【作者】 蔡虎志；

【导师】 陈新宇；

【作者基本信息】 湖南中医药大学 ， 中医内科学， 2014， 博士

【摘要】 1.文献研究本研究参考国内外文献,熟悉中西医对慢性心衰的认识,分别从病名、病机、辨证和治疗方面掌握了中医学对慢性心衰的研究进展,亦从致病机制和多种诊疗方案角度分析了西医学对慢性心衰的研究概况,为临床试验和动物实验研究打下坚实的理论基础。2.临床研究2.1目的客观评价温阳振衰颗粒治疗慢性心衰的安全性和临床疗效,并初步探讨其可能的作用机制,为新药开发提供理论依据。2.2方法通过与目前公认的西医基础治疗方案为对照,开展前瞻性的随机对照临床研究。将纳入病例随机分为治疗组和对照组,治疗组给予西医基础治疗加温阳振衰颗粒,每天冲服2次,每次半包,连续4周。对照组给予西医基础治疗。观察治疗前后两组患者的中医证候、心力衰竭和生活质量评分变化,以及超声心动图和血清细胞炎性因子的改变。2.3结果(1)两组心功能、中医证候和心力衰竭疗效相比,差异有统计学意义(P<0.05)。(2)两组中医证候和心力衰竭积分在治疗后均显著降低,较治疗前差异有统计学意义(P<0.05),两组积分差值相比有统计学意义(P<0.05)。(3)两组明尼苏达生活质量评分与治疗前比均有统计学意义(P<0.05),治疗组分值变化大于对照组,其差异有统计学意义(P<0.05)。(4)两组超声心动图指标与治疗前比差别均有统计学意义(P<0.05),治疗组超声心动图指标变化大于对照组,其差异有统计学意义(P<0.05)。(5)两组血清NT-proBNP. TNF-a、IL-1和IL-6与治疗前比差别均有统计学意义(P<0.05),治疗组上述指标变化大于对照组,其差异有统计学意义(P<0.05)。2.4结论(1)温阳振衰颗粒可以在西医基础治疗的基础上进一步改善慢性心衰患者的中医证候和心力衰竭积分；(2)温阳振衰颗粒可以在西医基础治疗的基础上进一步提高慢性心衰患者的生活质量；(3)温阳振衰颗粒可以在西医基础治疗的基础上进一步改善慢性心衰患者的心功能和降低血清NT-proBNP水平；(4)温阳振衰颗粒可以在西医基础治疗的基础上进一步下调慢性心衰患者的血清细胞致炎因子水平；(5)温阳振衰颗粒具有良好的安全性。3.实验研究3.1目的观察温阳振衰颗粒对慢性心衰模型兔心脏结构和功能的改善作用,同时探讨其对血清NT-proBNP及细胞炎性因子和细胞外信号调节激酶1/2相关蛋白及基因的影响,评价温阳振衰颗粒在延缓心室重构和抑制心肌细胞凋亡方面的疗效。3.2方法建立阿霉素诱导的慢性心衰兔模型,将实验动物分为正常对照组、模型对照组、温阳振衰颗粒低剂量组、温阳振衰颗粒中剂量组、温阳振衰颗粒高剂量组和阳性对照组。于第5周开始给予药物干预,连续4周。分别于第4周末和第8周末各组抽取5只实验兔,观察温阳振衰颗粒对各组实验兔超声心动图、血清NT-proBNP、血清细胞炎性因子、心肌ERK1/2、心肌P-ERK1/2、心肌ERK1/2mRNA、心肌细胞凋亡指数及心肌组织光镜和电镜的影响。3.3结果(1)造模第4周末时模型对照组及药物干预各组较正常对照组在LVEF、LVFE和E/A方面差别均有统计学意义(P<0.05)。至8周末时,各组实验兔的LVEF、 LVFS及E/A指标进一步降低,较正常对照组差异均有统计学意义(P<0.05)。药物干预各组与模型对照组比较,差异具有统计学意义(P<0.05)(2)造模第4周末时各组血清NT-proBNP、TNF-a、IL-1(?)口工L-6均高于正常对照组(P<0.05)。至8周末时,各组血清指标浓度进一步升高,其中以温阳中、高剂量组浓度升高较为缓慢(P<0.05)。(3)造模第4、8周末各组心肌ERK1/2和ERK1/2mRNA水平与正常对照组相比差异无显著性意义(P>0.05)。造模4周后,各组心肌P-ERK1/2水平均高于正常对照组(P<0.05)。随着造模时间的延长,模型对照组P-ERK1/2表达呈递增趋势。至8周末时,药物干预各组心肌P-ERK1/2水平较前仍有所上升,但均低于同时间模型对照组(P<0.05),其中温阳高剂量组和阳性对照组心肌P-ERK1/2水平升高趋势较温阳低、中剂量组更为缓慢(P<0.05)。(4)造模第4周末时各组心肌细胞凋亡指数均高于正常对照组(P<0.05)。至8周末时,各组心肌细胞凋亡指数进一步升高,其中以温阳中、高剂量组心肌细胞凋亡指数升高较为缓慢,与温阳低剂量和阳性对照组相比有统计学意义(P<0.05)。(5)造模第4周末时模型对照组及药物干预各组较正常对照组在LVDd和LVDs方面差别均无统计学意义(P>0.05),而在IVS和LVPW方面差别均有统计学意义(P<0.05)。至8周末时,药物干预各组心脏扩大趋势较模型对照组为缓(P<0.05),其中以温阳高剂量组心脏扩大最为缓慢(P<0.05)。(6)光镜结果显示模型对照组及药物干预各组均有不同程度的心肌细胞大小、形态不规则,心肌纤维排列紊乱,可见肌纤维断裂,伴心肌细胞水肿,可见炎性细胞浸润。其中以温阳高剂量组心肌组织病理改变相对略轻。电镜结果显示模型对照组及药物干预各组均可见肌纤维坏死或萎缩,部分线粒体水肿、空泡化,肌丝结构不清,可见炎性细胞浸润。温阳高剂量组和中剂量组电镜下改变相对于模型对照组为轻,阳性对照组和温阳低剂量组次之。3.4结论(1)温阳振衰颗粒可以有效提高慢性心衰模型兔的心功能和降低血清NT-proBNP水平；(2)温阳振衰颗粒可以下调慢性心衰模型兔的血清致炎因子水平；(3)温阳振衰颗粒可以下调慢性心衰模型兔的心肌细胞外信号调节激酶ERKl/2磷酸化的表达,但对ERKl/2总蛋白和ERK1/2mRNA的表达无明显调控作用；(4)温阳振衰颗粒可以减少慢性心衰模型兔的心肌细胞凋亡指数；(5)温阳振衰颗粒可以延缓慢性心衰模型兔的心脏结构变化,改善心肌组织的超微结构,具有部分抑制心室重构的作用。更多还原

【Abstract】 (?)Part one Literature ResearchThis research based on referring to domestic and international literature and observing the current research situation of CHF, and mastered the cognition of etiology, treatment based on syndrome differentiation and the clinical experience of modern traditional Chinese physician. We also summarized’the research method and achievements of TCM and western medicine in treating CHF for the past few years and provided solid theory support for clinical and experimental study.Part two Clinical Research1. ObjectiveTo objectively evaluate clinical safety and effect on treatment of CHF using wenyangzhenshuai granule and to provide the theoretical basis for wenyangzhenshuai granule being approved by the State for production and sale.2. MethodTaking the currently accepted treatment of CHF as a control, we carried out a prospective, randomized and controlled clinical study. Cases included in this study were randomly divided into control group and treatment group. Cases of control group received basic therapy and cases of treatment group received basic therapy plus wenyangzhenshuai granule, half of granule each time,2times a day and for4weeks.We observed the changes in ultrasound cardiogram, serum cytokines, TCM syndroms, heart failure syndromes and Minnesota Satisfaction Questionnaire Scales of patients with heart failure before and after treatment.3. Result(1) comparison of curative effect on TCM syndromes and heart failure syndromes, there was a statistically significant difference in efficacy between the two groups (P<0.05).(2) comparison of scores on TCM syndromes and heart failure syndromes showed that after treatment, changes of two groups had a statistically significant comparing with before treatment (P<0.05).Changes of treatment group decreased more significantly than that of control group(P<0.05).(3) comparison of scores of Minnesota Satisfaction Questionnaire Scale:after treatment, scores of two groups had a significantly lower, and comparing with before treatment, the difference was statistically significant(P<0.05).Scores of treatment group decreased more significantly than that of control group(P<0.05).(4) comparison of curative effect on ultrasound cardiogram showed that after treatment, changes of two groups had a statistically significant comparing with before treatment (P<0.05).Changes of treatment group increased more significantly than that of control group(P<0.05).(5) comparison of serum NT-proBNP,TNF-a,IL-1and IL-6:after treatment, changes of two groups had a significantly lower, and comparing with before treatment, the difference was statistically significant(P<0.05).Changes of treatment group decreased more significantly than that of control group(P<0.05).4. Conclusion(1) wenyangzhenshuai granule can further relieve clinical symptoms of patients with CHF based on the basic treatment of western medicine.(2) wenyangzhenshuai granule can improve the life quality of patients with CHF based on the basic treatment of western medicine.(3) wenyangzhenshuai granule can improve the heart function and reduce serum NT-proBNP of patients with CHF based on the basic treatment of western medicine.(4) wenyangzhenshuai granule can reduce serum cytokines of patients with CHF based on the basic treatment of western medicine.(5) wenyangzhenshuai granule possess good security.Part three Experimental Research1. ObjectiveObserved the protective effect of wenyangzhenshuai granule for heart structure and function of rabbit model with CHF and it’s influence on serum NT-proBNP, serum cytokines and extracellular signal-regulated kinase1/2, and evaluate the efficacy in delaying ventricular remodeling and inhibiting myocardial apoptosis by using wenyangzhenshuai granule.2. MethodMaking adriamycin-induced chronic heart failure animal model. The experimental animals were divided into control group, experimental control group, captopril group, wenyangzhenshuai low, medium and high dose groups. At5weeks after’ the first injection of adriamycin, rabbits in wenyangzhenshuai low, medium and high dose groups were perused orally with wenyangzhenshuai granules.5experimental rabbits in each group were sacrificed respectively at the end of the4th and8th week to investigate the effects of wenyangzhenshuai granule on ultrasound cardiogram, serum NT-proBNP, serum cytokines, extracellular signal-regulated kinase1/2, myocardial apoptosis and myocardial ultrastructure.3. Result(1) the LVEF, LVFS and E/A of experimental groups had a statistically significant difference to the control group at the end of4th weeks(P<0.05), the level of LVEF, LVFS and E/A decreased at the end of8th weeks, which had a statistically significant difference to the control group(P<0.05), the other experimental groups decreased slower than experimental control groups (P<0.05). (2) comparison of serum NT-proBNP and cytokines in each groups, the experimental groups were higher than the control group at the end of4th weeks(P<0.05), the level of serum NT-proBNP and cytokines increased at the end of8th weeks, the wenyangzhenshuai granule medium and high dose groups increased slower than other groups (P<0.05).(3) the myocardial ERK1/2and ERK1/2mRNA levels in each group at the end of4th and8th weeks were not significantly different than those in the other groups at the same time (P>0.05). The myocardial P-ERK1/2levels in the model control group and wenyangzhenshuai three dose groups were higher than that in the normal control group at the end of4th weeks (P<0.05). With the modeling time prolonged, P-ERK1/2expression in the model control group showed an increasing trend. At the end of8th week, the myocardial P-ERK1/2expressions in the wenyangzhenshuai three dose groups at4weeks after treatment were increased to some extent compared to previous levels, but were lower than that in the experimental control group (P <0.05), of which, the myocardial P-ERK1/2level in wenyangzhenshuai high dose and captopril groups was increased at the slowest pace compare to the wenyangzhenshuai low and medium groups (P<0.05).(4) comparison of apoptosis index in each groups, the experimental groups were higher than the control group at the end of4th weeks(P<0.05), the level increased at the end of8th weeks, the wenyangzhenshuai granule medium and high dose groups increased slower than other groups (P<0.05).(5) the LVDd and LVDs levels in each group at the end of4th weeks were not significantly different than those in the other groups at the same time (P>0.05). The IVS and LVPW levels of experimental groups had a statistically significant difference to the control group at the end of4th weeks(P<0.05). The trend of cardiac enlargement in the experimental groups decreased at the end of8th weeks compare to the experimental control group(P<0.05), which the wenyangzhenshuai high dose group was increased at the slowest pace(P<0.05).(6) results of optical microscopy:the myocardial structure of experimental control group and drug intervention groups were irregular, which had muscle fiber fracture and myocardial cell edema or inflammatory cells infiltration. The myocardial pathological changes in wenyangzhenshuai high dose group was better compare to the other groups. Results of electron microscopy:In the experimental control group and drug intervention groups, the muscle fiber were necrosis or atrophy, mitochondria edema and vacuolization, filament structure is also not clear and with inflammatory cells infiltration. The myocardial pathological changes in wenyangzhenshuai high and medium dose groups were better than the other groups.4. Conclusion(1) wenyangzhenshuai granule can effectively improve the heart function in chronic heart failure model in rabbits and decrease the serum NT-proBNP level.(2) wenyangzhenshuai granule can effectively reduce the serum cytokines level in chronic heart failure rabbit model.(3) wenyangzhenshuai granule can inhibit myocardial P-ERK1/2expressions in rabbit models of chronic heart failures, but had no significant impact on myocardial ERK1/2and ERKl/2mRNA levels.(4) wenyangzhenshuai granule can effectively reduce the apoptosis index level in chronic heart failure rabbit model.(5) wenyangzhenshuai granule can delay the cardiac structure changes in chronic heart failure rabbit model and improve the ultrastructure of myocardial tissue, it can also partly inhibit ventricular remodeling.更多还原