bubble_chart Concept

Chest pain encompasses a wide range of clinical conditions. Various diseases and syndromes such as chest impediment, heart pain, real heart pain, precordial pain, phlegm-fluid retention, lung abscess, pulmonary tuberculosis, and some conditions in acute Rebing can all present with chest pain symptoms. In some cases, chest pain is the primary clinical manifestation (e.g., chest impediment, heart pain, etc.). Anatomically, the chest is generally considered part of the upper energizer, with the heart and lungs residing within it. Therefore, chest pain is one of the manifestations of upper energizer diseases involving the heart and lungs. Since it is commonly seen in heart-related conditions, chest pain is sometimes used synonymously with heart pain. However, the chest is adjacent to the epigastrium (the area below the chest is the upper epigastrium), and in historical medical texts, heart pain and epigastralgia are often conflated as heart pain. For example, Qianjin Fang mentions nine types of heart pain (caused by parasites, stagnation, qi, palpitations, food, drink, cold, heat, and intermittent heart pain), which primarily refer to epigastralgia. This leads to confusion among chest pain, heart pain, and epigastralgia. In reality, chest pain can include heart pain, meaning heart pain is a subset of chest pain symptoms. Epigastralgia should not be conflated with chest pain or heart pain. As stated in Linzheng Zhinan Yi'an, "The situations may seem similar, but the symptoms are distinct... Heart pain and epigastralgia must be categorized separately."

This article primarily discusses chest pain as the main clinical symptom and sign (epigastric disorders are discussed separately; for chest pain caused by cough, hemoptysis, etc., please refer to the relevant chapters.)

bubble_chart Modern Research

Western medicine believes that chest (heart) pain is caused by various physical and chemical factors stimulating the sensory nerve fibers that innervate the chest wall, heart, and aorta. Various heart diseases can cause chest (heart) pain, but each has its own characteristics. For example, the onset of colicky pain in coronary artery disease is related to triggers such as physical activity and emotional excitement. The pain is usually located in the middle and upper part of the sternum, presenting as a crushing pain with a sense of pressure and tightness. Acute pericarditis often presents with sharp precordial pain, usually located at the left border of the sternum or the precordial area. Acute myocarditis often presents with stuffy pain in the precordial area. Cardiac neurosis Guanneng can present with persistent dull pain or stuffy pain below the nipple at the apex of the heart, or it can be a very brief stabbing pain.

In Western medicine, the diagnosis of cardiovascular system diseases primarily presenting with chest (heart) pain should be based on a comprehensive analysis of medical history, clinical symptoms and signs, and laboratory tests. The treatment of cardiovascular diseases needs to address the disease cause, pathological anatomy, and pathophysiology. For cases where the disease cause is clear, active treatment of the disease cause can yield good results. For example, antibiotics are used to treat infective endocarditis and pericarditis; interventional or surgical treatments can correct pathological anatomical changes. For example, in acute myocardial infarction, drugs or laser thrombolysis can be used via catheter to dissolve the thrombus in the coronary artery; for cardiovascular diseases that are currently incurable or difficult to cure, the main focus is to correct the pathophysiological changes, such as artificial cardiac pacing and electrical cardioversion.

Chest pain can be seen in Western medicine in conditions such as chronic bronchitis, pulmonary emphysema, pulmonary embolism, coronary heart disease, and cholecystitis, covering a wide range of conditions.

In Chinese medicine, conditions such as qi stagnation, cold coagulation, and static blood heart pain can be treated with reference to Western medicine's treatment of coronary atherosclerotic heart disease and colicky pain, mainly using vasodilators, lipid-regulating drugs, antiplatelet drugs, thrombolytics, and anticoagulants.

The syndrome of chest impediment is equivalent to coronary heart disease and colicky pain in Western medicine, generally classified into exertional colicky pain, spontaneous colicky pain, and mixed colicky pain for diagnostic purposes. During the attack stage, vasodilators such as nitroglycerin are used, while during the remission stage, long-acting anti-colicky pain drugs are used, which can be used alone, alternately, or in combination with nitrate preparations, β-blockers, calcium channel blockers, and coronary vasodilators.

In addition, there is a type of real heart pain, which is equivalent to acute myocardial infarction in Western medicine, with the vast majority of cases caused by coronary atherosclerosis. Hours to days before the formation of acute myocardial infarction, symptoms such as worsening colicky pain, prolonged duration, and increased frequency may occur. During the attack, there is persistent severe crushing or knife-like pain in the precordial area, accompanied by a special sense of impending doom, as well as symptoms such as decreased blood pressure, arrhythmia, and shock.

bubble_chart Pattern Analysis

1. Heart Qi Deficiency and Weakness︰The chest pain is dull, intermittent, and varies in intensity, accompanied by chest tightness, palpitations, shortness of breath, spontaneous sweating, fatigue, and worsening with activity. The complexion is pale, the tongue texture is pale, and the pulse is thin or weak and feeble. Clinical manifestations dominated by heart qi deficiency include palpitations, shortness of breath, spontaneous sweating, a pale tongue, and a thin pulse. The chest pain is not severe but dull and lingering. Treatment should focus on tonifying and replenishing heart qi, using modified Original-Qi Preserving Decoction. If accompanied by blood deficiency, herbs such as Chinese Angelica and Donkey-hide Gelatin can be added. If accompanied by static blood, herbs like Sichuan Lovage Rhizome and Red Peony Root may be included.
2. Congealing Cold and Qi Stagnation︰Chest pain with distension and oppression, varying in intensity from mild to severe, even radiating through the back and causing referred pain to the left shoulder and arm. In severe cases, there may be a pale complexion, spontaneous sweating, fear of cold, cold limbs, or reversal cold of the limbs. The tongue appears pale and moist or swollen with tooth marks, and the pulse is deep, slow, or irregular. Chest pain dominated by congealing cold and qi stagnation is more intense, accompanied by a sensation of fullness and oppression in the chest. In severe cases, the pain may radiate through the back due to insufficient chest yang, yang deficiency with cold congealing, and obstruction of qi movement. Jingui Yaolue states: "Chest obstruction with heart pain, shortness of breath, and abnormal pulse—the cause lies in extreme deficiency of the upper energizer." This refers to this very syndrome. Clinically, manifestations such as a pale complexion, spontaneous sweating, fear of cold, cold limbs, a pale tongue, and a slow pulse indicate heart yang deficiency. Treatment should focus on warming and unblocking heart yang, using prescriptions like Kuanxiong Wan or Red Halloysite Wan. In severe cases where yang deficiency verges on collapse, chest pain may feel like cutting, accompanied by profuse cold sweating, reversal cold of the limbs, and a faint, barely perceptible pulse—as described in Lingshu．Jue Lun: "Real heart pain, with cyanosis of the hands and feet reaching the joints, severe heart pain, leading to death by evening if it occurs in the morning, or death by morning if it occurs in the evening." Emergency treatment should aim at restoring yang to rescue from collapse, using prescriptions like Ginseng and Aconite Decoction or Shenfu Longmu Tang.
3. Heart Blood Stasis and Obstruction︰The chest pain is severe, mostly stabbing pain, fixed and unrelenting, and in severe cases, it may occur suddenly, feeling as sharp as a knife cut. Cold sweating appears spontaneously, accompanied by palpitation or severe palpitation, along with restlessness and fear. After relief, the body feels fatigued, and there is mental fatigue or listlessness. The tongue appears bluish-purple and dull or with ecchymosis, and the pulse is deep and thin or choppy, or intermittent. For chest pain primarily caused by heart blood stasis and obstruction, the nature of the pain is stabbing and fixed. Clinical manifestations may include a dull purple tongue or ecchymosis, and a slow, choppy pulse—signs of static blood. The treatment principle is to invigorate blood and resolve stasis. The recommended formula is Blood House Stasis-Expelling Decoction combined with Sudden Smile Powder with modifications.
4. Deficiency of Both Qi and Yin︰Dull pain in the chest, lingering and unceasing, sometimes mild and sometimes severe, palpitation and restlessness, dreamfulness and insomnia, spontaneous sweating, shortness of breath or panting, especially noticeable after activity. Subjective fever, dry tongue with little fluid, dark urine, red tongue with scant coating, thin or rapid and weak pulse, or intermittent. This indicates deficiency of both heart qi and heart yin, hence manifestations of yin deficiency such as dry mouth with little fluid, dark urine, red tongue with scant coating, thin and rapid weak pulse, etc. Treatment should focus on tonifying qi and nourishing yin, using Pulse-Reinforcing Powder or Prepared Liquorice Decoction with modifications.
5. Phlegm-Dampness Internal Obstruction︰chest pain, cough with profuse sputum, or coughing up thin and clear phlegm, or thick and sticky sputum, shortness of breath or panting, and in severe cases, pain radiating to the back, making it difficult to lie flat, tongue coating white and moist or slippery, pulse slippery. This is a deficiency-type pathogen with excess syndrome, Suwen as stated in the "Discussion on Impediment": "Heart impediment is due to obstructed vessels," and obstruction leads to pain. When phlegm-turbidity is the cause, besides chest pain, it must also be accompanied by cough, panting, profuse sputum, white and moist tongue coating, slippery pulse, and other signs of internal exuberance of damp-phlegm. This is easily distinguishable from heart blood stasis and obstruction chest pain, which presents with stabbing pain, fixed pain location, purple tongue, and choppy pulse. Treatment should focus on resolving phlegm and unblocking yang, using formulas such as Trichosanthes, Chinese Chive and Pinellia Decoction or Immature Orange Fruit, Longstamen Onion Bulb, and Cinnamon Twig Decoction. Clinically, there are also cases of chest pain caused by the mutual obstruction of phlegm and stasis. As mentioned in *Liu Xuan Si Jia Yi An* (Liu's Selected Cases from Four Physicians), Trichosanthes, Chinese Chive and Pinellia Decoction can be used to dispel phlegm-turbidity, supplemented with Peach Kernel, Carthamus, Typha, and Clam Shell to transform static blood, embodying the method of treating both the heart and stomach simultaneously.
6. Lung Abscess︰Chest pain is dull, with coughing up of yellow phlegm or purulent and bloody sputum, which has a foul and fishy odor. There is dry mouth and thirst but no desire to drink, or irritability and fullness, sweating, alternating chills and fever, a red tongue, and a slippery or slippery and rapid pulse. Due to heat toxin damaging the lungs and causing flesh to rot into pus, leading to lung abscess, in addition to chest pain, there must be coughing up of thick, purulent, and bloody sputum with a foul and fishy odor, as well as symptoms of internal accumulation of heat toxin such as vexing heat in the chest, dry mouth and throat, a red tongue, and a slippery and rapid pulse. Treatment should focus on clearing heat, removing toxin, and expelling pus. The formula used is Qianjin Phragmites Stem Decoction with additions such as Lonicera, Forsythia, and Heartleaf Houttuynia Herb, or the modified Pneumonia Formula No. 2. If the disease persists and damages yin, it is often accompanied by symptoms of yin deficiency with internal heat such as night sweats, steaming bone fever, and vexing heat in the chest, palms, and soles. Treatment should then include sweet and cold herbs to nourish yin, such as Ophiopogon Tuber and Fourleaf Ladybell Root. If heat damages the blood collaterals, leading to profuse hemoptysis, hemostatic medicinals such as common bletilla pseudobulb and Sanqi should be added.
7. Traumatic Injury︰Static blood chest pain is an excess pattern, suitable for invigorating blood and resolving stasis. The prescription uses Peach Kernel, Carthamus and Four-Ingredient Decoction combined with Cock Crow Powder with modifications.

Weakness of heart qi, congealing cold and qi stagnation, and heart blood stasis and obstruction are three conditions: one is insufficiency of heart qi (the milder among the three), one is deficiency of heart yang, and one is static blood obstructing the meridians. The first two are deficiency pattern, while the latter is a deficiency-type pathogen with excess. Heart blood stasis and obstruction can result from weakness of heart qi, which fails to promote the circulation of heart blood, or from insufficiency of heart yang, congealing cold, and qi stagnation, leading to blood stagnation. Therefore, chest pain caused by weakness of heart qi and chest pain caused by congealing cold and qi stagnation may both exhibit manifestations of static blood. Thus, chest pain caused by qi deficiency, yang deficiency, and static blood often overlap clinically.

Chest pain is a common symptom that can appear in various clinical conditions, including deficiency pattern, excess pattern, and pattern of healthy qi deficiency and pathogenic factors excess. Deficiency pattern can result from insufficiency of heart qi, lack of heart yang, or deficiency of both qi and yin. Chest pain due to heart blood stasis and obstruction is often a condition of root deficiency with superficial excess. On the other hand, chest pain caused by lung abscess may initially present as an excess pattern, but over time, it can transform into a deficiency-type pathogen with excess.

bubble_chart Documentation

1. Zhengyin Maizhi．Chest Pain》: "The causes of internal damage chest pain are the seven emotions and six desires, which stir the heart fire and harm the lung metal, or the counterflow of qi due to depression, injuring the lung pathway, leading to phlegm coagulation and qi stagnation, or excessive consumption of pungent and hot substances, injuring the upper energizer, resulting in blood accumulation internally and causing oppressive chest pain."
2. Zhengzhi Zhunsheng．Chest Pain》: "Chest pain extending to the ribs, fullness of the rib supports, pain in the chest, back, shoulders, and the inner sides of both arms,... If the pulse is full and rapid, it is appropriate to use fire-reducing and cooling agents; chest pain radiating to the back, fullness and pain in both flanks extending to the lower abdomen... This is due to metal evil injuring the liver, and it is appropriate to use liver-tonifying agents; pain in the chest extending to the large and small abdomen is due to kidney deficiency, and it is appropriate to first take the blood from the Shaoyin and Taiyang channels, then use kidney-tonifying medicine; pain in the chest extending to the hypochondriac region, thigh, and outer knee is due to disease of the gallbladder and foot Shaoyang wood, and the treatment should be detailed according to the conditions of excess, deficiency, heat, cold, and sinking."