Volume 6, Number 1 | Spring 2011

Kampo Medicine - Current Research
Three Cases of Severe Bradyarrhythmia in Elderly
Dementia Patient Successfully Treated with Goreisan(Powder of Five Ingredients with Poria) Extract
Formulation for Prescription
Kazunari Ozaki1)2), MD, Mitsuru Kageyama3)4),
MD, PhD, Hiromi Rakuga2), MD, PhD
1) Department of Clinical Gene Therapy, Osaka
Univerisity Graduate School of Medicine,
Suita, Osaka, Japan
2) Department of Geriatric Medicine and Nephrology,
Osaka University Graduate School of Medicine,
Suita, Osaka, Japan
3) Kageyama Clinic, Sakai, Osaka, Japan
4) Department of Obstetrics and Gynecology,
Osaka City University Graduate School of Medicine,
Osaka, Japan

Case reports: All three patients had dementia,
bradycardia and sui-doku (disorders of the body’s
fluid metabolism). Two of the patients had severe
bradycardia with minimum pulse rate of less than 40
beats/min (bpm). All patients were treated with

Goreisan extract formulation for prescription for suidoku.

Allpatients

Introduction: Sick sinus syndrome (SSS), or sinus
node dysfunction (SND), is a heterogeneous clinicalsyndrome of various etiologies, such as sinus
bradyarrhythmia, sinus arrest, and sinoatrial (SA)block, with periods of bradyarrhythmia. In thispaper we would like to describe three patients withelderly dementia who had severe bradyarrhythmia,
and who have shown remarkable improvementswith Goreisan (Powder of Five Ingredients with
or

from

the treatment. Severe bradycardia associated withlatent SSS (case 1), severe bradycardia associatedwith drug-induced bradycardia with SSS (case 2)
and moderate bradycardia with infectious diarrhea(case 3) were controlled successfully with Goreisan.

Discussion: There is little literature for treatment of
SSS with Kampo formulation. For treatment of
and/orslow-pulse

in

Kampo

formulation, on the other hand, some doctors take it
for symptoms for cold and use drugs with Processed
Aconitine Root (Processi Aconiti Tuber) or with
Processed Ginger (Zingiberis Rhizoma). Ebe, et al.
reported that Keishi (Cinnamomi Ramulus, or
Cinnamon Twig, Gui-Zhi) and Keihi (Cinnamomi
Cortex, Cassia Bark, Gui-Pi (Rou-Gui)) increase
heart rate in his book: Keihou-Igaku (Theoretical
Explanations and Assemblage of Prescriptions of"Cold Damage" and "Golden Chamber"). Goreisan

Abstract

Poria,

recovering

bradycardia within a few days from the beginning ofbradyarrhythmia

Key words:
bradyarrhythmia, bradycardia
Goreisan (五苓散, Wu-Ling-San, or Powder of Five
Ingredients with Poria)
Kampo (漢方, the medicine traditionally practiced inJapan, based on ancient Chinese medicine)
Kampo extract formulation for prescription
sick sinus syndrome (SSS)
sui-doku (水毒, disorders of the body’s fluid metabolism)

startedWu-Ling-San), which is a Kampo(traditional Japanese medicine) formula for sui-doku

contains Cinnamon which can increase pulse rate.

Conclusions: This report suggests the possibility ofusing Kampo medicine for the treatment of severe
bradyarrhythmia including SSS in elderly dementia
patients. Our data and some reports suggest that

Goreisan may be useful not only for the managementof dizziness, edema, vomiting and diarrhea, but also
for that of severe bradyarrhythmia in aged dementia.
Further accumulation of the similar cases might behelpful for us to interpret the mechanism of rate
control with Goreisan in future.

(disorders of the body’s fluid metabolism).

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

7

Volume 6, Number 1 | Spring 2011

Background:

The sick sinus syndrome (SSS), or[Western medical findings:]Height of 153cm. Weightsinus node dysfunction (SND), is a combination ofof 54.5kg. Body temperature (BT) of 36.2℃. Blood

symptoms (dizziness, fatigue, syncope, pre-syncope,pressure (BP) of 169/95 mmHg. Pulse rate (PR) of

and palpitations) caused by sino-atrial (SA) node

38bpm (regular). Conscious level was clear: GCS15

dysfunction

sinus(E4,V5,M6). Dementia-level was observed with

bradyarrhythmia, SA block, or sinus arrest ( i ).

MMSE (Mini-mental State Examination) scores,

Although the term SSS has been popular since thewhich were 19points.

definition by Rubenstein (ii), the more comprehensive

Results of physical examination were normal except

title SND is gaining prevalent. In this paper we wouldthat the bowel sounds were slightly hyperactive.

like to use the term SSS instead of SND. SSS is quite

Schellong’s test (head-up tilting test) was withincommon, and its incidence increases with advancing

normal limits (W.N.L.).

age (iii ). Symptomatic SSS patients are treated with

Blood chemistry findings were all within normal

implantableoflimits except the one-hour postprandial blood

bradyarrhythmia at which to consider pacing is

glucose was 111mg/dL. Thyroid function tests andgenerally accepted to be “a rate of less than 40

CK-MB was within normal limit.

beats/min (bpm) during waking hours” ( iv ). In SSS

Electrocardiogram

without

pacemaker

bradyarrhythmia at a heart rate of 38bpm, left axis

implantation, drug therapy approaches, occasionally,

deviation, inverted T-wave in V4-5, and minor ST-

have been temporarily introduced (v).

segment depressions in V6.

andmanifested

pacemakers.

absolute

bysevereThe

indications

degreefor(ECG)

markedsinus

On the other hand, there is no evidence-based

Chest X-ray films, computed tomographic (CT) scan

Kampo

of the brain and the neck: W.N.L. for her age,guideline

fortreatment

of

SSS

with

although there was mild brain atrophy in theformulation.
We report a patient suffering from severe

subcortex.

bradyarrhythmia treated effectively with Goreisan

Ultrasound study of the neck and the heart: W.N.L.

(Powder of Five Ingredients with Poria, or Wu-Ling-

for her age.

San) extract formulation for prescription.

[Kampo findings:] On general diagnosis: Thirsty.
Little urine. Pulse diagnosis: Superficial and slow.

Case Reports:

Tongue diagnosis: Light-red tongue with teeth

Case one: 82-year-old female.

indentation. Also, slightly dry, thin and white fur.

[Chief complaint:] Dizziness.

Abdominal diagnosis: Slightly weak abdominal[History:] The patient and her family consulted astrength. Sound of fluctuating liquid.

local clinic due to dementia, just after death of her

Level of sui-doku (disorders of the body’s fluid

daughter, in the spring of 200X. Her family rejected

metabolism) : At least 32points with water retention

nursing by themselves, so they consulted H hospitalscores (vi) (Table 1).

and admitted its old people’s home (elder care

[Progress notes (Figure 1)]: Because of ECG findings,

facility: H-home) on June 15. On the second post-

she should be admitted to another hospital with theadmission day, she had dizziness, vomit, and loose

cardiac care unit for arrhythmia monitoring, but thestools, therefore the nurse at H-home brought her tofamily selected palliative treatment. The patient did

our department on June 18.

not meet the diagnostic criteria of orthostatic[Past history:]Hypertension, latent SSS (the family

hypotension ( vii ). From physical examinations andsaid, “A series of alphabet ‘S’ or something likeroentgenological studies, there were little possibility

that.”)of orthopedic, oto-rhino-laryngologic, and neurosurgeric

8

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 1 | Spring 2011

diseases. An ECG was characteristic of SSS (Rubenstein

Her condition was diagnosed as sui-doku (disorders

type I). The presumative diagnosis, therefore, wasof the body’s fluid metabolism) from Kampo findings.

dizziness due to severe bradyarrhythmia.

Goreisan (6g / day, b.i.d., Kracie Pharmaceutical, Ltd.

Initially, atropine (0.5mg, intramuscularly) was(KB-17) was introduced orally. The dizziness andgiven. However, the patient reported thirsty without

bradycaridia improved within 30 minutes. Before

pulse rate improvement. We did not continue

administration of Goreisan, although, minimum

injection

heart rate was 30bpm at night and 38bpm atofatropineenoughtoblock

daytime, after administration of Goreisan theparasympathetic nerve.

minimum heart rate was about 55bpm at daytime forfive month. The patient says, “Thismedicine (Goreisan) is very tasty and I

Table 1: Diagnostic score of water retention

always feels good by taking thisBody feels heavy

3

Nausea, Vomitting

3

Pulsating headache4

Increased gurgling3

Dull headache

3

Morning stiffness

7

Case two: 87-year-old female.

Getting motion sickness easily

5

Tendency toward edema, gastric clapotage

15[Chief complaints:] Loose stools, legLightheadedness, dizziness

5

Pleural effusion, cardiac water retention, ascites

15

edema, excessive daytime somnolence,

Syncope5

Epiumbilical palpitaion1)

5

Watery nasal discharge

3

Watery diarrhea

5Hypersianosis

3

Decrease urinary volume

7

carbamazepine

Foamy sputum

4

Diuresis5

severalmedicine.”

respiratory failure.
[Past History:] Cerebral infarction (76
y.o.

in

1997),

epilepsy(with

600mg/dayt.i.d.),

contusions

andfractures,

behavioral and psychological symptoms

Diagnostic criteria: A score of more than 13 points indicates water retetion.
Note 1: Epiumbilical palpitaion refers to an increased pulsation of the abdominal
aorta that is felt during light massage of the umbilical area.

of dementia (BPSD, in 2005)[Present History:] The patient and her

Cf. The Journal of Kampo, Acupuncture and Integrative Medicine 2005;1Special Edition:12

familyconsulted

S-clinic

andshe

admitted its old people’s home (S-home)
in September, 2005. On October 5, 2008,
Atr: Atropine (i.m.)
WLS: Wu-Ling- San

Atr
0.5
mg

she had a cold and this preceded theonset of pneumonia (Pn).

Goreisan (WLS) 6g/d

The use of antibiotics (CTM, 2g/day,

VommitingLoose Stools

d.i.v.) and oxygen (Ox) therapy for fourbpm

days showed good effectiveness forHtreatment of Pn, so antibiotics was
switched

-

- c

-

-

-J

-J

?

-J

H

-J

WLS p.oi?
Admission
?
-J

mmHg
or mm

?

from

(300mg/day,

CTM

p.o.)

and

to

CEPN-PI

Ox

therapytapered off. On Oct.14, loose stools, leg
-

- c

-

-

-J

-J

-J

-J

H
i

-J

edema and sleep disorders were shown,i iFigure 1: Clinical course of case 1
Change in BP, HR(PR),and VAS of dizzinessmeasured before and after Goreisan administration

VAS:Visual Analogue Scaleso she and the nurse consulted S-clinic
and we made a house-call on the nextday.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

9Volume 6, Number 1 | Spring 2011

[Western medical findings:] Height of 151cm. Weight

bradycardia developed with decreased level ofof 41.6kg. BT of 36.6℃, BP of 114 / 68 mmHg with aconsciousness.

PR of 36bpm (regular). Conscious level was GCS10

prescriptions as of Oct.15 immediately (Goreisan,(E3,V3,M4). Her dementia-level was 15points withtulobuterol-tape, and aspirin were reintroduced andMMSE.

SpO2：98% (O2 3 l/min), Moist rale (coarse

carbamazepine was discontinued). On the next day,crackles) was heard at the right upper lung field. Her

her status improved again. She had had no trouble

legs were slightly edematous.

with heart rate of 55 bpm until November 12, andLaboratory data on admission are shown in Figure 2.

subsequently the Goreisan was tapered off.

Therefore,wechangedthe

An ECG performed in a comatose state (Oct.23)
revealed

episodesofsevereAspirin 100mg/d

bradyarrhythmia at a rate of 20bpm. A

Tulobuterol-tape 2mg/d
WLS 6g/d

12-lead ECG tracing on the next day
showedepisodesofrates of 37bpm.
[Kampofindings:]

On

Carbamazepine 600mg/d

sinus

bradyarrhythmia with minimum heart
generaldiagnosis: Thirst, sweat and little urine.
knottedpulse.

Tonguediagnosis:

Unknown.

The

patient

rejected to open her mouth. Abdominal
diagnosis by palpation: Slightly weak
abdominal

strength,

sound

of

CEPN-PI 300mg
p.o.

SD

140
SBP
or
DBP
120
(mmHg)

WLS: Wu-Ling-San, (Goreisan)
CBZ: Carbamazepine
CEPN-PI: Cefcapene pivoxilhydrochloride
LS: Loose Stools
LE: Leg Edema
SD: Sleep Disorders(excessive daytime somnolence)

CBZ

Cefotiam (CTM)2g
d.i.v.

CTM2g
d.i.v.

SD

SD

LS, LE

100

HR
(bpm)

HR

80

SBP
60

Pulse diagnosis: Superficial and slow.
Sometimes

WLS 6g/d

Lactomin 3g/d

DBP

40
20
S24 HR S30 O1 O2 O5 O6 O7 O8 O9 O10 O11 O12 O13 O14 O15 O16 O17 O18 O20 O22 O23 O28 N1 N3 N5 N12 N19
min
CRP(Mg/dl)or
W BC(×1000/mm 3)
orO2(l/min,nasal)

CBZ discontinued
and WLS introduced orally?

×

fluctuating liquid, epigastric discomfort

Figure 2: Clinical course of case 2slightly.

: (Top), Change in BP and HR(PR) measured before and after Gorei-san administration.
: (Bottom), Change in CRP, WBC, and Oxygen.

Level of sui-doku : At least 26points.
[Progress notes (Figure 2):] Although the family
hoped palliative care at S-home, her condition wasbad enough to be referred to the other hospital for
immediate

admission.

As

her

condition

wasdiagnosed as sui-doku, Goreisan (6g / day, b.i.d; KB17) was introduced orally. CTM was reintroduced.
Tulobuterol-tape 2mg/day and aspirin 100mg/day
were continued and the other drugs (carbamazepine
600mg/day etc.) were discontinued. Within two days,
her loose stools, leg edema, severe bradyarrhythmia,
conscious level, and respiratory failure improved.
Four days later, she did not need antibiotics (CTM)
and oxygen therapy. Seven days later (Oct.22), herlaboratory findings such as CRP were improved, andthe drugs (carbamazepine etc.) were reintroduced
and Goreisan was discontinued. Within one day, her

10Case three: The third case was a 72-year-old female.
[Chief complaints:] Watery diarrhea, vomiting.
[Past History:] Cerebral infarction.
[Present History:] The patient and her family
consulted S-clinic and she entered its old people’s
home in October, 2001. On February 21, 2008, she
noted the onset of nausea and vomiting. And for thefollowing several days she had had recurrent waterydiarrhea, which remained unresponsive despite
lactominanddomperidone,

accompaniedbyvomiting and sweating.
[Western medical findings:] Height ;145cm, Weight ;54kg, BT; 37.3℃, BP; 127/ 71 mmHg, PR; 48bpm(regular). Conscious level; clear. Dementia-level;
16points (MMSE). There were no resistance and no
tenderness, but the bowel sounds are hyperactive.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 1 | Spring 2011

ECG findings: Sinus bradycardia, abnormal Q

in patients with SSS are listed in the ACC/AHA/

waves in III and aVF.

NASPE 2002 guideline ( viii ). Due to limitations of[Kampo findings:] On general diagnosis; thirst,

space, a detailed discussion on the indications for

sweat, little urine, slight cold sensitivity. Pulse

pacemaker implantation is not possible here. Pleasediagnosis: Superficial and slowed-down (Huan).

refer the guideline for more information.

Tongue diagnosis: Dark-red tongue with teeth

In SSS without absolute indications for pacemakerindentation, slightly dry, thin and white fur.

implantation, drug therapy, occasionally, have been

Abdominal diagnosis: Slightly weak abdominal

temporarily introduced (ix). Drug treatment of sinus

strength, sound of fluctuating liquid.

bradyarrythmia

Level of sui-doku : At least 33points.

asymptomatic patients. While intravenous atropine[Progress notes:] Examination disclosed infectious

has aided some patients transiently, most patients

diarrhea due to norovirus-related gastroenteritis.

ultimately require placement of a pacemaker.

Her condition was diagnosed as sui-doku. On

Although in the past, isoproterenol was used quite

February 25, Goreisan (6g / day, b.i.d; KB-17) werecommonly

introduced orally for sui-doku. By the next day,further appreciation of its substantial risks of theabdominal symptoms subsided and besides her

increasemoderate bradyarrhythmia improved. She had had

diminished

its

role.

no trouble with heart rate of 50-60 bpm until Marchtheophyllineorcilostazol

4, when Goreisan were discontinued. Since then, thethough these are drugs of off-label use under healthheart rate has been decreased gradually to 45-

insurance

50bpm.

bradyarrhythmia secondary to therapeutic use of

is

in
in

usuallypatients

withmyocardialinJapan.

notindicatedbradyarrhythmia,

oxygen
Some

In

for

for

demandhas

physiciansusebradyarrythmia,

patients

with

sinus

digitalis, beta-blockers, carbamazepine or calcium

Summary of three cases: All three patients had
dementia, bradycardia and sui-doku. Two of thechannel blockers, simple discontinuation of the drug
are often all that is necessary.

patients had severe bradycardia with minimum PRof less than 40 bpm. All patients wereTable 2: Baseline characteristics of three patientstreated with Goreisan for sui-doku.

No.

case1

case2

Severe bradycardia associated with SSS

Age, Gender

82、Female

87、Female

72、Female(case 1), severe bradycardia associatedDiseases other thanbradycardia

Dementia(AD)、HT

Dementia+Brain infarction,knee-OA, Asthma

Dementia+Brain infarction,
Fx at Lumbar discs, HTwith drug-induced bradycardia with SSS

Level of the Dementia

MMSE 19/30
HDS-R 18/30

MMSE 15/30
HDS-R 16/30

MMSE 16/30
HDS-R 16/30(Active) Symptoms

Dizziness, Thirst, Oliguria

Loose stools, slight leg edema
and sleep disorders

Diarrhea (norovirus-related
gastroenteritis)

ADL (Barthel Index)

95/100 ? 100/100

0/100 ? 45/100

20/100 ? 55/100

Water Retention Score(Terasawa)

32/100At least 26/100

At least 33/100

WLS(Gorei-san)

6g/day b.i.d.

6g/day b.i.d.

6g/day b.i.d.

ECG

Sinus bradyarrhythmia ata heart rate of 38bpm.
Rubenstein type I .

Sinus bradyarrhythmia withminimum heart rates of
37bpm .

Sinus bradyarrhythmia at aheart rate of 38bpm.

Change in HR(PR) HR(PR)of pre-administration ?
HR(PR) of postadministration

30bpm at night, 38bpm at
daytime ?
about 55bpm at daytime

20bpm at night(with CBZ),
37bpm at daytime ?
about 55 bpm at daytime

48 bpm ? 50-60 bpm (withWLS) ? 45-50 bpm (without
WLS)(case 2) and moderate bradycardia with
infectious

diarrhea

(case

3)

were

controlled successfully with Goreisan(Table 2). All patients started recoveringfrom bradycardia within a few days fromthe start of the treatment without any
adverse reaction.

case3

Discussion
Standard

treatmentofbradyarrythmias including SSS: The

Abbreviations:
MMSE, Mini-Mental State Examination; HDS-R,Hasegawa Dementia Scale-Revised ; AD, Alzheimer's disease.
HT, Hypertension; ADL;Activities of Daily Living, WLS;Wu-Ling-San,or Goreisan Kracie Pharmaceutical, Ltd., (KB17) , OA; Osteoarthrities, DM; diabetes mellitus, Fx;fracture

indications for pacemaker implantation

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

11

Volume 6, Number 1 | Spring 2011

Treatment of bradyarrythmias including SSS with

inhibited urination, slight heat, and dispersion-

Kampo formulation: On the other hand, there islittle literature for treatment of SSS with Kampo

thirst. Goreisan governs. (xi)”And the “Jin-Kui-Yao-Lue” says “When a thin person presents withformulation. For treatment of bradyarrhythmia

palpitation below the umbilicus, drooling andand/or slow-pulse with Kampo formulation, on the

foaming at the mouth, withdrawal, and dizziness,other hand, some doctors take these symptoms forthis indicates water. Goreisan governs. ( xii )”kan-sho (cold pattern) and use drugs with bushi

Indications for Goreisan is acute and chronic(Aconiti Later Radix, Processed Aconitine accessory

diseases due to sui-doku, such as headache, severe

root, or Fu-Zi) or with kankyo (Zingiberis Rhizoma,

thirstDried Ginger Rhizome, or Gan-Jiang) ( x ). Somedifficulty,

Japanese doctors have used Kampo drugs forfluctuating liquid in the epigastric region, vomiting

treatment of bradyarrhythmia and/or slow-pulse as

frothy saliva, and vertigo.

Table 3 shows.

Author

Literature

Organisation

Cardiacdiseases

Age
Sex

Pulse
Diagnosis

HR change

Kampo fomula

TauchiN. et al.

The Japan
Pediatric
society for
Oriental
Medicine
2003 Vol.19
pp.5-12

Dept. of
Pediatric
Cardiology and
NICU, Ogaki
Municipal
Hospital, Japan

Advancedatrioventricular(AV)
block(2:1)

5y.o.
male

Not
commented

63bpm?
improvementof AV block(HR:
unknown)

Ling-Gui-ZhuGan- Tang (Extract
Granules)
2.0g/day t.i.d.

Kampo-noRinsho,
46(5)(1999)

Watanabe
OB/OG,
Fujieda-city,
Japan

Left
Ventricular
Hypertrophy(LVH),
extrasystolicarrhythmia,
Mitral Stenosis(MS) susp.

66y.o.
femaleUnknown
Origin88y.o.
femaleSakamoto T.

KampoKenkyu
No.444, pp.3
68-369(2008)

vomiting

edema,

after

generaldrinking,

urinary

fatigue,diarrhea,

Medicinal Constituents of Goreisan:

Table 3䠖Cases with Kampo formula for bradycardia

Watanabe Y.

withSakamoto
Clinic,Hirosaki-city,
Aomori, Japan

Goreisan is not a simple preparation of
medicine, but contains multiple herbal
medicines such as

Deep
and
Slow
?
Big and
SlowedDown

45bpm ?
59bpm

Deep,
Weak,
Fine,
and
Slow
? Not
commented

30bpm ?
70bpm

(Pharmaceutical
Manufacturers unknown)

Ren-Shen-Tang(Extract Granules)
4.0g/day(OHSUGIPHARMACEUTICAL
Co.,LTD.), Da-JianZhong-Tang(Extract Granules)
5.0g/day(Tsumura &Bukuryo (茯苓, Poria, Hoelen, or
Fu-Ling) 3g :For drain dampness and(1)

tonify spleen Qi.
(2)or

Chorei (猪苓, Polyporus, polyporus,
Zhu-Ling) 3g. For eliminate

dampness and promote urination.

Co.)

San-Huang-XieXin-Tang (Extract
Capsules) 6g/day
t.i.d (for 2 weeks)(Kotaro Kampo
Pharmaceutical Co., Ltd. )(3)

Byakujutu ( 白 朮 , Atractylodis

Macrocephalae

Rhizoma,White

Atractylodes Rhizome, or Bai-Zhu) 3g:
For tonify spleen-Qi and promotes
transformation and transportation of
the spleen-Qi.

How dose they describe Goreisan in classics:(4) Takusha ( 沢 瀉 , Alismatis Rhizoma, Water

Goreisan comes from the “Shan-Han-Lun (On Cold
Damage)” and “Jin-Kui-Yao-Lue (Synopsis of Golden

Plantain Rhizome, or Ze-Xie) 5g: For drains
dampness and promotes urination.

Chamber)”, which classical textbooks written by
Zhang-Zhong-Jing during the Latter (East) Hun era.

(5) Keishi (桂枝, Cinnamomi Ramulus, Cinnamon

The “Shan-Han-Lun” says, “When in Greater-Yang

Twig, or Gui-Zhi) and Keihi (桂皮, Cinnamomi

disease, after sweating is promoted and great sweat

Cortex, Cassia Bark, or Gui-Pi (Rou-Gui)) 2g:

issues, if there is dryness in the stomach, vexation

For warm vitality gate and tonify yang.

and agitation with insomnia, and a desire to drink
water, giving a small amount of water will
harmonize the stomach-Qi so that recovery will leadto ensue. If the pulse is floating and there is
12

The presumable reasons for successful treatment
for this case of bradyarrhythmia with Goreisan
were:

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 1 | Spring 2011

1: Cardiologically, Goreisan, which is diuretics forincreases amount of Qi and this leads to increase ofeliminating dampness, made an improvement of theheart rate.

extravascular volume overload. This improvement in

In Japan, although, some researches on Kampo

the extravascular volume overload led to an

formulation have been carried out from theimprovement of bradyarrhythmia.

viewpoint of the Koho-ha School (the classical school),

2:

From

the

pharmacologic

point

of

view,

they

use Keishito-group (Ramulus Cinnamoni

withdrawal and discontinuation of the medicine that

Decoction group) for treatment of reversed-Qi (Ki-inducestogyaku or rising of Qi), which is manifested by so-

improvement of bradyarrhythmia. In second case,called hot flush. There are two types of hot flush as

discontinuation of carbamazepine can be effective forfollows (xv): Active-type hot flush that observed when

improvement of bradyarrhythmia. serum half-life

individuals feel nervous, disappearing when thebradyarrhythmia

cancontribute

From Keihou-Igaku point of view, Keishi moves

stress is removed. And fixed-type hot flush is always

the Qi from Stomach and increases amount of Qi toobserved, increasing in the face due to tension as

outside-tract and this leads to increase of heart rate.

well as blood engorgement. The patients with active-

According to Ebe, et al.( xiii ), the Qi runs fromtype reversed-Qi normally experience “palpitation”

Stomach to outside-tract through Epigastric region

or “tachycardia”.

(Xin-Xia), Chest, Lung and Pericardium (Xin-Bao:

At first glance, the usage of Keishito-group forconnecting channel of the envelope of the Heart). If

treatment of reversed-Qi, which usually contains

the Qi from Lung to Pericardium is difficult to bepalpitation or tachycardia, seems to be inconsistentdispersed (sen-san), the amount of Qi to Pericardium

withdecreases, this leads to “slow-pulse”. According tobradyarrhythmia or for augmentation of Qi. Where“Keihou-Igaku (six-channel pattern indication)”, thethis contradiction comes from?

factor which decides pulse rate is the amount of

One possible reason for this contradiction comesLung-Qi, which runs from Lung to Pericardium.

from our intention to discuss has not been on Ketsu

Goreisan contains Gui-Zhi which can increase pulse
rate. Gui-Zhi moves the Qi and increases amount(Blood) and Sui (all bodily fluids other than Ketsu)

of Qi, from Stomach to Pericardium and this makesof Ki (Qi), Ketsu, and Sui, because a balance of these

the pulse increased.

three concepts is,

3: From a viewpoint of traditional Chinese medicine

indispensable in order to take full advantage of the(TCM), Goreisan contains Gui-Zhi, which is an acrid,

bradyarrhythmia-relieving aspect of the treatment.

warm medicinal which enters and warms the

If the increase in pulse rate by an improvement ofchannels and network vessels, dissipates cold andthe extravascular volume overload with Goreisan ismoves the Qi and blood (xiv). Furthermore, Gui-Zhi

much greater than the decrease in pulse rate by anwarms the yang specifically of the Heart, Spleen,

improvement of the active-type reversed-Qi withand Kidneys. If Qi is plentiful, then Yang is warm

Gui-Zhi, Goreisan, which contains Gui-Zhi, may

and energetic enough. If Qi is weak and empty, Yang

have effect of increase in pulse rate or improvement

is lacking and the systemic body and extremitiesof bradycaridia in the total amount.

become cold. If Heart-Qi and/or Heart-Yang are weak

Another possible reason for this contradictionand empty, the pulse rates become slow andcomes from “Our argument has been done with thesometimes irregular, and also Blood and Qi are notconcept of Qi.” This may be said, “Are both Kampo,

circulated throughout the whole body. Gui-Zhi,

traditional Chinese medicine (TCM), and Keihou-

which is contained in Gorei-san, moves the Qi andIgaku based on metaphysical consepts of which there

that

of

Gui-Zhifortreatmentofbut on Ki (Qi) in this argument. Now, we must think

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

like three wheels in tricycle,

13Volume 6, Number 1 | Spring 2011

are no plausible scientific rationale for understanding

where the idea that “the care of the elderly is theQi?” Or “Are there any effects of Gui-Zhi or its

responsibility of the family” has long been strongly

ingredients on the improvement or decrease of pulse

held. Sometimes we encounter patients who arerate pharmacologically?” To the best of our knowledge,

within indications for aggressive treatment in

there has not been any report on the in vitro

medically, but are out of curative indications ofcardiotonic action of Gui-Zhi like that of Fu-Zi. But, itaggressive treatment in socially. For example, a

may be said that “A drug may have two opposite

super-aged dementia patient, whose family rejected

effects on the disease”, like the efficacy of low-dose

nursing by themselves, is within indications for

dopamine as a renal-protective agent during vigorous

aggressive treatment in medically. In this case, thediuresis for CHF associated with moderate renal

patient and one’s family might choose palliative careinsufficiency and that of high-dose dopamine without

instead of aggressive treatment. And this may lead

diuretic effect for CHF(xvi). According to some reports,

to worse prognosis of the patient compare to that of

cinnamaldehyde in Gui-Zhi is a central nervous

the patient who took aggressive treatment. In thosesystem (CNS) stimulant at low-doses and a sedative
at high-doses (xvii), (xviii), (xix). And we may attributesuch CNS stimulation (low-dose) and sedation (highdose) to acceleration and suppression ofcases, through Kampo

medical diagnosis andtreatment,

teams

catecholamine (mainly adrenaline) release from the

medicalcandevelopcomprehensive geriatric assessment (CGA) and offer
true whole-person medicine, and this will lead to
improvement of the patients’ quality of life (QOL).

adrenal glands. Briefly, it may be said that, on the one
hand low-dose Gui-Zhi accelerates pulse rate throughConclusions:

CNS stimulation directly and through promotion ofThis report suggests the possibility of using Kampo

urination by warming yang for dieresis or by

medicine

eliminating dampness and diuresis indirectly. On thebradyarrhythmia including SSS in elderly dementia

other hand, high-dose Gui-Zhi suppresses pulse ratepatients. Further accumulation of the similar cases

through

CNS

sedation

directlyandthrough,forthetreatmentofseverefrom patients in clinical settings and extensive

indirectly, promotion of harmonizing yingfen andmolecular

weifen by relieving exterior syndrome with pungent

syndromes are required to gain insight into severe

and warm natured drugs like Keishito (Ramulus

bradyarrhythmia, including SSS, and to develop new

Cinnamoni Decoction, or Gui-Zhi-Tang).

target therapies and preventive strategies.

andcellularresearch

into

these

So far we have outlined on the presumable reasonsdizziness, edema, vomiting and diarrhea, but also for

Additional remark (Acknowledgements):(OZAKI K., et al. have been reported as “Threecases of severe bradycardia including Sick Sinus
SyndromeinElderly
Dementia
Patients
Successfully Treated with Herbal Medicine Goreisan (Wu-Ling-San, or Poria Powder with Five
Herbs).” at the 6th World Congress of Chinesethat of severe bradyarrhythmia in aged dementia.

Medicine 2009 Melbourne, Australia, Dec. 2009.

for successful treatment for bradyarrhythmia in aged
dementia

withGoreisan. Briefly, functions ofGoreisan are not only to promote urination and todrain damp accumulation, but also to warm yang Qi.
Our data and some reports suggest that Goreisan
may be useful not only for the management ofGoreisan is thought to be effective for the treatment

We would like to thank Dr. Nelson Yoshiokiof bradyarrhythmia in elderly patients whose sinus

YAMAWAKE for his suggestions, some of which wenode and heart function are aggravated withhave adopted, in particular the translation ofadvancing age.

technical terms of Kampo from Japanese into

We are facing a prominent aging society in Japan,

14

English.

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 6, Number 1 | Spring 2011

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