【作者】 吴峻豪；

【导师】 陈群；

【作者基本信息】 广州中医药大学 ， 中医诊断学， 2011， 博士

【摘要】 研究背景心律失常在临床上十分常见,以心动过缓或过速伴或不伴心动不规律为主要特点。心律失常的种类繁多,轻重不一。辨证论治是将所收集的症状和体征资料,通过分析、综合,辨清疾病的原因、性质、部位以及邪正之间的关系,概括、判断为某种性质的证候,是中医学的基本特点,也是中医学精华所在。但由于中医诊断标准的不规范,各医家基本上是结合个人临床经验进行分型论治或单一证型论治,辨证分型标准不统一,辨证分型繁杂,证型不规范,方药选用不尽相同。这给心律失常的中医临床诊疗、科研都带来一定的困难和阻力,也限制了中药在心律失常治疗上应用的进一步推广,所以有必要进一步开展心律失常的中医辨证的研究,尤其是辨证分型标准化方面,更是任重而道远。研究目的当前中医辨证分型研究中存在以下多个方面的不足,如在辨证论治上尚缺少统一的客观化辨证标准,没有进行多中心、大样本、双盲的临床研究,宏观研究和微观研究相分离,病和证的研究相分离等。因此,在加强病证结合、宏观微观结合的基础上,将心律失常分为快速型心律失常、缓慢性心律失常两大类,开展多中心、大样本临床研究,通过对心律失常客观化指标的临床验证,并有机地组合各种有效指标,分别针对快速型心律失常、缓慢性心律失建立一套比较规范的症状和证候诊断标准,使中医的症状和证候诊断标准达到一定程度上的统一,使其各种临床或实验研究结果具有有效性、科学性,从而提高中医学科研领域的效率,获得最佳的经济效益比。研究方法1.文献研究通过对心律失常古文献病名、病证、病因病机、脉象、客观指标、中医分型、辨证论治等方面的系统回顾,总结临床经验,从而较全面地认识心律失常的发病特点、中医分型与辨证治疗等,为进一步进行心律失常的中医辨证研究提供理论基础。2.临床研究病例来源于台湾恩典怀恩堂中医联合诊所的病人且经西医心血管内科确诊为心律失常者,共102例。严格按照纳入标准、排除标准进行筛选。收集大样本、多类型的心律失常诊断病例,记录并量化处理患者的相关症候,检测患者入院未治疗前的心律失常相关微观指标,在充分调研现有的分型诊断的基础上选取了一套详细的分型标准。即将心律失常分为(1)快速型心律失常分为：①心气阴虚、血脉瘀阻、瘀而化热型；②心脾不足、湿停阻脉、瘀而化热型；③心气衰微、血脉瘀阻、瘀而化热型；④心阴血虚、血脉瘀阻、瘀而化热型；⑤心气阴虚、肺瘀生水、瘀而化热型。(2)缓慢型心律失常分为：①心脾气虚、湿邪停蓄、心脉受阻型；②心脾气虚、心脉瘀阻、血流不畅型；③心脾肾虚、寒邪内生、阻滞心脉型；④心肾阴阳俱虚、寒湿瘀阻、心脉涩滞型；⑤心脾肾虚、寒痰瘀结、心脉受阻型。将症候、微观指标与心律失常的类型进行相关性分析,以及多因素Logistic回归分析,寻找影响证型的症候和微观指标,从而为辨证治疗提供依据。研究结果1.一般情况：102例中,男性57例,占55.9%,女性45例,占44.1%。患者年龄在38～85岁之间,平均62.5±4.7岁。61～70岁人群的心律失常发病率最高,占44.1%,其次是51～60岁年龄组人群,占36.3%。快速型心律失常49例占48.0%,缓慢型心律失常53例占52.0%。2.快速型心律失常：(1)五型快速型心律失常患者的血压(收缩压、脉压差)、血脂(TC、TG、LDL-C、HDL-C)、心肌酶谱水平(AST、LDH、CK、CK-MB)、凝血水平(PT、APTT、PIB、INR)、血尿酸水平等微观指标以及心悸、胸闷、胸痛、乏力、头晕、气促、气短、惊慌感、失眠、苔腻、脉弦、脉滑、脉促、脉涩、脉缓等症候均有差异。(2)以心气阴虚、血脉瘀阻、瘀而化热型为参照进行Logistic回归分析,结果：①收缩压、TC、AST、LDH、CK、心悸、胸痛、乏力、头晕、气短、惊慌感、失眠、苔腻、脉弦、脉滑、脉促、脉缓等17个微观指标及症候是心脾不足、湿停阻脉、瘀而化热型心律失常的独立影响因素。②收缩压、脉压差、LDL-C、HDL-C、AST、CK、CK-MB、APTT、INR、血尿酸、心悸、胸痛、气促、失眠、苔腻、脉促、脉涩、脉缓等18个微观指标及症候是心气衰微、血脉瘀阻、瘀而化热型心律失常的独立影响因素。③脉压差、TG、LDH、CK、CK-MB、血尿酸、心悸、胸闷、胸痛、气促、气短、惊慌感、失眠、苔腻、脉涩等15个微观指标及症候是心阴血虚、血脉瘀阻、瘀而化热型心律失常的独立影响因素。④脉压差、LDH、CK、APTT、PIB、血尿酸、心悸、头晕、脉弦、脉促、脉缓等11个微观指标及症候是心气阴虚、肺瘀生水、瘀而化热型心律失常的独立影响因素。3.缓慢型心律失常：(1)五型缓慢型心律失常患者的血压(收缩压、脉压差)、血脂(TG、apo-A)、心肌酶谱水平(AST、LDH、CK、CK-MB)、凝血水平(PT、APTT、PIB、INR)、血尿酸水平等微观指标以及心悸、胸闷、乏力、头晕、气促、气短、惊慌感、失眠、脉弦、脉滑、脉结或代、脉涩、脉缓等症候均有差异。(2)以心脾气虚、湿邪停蓄、心脉受阻型为参照进行Logistic回归分析,结果：①apo-A、LDH、CK、CK-MB、APTT、PIB、血尿酸、心悸、乏力、惊慌感等10个微观指标及症候是心脾气虚、心脉瘀阻、血流不畅型心律失常的独立影响因素。②CK-MB、PT、APTT、INR、头晕、气促、失眠等7个微观指标及症候是心脾肾虚、寒邪内生、阻滞心脉型心律失常的独立影响因素。③收缩压、脉压差、CK、CK-MB、PT、APTT、血尿酸、气促、惊慌感、失眠、脉滑、脉缓等12个微观指标及症候是心肾阴阳俱虚、寒湿瘀阻、心脉涩滞型心律失常的独立影响因素。④AST、LDH、APTT、心悸、乏力、惊慌感、脉滑、脉缓等8个微观指标及症候是心脾肾肾虚、寒痰瘀结、心脉受阻型心律失常的独立影响因素。结论本课题主要探讨心律失常的中医辨证研究,将心律失常分为快速型和缓慢型两种。分别将快速型心律失常和缓慢型心律失常分为五种证型,本课题创新点总结如下：1.通过对心律失常患者中医症候的客观化度量,以及将症候与中医分型进行对比研究,五型快速型和缓慢型心律失常患者的心悸、胸闷、胸痛、乏力、头晕、气促、气短、惊慌感、失眠、苔腻、脉弦、脉滑、脉结或代或促、脉涩、脉缓等症候上均有不同,差异有统计学意义。能够认清不同中医分型下心律失常患者在各种症候的不同表现,为从中医症候的表现进行各型心律失常的辨证分型提供客观依据。2.单因素方差分析结果显示,收缩压、脉压差、总胆固醇TC、高密度脂蛋白HDL-C、低密度脂蛋白LDL-C、甘油三酷TG、心肌酶谱、血浆凝血酶原时间PT、活化部分凝血活酶时间APTT、纤维蛋白FIB及国际标准化比值INR、血尿酸等指标在五种快速型心律失常的差异有统计学意义。收缩压、脉压差、总胆固醇TC、载脂蛋白apoA、心肌酶谱、血浆凝血酶原时间PT、活化部分凝血活酶时间APTT、纤维蛋白FIB及国际标准化比值INR、血尿酸等指标在五种缓慢型心律失常的差异有统计学意义。以上表明,这些个体微观指标未来可作为心律失常不同中医证型的辨证参考依据。3.将单因素有统计学意义的微观指标与中医症候同时纳入进行多因素Logistic回归分析可见,影响各型快速型心律失常和缓慢型心律失常的各种中医证型其个别症候和个体微观指标组合不尽相同。不同心律失常中医证型均在一定程度上受到以上症候和微观指标的影响。这充分说明,单一的症候或微观指标不足以对某一中医证型的心律失常进行判定,而这也符合中医整体观念的集中体现。本研究在加强病证结合、宏观微观结合的基础上,提供从整体和客观的角度来研究心律失常的不同中医证型的诊断基础。未来可通过针对性的症候和个体微观指标建立一套比较规范的中医辨证标准,可能对各型心律失常进行正确、科学的诊断和证明。并为治疗该种证型的心律失常提供了针对性的指标参考。更多还原

【Abstract】 BackgroundArrhythmia is clinically common, with bradycardia with or without irregular heartbeat for the main characteristics. There are many types of arrhythmia, with different priorities. Differentiation is collected the signs and symptoms of material, through the analysis and synthesis, distinguish reason, nature, place and relationship between disease and evil, generalize and judge properties of TCM syndrome, is the basic characteristics of TCM essence, also its essence. But because of TCM diagnosis standard is not standard, each individual physicians are basically using clinical experience for treatment or single syndrome differentiation and treatment. The discriminate of standard is different, the subtype’s multifarious and irregular, formulas choosing different. This makes clinical diagnosis and scientific of arrhythmia difficult and resistance, also limits the application of traditional Chinese medicine on arrhythmia. So, it is necessary to further promote the development of syndrome discrimination arrhythmia, especially the study of standardization, much still remains to be done.Research purposesThe dialectical typing study of current Chinese Medicine exists much shortage, such as there’s still missing unity and objective criteria on the dialectical typing of current Chinese Medicine. No large sample, double-blind clinical study, macro and micro studies are separating, disease and evidence are separating. Therefore, on the basis of strengthening the disease and syndrome, macro and micro combination, this paper divided arrhythmia into fast arrhythmia and slow arrhythmia, conduct multi-center, large sample clinical trials. By clinical validation of objective indicators of arrhythmia, and combination of a variety of effective index, respectively establish diagnostic criteria of relative normative symptoms and diagnosis of syndromes for rapid arrhythmia and slow arrhythmia. Which can makes the diagnosis of symptoms and syndromes of traditional Chinese medicine to a certain extent union, the results of various clinical or experimental studies effective, improve efficiency of medical research, so to obtain best value for money ratio.Research methods1 literature researchThrough systematic review of arrhythmia form names, disease and syndrome, etiology, pulse condition, objective index, the Chinese type, syndrome discrimination and treatment aspects to do systematic review, summarize clinical experience, and try to understand characteristics, Chinese types of clinical experience of palpitation, in order to provide theoretical basis of Chinese discrimination of arrhythmia.2. Clinical researchWe totally studied 102 subjects were patients of En Dian Huai En Tang Traditional Chinese Medicine Clinic who were diagnosed as arrhythmia by the Department of Cardiology. Do strictly screening according with the inclusion and exclude criteria. Collecting large and many types of arrhythmia samples, record and quantitative diagnose symptoms of patients, inspect micro index before therapy of arrhythmia, put forward a set of more detailed classification standards. To classify arrhythmia into (1) fast arrhythmia, which was divided into:①the Xinqiyinxu, Xuemaiyuzu, Yuerhuare type②Xinpibuzum, Shitingzumai, Yuerhuare type③Xinqishuaiwei, Xuemaiyuzu, Yuerhuare type④Xinyinxuexu, Xuemaiyuzu, Yuerhuaer type⑤Xinqiyinxu, Feiyushengshui, Yuerhuare type. (2) slow arrhythmia was divided into:①the Xinpiqixu, Shixiatingxu, Xinmaishouzu type②Xinpiqixu, Xinmaishouzu, Xueliubuchang type③Xinpiqixu, Hanxianeisheng, Zuzhixinmai type④Xinshenyinyagnjuxu, Hanshiyuzu, Xinmaisezhi type⑤Xinpishenxu, Hantanyujie, Xinmaishouzu type. To do correlation analysis and multiple Logistic regression analysis of symptom, micro index and types of arrhythmia, to find micro index which affects symptom of arrhythmia and provides the basis for the dialectical therapy.Research results1. General situation:102, male,57 cases (55.9%), women 45 cases (44.1%). Patients are at the age of 38-85, average age 62.5±4.7years old. Incidence of arrhythmia of 61~70 year-old people was highest, accounted for 44.1%, followed by 51-60 year-old groups, accounts 36.3%.49 fast arrhythmia patients accounted for 48.0%, slow arrhythmia patients 53, accounted for 52.0%.2. Fast arrhythmia (1) According to single factor analysis, micro factors such as the blood pressure (systolic blood pressure and pulse pressure differential), lipids (TC and TG, LDL-C, HDL-C), level of serum myocardial zymogram (AST, LDH, CK, CK-MB), clotting level (PT, APTT, PIB, INR), level of serum uric acid and symptoms such as palpitations, chest tightness, chest pain, weakness, dizziness, quickness of breath, shortness of breath, panic, insomnia, moss greasy, strings pulse, smooth pulse, intermittent pulse, tart pulse and fast pulse etc. (2)Took Xinqiyinxu-Xuemaiyuzu-Yuerhuare type as reference to do multiple Logistic regression analysis. The results were:(1) 17 micro index such as the systolic blood pressure, TC, AST and LDH, CK, palpitations, chest pain, weakness, dizziness, shortness of breath, panic, insomnia, moss greasy, strings pulse, smooth pulse, intermittent pulse and fast pulse were independent influencing factors for Xinpibuzu-Shitingzumai-Yuerhuare type. (2) 18 micro index such as the systolic blood pressure, Moots-McKesson ratio, LDL-C, HDL-C, AST, CK, CK-MB, APTT, INR, uric acid, palpitations, chest pain, quickness of breath, insomnia, moss greasy, strings pulse, tart pulse and fast pulse were independent influencing factors for Xinqishuaiwei-Xuemaiyuzu-Yuerhuare type. (3) 15 micro index such as Moots-McKesson ratio, IG, LDH, CK, CK-MB, uric acid, palpitations, chest tightness, chest pain, quickness of breath, shortness of breath, panic, insomnia, moss greasy, strings pulse were independent influencing factors for Xinyinxuexu-Xuemaiyuzu-Yuerhuare type. (4) 11 micro index such as Moots-McKesson ratio, LDH, CK, APTT, PIB, uric acid, palpitations, dizziness, strings pulse, intermittent pulse and fast pulse were independent influencing factors for Xinqiyinxu-Feiyushengshui-Yuerhuare type.3. Slow arrhythmia (1) According to single factor analysis, micro factors such as the blood pressure (systolic blood pressure and pulse pressure differential), lipids (TC, apo-A), level of serum myocardial zymogram (AST, LDH, CK, CK-MB), clotting level (PT, APTT, PIB, INR), level of serum uric acid and symptoms such as palpitations, chest tightness, weakness, dizziness, quickness of breath, shortness of breath, panic, insomnia, strings pulse, smooth pulse, intermittent pulse, tart pulse and slow pulse etc. (2)Took Xinpiqixu-Shixiatingxu-Xinmaishouzu type as reference to do multiple Logistic regression analysis. The results were:(1) 10 micro index such as the apo-A, LDH, CK, CK-MB, APTT, PIB, level of serum uric acid, palpitations, weakness, panic were independent influencing factors for Xinpiqixu-Xinmaiyuzu-Xueliubuchang type. (2) 7 micro index such as CK-MB, PT, APTT, INR, dizziness, quickness of breath, insomnia were independent influencing factors for Xinpishenxu-Hanxianeisheng-Zuzhixinmai type. (3) 12 micro index such as systolic blood pressure, Moots-McKesson ratio, CK, CK-MB, PT, APTT, uric acid, quickness of breath, panic, insomnia, strings pulse and slow pulse were independent influencing factors for Xinshenyinyangjuxu-Hanshiyuzu-Xinmaisezhi type. (4) 8 micro index such as AST, LDH, APTT, palpitations, weakness, panic, smooth pulse and slow pulse were independent influencing factors for Xinpishenxu-Hantanyujie-Xinmaishouzu type.ConclusionThis subject mainly discusses Chinese medicine dialectical studies of arrhythmia, divide arrhythmia into fast and slow type, and each divide into five kinds of arrhythmia syndrome type. Preliminary conclusions are as follows:1. Five types of fast and slow arrhythmia patients with palpitations, chest tightness, chest pain, fatigue, dizziness, quickness of breath, shortness of breath, a sense of panic, insomnia, moss greasy, strings pulse, slippery pulse, rapid pulse, tart pulse and smooth pulse have different symptoms, the difference was statistically significant.2. ANOVA analysis showed that systolic blood pressure, pulse pressure, total cholesterol, TC, high density lipoprotein HDL-C, low density lipoprotein LDL-C, triglyceride TG, myocardial enzymes, prothrombintime PT, activated partial thromboplastin time APTT, Fibrin FIB and international normalized ratio INR, serum uric acid and other indicators in five kinds of fast arrhythmia syndrome types was statistically significant. Systolic blood pressure, pulse pressure, total cholesterol, TC, apolipoprotein apoA, myocardial enzymes, prothrombin time PT, activated partial thromboplastin time APTT, FIB and fibrin international normalized ratio INR, serum uric acid and other indicators in five kinds of slow arrhythmia syndrome types was statistically significant.3. multivariate Logistic regression analysis shows that, of all types of fast and slow arrhythmia syndromes, TCM symptoms and their individual micro-indicators vary individual.This fully shows that a single symptom or not enough of a micro-indicators of arrhythmia syndromes were determined, and this is consistent with the overall concept embodies the traditional Chinese medicine. Statistically significant integration of the various symptoms and micro indicators, may correct the arrhythmia, diagnostic and scientific proof.In summary, fast and slow arrhythmia syndromes are different to some extent by the above symptoms and microscopic indexes. In this study strengthen the disease and syndromes, based on the combination of macro and micro, from the perspective of the overall objective to study and the different arrhythmia diagnosis based on TCM. Through targeted micro-target individual symptoms and the establishment of a fairly standard TCM standards, and to treat the arrhythmia syndromes provide a specific target reference.更多还原