加味参附颗粒对慢性心力衰竭及心肌能量代谢的研究

【作者】 刘秋江；

【导师】 王清海；

【作者基本信息】 广州中医药大学 ， 中医内科学（专业学位）， 2013， 博士

【摘要】 目的通过临床研究观察加味参附颗粒对慢性心力衰竭患者心功能、运动耐力的影响；并通过动物实验观察其对心衰大鼠心肌超微结构及线粒体Na+-K+-ATP酶、Ca2+-ATP酶活性的影响,进而从能量代谢方面探讨加味参附颗粒治疗慢性心力衰竭的可能机制。方法本研究包含两部分内容,第一部分是以慢性心力衰竭患者为研究对象。第二部分是以慢性心力衰竭模型大鼠为研究对象。(一)第一部分(临床研究)按照随机对照研究原则,将80例符合慢性心力衰竭西医诊断标准(NYHA心功能分级Ⅱ、Ⅲ)并且中医辨证属于“心肾阳(气)虚、血瘀水停证”患者分为治疗组及对照组,对照组选用常规西医药物治疗,治疗组在对照组的基础上加用加味参附颗粒。观察患者治疗前后临床症状、BNP、EF%、E/A.6分钟步行试验的变化。(二)第二部分(动物实验)清洁级SD雄性大鼠40只,按照数字表原则分为正常对照组、模型对照组、西药组、加味参附颗粒组A(临床等效量组)和加味参附颗粒组B(2倍临床等效量组),每组8只大鼠。除正常对照组外各组先进行造模处理。造模成功后,各组予相应的干预：正常对照组：给予每日灌服蒸馏水2ml；模型对照组：给予每日灌服蒸馏水2ml；西药组：给予每日灌服5.4mg/kg曲美他嗪片；加味参附颗粒组A：给予每日灌服6.84g生药/kg(等同于临床效量),加味参附颗粒组B：给予每日灌服13.68g生药/kg(等同于2倍临床效量)疗程4周。观察指标包括：体重、心脏重量、左室重量、心体重量比、左室全心比、动脉压、右心室内压力、心率、左心室内压最大上升和下降速率[Max±dP/dt (mmHg/s)]、心肌线粒体结构、线粒体Na+-K+-ATP酶和Ca2+-ATP酶活性。结果(一)第一部分(临床研究)1.两组心功能NYHA分级疗效比较,治疗组总有效率87.50%,对照组总有效率为70.00%,两组比较,治疗组总有效率高于对照组,且差异有统计学意义(P<0.05)。2.两组Lee氏心衰记分法疗效比较,治疗组总有效率85.00%,对照组总有效率为67.50%,两组比较,治疗组总有效率高于对照组,且差异有统计学意义(P<0.05)。3.两组治疗后6MWT距离均增加,治疗组由治疗前288.57±46.10增加至336±40.12,对照组由治疗前的273.94±31.17增加至312±38.69,同组治疗前后对比及治疗后组间对比,差异显著(P<0.05),有统计学意义。说明两组均能明显延长6MWT距离,且治疗组优于对照组。4.两组治疗后LVDd/cm、LVDs/cm、LVEF及E/A均有所改善。LVEF方而,治疗组由治疗前的45.44±7.19升至56.38±7.07,对照组由治疗前的46.49±7.63升至49.32±6.22：E/A方面,治疗组由治疗前的0.78±0.39升至1.43±0.49,对照组由治疗前的0.79±0.41升至1.08±0.35；LVDd/cm方面,治疗组由治疗前的5.88±1.04下降至5.48±0.86；LVDs/cm方面,治疗组由治疗前的5.86±0.78下降至5.82±0.90。均显示治疗组优于对照组,差异显著,有统计学意义。说明加味参附颗粒有改善慢性心力衰竭患者的收缩及舒张功能,并且有防止心室重构的作用。5.两组治疗后BNP均有所下降,治疗组由治疗前的754.37±53.10下降至286±52.32；对照组由治疗前的738.64±41.32下降至352±38.6,同组治疗前后比较,差异显著(P<0.05)；组间对比,差异显著(P<0.05)；说明加味参附颗粒有改善患者BNP的作用。(二)第二部分(动物实验)1.心率方面：模型组心率高于正常组、曲美他嗪组、加味参附颗粒组A及加味参附颗粒组B(p<0.05)；而加味参附颗粒组A及加味参附颗粒组B改善心率优于曲美他嗪组,组间相比(p<0.05),但加味参附颗粒组A及组B,组间对比差异无统计学意义(P>0.05)2.心脏重量方面：大鼠造模后心脏重量明显增加,模型组、曲美他嗪组、加味参附颗粒组A、加味参附颗粒组B与正常组对比,差异显著(*P<0.05),有统计学意义；加味参附颗粒组A,即经临床等效量加味参附颗粒干预后,与模型组对比,心脏重量增加有抑制作用,组间对比,差异显著,(P<0.05),有统计学意义；左心室重量指数方面：造模后左心室重量指数升高,与正常组对比,*P<0.05,差异有统计学意义：加味参附颗粒组A、组B、曲美他嗪组与模型组对比,P<0.05,有统计学意义；而加味参附颗粒组A、组B与曲美他嗪组对比,P>0.05,差异无统计学意义；揭示加味参附颗粒有预防心室重构的作用。3.±dP/dt max方面：曲美他嗪组、加味参附颗粒组A及加味参附颗粒组B±dP/dt max高于模型组(p<0.05)；而加味参附组A及组B更高于曲美他嗪组,但无统计学意义(P>0.05)；4.血压方面：造模后各组动脉收缩压(SAP)、动脉舒张压(DAP)、左室舒张末压(LVEDP)与正常组对比,差异显著(p<0.01),有统计学意义；与模型组对比,曲美他嗪组、加味参附颗粒组A、加味参附颗粒组B均有明显改善,差异显著(p<0.01),有统计学意义；曲美他嗪组、加味参附颗粒组A、加味参附颗粒组B,组间对比,有差异,但无统计学意义。5.Na+-K+-ATP酶和Ca2+-ATP酶活性方面：模型组中Na+-K+-ATP酶和Ca2+-ATP酶活性均较低,而曲美他嗪组、加味参附颗粒组A及加味参附颗粒组B较模型组明显升高,与模型组对比,差异显著(P<0.05),有统计学意义；加味参附颗粒组A、组B与曲美他嗪组,组间对比存在差异,但p>0.05,无统计学意义；加味参附颗粒组A、组B,组间对比亦存在差异,同样p>0.05,无统计学意义。6.心肌超微结构方面：经加味参附颗粒干预后慢性心力衰竭大鼠心肌肌原纤维排列整齐,肌节结构明显,肌丝排列整齐,明暗带清楚,其间可见线粒体及肌浆网,线粒体排列较整齐,结构清楚,嵴结构清晰,未见明显肿胀,线粒体间可见少量脂滴,细胞核核膜较清楚,包膜完整,无结块及边集现象,无空泡形成。结论(一)临床研究部分1.加味参附颗粒可以改善慢性心力衰竭患者的心功能,减轻临床症状,是治疗慢性心力衰竭的有效中成药。2.加味参附颗粒可以改善慢性心力衰竭患者的中医临床证候。3.加味参附颗粒可以增加慢性心力衰竭患者的活动耐力。(二)实验研究部分1.慢性心力衰竭大鼠造模成功,运用造模方法是腹主动脉缩窄法,操作步骤相对简单,成功率高。2.加味参附颗粒可以改善慢性心力衰竭模型大鼠的血流动力学,包括心率、血压及±dP/dt max。3.加味参附颗粒可以改善慢性心力衰竭模型大鼠的心肌超微结构,改善左心室重量指数,有抑制慢性心力衰竭模型大鼠心室重构的作用。4.加味参附颗粒可以改善慢性心力衰竭模型大鼠Na+-K+-ATP酶和Ca2+-ATP酶活性的抑制作用,进而改善心肌能量代谢。因此,加味参附颗粒是治疗“心肾阳(气)虚、血瘀水停”证慢性心力衰竭患者的有效中成药,可以改善心脏射血分数、降低BNP,逆转心室重构,提高患者的运动耐量,其可能机制之一为提高心肌能量代谢。更多还原

【Abstract】 ObjectiveModified Shen Fu particles chronic congestive heart failure, exercise tolerance observed in clinical studies; observed in animal experiments on rats with heart failure myocardial ul trastructure and mitochondrial Na+-K+-ATPase enzyme, Ca2+-ATPase activity the impact in terms of energy metabolism, and then explore the possible mechanism of the modified Shen Fu particle treatment of chronic heart failure.MethodThis study consists of two parts, the first part is for the study of patients with chronic heart failure. The second part of the chronie heart failure rat, model for the study.(A) The first part (clinical research)In accordance with the principles of randomized controlled study,80patients with chronic heart failure Western diagnostic criteria (NYHA Heart Association functional class Ⅱ, Ⅲ) were divided into treatment group and TCM belong to the "the heart yang (gas) virtual stasis water retention certificate" and the control group, the treatment group selection of flavored Shenfu particles, the control group used the conventional Western medicine treatment. The key observation of patients before and after treatment clinical symptoms, BNP, ef%,E/A,6-minute walk test.(B) The second part (animal experiments)Clean SD male rats40, in accordance with the digital tables principles are divided into normal control group, model control group, western medicine group, modified Shen Fu particle group A (clinical equivalent group) and modified Shen Fu particle group B (2times the clinical equivalent amount of group),8rats in each group. In addition to the normal control group, each group first modeling process. After the modeling of each group to the appropriate intervention:control group:to give daily fed with distilled water2ml; model control group:to give daily fed with distilled water2ml; western medicine group:daily gavage5.4mg/kg given qumei He hydrochloride tablets; modified Shen Fu the particle group A:give fed daily6.84g crude drug/kg (equivalent to the clinical effective amount) Modified Shen Fu the particles group B:to give fed daily13.68g of crude drug/kg (equivalent to2times the clinical effective amount) 4weeks. OUTCOME MEASURES:body weight, heart weight, left ventricular mass, heart weight ratio, left ventricular heart than arterial pressure, right ventricular pressure, heart rate, left ventricular pressure maximum rise and fall rate [Max+DP/dt (mmHg/s)], myocardial mi tochondrial structure, mitochondrial Na+-K+-ATP enzyme and Ca2+-ATPase enzyme activity.Result(A) The first part (clinical research)(1)Groups NYHA class compare the efficacy of the treatment group was87.50%, total effective rate was70.00%in the control group, two groups, treatment group, the total effective rate was higher than that in the control group, and the difference was statistically significant (P<0.05).(2) two sets of Lee’s heart failure efficacy of scoring method to compare the treatment group the total effective rate was85.00%, total effective rate was67.50%in the control group, two groups, treatment group, the total effective rate was higher than that in the control group, and the difference was statistically significant (P<0.05).(3)After treatment6MWT distance increased, the treatment group increased to336by the pre-treatment288.57±46.10±40.12, control group increased to312by the pre-treatment273.94±31.17±38.69, the same group before and after treatment and after treatment groups contrast, the difference was significant (P<0.05) was statistically significant. The two groups could significantly extend the6MWT distance, and the treatment group than the control group.(4)After treatment LVEF and E/A has been reduced. LVEF, the treatment group before treatment45.44±7.19to56.38±7.07in the control group before treatment46.49±7.63to49.32±6.22; E/A aspects of the treatment group before treatment,0.78±0.39to1.43±0.49, control group before treatment to0.79±0.41increased to1.08±0.35, in terms of both the treatment group than the control group, the difference was significant, statistically significant. Modified Shen Fu particles systolic and diastolic function improved in patients with chronic heart failure.(5)Treatment after BNP has decreased in the treatment group decreased from754.37±53.10before treatment to286±52.32; control group decreased from738.64±41.32before treatment to352±38.6, compared wi th the group before and after treatment, significant differences (P<0.05); comparison group,the difference was significant (P<0.05); improve patient BNP modified Shen Fu particles(B) The second part (animal experiments)(1)Heart rate:the model group heart rate is higher than the normal group, the trimetazidine group of Modified Shen Fu the particle group A modified Shen Fu the particles group B (p<0.05); Modified Shen Fu particle group A and the modified Shen attached particle group B to improve heart rate is better than the trimetazidine group compared between groups (p<0.05), but flavored Shenfu the particle group A and group B, the contrast between the two groups was no significant difference (P>0.05)(2)Heart weight:Rats in heart weight increased significantly, model group, trimetazidine group, flavored Shenfu particle group A modified Shen Fu the particles group B with the normal group contrast, significant difference (P <0.05), was statistically significant; modified Shen Fu particle group A, which is the the clinical equivalent amount flavored Shenfu particles intervention, with the model group compared the increase in heart weight inhibition, comparison group, the difference was significant (P<0.05), and was statistically significant; left ventricular mass index:modeling elevated left ventricular mass index, compared with the normal group, P<0.05, the difference was statistically significant; Modified Shen Fu the particle group A, group B, Trimetazidine triazine group and model group comparison, P<0.05, statistically significant; modified Shen Fu particle group A, group B with trimetazidine group compared P>0.05, the difference was not statistically significant; reveal Modified Shen Fu particles prevention of ventricular remodeling.(3)±dP/dt max aspects:trimetazidine group, flavored Shenfu the particle group A and flavored the Shenfu particle group B±dp/dt max higher than model group (p<0.05); Modified Shen Fu group A and group B higher in the trimetazidine group, but not statistically significant (P>0.05);4blood pressure:modeling groups systolic arterial pressure (SAP), diastolic blood pressure (DAP), left ventricular end-diastolic pressure (LVEDP) compared with the normal group, a significant difference (p<0.01) was statistically significant; with the model group compared trimetazidine group, modified Shen Fu the particle group A, Modified Shen Fu the particles group B showed significant improvement, significant difference (p<0.01) was statistically significant;Trimetazidine triazine group, Modified Shen Fu particle group A modified Shen Fu particle group B, group comparison, there are differences, but not statistically significant.(4)Na+-K-ATP enzyme and Ca2+-ATPase enzyme activity:the model group Na+-K+-ATP enzyme and Ca2+-ATPase enzyme activity were lower, while qumei he triazine group, flavored parameters attached to particles of group A and flavored Shenfu particle group B compared with the model group was significantly increased compared with the model group, the difference was significant (P<0.05), a statistically significant; modified Shen Fu particle group A, group B with trimetazidine group, the contrast between the two groups exist difference, but p>0.05, not statistically significant; modified Shen Fu the particle group A, group B, the contrast between the two groups there are differences between the same p>0.05, not statistically significant. Chronic heart failure after myocardial ultrastructure:flavored Shenfu particles intervention rat cardiac myofibrils arranged in neat rows, the sarcomere structure, neatly myoneme, light and dark with clear, during which the visible mitochondria and sarcoplasmic reticulum, mitochondria arranged in neat, clear structure, the ridge structure is clear, no significant swelling, shows a small amount of lipid droplets in mitochondria,nucleus nuclear membrane more clearly, encapsulated, non-caking and edge set of phenomena, vacuolization.Conelusion(A) clinical research component(1)Modified Shen Fu particles can improve cardiac function in patients with chronic heart failure, reduce symptoms, is an effective medicine treatment of chronic heart failure.(2)Modified Shen Fu particles can improve clinical medicine chronic heart failure syndromes.(3)Modified Shen Fu particles can increase endurance activity in patients with chronic heart failure.(B) Experimental research component(1) successful model in rats wi th chronic heart fai lure, the use of modeling methods are abdominal aortic coarctation, the steps are relatively simple, high success rate.(2)Modified Shen Fu particles rats with chronic heart failure can be improved hemodynamics, including heart rate, blood pressure and±dP/dt max.(3)Modified Shen Fu particles can improve chronic heart failure rat model of myocardial ultrastructure and improve left ventricular mass index, inhibit ventricular remodeling in rats with chronic heart failure role.(4)Modified Shen Fu particles can improve chronic heart failure rats Na+-K+-ATP enzyme and Ca2+-ATP inhibition of enzyme activity, thereby improving myocardial energy metabolism.Therefore, the particle is the treatment of Modified Shen Fu "heart yang (gas) deficiency, blood stasis water stop" permit effective medicine in patients with chronic heart failure can improve cardiac ejection fraction, lower BNP, reverse ventricular remodeling, improve patient exercise tolerance, which may be one of the mechanisms to enhance myocardial energy metabolism.更多还原