Important to know: Chronic health conditions should be addressed under direct medical supervision of your GP or consultant, and acupuncture would be an adjunct or complement to usual care – we advise that you let you doctor know when you use this approach.
The British Acupuncture Council (BAcC) has produced an evidence based factsheet about Angina, Coronary Heart Disease, Atrial Fibrillation and Heart Failure including specific research, trials and mechanisms of action for acupuncture in this condition, we recommend taking a look via the underlined link above. Their Factsheet on Hypertension, High Blood Pressure may also be of interest.
Research and Resources on Arrhythmia and Heart Failure and Acupuncture:
A scholarly search of the available research studies on “acupuncture” +”arrhythmia” reveals over 7,400 papers from journals, and narrowing this to “RCT” leads to over 630 hits, of which 40% have been carried out since 2017. A scholarly search of the available research studies on “acupuncture” + “heart failure” reveals over 18,000 papers from journals, and narrowing this to “RCT” leads to over 1,700 hits, of which 52% have been carried out since 2017. From this we can deduce that acupuncture is being used traditionally and currently in this area; scientifically researched for this, and that the pace of the research is increasing – leading us to see these as areas worthy of scientific appraisal and consideration.
Interpreting the research:
When reading health research, it is important to know that Systematic Reviews or Meta Analyses of a large number of high-quality research studies are the very best way to be able to say to what extent a given treatment can address a condition, symptom, or set of symptoms. The next best level of evidence is the individual Randomised Controlled Study (RCT) which uses a systematic technique to compare two or more groups of patients receiving different treatments (or a treatment against a “control”, or no treatment). In acupuncture trials, the nature of the control group is of particular interest as it is hard to blind a patient to whether they are having a needle inserted or not, and even more challenging to blind the researcher/team to this.
The means and quality of how research is carried out varies considerably from country to country, and in terms of how an intervention is compared to another intervention (or a control). Of note is the fact that “sham” acupuncture (where needles are placed in apparently inert locations rather than traditional acupuncture points) is not really an inert process as it has physiological effects, so that comparing sham and “true acupuncture” may therefore not give a clear picture alone; but and form a part of a research body where acupuncture versus no treatment, vs conventional treatment or vs a different approach/modality also form part of the evidence base.
The n= figure (where quoted in research) tells you how many people were participants in the study, and usually the larger a study (when it is of good quality and design), the more likely it is to be reliable and applicable to larger populations. When (statistical) “significance” is discussed in view of studies it has a very particular meaning – it is the confidence in the data (using statistical tests) that tells us how likely a result could have just come about by chance. The lower the possibility of a chance result, the more likely it is due to the intervention in the experiment. When you are reading a trial/study, the “p” is the number telling us of significance, and this must be under 5% (or p less than 0.05) to mean we can say it is a (statistically) “significant” result.
A systematic review and meta-analysis of 12 studies (Lu et al, 2022; n=1203) looked at treating cardiovascular disease complicated with depression, and found that acupuncture reduced HAMD (Hamilton scale for depression) score, SDS (self-rating depression scale) score and also reduced the attack frequency of angina pectoris and the VAS (visual analogue scale) score for angina pain. They concluded that acupuncture could be a good complementary and alternative therapy for CVD complicated with depression.
Lomuscio et al, 2011 (n=80) concluded that acupuncture prevented arrhythmic recurrences after cardioversion in patients with persistent AF, and was safe and well tolerated.
Li et al, (2022) made a meta-analysis and systematic review of RCTs that had compared acupuncture with pharmacological conversion for treating atrial fibrillation. They looked at 11 papers, and concluded that “ acupuncture significantly effectively benefitted the patients with atrial fibrillation”, and overall combining the pharmacological (medicinal) cardioversion with acupuncture was significantly more beneficial than was the pharmacological approach alone.
Following Valve Surgery: Cardioprotective Effects
Feingold et al, 2023 (n=100) carried out an RCT with 100 patients undergoing primary valve surgery via sternotomy. They found acupuncture after valve surgery to be feasible, well tolerated, and having clinical benefit. Specifically, there were no adverse events, and the acupuncture group had reduction in pain, nausea, stress, and anxiety, as well as reduced postoperative stress and anxiety and reduced postoperative atrial and fewer hours in the intensive care unit than those patients on standard care alone.
Yang et al, (2010, n-=60) conducted an RCT to investigate the cardioprotective effects of electroacupuncture (EA) pretreatment on patients undergoing heart valve replacement surgery. They measured the levels of cardiac troponin I (CTnI) which is a protein released into the blood when the heart muscle is damaged (e.g. during a heart attack). Other outcomes, such as blood pressure, heart rate, use of drugs, and length of stay in the intensive care unit (ICU) were also compared between a pretreatment group and a control (no acupuncture) group. They found that EA pretreatment significantly lowered the levels of CTnI in acupuncture patients after surgery vs control, therefore EA pretreatment reduced the amount of heart injury caused by the surgery. EA pretreatment also reduced the use of drugs such as inotropes, after surgery (indicating more improved heart function after surgery, shortened stay in ICU; versus the non-acupuncture group.
Coronary Artery Disease, PCI procedure
Ho et al, (1999, n=44) looked at the PC6 point also (note, Nei-Kuan is an alternative spelling), in their case they examined that effect upon Left Ventricular Function in Patients with Coronary Artery Disease (CAD). The left ventricle is the main pumping chamber of the heart, and in CAD, the blood vessels that supply heart become narrowed or blocked by fatty deposits called plaque. The study measured how much blood the left ventricle pumps out with each contraction (left ventricular ejection fraction, LVEF) in 22 patients with coronary artery disease and 22 normal subjects. Acupuncture caused an increase in the LVEF in patients with coronary artery disease, especially in the first 15 minutes of stimulation. This persisted for 15 minutes after acupuncture, but became insignificant after one week. They concluded acupuncture at PC6 could temporarily improve left ventricular function in CAD patients, but more studies were needed to confirm its long-term effects and mechanisms.
An RCT (Wang et al, 2015), aimed to understand if pretreatment with electroacupuncture (EA) could reduce the damage to the heart muscle caused by percutaneous coronary intervention (PCI). PCI is used to treat CAD by inserting a thin, flexible tube called a catheter, where it’s x-ray guided to the and a small balloon is inflated to widen the narrowed coronary artery, and possibly a small metal mesh tube (“stent”) placed like a scaffold to keep it open. However, PCI can cause damage the heart muscle (ischemia-reperfusion injury). Wang et al (2015) compared EA with sham EA in 204 CAD patients undergoing PCI. They found that EA: significantly lowered the levels of cTnI (cardiac troponin I); reduced the use of drugs (inotropes); shortened the length of stay in the intensive care unit (ICU); and decreased the rate of MACCE (major adverse cardiac/cerebrovascular events) at 24 months after PCI, compared to sham EA. They concluded that EA prior to PCI “significantly reduced cTnI release and protected patients with CAD from subsequent myocardial injury after PCI procedure.”
Mechanisms of action
Li et al (2014) proposed a possible mechanism of action for the lowering of blood pressure, in that acupuncture could regulate the renin-angiotensin-aldosterone system (RAAS), which is involved in blood pressure regulation, by stimulating specific acupoints that correspond to the kidney and liver meridians. The other mechanism is based on the Western medicine theory of modulating the autonomic nervous system (ANS), which controls the heart rate and vascular tone. They further hypothesized that acupuncture might activate the parasympathetic branch of the ANS, thus lowering the sympathetic activity and reducing the release of stress hormones that constrict the blood vessels.
Li et al, (2022), theorised about specific points in the process of cardioversion, whereby acupuncture in addition to medication was shown to benefit the outcome. In particular a specific point on the arm called Neiguan (pericardium 6), which has mechanisms of action including: Downregulating the amygdala (involved in stress response) in the brain; desensitising the nucleus tractus solitarius, (area in the brain that controls heart rate and blood pressure); reducing levels of inflammatory substances in the blood, including CRP, IL-8, and TNF-α (which can cause swelling and pain, damage the heart tissue and make AF worse); improving the index of heart rate variability (HRV) – is a measure of how well the heart adapts to different situations.
Yang et al (2010) in their RCT on cardioprotective effects of EA for valve surgery discussed possible mechanisms for how EA pretreatment could protect the heart from injury, such as activating certain pathways in the brain and nerves that regulate blood flow and inflammation. Specifically, they put forward the way in which EA at Neiguan (PC-6) can influence the neuroendocrine system and the inflammatory response, which are both involved in the pathogenesis and progression of coronary artery disease. Stimulating this point can activate certain pathways in the brain and nerves that regulate blood pressure, heart rate, vascular tone, and stress hormones, as well as reduce the levels of substances in the blood that cause inflammation, such as cytokines, chemokines, and adhesion molecules.
Li et al (2012) also discussed PC6, and the sympathoexcitatory cardiovascular reflex responses, which are reactions that make the heart beat faster and stronger when the body is under stress or danger. Point PC6 can reduce the sympathoexcitatory cardiovascular reflex responses, reducing this effect and relaxing the heart muscle to modulate the response to an appropriate level. They also discuss brain activity that may govern the cardiovascular response, and be influenced by acupuncture, namely some parts of the brain that are involved in acupuncture, such as the rostral ventrolateral medulla (RVLM), the arcuate nucleus (ARC), and the ventrolateral periaqueductal gray (vlPAG), which are parts of the brain that control the blood pressure, heart rate, and stress response. Acupuncture can do this by activating some pathways in the brain that send messages to the heart and blood vessels to relax, and can also make these pathways less sensitive to signals from other organs or tissues that can trigger these reflexes. Acupuncture can have a long-lasting effect on these reflexes, even after the needles are removed. Acupuncture can do this by changing some proteins or chemicals in the brain that are involved in these reflexes, such as opioids, serotonin, or nitric oxide.
Another mechanism of action involved adenosine receptors, as examined by Malik et al (2019); EA activates the A2a adenosine receptors in the RVLM (rostral ventrolateral medulla of the brain), making the nerve cells in the RVLM less active and less likely to increase the blood pressure and heart rate. This process is dependent on the body’s natural opioids, and the fact that EA can increase the amount of opioids in the RVLM, can help activate the A2a adenosine receptors. This process has been proven further by the fact that if the opioids are deliberately blocked by some drugs, EA’s effect on the A2a adenosine receptors is also blocked.
In a rat model, Su et al (2022) used PC6 point to study atrial fibrillation, in order to understand the mechanism of action whereby electroacupuncture at this point was demonstrated in many previous studies to benefit AF. EA at PC6 was shown to affect the brain and the nerves that control the heart in different ways: making it harder for AF to start or continue by changing how the heart cells react to certain chemicals, such as ACh and CaCl2, that can trigger AF; improving the HRV; balancing the activity of the sympathetic and vagal nerves, which are part of the nervous system that controls the heart rate and blood pressure (the sympathetic nerve makes the heart beat faster and stronger, while the vagal nerve makes it slower and weaker); reducing the sympathetic nerve activity and increase the vagal nerve activity, which can help lower the heart rate and make it more stable; affecting the expression of c-Fos, which is a protein that shows how active certain brain regions are, and decreasing the activity of some brain regions that are involved in stress and blood pressure regulation, such as PVN, RVLM, and DMV; whilst increasing the activity of another brain region that is involved in heart rate regulation.
Several hypotheses have been proposed based on anatomical, physiological, pharmacological, and neuroscientific evidence. One of the main mechanisms is the modulation of the autonomic nervous system, which regulates the heart rate, blood pressure, and vascular tone. Acupuncture can activate specific reflexes that involve peripheral nerves, spinal cord, brainstem, hypothalamus, and other brain regions to inhibit sympathetic activity and enhance parasympathetic activity. This can result in vasodilation, decreased cardiac output, and reduced blood pressure.
Another mechanism is the release of endogenous substances that have cardiovascular effects, such as endorphins, enkephalins, serotonin, nitric oxide, and angiotensin II. These substances can act on various receptors and channels to modulate vascular tone, cardiac contractility, inflammation, and oxidative stress.
A third mechanism is the stimulation of angiogenesis and neurogenesis in the heart and brain tissues. Acupuncture can increase the expression of growth factors and cytokines that promote the formation of new blood vessels and nerve fibres. This can improve blood supply and oxygen delivery to the ischemic areas and enhance tissue repair and regeneration.
Regarding Your Individual Condition and Symptoms:
Whilst the scientific studies are of great interest to researchers and acupuncturists in terms of comparing protocols, for the patient not versed in research they are less accessible, which is why when we asked “can acupuncture work for my (condition or symptom) we are not able to give a simple yes or no response. We are able to tell you what experience we have had in our decades of experience in practise, of the types of outcomes we have seen in similar cases, and give you an idea of our level of experience and knowledge in that area, and how this could relate to your own individual situation. For this, we recommend booking a free telephone consultation where we can answer any questions you have and give a realistic appraisal of what acupuncture may be able to provide.
BAcC Factsheet: Hypertension
BAcC Factsheet: Stroke
Feingold, K.L., Moskowitz, J.T., Elenbaas, C., Andrei, A.C., Victorson, D., Kruse, J., Grote, V., Patil, K.D., Shafiro, T., Grimone, A. and Lin, F., 2023. Acupuncture after valve surgery is feasible and shows promise in reducing postoperative atrial fibrillation: The ACU-Heart pilot trial. JTCVS Open.
Ho, F.M., Huang, P.J., Lo, H.M., Lee, F.K., Chern, T.H., Chiu, T.W. and Liau, C.S., 1999. Effect of acupuncture at nei-kuan on left ventricular function in patients with coronary artery disease. The American journal of Chinese medicine, 27(02), pp.149-156.
Li, D.Z., Zhou, Y., Yang, Y.N., Ma, Y.T., Li, X.M., Yu, J., Zhao, Y., Zhai, H. and Lao, L., 2014. Acupuncture for essential hypertension: a meta-analysis of randomized sham-controlled clinical trials. Evidence-Based Complementary and Alternative Medicine, 2014.
Li, J., Li, J., Chen, Z., Liang, F., Wu, S. and Wang, H., 2012. The influence of PC6 on cardiovascular disorders: a review of central neural mechanisms. Acupuncture in Medicine, 30(1), pp.47-50.
Li, Y., Song, J., Wu, B., Wang, X., Han, L. and Han, Z., 2022. Acupuncture versus pharmacological conversation in treatment of atrial fibrillation in a randomized controlled trial: a systemic review and meta-analysis. European Journal of Medical Research, 27(1), pp.1-14.
Lomuscio, A., Belletti, S., Battezzati, P.M. and Lombardi, F., 2011. Efficacy of acupuncture in preventing atrial fibrillation recurrences after electrical cardioversion. Journal of cardiovascular electrophysiology, 22(3), pp.241-247.
Lu, L., He, W., Guan, D., Jiang, Y., Hu, G., Ma, F. and Chen, L., 2022. Acupuncture in treating cardiovascular disease complicated with depression: A systematic review and meta-analysis. Frontiers in Psychiatry, 13, p.1051324.
Ma, J., Zhang, Y., Ge, Q. and Wu, K., 2023. The effect of auricular acupuncture on preoperative blood pressure across age groups: a prospective randomized controlled trial. Clinical and Experimental Hypertension, 45(1), p.2169452.
Malik, S., Samaniego, T. and Guo, Z.L., 2019. Adenosine receptor A2a, but not A1 in the rVLM participates along with opioids in acupuncture-mediated inhibition of excitatory cardiovascular reflexes. Frontiers in Neuroscience, p.1049.
Su, Y., Huang, J., Sun, S., He, T., Wang, T., Fan, M., Yu, H., Yan, J., Yao, L., Xia, Y. and Zhang, M., 2022. Restoring the Autonomic Balance in an Atrial Fibrillation Rat Model by Electroacupuncture at the Neiguan Point. Neuromodulation: Technology at the Neural Interface.
Wang, Q., Liang, D., Wang, F., Li, W., Han, Y., Zhang, W., Xie, Y., Xin, W., Zhou, B., Sun, D. and Cao, F., 2015. Efficacy of electroacupuncture pretreatment for myocardial injury in patients undergoing percutaneous coronary intervention: a randomized clinical trial with a 2-year follow-up. International journal of cardiology, 194, pp.28-35.
Yang, L., Yang, J., Wang, Q., Chen, M., Lu, Z., Chen, S. and Xiong, L., 2010. Cardioprotective effects of electroacupuncture pretreatment on patients undergoing heart valve replacement surgery: a randomized controlled trial. The Annals of thoracic surgery, 89(3), pp.781-786.
Yin, C., Seo, B., Park, H.J., Cho, M., Jung, W., Choue, R., Kim, C., Park, H.K., Lee, H. and Koh, H., 2007. Acupuncture, a promising adjunctive therapy for essential hypertension: a double-blind, randomized, controlled trial. Neurological research, 29(sup1), pp.98-103.