action include modulation of oxidative stress, inflammation, and electrical remodeling pathways.
In conclusion, traditional Chinese herbal decoctions like Buyang Huanwu, Yangyin Shuxin, and Zhenwu hold promise as adjunctive therapies for heart failure management. However, further research is warranted to elucidate their mechanisms of action and optimize treatment protocols for improved patient outcomes.
Oral Chinese patent medicine
In a comprehensive review of clinical studies, the efficacy of traditional Chinese medicine (TCM) formulations, particularly Qishen Yiqi dripping pills and Buyi Qiangxin tablets, in the management of heart failure (HF) was highlighted. A randomized, double-blind, multicenter study involving patients with left ventricular ejection fraction (LVEF) ≤45% demonstrated that Qishen Yiqi dripping pills, when added to standard treatment, led to significant improvements in the 6-minute walk test (6MWT) distance and Minnesota Living with Heart Failure Questionnaire (MLHFQ) scores compared to placebo. Notably, these improvements were associated with amelioration in symptoms and quality of life. However, there were no significant differences in B-type natriuretic peptide (BNP) levels or composite clinical events between the Qishen Yiqi dripping pills group and the placebo group.
Further evidence from prospective multicenter cohort studies and meta-analyses supported the beneficial effects of Qishen Yiqi dripping pills in HF patients, particularly in enhancing diastolic function, reducing inflammatory markers, and improving exercise capacity. Moreover, Qishen Yiqi dripping pills exhibited promising outcomes in HF patients with comorbid diabetes mellitus by lowering fasting blood glucose and glycated hemoglobin levels.
Similar favorable results were observed with Buyi Qiangxin tablets, which demonstrated improvements in left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) classification, MLHFQ scores, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels in chronic HF patients. Mechanistically, Buyi Qiangxin tablets exerted anti-inflammatory, antiapoptotic effects, and mitigated ventricular remodeling, possibly through modulation of the PI3K/AKT signaling pathway and inhibition of the renin-angiotensin-aldosterone system (RAAS).
Moreover, Qili Qiangxin capsules exhibited efficacy in both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF) patients, as evidenced by improvements in NT-proBNP levels, 6MWT distance, MLHFQ score, NYHA classification, and echocardiographic parameters. Notably, Qili Qiangxin capsules enhanced diastolic function and quality of life in HFpEF patients, possibly through inhibition of the ROS/AMPK/mTOR signaling pathway.
Overall, these findings underscore the potential of TCM formulations, including Qishen Yiqi dripping pills, Buyi Qiangxin tablets, and Qili Qiangxin capsules, as adjunctive therapies for HF management. However, further well-designed, large-scale clinical studies are warranted to validate these observations and elucidate the underlying mechanisms of action.
TCM injection
Recent studies have highlighted the promising outcomes of integrating traditional Chinese medicine (TCM) injections with Western medicine (WM) for the treatment of heart failure (HF). Huangqi injection, when combined with WM, has shown significant improvements in cardiac functions, including increased left ventricular ejection fraction (LVEF) and decreased levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP). Moreover, it has demonstrated efficacy in enhancing quality of life and mitigating ventricular remodeling and inflammation.
YiQiFuMai lyophilized injection, another TCM therapy, has exhibited notable improvements in LVEF, cardiac output (CO), left ventricular end-systolic diameter (LVESD), and 6-minute walk test (6MWT) distance when used in conjunction with WM. Mechanism studies have suggested its ability to inhibit apoptosis, regulate autophagy, improve mitochondrial function, and alter metabolic patterns in HF patients.
Shenmai injection has shown promising results in improving left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVEDD), and 6MWT distance, along with reductions in NYHA classification and serum levels of various biomarkers associated with inflammation and oxidative stress. Additionally, it has demonstrated efficacy in reducing cardiogenic mortality and readmission rates in chronic HF patients.
Shenfu injection has exhibited significant improvements in NYHA classification and traditional Chinese medicine (TCM) syndrome scores in acute phase chronic HF patients. Animal studies have highlighted its ability to improve ventricular structure and function while reducing cardiac fibrosis through modulation of the TGF-β/Smads signaling pathway.
Xinmailong injection has demonstrated efficacy in improving NYHA classification, 6MWT distance, LVEF, and BNP levels in HF patients. It has also shown potential in alleviating inflammation and myocardial damage in HFpEF patients.
In addition to TCM injections, acupuncture and moxibustion have been identified as safe modalities for enhancing cardiac functions, as evidenced by improvements in LVEF, 6MWT distance, and BNP levels in HF patients. These findings underscore the potential of integrating TCM therapies into the treatment regimen for HF, offering promising avenues for improving patient outcomes and quality of life.
Conclusion
The discussion revolves around the clinically common heart failure (HF) syndromes, including qi deficiency with blood stasis, dual deficiency of qi and yin with blood stasis, and dual deficiency of qi and yang with blood stasis. Recent evidence from randomized controlled trials (RCTs) suggests that integrative traditional Chinese and Western medicine (ITCWM) treatments, such as traditional Chinese medicine (TCM) decoctions, oral patent Chinese medicines, TCM injections, as well as acupuncture and moxibustion, hold promise in HF management.
Guidelines from the Chinese Society of Cardiovascular Diseases stress the significance of symptom-based diagnosis and intervention with TCM, along with tailored treatments targeting specific symptoms. Notably, there is a growing recognition of TCM’s potential benefits in HF management, as evidenced by its inclusion in HF treatment guidelines in the United States. This acknowledgment reflects a shift towards integrating TCM into conventional approaches to HF management.
Looking ahead, ITCWM for HF is poised to continue offering its distinct advantages, providing increased hope and enhanced well-being for HF patients. By synthesizing key principles from guidelines of both China and the United States, the future of HF treatment stands to benefit from a comprehensive approach that combines the strengths of traditional and conventional medicine paradigms.
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