Bradycardia is a common type of arrhythmia. However, bradycardia can be a symptom of internal illnesses. In some cases, when the automatism of both the sinus and the atrioventricular nodes decrease, the heart rhythm can become idioventricular. According to cardiologists, if the heart rate is less than 40 BPM for more than a month, there is no reliable drug treatment, and for bradycardia with an idioventricular rhythm; the only option is a pacemaker. However, the use of acupuncture as a primary treatment for patients with bradycardia is another option but is not widespread [1]. In this case, an attempt was made to help a patient with a heart rate of < 40 BPM for more than a month who refused to undergo the operation to implant a pacemaker. This treatment was designed and delivered with the written consent of the patient.

This case report follows the CARE Guidelines (Riley DS, Barber MS, Kienle GS, et al. CARE Explanation and Elaborations: Reporting Guidelines for Case Reports. J Clin Epi 2017 Sep;89:218-235. doi: 10.1016/jclinepi.2017.04.026).

Here we report the case of a 71-year-old patient with sudden onset bradycardia who was treated with acupuncture for a month and a half after refusing to undergo pacemaker surgery. At baseline, the patient had an idioventricular rhythm with an average heart rate of 34 BPM, 405 bradycardia episodes, and a total duration of 18 h 50 min. These data were confirmed by a Holter monitor.

Acupuncture treatment was carried out using a combined method: acupuncture with metal needles alternated with electropuncture sessions. Metal needles were applied to points located on the abdomen, chest, and head. Electrodes were placed on points located on the limbs and back.

A new method of complex acupuncture treatment was developed based on traditional Chinese medicine. This was carried out on the points recommended in the literature for the treatment of heart diseases: angina pectoris, cardiac neurosis, heart flutter, and bradycardia (Table 1).

Table 1

Description of treatment regimen.

Style of acupuncture	Traditional Chinese acupuncture
Rationale for treatment	Spleen/kidney/heart/liver
Needling details	Bilateral needling points	ST36, SP4, SP6, KI1, KI4, KI7, LI4, LI11, SI14, TE5, BL17, BL45, BL60, GB20, LR2, LR14
	Unilateral needling points	CV6, CV12, CV14, CV16, CV17, GV20
Number of needles	30 needles	Needle description Needle type: Seirin - J type0.18 mm × 15 mm (1/2 tsun) 0.18 mm × 30 mm (1 tsun)
Depth of insertion 0.5-2 cm in depth	Response elicited De Qi	Needle stimulation method Manual stimulation Electrical impulse stimulation
Needle retention time	Acupuncture - 21 minutes
	Electroacupuncture- 21 minutes

Since this treatment was planned to target points located on the limbs, the head, and the back and abdomen, a combined treatment regimen was developed consisting of acupuncture sessions with metal needles and electropuncture sessions [2].

Metal needles, up to 3 cm long, 0.01 mm in diameter, with rounded tips, were inserted to a depth of 0.5-2 cm at points located on the abdomen, feet, and head until a “response” was obtained, as well as a feeling of heat and distention at the insertion site [3]. The duration of exposure to metal needles was 21 min in total.

Silver electrodes with an area of 1 mm2 were placed on the points of the “five elements”, as well as on the back and sternum. The electric acupuncture device current settings were the following: 20 μA maximum; voltage 9V; impulse. The impulse was rectangular bipolar, with a frequency of 0.1, 1, 10 Hz, and a duty cycle of 2:1. The duration of the exposure intervals at the three indicated frequencies was 7 min each [4].

Points: ST36, SP4, SP6, KI1, KI4, KI7, LI4, LI11, SI14, CV6, CV12, CV14, CV16, CV17, TE5, BL17, BL45, BL60, GB20, GV20, LR2, LR14.

Currently, various non-invasive transthoracic pacemakers are used to maintain the heart rate in patients with bradycardia. The parameters of the ZOLL M temporary pacing device (ZOLL Medical Corporation, Chelmsford, MA, USA) are known and described below. The pacemaker stimulation current is up to 140 mA and the frequency is up to 180 pulses per minute. The pacing output is delivered to the heart using electrodes located on the back and in the precordial region [5].

The novelty of the acupuncture method developed for the treatment of this patient consisted of a combination of treatment with metal needles and electropuncture.

The patient was male, 71 years old, a former athlete, and currently a pensioner. In 1995 he suffered a myocardial infarction. His rehabilitation went well and for many years there were no complaints about the condition of his heart. In August 2021, he suddenly felt unwell with general weakness and rapid fatiguability appearing. An ECG registration did not reveal new signs of ischemic heart disorders, however, it was established that at the time of ECG registration the heart rate was 39 BPM. The patient then went to the hospital for help. A first 24 h Holter monitoring was prescribed and installed. It found the presence of sinus rhythm, seconddegree atrioventricular block, single ventricular extrasystoles with a total of 2,267 over the observation period, and heart rate from 29 to 53 BPM. Drug treatment was started to relieve bradycardia. The medications given were orciprenaline, riboxin, mildronate, atropine preparations, isadrinum, and Tonginal. However, these showed little to no positive results.

After pharmaceutical treatment, the patient underwent a second Holter monitoring, which established the following: There were no ischemic changes in ST-T, idioventricular rhythm, third-degree atrioventricular block during 90% of the monitoring time, and second-degree block during 10% of the monitoring time. Average heart rate 34 BPM, minimum 30, maximum 35, and 3289 ventricular extrasystoles during the observation period.

The patient was offered surgery to install a pacemaker which he refused.

The patient was also offered acupuncture treatment, which he accepted and freely signed a document of his consent for such therapy.

External pacing can be used for the primary stabilization of a patient, but it does not preclude the implantation of a permanent pacemaker. This technique consists of placing two stimulator plates on the surface of the chest. One of them is usually located on the upper part of the sternum, and the second is placed behind on the left, almost at the level of the last ribs. When an electrical discharge passes between these two plates, it causes contraction of all muscles located in its path, including the heart and muscles of the chest wall.

A similar stimulation has been applied through specific cutaneous points using electropuncture techniques (Fig. 1) [6].

Figure 1. Acupoints used in bradycardia treatment.

The acupuncture and electropuncture treatments were carried out with a different combination of points, but each time at no more than six simultaneously. The first session consisted of a single insertion at the BL17 point, which generated a response upon insertion, and rapid stimulation of the point by turning the needle for 1 min. As a result, the patient’s pulse rose to 60 BPM within 30 min after needle insertion and was stable for approximately 50 min, then it dropped back to the initial 36 BPM. On the following days of treatment, along with intervals of the pulse increasing to > 60 BPM, cases of unstable pulse appeared with the heart rate repeatedly fluctuating between 36-62 BPM.

In total, the patient underwent three courses of treatment within 50 days: 10 sessions per course with two resting intervals of 10 days. Each session in its turn consisted of both electropuncture and acupuncture methods. The electropuncture was performed as described in the methodology above. It was followed by 2 h of rest, and then acupuncture finished each session. After the end of the third course, the patient underwent the third 24 h Holter monitor assessment.

Some of the results from the Holter monitor are presented in Table 2.

Table 2

Holter monitoring parameters of a patient with bradycardia.

Parameter	08.31.2021	09.07.2021	11.15.2021
Rhythm	Sinus	Idioventricular in AV3	Sinus
		Sinus with AV 2
Blockade	AV 2	AV 3-90% AV 2-10% of observation time	AV 1
		Mobitz2 conduct 2: 1	Alone episode AV 2 during a single paired ventricular extrasystole
General average
HR	38	34	71
HR min	29	30	52
HR max	53	35	115
Extrasystoles single	2267	3289	91
Bigeminia/trigeminia	14/8	20/0	1
Paired ventricular	Not indicated	35	1
Pauses > 2 sec	2426	More than 3 seconds - no	-
Episodes of bradycardia (< 40 bpm)	20976; duration 9 hours 20 mins	405; duration 18 hours 49 min 50 sec	-

In all three cases, there were no ischemic changes in the ST segment.

Two months after the appearance of a stable heart rate, the pulse constantly persists in the range of 62-72 BPM at rest, with a corresponding increase to 80-100 BPM during physical activity.

There have been no complaints of fatigue, dizziness, or other manifestations of hypoxia since treatment ended.

Ten months after the end of the acupuncture treatment the patient underwent a cardiac examination. Some of the results are shown in Fig. 2. As can be seen from the description, the patient has serious heart disease, but the rhythm is sinus, the rate is 61 BPM, and there are signs of first-degree AV blockade.

Figure 2. Patient’s ECG, 10 months after treatment.

We believe that this result was achieved thanks to a combination of two methods of acupuncture: needle acupuncture and electroacupuncture with impulses of different frequencies. This utilized parameters like those of an external pacemaker used in the emergency treatment of bradycardia before the moment of internal pacemaker implantation. In this case, not just the projection area of the heart was stimulated, but also acupuncture points used in the treatment of angina pectoris, heart neurosis, and heart flutter. Based on the successful outcome of the treatment of this patient with the proposed new method of acupuncture which combines traditional Chinese medicine and electropuncture, research should be conducted on the indications and possible contraindications for its use to treat persistent bradycardia with a third-degree atrioventricular block. This is especially important given that there is no reliable drug treatment method that provides a stable outcome for this disease, and in the majority of cases a pacemaker is implanted [7].

Reinforcement of this result through the traditional Chinese medicine acupuncture method, in our opinion, made it possible to redistribute energy through the meridians, which contributed to the consolidation of the beneficial effect achieved through electroacupuncture.

In our opinion, the effectiveness of the method of treatment proposed by the authors, and electropuncture and acupuncture methods in general, is based on its impact on electrochemical processes occurring in various tissues and organs [8]. In the human body, as a result of ongoing biochemical processes, weak electrical currents, vortices, discharges, and flashes are generated. We all know about the electrical activity of the heart, brain, and muscles, and electrical reactions accompany all elemental biochemical interactions within the body. Moreover, the impact of these types of treatment courses, along with the help of medications, does not always reach the target due to the impossibility of pharmacological substances reaching such elementary, precellular, basic, perhaps not even biochemical, but chemical level processes. In contrast, a weak external electrical impulse received from electropuncture exposure or generated at a specific point as a result of a needle prick can create conditions for the occurrence of electrochemical processes in affected body structures.

Therefore, the impact of acupuncture methods, which hierarchically affect the most basic levels of the biochemical processes of the body, can cure some diseases, especially those associated with disorders related to nerve conduction that are not amenable to drug treatment methods.

The authors declare no conflict of interest.