【作者】 张娅；

【导师】 陈慧；

【作者基本信息】 福建中医药大学 ， 中西医结合临床， 2011， 博士

【摘要】 第一部分影响冠脉介入术预后的中西医临床危险因素分析一、目的探讨影响冠脉介入术(PCI)预后的中西医临床危险因素,观察PCI术后气虚血瘀证对抗栓疗效的影响,并分析PCI术后气虚血瘀证与CYP2C19*2基因多态性的相关性。二、方法1.505例行PCI成功的冠心病患者进行术后规范抗栓治疗,根据术后1年是否发生主要心血管事件分为发生组和未发生组,对可能影响PCI预后的中西医临床危险因素进行多因素logistic回归分析。2.256例行PCI成功的冠心病患者进行术后规范抗栓治疗,术后1周采血检测血小板计数(PLT)、最大血小板聚集率(MPA)、血管性假血友病因子(vWF)、血小板膜糖蛋白Ⅱb/Ⅲa (GPⅡb/Ⅲa)、凝血酶原片段1+2(F1+2)和纤维蛋白原(FIB),同时进行中医辨证分为气虚血瘀证和非气虚血瘀证。3.505例行PCI成功的冠心病患者进行术后规范抗栓治疗,术后1周根据是否存在气虚血瘀证表型分为气虚血瘀组和非气虚血瘀组,抽取外周静脉血提取DNA,采用PCR-RFLP基因分析方法检测CYP2C19*2基因多态性。三、结果1.单因素分析和多因素logistic回归分析显示气虚血瘀证、MPA(≥70%)、血浆vWF水平和CYP2C19*2基因突变是影响PCI术后1年主要心血管事件的独立危险因素(P均＜0.01)。2.PCI术后气虚血瘀组MPA、vWF、GPⅡb/Ⅲa高于非气虚血瘀组(P均<0.01),而PLT、F(1+2)和FIB两组间差异无统计学意义(P＞0.05)。3.单因素分析显示：气虚血瘀组CYP2C19*2基因突变型(GA+AA)明显高于非气虚血瘀组(X2=26.952,P<0.01)。多因素logistic回归分析显示：以非气虚血瘀组为参照系,调整诸混杂危险因素后,CYP2C19*2基因突变型(GA+AA)的相对危险度(OR)为2.551(95%C1：1.463-4.446,P=0.001)。四、结论1.气虚血瘀证、血浆vWF水平、MPA70%切割点和CYP2C19*2基因突变对评价PCI预后具有重要意义。2.在目前强化抗栓治疗的基础上,PCI术后气虚血瘀证仍存在明显的血小板活化和血管内皮损伤,但对血小板数量和凝血功能影响不大,是PCI术后1年发生主要不良心血管事件的独立危险因素。3. CYP2C19*2基因突变可能是PCI术后气虚血瘀证的易患因素之一第二部分验证依据气虚血瘀证和CYP2C19*2基因突变联合分析指导冠脉介入术后个体化抗栓治疗药物选择的作用(前瞻性、随机、单盲、对照临床试验)一、目的探讨益气活血的中药复方脑心通胶囊干预PCI术后个体化抗栓治疗的疗效。二、方法选取行PCI成功,中医辨证属于气虚血瘀证且CYP2C19*2基因突变型(GA+AA)的冠心病患者54例,采用随机单盲对照法分为治疗组和对照组,各为27例。对照组进行术后规范抗栓治疗,治疗组在术后规范抗栓治疗的基础上加用脑心通胶囊,每次4粒,一天3次,连续使用1个月。观察治疗前、治疗后10天气虚证、血瘀证积分及远近期抗栓疗效,同时评估抗栓治疗的安全性。三、结果1.治疗组和对照组两组患者治疗前气虚证和血瘀证积分比较无统计学意义(P>0.05)。与治疗前比较,治疗后10天治疗组气虚证积分明显降低(P＜0.01),而对照组明显升高(P＜0.01),治疗后10天治疗组气虚证积分较对照组降低(P＜0.05)。与治疗前比较,治疗后10天两组患者血瘀证积分均明显降低(P均＜0.01),治疗后10天血瘀证积分治疗组较对照组降低(P<0.05)。2.治疗前,两组患者PLT、MPA、血浆vWF、GPⅡb/Ⅲa、F(1+2)和FIB比较均无统计学意义(P>O.05)。与治疗前比较,治疗后10天两组患者MPA、血浆vWF、GPⅡb/Ⅲa、F(1+2)和FIB均显著降低(P均<0.01),而PLT无显著性差异(P＞0.05)。治疗后10天,治疗组MPA、血浆vWF、GPⅡb/Ⅲa、F(1+2)和FIB较对照组降低(P均<0.05),而PLT无统计学差异(P>0.05)。3.两组患者PCI术后1个月终点事件比较发现：对照组3例发生心血管事件,其中2例发生不稳定性心绞痛,1例发生急性心肌梗死；治疗组均未发生心血管事件。根据是否发生终点事件,进行Fisher精确检验,两组差异未见统计学意义(P>0.05),有待继续扩大样本量进行观察。4.根据PCI术后1个月的随访记录发现,治疗组和对照组在服药期间均无主要出血事件和次要出血事件发生。四、结论1.PCI术后气虚血瘀证且CYP2C19*2基因突变患者在标准抗栓治疗的基础上合用脑心通胶囊能明显降低术后10天的气虚证和血瘀证积分。2.PCI术后气虚血瘀证且CYP2C19*2基因突变患者在标准抗栓治疗的基础上合用脑心通胶囊可明显抑制血小板活化,保护血管内皮细胞和改善机体凝血功能。3.PCI术后气虚血瘀证且CYP2C19*2基因突变患者在标准抗栓治疗的基础上合用脑心通胶囊有降低术后1个月心血管事件发生的趋势,有待继续扩大样本量进行观察。4.PCI术后气虚血瘀证且CYP2C19*2基因突变患者在标准抗栓治疗的基础上合用脑心通胶囊引起血小板减少和出血等药物不良反应可能性小。第三部分脑心通胶囊对人肝微粒体CYP2C19酶活力的影响一、目的研究脑心通胶囊对人肝微粒体中CYP2C19酶活力的影响。二、方法以美芬妥英为CYP2C19探针药,利用HPLC方法测定美芬妥英的代谢产物4-OH美芬妥英的浓度,研究脑心通胶囊在人肝微粒体孵化体系中对CYP2C19酶活力的影响。三、结果在人肝微粒体反应体系中,脑心通胶囊(0-250μg/m1)自150μg/ml开始对CYP2C19有酶促作用,且随着浓度的增加逐渐增强。四、结论在人肝微粒体反应体系中,脑心通胶囊(0-250μg/ml)自150μg/m1开始对CYP2C19有酶促作用,且随着浓度的增加逐渐增强。PCI术后气虚血瘀证且CYP2C19*2基因突变的患者在标准抗栓治疗的基础上合用脑心通胶囊有可能通过上述机制增强氯吡格雷抗血小板的疗效,在一定程度上改善氯吡格雷抵抗。更多还原

【Abstract】 Part I Analysis of the clinical risk factors of Traditional Chinese Medicine (TCM) and Western Medicine affecting prognosis of percutaneous coronary intervention (PCI)ObjectiveTo research the clinical risk factors of TCM and Western Medicine affecting the prognosis in patients undergoing PCL and observe the effect of qi deficiency and blood stasis syndrome after PCI on antithrombotic treatment, and analyze the relationship between qi deficiency and blood stasis syndrome after PCI and polymorphisms of CYP2C19*2 gene.Medthods1.505 CHD patients after receiving successful PCI were adopted in this study.They were divided into with major adverse cardiac events (MACE) group and without MACE group.Multivariate logistic analysis was used to analyze the independent influencing factors of prognosis after PCI.2.We adopted 256 CHD patients after receiving successful PCI.After 1 week of standard antithrombotic treatment, TCM syndromes were differentiated into qi-deficiency blood-stasis type and non-qi-deficiency blood-stasis type.All patients detected platelet count (PLT) n maximum platelet aggregation rate (MPA)% plasma von Willebrand factor (vWF) n platelet membrane glycoproteinsⅡb/Ⅲa (GPⅡb/Ⅲa)%prothrombin fragment 1+2 (Fl+2) and fibrinogen (FIB)3.505 CHD patients after receiving successful PCI were adopted in this study. TCM syndromes were differentiated into qi-deficiency blood-stasis type and non-qi-deficiency blood-stasis type after 1 week of standard antithrombotic therament. All patients were genotyped for the polymorphisms of CYP2C19*2 by PCR-RFLP, and the genetic variants frequencies were compared in subjects.Results1.The univariate analysis and logistic regression analysis indicated that qi deficiency and blood stasis syndrome^ more than 70% in maximum platelet aggregation rate (MPA)> the level of plasma von Willebrand factor (vWF) and CYP2C19*2 gene mutation were the independent risk factors of MACE in the following 1 year after PCI (P<0.01) 2.Compared with the non-qi- deficiency blood-stasis group after PCI, the MPA、vWF and GPⅡb/Ⅲa were obviously higher in qi- deficiency blood-stasis group (P<0.01), and there were no statistical difference of PLT、F (1+2) and FIB between the two groups (P>0.05)3.The patient genotype distribution was in Hardy-Weinberg equilibrium. Partitions ofχ2 method showed that GA+AA was higher in qi-deficiency blood-stasis group than in non-qi-deficiency blood-stasis group (χ2=26.952, P<0.01).After adjusting for common risk factors of CHD after PCI, logistic regression analysis indicated that the odds ratios (OR) of GA+AA (vs GG) genotype for qi deficiency and blood stasis syndrome was 2.551 (95%Cl:1.463-4.446, P=0.001) with the reference category of non-qi-deficiency blood-stasis syndrome.Conclusions1.Qi deficiency and blood stasis syndrome、70% cut-off in MPA、the level of plasma vWF and CYP2C19*2 gene mutation are very important to evaluate the prognosis for CHD patients after receiving successful PCI.2.Qi deficiency and blood stasis syndrome after PCI affects platelete activation and ndothelial function on standard antithrombotic treatment, whereas the number of blood platelet and coagulation function may be not. Qi deficiency and blood stasis syndrome is the independent risk factor of MACE in the following 1 year after PCI.3.The GG+AA genotype may be some heritable susceptibility to disease of qi deficiency and blood stasis syndrome after PCI. PartⅡThe directive effect of conjoint analysis qi deficiency and blood stasis syndrome and CYP2C19*2 gene mutation on individualized antithrombotic durg selection after percutaneous coronary intervention (a prospective, randomized, single-blind, controlled clinical trial)ObjectiveTo investigate the therapeutic effect of nao xin tong capsule on individualized antithrombotic treatment of patients undergoing PCI.Medthods54 CHD patients with qi deficiency and blood stasis syndrome and CYP2C19*2 gene mutation, who had received revascularization by PCI successfully, were randomized into the treatment group and the control group, both treated with conventional western medical treatment, but the treatment group combined, respectively, with nao xin tong capsule for 1 month.The investigating items included Chinese medicine syndrome scores, short and long-term efficacy and safety assessment of antithrombotic treatment. Resultsl.The baseline between the two groups was similar. Before treatment* there was no significant difference in Chinese medicine syndrome scores (P>0.05). After treatment, qi deficiency syndrome and blood stasis syndrome scores reduced significantly in the treatment group (PO.01) and the control group showed a higher qi deficiency syndrome score and lower depressive amplitude of blood stasis syndrome score (PO.01),while significantly superior to qi deficiency syndrome and blood stasis syndrome scores in the treatment group (P<0.05).2.Before treatment, there were no statistical difference of PLT、MPA. vWF、GPⅡb/Ⅲa, F(1+2) and FIB (P>0.05). After treatment, the indicators of MPA、vWF、GPⅡb/Ⅲa、F (1+2) and FIB went down in both groups (P<0.01), but the lowering in the control group were lesser (P0.05).The change ofPLT was insignificant between two groups (P>0.05)3.During the period of one-month follow-up,3 MACE and zero MACE occurred in the control group and the treatment group respectively, no statistical difference was found between them (P>0.05)4.There was no major and minor hemorrhagic complication in the treatment group and the control group.Conclusions1.Nao xin tong capsule may decrease qi deficiency syndrome and blood stasis syndrome scores of ten days after PCI in patients with qi deficiency and blood stasis syndrome and CYP2C19*2 gene mutation.2. Combination of conventional western antithrombotic treatment and nao xin tong capsule shows better efficacy in inhibiting activity of blood platelet%alleviating endothelial cell damage and improving coagulation function.3.Along with nao xin tong capsule administration, there is a depress tendency for the occurrence of cardiovascular events during one month after PCI in patients with qi deficiency and blood stasis syndrome and CYP2C19*2 gene mutation.4.Combination of conventional western antithrombotic treatment and nao xin tong capsule may not increase the incidence of thrombocytopenia and bleeding complications. PartⅢEffect of nao xin tong capsule on the activity of cytochrome P2C19 (CYP2C19) in human microsomeObjectiveTo observe the effect of nao xin tong capsule on CYP2C19 activity in human liver microsome in vitro.MedthodMephenytoin (the probe drug of CYP2C19) was incubated with or without nao xin tong capsule in human liver microsome respectively.The concentrations of mephenytoin and its metabolity (4-OH mephenytoin) were determined by HPLC, and the CYP2C19 activity was reflected by the metabolite production (4-OH mephenytoin)ResultCompared with pre-incubation without nao xin tong capsule, the metabolite concentration of 4-OH mephenytoin had statistical difference in pre-incubation with nao xin tong capsule (150-250μg/ml)ConclusionNao xin tong capsule results in an induction of CYP2C19 activity of in vitro in a dose-depentent manner. The combination of nao xin tong with clopidogrel may be reinforce the effect of antiplatelet through the above-mentioned mechanism in patients with qi deficiency and blood stasis syndrome and CYP2C19*2 gene mutation after PCI.更多还原