Zhao Xinbo's Clinical Experience in Treating Viral Myocarditis

Viral myocarditis is currently one of the more common post-COVID sequelae. The disease is complex, has a long course, greatly affects the patient's quality of life, and is not easy to treat. Here we excerpt the experience of the late veteran TCM physician Zhao Xinbo in treating viral myocarditis, for readers' reference.

Dr. Zhao held that in critical cases (with heart failure, cardiogenic shock, etc.), rescue must combine Chinese and Western medicine and must not be taken lightly. Dr. Zhao advocated that in treating all myocarditis patients, one should avoid extremely bitter-cold, pungent-dry, harsh and potent herbs that damage fluids and consume qi; instead, use sweet-flavored, bland and sweet-neutral herbs for gentle gradual regulation, and treatment should not be rushed.

Acute viral myocarditis commonly presents with low fever, spontaneous sweating, palpitations, shortness of breath, irritability, a pale complexion, and so on; the pulse is rapid, fine and forceless; the tongue body is red with a white or yellow coating. This mostly belongs to internal harassment by heat evil with damage to heart qi and injury to lung yin. Treatment should clear heat and generate fluids, and nourish heart and boost qi; the formula chosen is a modified combination of Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction) and Shengmai San (Pulse-Generating Powder):

Bamboo Leaf (danzhuye) 6 g, raw Gypsum (shigao) 15 g (decoct first), Radix Ophiopogonis (maimendong) 10 g, prepared Pinellia (qing banxia) 3 g, Fructus Schisandrae (wuweizi) 10 g, Radix Ginseng (renshen) 6 g, Fructus Forsythiae (lianqiao) 10 g, raw Radix Glycyrrhizae (sheng gancao) 3 g, Radix Polygalae (yuanzhi) 6 g, Semen Platycladi (baiziren) 6 g.

Note: This formula combines Zhuye Shigao Tang from Shanghan Lun (composed of Bamboo Leaf, Gypsum, Ginseng, Ophiopogon, Pinellia, Licorice and rice) with the famous warm-disease formula Shengmai San (composed of Ginseng, Ophiopogon and Schisandra), removing the rice and adding Forsythia, Polygala and Platycladi.

Zhuye Shigao Tang treats the pattern of unresolved remnant heat from cold damage, warm disease or summerheat illness with simultaneous injury to qi and fluids: symptoms include fever with profuse sweating, irritability in the chest, qi counterflow with a desire to vomit, dry mouth with a desire to drink, shortness of breath and fatigue, or vacuity vexation and insomnia, a red tongue with scant coating, and a deficient rapid pulse. Shengmai San, on the other hand, boosts qi and generates fluids, astringes yin and stops sweating; it is indicated for warm-heat or summerheat consuming qi and damaging yin: profuse sweating with spirit fatigue, lassitude and weakness, shortness of breath and reluctance to speak, dry throat and thirst, a dry red tongue with scant coating, and a deficient rapid pulse.

The indications of Zhuye Shigao Tang and Shengmai San both resemble viral myocarditis, and combining the two gives greater strength. Adding Forsythia to clear heat and resolve toxin, and Polygala and Platycladi to expel phlegm and quiet the spirit, yields an even better effect on viral myocarditis.

Chronic viral myocarditis patients, on the other hand, need differentiation as to whether the pattern is heart-qi deficiency or heart-yin deficiency.

Those with heart-qi deficiency have palpitations and shortness of breath, fatigue and weakness that worsen on exertion, generalized edema (more severe in the lower limbs), poor appetite, fullness and oppression in the chest and abdomen, and irregular bowel movements. The pulse is fine and rapid, or knotted/regularly irregular; the tongue body is pale with a white coating. Such patients should be treated according to the principles of boosting qi and strengthening the heart, and supplementing the spleen and purifying the lung.

Dr. Zhao's experiential formula is as follows: Radix Ginseng (or Radix Codonopsis, dangshen) 6 g, Poria (fuling) 10 g, prepared Pinellia (fa banxia) 3 g, Radix Ophiopogonis (maimendong) 10 g, Radix Polygalae (yuanzhi) 5 g, fried Endothelium Corneum Gigeriae Galli (cha jineijin) 10 g, fried Fructus Hordei Germinatus (cha maiya) 6 g, fried Rhizoma Atractylodis Macrocephalae (cha baizhu) 6 g, Colla Corii Asini (ejiao) 10 g, honey-fried Radix Glycyrrhizae (zhi gancao) 6 g, Bulbus Fritillariae Cirrhosae (chuanbei) 3 g.

Note: This formula is Liujunzi Tang (Six Gentlemen Decoction, composed of Ginseng, Atractylodes, Poria, honey-fried Licorice, prepared Pinellia and Tangerine Peel) minus Tangerine Peel, combined with Shengmai San (Ginseng, Ophiopogon, Schisandra) minus Schisandra, and augmented with fried Chicken Gizzard Lining, fried Barley Sprout, Ejiao and Chuan Fritillaria. Six Gentlemen Decoction strengthens the spleen and boosts qi, disperses distention and glomus, and drains dampness and reduces edema; Shengmai San boosts qi and nourishes yin. Combined, they act well on the patient's generalized edema and qi-deficiency weakness. The fried Chicken Gizzard Lining and fried Barley Sprout aid digestion, Ejiao nourishes yin, and Chuan Fritillaria clears heat and resolves phlegm; used together, they have a strong targeted effect on the symptoms of chronic viral myocarditis.

Those with heart-yin deficiency have palpitations, irritability and insomnia, frequent dreams, and a sensation of heat in the five centers (palms, soles and chest), especially marked in the afternoon; the pulse is fine and rapid, the tongue body red with scant coating. Such patients should be treated according to the principles of nourishing heart yin, downbearing vacuity fire, and clearing lung qi.

Dr. Zhao's experiential formula: Radix Ophiopogonis (maimendong) 10 g, Fructus Schisandrae (wuweizi) 6 g, raw Radix Rehmanniae (sheng dihuang) 10 g, prepared Radix Rehmanniae (shu dihuang) 10 g, Cortex Moutan (mudanpi) 6 g, Fructus Corni (shanzhuyu) 10 g, Poria cum Ligno Hospite (fushen) 10 g, Rhizoma Alismatis (zexie) 6 g, Radix Polygalae (yuanzhi) 6 g, Radix Ginseng (renshen) 6 g, Colla Corii Asini (ejiao) 6 g, Rhizoma Polygonati Odorati (yuzhu) 6 g, Radix Glehniae/Adenophorae (shashen) 6 g.

Note: This formula is composed of Shengmai San (Ginseng, Ophiopogon, Schisandra) and Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill, composed of raw Rehmannia, prepared Rehmannia, Moutan, Cornus, Fushen, Alisma and Chinese yam), minus Chinese yam, and augmented with Polygala, Ejiao, Yuzhu and Shashen. Shengmai San boosts qi and nourishes yin; Six-Ingredient Rehmannia Pill enriches yin and supplements the kidney; Polygala quiets the spirit and expels phlegm; Ejiao enriches yin and nourishes blood; Yuzhu and Shashen nourish lung yin and can expel phlegm and stop cough. Used together, they provide symptomatic treatment for chronic viral myocarditis patients of the heart-yin-deficiency type.

Viral myocarditis has a long course, and some patients cannot long tolerate taking decoctions. If these formulas of Dr. Zhao's prove effective, the patients may have them processed into pills according to the recipe.