CHAPTER 4 Cardiopulmonary disease and lupus

Contents

1. Western medical aetiology and pathology 79

(1) Cardiac involvement 79

(2) Pulmonary involvement 80

2. Diagnosis by Western medicine 81

(1) Cardiac involvement 81

(2) Pulmonary involvement 81

3. Chinese medicine aetiology and pathology 82

Differentiation and treatment 82

1 Obstruction of Yang in the chest 82

2 Blood stasis in the blood vessels of the Heart 83

3 Deficiency of both Qi and Yin 83

4 Kidney and Heart Yin deficiency 84

Case studies 85

4. Analysis of the cases 88

5. Lifestyle prescriptions and health issues 91

Conclusion 92

The heart and lungs are frequently affected in people with systemic lupus erythematosus (SLE). Complications in these organs can cause a variety of problems, ranging from mild to serious or even life threatening. These complications are known as cardiopulmonary disease.

1 Western medical aetiology and pathology

(1) Cardiac involvement

In Western medicine, the term cardiac includes the pericardium, myocardium, endocardium and coronary artery. One or more of these tissues can be damaged when there is cardiac involvement in systemic lupus erythematosus (SLE).

1. The pericardium is a sac surrounding the heart. The most common heart involvement in people with SLE is pericarditis – inflammation of the pericardium. This condition occurs when antigen–antibody complexes, also known as immune complexes, are made during active SLE and cause inflammation within the pericardium.

2. The myocardium is the muscle layer of the heart. When SLE causes inflammation of the tissue of the heart muscle, it is called myocarditis.

3. The endocardium is the lining of the inside of the heart. When SLE causes inflammation of the lining of the inside of the heart, it is called endocarditis.

4. The coronary artery delivers blood and oxygen to the heart muscle and is vital to the heart’s pumping function. In people with SLE this artery can become prematurely narrowed, causing coronary artery disease. This blockage can be due to arteritis, or inflammation of the artery wall; atherosclerosis, or cholesterol deposits inside the wall; arterial spasm; or thrombus, which is a blood clot.

(2) Pulmonary involvement

The lungs are often involved in SLE. This is usually due to disordered immunity impairing a single or multiple tissues of the lungs, which includes the pleura, lung tissues and blood vessels in the lungs.

1. The pleura are membranes that surround the lungs. Although SLE can affect the lungs in many ways, pleurisy, also known as pleuritis, is the most common pulmonary manifestation.

2. Sometimes an excessive amount of fluid builds up in the pleural space between the lungs and the chest wall, causing pain or tenderness in the chest. This is called pleural effusion in Western medicine and it is characterized in Chinese medicine by the term Xuan Yin .

3. Lupus pneumonitis is inflammation within the lung tissue. Infection is the most common cause of pneumonitis in people with SLE. Certain bacteria, viruses or fungi can cause infection in the lungs, especially if the patient takes steroids and/or immune-suppressant medicine. Sometimes pneumonitis may occur without infection and is then called non-infectious pneumonitis.

4. Although rare in people with SLE, chronic diffuse interstitial lung disease causes fibrosis, or scarring of the lungs. This scarred tissue acts as a barrier to the oxygen that normally transfers from the alveoli into the blood, causing hypoxia.

5. Some people with SLE may develop pulmonary hypertension, or high blood pressure in the blood vessels within the lungs. It becomes difficult for the right side of the heart to pump to the left side, because of high blood pressure in the lungs.

6. Pulmonary emboli are blood clots that block the pulmonary arteries.

7. Pulmonary haemorrhage, or bleeding into the lungs, is a rare but potentially fatal complication of SLE.

2 Diagnosis by Western medicine

(1) Cardiac involvement

A Diagnosing pericarditis

As pericarditis can occur in conditions other than SLE, the cause must be determined before treatment begins. To diagnose pericarditis, the following tests may be ordered:

• Blood tests

• Chest radiography

• Electrocardiography

• Echocardiography (ultrasonography of the heart) to determine whether there is fluid around the heart.

B Diagnosing myocarditis

Myocarditis is often seen with inflammation of other muscles in the body and this condition can lead to tissue damage that replaces heart tissue with scar tissue. This scar tissue reduces the heart’s contractility, causing some people eventually to die from heart failure.

C Diagnosing endocarditis

This condition rarely affects the pumping efficiency of the heart, although it can damage the heart valves. The surface of the valves can thicken or develop wart-like growths called Libman–Sacks lesions, which may cause heart murmurs.

D Diagnosing coronary artery disease

To diagnose coronary artery disease, the following tests may be ordered:

• Chest radiography

• Electrocardiography

• Echocardiography

• Blood tests to evaluate SLE activity.

(2) Pulmonary involvement

Diagnostic tools can include:

• Chest radiography

• Ventilation–perfusion scan of the lungs

• Gallium scan

• High-resolution computed tomography

• Bronchoalveolar lavage

• Pulmonary function tests.

Although the usefulness of all these tests varies depending on the type of lung involvement, close follow-up and monitoring is crucial to minimize long-term complications.

3 Chinese medicine aetiology and pathology

Based on cardiopulmonary symptoms, Chinese medicine may diagnose Xin Ji , palpitations, Xiong Bi , an obstructive feeling in the chest, or Zhen Xin Tong , angina pectoris.

In Chinese medicine, the Heart and Lung reside in the Upper Jiao. The function of the Heart is to govern Blood circulation in the body. The Heart is linked with the blood vessels to form a closed system. Its contractions continuously pump the Blood smoothly within the vessels to nourish itself and other organs. When external pathogenic factors invade the body, or improper foods or emotions affect Heart function, the body’s first reaction is that vital Qi will be in conflict with the pathological factor, leading to Heat symptoms and improper Heart function. In such a case, the Heart may become disordered and symptoms will occur. The Lung is the organ that governs respiration and metabolism of body fluid. The Heart governs Blood, and the Lung governs Qi. The Heart and Lung depend on each other for coexistence. We say that Qi moves the Blood and that Blood is the mother of Qi. Blood circulation relies on Qi to drive it; Qi needs Blood circulation to perform its function of transportation and distribution. Anything that disturbs the normal relationship between the Heart and Lung leads to Qi stagnation, and Qi will not drive the Blood to flow smoothly in the vessels. Slowly moving Blood can become stasis due to this Qi stagnation. Excess Heat builds up based on long-term stagnation of either Qi or Blood. Eventually, chronic illness will damage Yin of the Heart and Lung. Therefore, the pathologies in this process of disease are mainly Heat, Blood stasis and Yin deficiency.

Differentiation and treatment

1 Obstruction of yang in the chest

Clinical manifestations

Oppressed feelings in the chest or paroxysmal chest pain and palpitation, or shortness of breath. The tongue has a white, greasy coating. The pulse is taut.

Treatment principle

Warm the Yang of the chest and remove obstruction in the blood vessels of the Heart.

Herbal treatment

GUA LOU XIE BAI BAN XIA TANG variation

Trichosanthes Fruit, Chinese Chive and Pinellia Decoction

Gua Lou Trichosanthis Fructus 20 g

Xie Bai Allii macrostemi Bulbus 12 g

Zhi Ban Xia Pinelliae Rhizoma preparatum 10 g

Gui Zhi Cinnamomi Ramulus 10 g

Dan Shen Salviae miltiorrhizae Radix 15 g

Pu Huang Typhae Pollen 10 g

Wu Ling Zhi Trogopterori Faeces 10 g

The herbs above are decocted in water for oral administration.

Acupuncture

Du-20 Baihui, BL-15 Xinshu, PC-6 Neiguan, Ren-17 Tanzhong and LIV-3 Taichong.

2 Blood stasis in the blood vessels of the heart

Clinical manifestations

Sharp pain in the chest that may radiate to the shoulder area and back; stuffy sensation in the chest or upper stomach; and shortness of breath. The tongue is deep purple. The pulse is taut and uneven.

Treatment principle

Promote the flow of Qi, remove Blood stasis and activate the blood vessels of the Heart.

Herbal treatment

DAN SHEN YIN and TAO HONG SI WU TANG variation

Salvia Decoction and Four-Substance Decoction with Safflower and Peach Pit

Dan Shen Salviae miltiorrhizae Radix 30 g

Tan Xiang Santali albi Lignum 3 g

Sha Ren Amoni Fructus 6 g

Qing Pi Citri reticulatae viride Pericarpium 5 g

Dang Gui Angelicae sinensis Radix 12 g

Chuan Xiong Chuanxiong Rhizoma 10 g

Chi Shao Paeoniae Radix rubra 12 g

Hong Hua Carthami Flos 10 g

Tao Ren Persicae Semen 10 g

The herbs above are decocted in water for oral administration.

Acupuncture

BL-15 Xinshu, BL-17 Geshu, BL-18 Ganshu and SP-6 Sanyinjiao.

Supplementary treatment

If precardial pain is accompanied with emotional disorder or anxiety and a choking sensation in the chest, add SI NI SAN Frigid Extremities Powder, composed of Chai Hu Bupleuri Radix, Zhi Ke Aurantii Fructus, Bai Shao Paeoniae Radix alba and Gan Cao Glycyrrhizae Radix, and add Xiang Fu Cyperi Rhizoma and Yu Jin Curcumae Radix to remove Liver Qi and Blood stasis. If the patient has an oppressive sensation in the chest with a white and greasy tongue coating and a taut and slippery pulse, add WEN DAN TANG Warm the Gallbladder Decoction, composed of Zhi Ban Xia Pinelliae Rhizoma preparatum, Chen Pi Citri reticulatae Pericarpium, Zhu Ru Bambusae Caulis in taeniam, Zhi Shi Aurantii Fructus immaturus and Fu Ling Poria.

3 Deficiency of both qi and yin

Clinical manifestations

Indistinct pain in the precordial region, lassitude, palpitations, shortness of breath, fatigue and dry mouth. The tongue is red with less coating. The pulse is taut and thready.

Treatment principle

Replenish Qi and nourish Yin, and promote Blood flow.

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