Ask an expert - body - chest - palpitation

3 questions

Q: Hi. I suffer from ventricular ectopics,I have seen Drs regularly and take beta blockers which work to a degree. I have periods when things aren't too bad and periods when things are really bad,I do get quite down during these times. Do you think acupuncture would help?

A: We have been asked similar questions before, and in reply to one we said:

One has to be very careful answering questions such as these. Taking the pulse a the wrist is one of the key diagnostic techniques in Chinese medicine, along with looking at the tongue and a number of other evaluations. The irregular pulse has clinical significance in the tradition, and point to specific disorders of organic function as understood within this paradigm of medicine. However, these may not all involve the heart - in fact, most of them don't - and any suggestion that this is treating the heart as it is understood in the west needs to be set aside.

From a conventional medicine point of view, there is not a great deal of evidence that acupuncture can treat these problems, although what little there is does tend to be very positive, although not always methodologically sound enough to use as the basis for a recommendation. A good example of a systematic review is:

http://www.ncbi.nlm.nih.gov/pubmed/18992625

Some of the published research also involves animal experiments, sometimes called 'ratpuncture' in the trade, and although the results here may be promising it is quite a large assumption to believe that human physiology will respond in the same way.

We think that it would certainly be worthwhile talking to a BAcC member local to you about what the conditions may be telling them about the way your system as a whole is functioning. From our perspective all of our members are equally well-qualified to deal with the vast majority of patients who present at their clinics, and it is obvious from what we have said earlier that there are no specialists in heart problems per se - Chinese medicine primarily treats the person, not the condition which someone has.


There have been a couple of other systematic reviews

https://www.ncbi.nlm.nih.gov/pubmed/28432528

http://www.internationaljournalofcardiology.com/article/S0167-5273(11)00227-0/fulltext

which make largely positive noises, but as in all of these kinds of studies the treatment which is given is largely formulaic, and does not really represent what a traditional acupuncturist does, which is to gear treatment to the individual and his/her unique balance of energies. Where trials offer designs which allow the practitioner to do what they might normally do, so called 'black box' trials, the results tend to get better and better.

The bottom line, though, is that from a Chinese medicine perspective there are often functional disturbances which can generate symptoms, often far away from the source of the manifesting problem. The skill and art of the practitioner is to make sense of the diagnostic information and treat the root of the problem. This can often cause a symptom to reduce or even disappear without there having been any apparent connection between where the needles were placed and the part of the body in distress.

The advice we gave before still holds good, to visit a local BAcC member for advice and a short face to face assessment of what may be happening. Most BAcC members are only too happy to give a small amount of time without charge to prospective patients to enable them to assess whether acupuncture is the best treatment for their problem. This will obviously give a far better idea of what may be possible than what we can say at a distance.

Q: I am booked in for acupuncture for neck pain. I am now having second thoughts as I am on warfarin for atrial fibrillation. My questions are: Will it interfere with the electrical impulses from the needles causing me to have an atrial fibrillation attack and could it cause localised bleeding?

A: Let us first put your mind at rest about using acupuncture when on warfarin. The advice we give to members in a Guide to Safe Practice is:

Patients on anti-coagulant medication

You must take great care when needling patients who are taking anti-coagulant drugs such as Warfarin. Only very superficial needling with fine needles (0.20mm) is recommended.  

The risk appears small but internal bleeding leading to compartment syndrome can have extremely serious consequences. There is one report in the medical literature of a case of compartment bleeding following acupuncture in a patient taking anti-coagulants (see link to article at the end of this section).  

Warfarin prevents the body from metabolising vitamin K. Vitamin K controls the formation of a number of coagulation factors in the liver and is an essential substance for blood clotting. Vitamin K is present in most of the foods that are considered to be blood-forming according to Chinese medicine such as green leafy vegetables. This is important to consider if you are giving dietary advice to patients on Warfarinsince these foods can lessen the desired effect of the drug.  

Patients are put on Warfarin or other anti-coagulants for a number of different reasons. These may be purely preventive if, for example, the patient suffers from atrial fibrillation or has mechanical heart valves, or because of recent surgery, stroke, heart attack or thrombosis. The dosage of the medication depends on the desired amount of anti-coagulation for that particular condition.  

Every patient on Warfarin has to undergo tests on a regular basis to check how long it takes for their blood to clot. The frequency of these tests depends on the dosage of their medication and their condition. It is good practice to encourage your patient to have more frequent tests while they are receiving a course of acupuncture as the treatment can positively influence their blood values and may require their Warfarin dosage to be reduced.  

Ask your patient for their INR (international normalised ratio). The INR is a ratio established by measuring the prothrombin time (PT), which is the length of time it takes for the patient’s blood to clot, and then by comparing this value to an average.  

In a healthy person the INR is about 1.0. Patients on Warfarin tend to have an INR somewhere between 2.0 and 3.0 or even higher, depending on the desired amount of anti-coagulation. A higher INR signifies a stronger effect of anti-coagulation.  

The main risk associated with acupuncture is internal bleeding. Depending on the depth of needling and the underlying structures involved this may be insignificant, but there is a chance that it can result in compartment syndrome. Although the risk is small this condition can have serious consequences and often requires surgery.  

Needling should only be done superficially and with fine needles. The higher the INR, the greater the risk of bleeding. Patients with an INR of 3.5 (sometimes therapeutically necessary in the treatment of valvular disease) or higher should be treated with greater care.  

It is also advisable not to use guasha and cupping on patients on anti-coagulants since these techniques tend to draw blood to the upper layers of the skin and can cause severe and prolonged bruising to larger areas of the body.

Of course, we have had to adjust this advice in the new version which we are just about to publish because there is a new generation of anticoagulants like dabigatran (Pradaxa) which do not require the regular monitoring of INR levels, so practitioners need to be vigilant in looking at what happens after they have needled someone. If the patient bruises unexpectedly or with every needle insertion then it may be sensible to refer someone back to their GP for testing to ensure that the dose is correct for them.

Our main caution in Chinese medicine would be where there are syndromes which describe the blood as 'stuck', a term often used being 'blood stasis'. It is just possible that someone being treated with Chinese medicine for blood stasis while at the same time being prescribed anti-coagulants might just find that they clotted a little less quickly than before, but change in this department is never that rapid or dramatic, and the appearance of bruises or bleeding which is harder to stop might well be the first sign of an over-effective combination of therapies. As would always be the case the practitioner would usually refer the patient back to their doctor for re-assessment.

However, we monitor adverse events very closely, both through our own safe practice staff and through our professional insurers, and we have yet to see a claim or report in 30 years based on a bleed from a patient on anti-coagulants.

As far as atrial fibrillation is concerned, we were asked about this recently, and our answer was:

There are some early indications that acupuncture may have an anti-arrhythmic effect in patients with atrial fibrillation. A study published earlier this year    

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312232/

concluded that there appeared to be benefits and that further large scale trials would be valuable to test the hypothesis more carefully.   However, it is only fair to say that needling a single point such as Neiguan repeatedly is not a fair representation of what a traditional acupuncturist does in practice. Although there is considerable overlap between eastern and western systems the arrhythmia typical of AF could be classified in several different ways within Chinese medicine, and the practitioner would be guided by evidence other than simply a reading of the rate of the pulse. That in turn would mean that ten people with AF might receive ten different treatments. To that extent, it is not that straightforward to extrapolate from research studies like this and conclude that 'acupuncture works'.  

The skill of the practitioner lies in making sense of the symptom of AF within an entirely different theoretical framework, and understanding each presentation in each individual patient as unique. The best advice we can give any prosepctive patient is to contact a BAcC member local to them to seek a short face to face consultation at which they can be given a better assessment of whether acupuncture might benefit them.  

The one caution with AF is that most patients are taking some form of medication to control the problem, and the cessation of medication can quickly provoke a return of the symptoms. For people involved in highly technical or responsible work this might represent a serious risk. We would always recommend that any member contemplating treating someone with a condition like AF should talk to the patient's GP to ensure that nothing they do will undermine the current treatment regime. 

A more recent review

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4321072/

reinforces this perspective.

As far as 'electrical impulses from the needles' is concerned, only a small minority of our members actually use electro-acupuncture machines attached to the needles, and even where they do there is no risk from their use. One of our senior colleagues has written the definitive guide to electroacupuncture and there is no mention in it of any cautions about AF. If a machine is used correctly, there should be no problem. Where members are using good old-fashioned needling there is no risk of which we are aware that there could be side effects from its use.

We believe that you can go ahead with your treatment in complete confidence that your practitioner is extremely unlikely to cause any problems and will probably have a good impact on your neck. Talk to them about your fears, though; it is far better that they know you are apprehensive, and we are sure that they will do their very best to address your concerns and talk you through what is happening.

Q:  Can accupuncture help relieve regular and sometimes continuous heart palpitations called supra ventricular complexes?

 

A:  There is not a great deal of published research on supra ventricular complexes as a general grouping. Occasionally studies such as this one:
 
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3312232/on atrial fibrillation show some encouraging signs of the effectiveness of acupuncture treatment. It has to be said, however, that the repeated use of a specific point to treat a problem would be highly unusual in Chinese medicine, and this can often be a problem when research shows positive results, and even more so when it shows inconclusive results. We are reluctant to make a fuss about research of this kind which seems to be successful but the kind of treatment which we do, which is dynamic and evolutionary, i.e. changes in relation to feedback, will never satisfy the requirements of the western gold standard of research, the randomised double blind control trial, and is rarely applied in testing efficacy.
 
That said, palpitations have been around for thousands of years, and Chinese medicine has built up over this period some well defined syndromes which make sense of their occurrence from a Chinese medical perspective. Even when as a symptom it cannot be immediately assigned to a clearly defined pattern the initial premise of Chinese medicine was that symptoms were merely the alarm bells of internal disharmony, and that balancing the system as a whole was a legitimate strategy for reducing or removing them. In practice treatment often operates on both levels at the same time, supporting the specific problem while ensuring that the system as a whole is balanced and can retain the gains which have been achieved. It would be worthwhile seeking the advice of a BAcC member local to you in a short face to face chat to see what their view of the appropriateness of treatment is.
 
One cautionary note is that many patients have prescribed medications for PSVT-type conditions, and are very keen not to have to take them. We advise our members to be very careful not to let people's enthusiasm get the better of them. The consequences of an attack, as you know well, can be severe and debilitating, and not the sort of thing you would want happening at 70mph in the outside lane of a motorway. If the incidence of episodes reduces with treatment the patient should be referred back to the GP for advice on how best to reduce their meds.  
 
 
 

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