冠心病中医证候特点与冠脉病变程度相关性的临床研究

【作者】 安超；

【导师】 林谦；

【作者基本信息】 北京中医药大学 ， 中西医结合临床， 2009， 博士

【摘要】 冠心病是严重危害人类健康的常见病。冠心病的介入诊断和治疗近年来日益得到重视,冠状动脉造影(CAG)被称为冠心病诊断的“金标准”。证候是中医辨证的对象和论治的依据,对冠心病中医证候的深入研究有助于提高中医药防治冠心病的临床水平。本研究分析冠心病证候及证候组合特点,并进行冠心病中医证候与冠脉病变程(Gensini积分、冠脉病变支数)的相关性研究;对四诊信息和证候因素进行因子分析,总结以证候因素为基础的冠心病的证候特点,并分析证候要素组合与冠脉病变程度的相关性。方法:(1)以2005年3月～2009年3月在东方医院和垂杨柳医院做过冠状动脉造影检查的资料完整的502例住院患者为研究对象。(2)采用标准技术进行冠状动脉造影检查,于冠状动脉造影检查后48h内完成病史和中医症状、体征的采集,做出中医证候诊断,冠状动脉造影检查前后一周内完成相关理化检查,参照相关标准,作出西医诊断,并完成统一制作的临床调查记录表。(3)统计学方法:应用SPSS13.0统计学软件,计量资料采用t检验,计数资料采用卡方检验,等级资料采用秩和检验;多因素分析应用二值Logistic回归分析、多重线性回归分析、有序多分类Logstic回归分析;无监督数据分析采用因子分析。结果:(1)冠心病证候分布:冠心病中医证候以血瘀证(77.3%)和气虚证(75.9%)最为多见,其次是痰浊证(42.7%)、阴虚证(37.4%)和阳虚证(31.9%),气滞证和寒凝证较少(11.5%,10.1%);脏腑虚证以心虚证(84.2%)、肾虚证(74.3%)最为多见。经卡方检验,冠心病组气虚证、血瘀证、痰浊证、寒凝证构成比高于非冠心病组:(2)冠心病证候组合特点:冠心病中医证候组合和脏腑虚证组合均以三证组合最为多见(42.2%,35.8%),其次为两证组合(28.7%,20.9%)和四证组合(20.0%,13.5%),冠心病证候组合的变化规律为:以气虚血瘀为基本中医证候组合,以心肾两虚为基本脏腑虚证组合,以气虚→阳虚→寒凝为变化轴线。(3)冠心病发病的证候影响因素:经二值Logistic回归分析,血瘀证、气虚证、痰浊证(相对危险度分别为2.952、2.295、2.266)是冠心病发病的影响证候因素;出现血瘀证、气虚证、痰浊证的患者更易于患冠心病;心虚、肾虚是冠心病发病的脏腑虚证证候(相对危险度分别为1.844和2.184),出现心虚证、肾虚证者更易患冠心病。(4)冠心病中医证候与冠脉病变程度的相关性分析:经多重线性回归分析,寒凝证、痰浊证、血瘀证与Gensini积分正相关(偏相关系数分别为0.219,0.164,0.159),表明此三证与Gensini积分的相关性由大到小依次为寒凝证＞痰浊证＞血瘀证。经有序多分类Logistic回归分析,痰浊、血瘀、寒凝、气虚四个证候与病变支数相关。与0支病变相比,单支病变与证候相关性无统计学意义;血瘀证、气虚证、痰浊证与双支病变相关,血瘀证患者冠脉造影结果为双支病变的概率是无血瘀证患者的3.057倍,气虚证患者冠脉造影结果为双支病变的概率是无气虚证患者的2.912倍,痰浊证患者冠脉造影结果为双支病变的概率是无痰浊证患者的2.119倍,寒凝证、痰浊证、气虚证与三支病变相关,与0支病变相比,寒凝证患者冠脉造影结果为三支病变的概率是无寒凝证患者的4.565倍;痰浊证患者冠脉造影结果为三支病变的概率是无痰浊证患者的2.268倍;气虚证患者冠脉造影结果为三支病变的概率是无气虚证患者的2.044倍,此外,血瘀证与左主干病变相关,血瘀证患者发生左主干病变的危险度是无血瘀证患者的2.3倍。(5)四诊信息因子分析的方法将本研究冠心病四诊信息降维到15个公因子,其中代表虚证的有7个公因子,代表虚实夹杂证的有4个公因子,代表实证的有4个公因子;证候要素因子分析将证候要素归为5个公因子中,公因子1、2为病位证候要素(脏腑虚证)公因子,公因子3、4、5为病性证候要素公因子,符合设定的证候要素分类框架。其中与Gensini积分正相关的是公因子2、公因子5,分别代表心、肝、肾虚证和阳虚寒凝证。结论:(1)气虚血瘀是冠心病的基本病机,冠心病证候特点以虚为本,以脏腑虚为主,气虚为多。(2)气虚证、血瘀证、痰浊证、心虚证和肾虚证是冠心病发病的证候因素,出现气虚证、血瘀证、痰浊证、心虚证、肾虚证者更易于患冠心病。(3)寒凝证、痰浊证、血瘀证、气虚证与冠脉病变程度相关,随着寒凝证、痰浊证、血瘀证的出现,提示其冠脉病变程度趋于严重,且反映虚实夹杂的病性特点。冠心病证候要素对区分无病变和单支病变贡献度不高;而痰浊证、血瘀证、寒凝证、气虚证与双支病变、三支病变相关,与无病变相比,有痰浊证、气虚证、血瘀证患者倾向于双支病变;而有痰浊证、气虚证、寒凝证倾向于三支病变。冠心病患者有血瘀证,发生左主干病变的危险性大。(4)因子分析的方法将本研究冠心病四诊信息降维到15个公因子,从因子代表的虚实属性和数量中可以看出冠心病以虚为主的病性特点,气虚证为多,脏腑虚证普遍存在,虚实夹杂四诊信息组合反映了一定的病机规律。因子分析将13个证候要素降维到5个公因子,与预先设计的以病位证候因素、病性证候因素为纲的证候分类框架相符。证候因子与反映冠状动脉病变程度的Gensini积分进行Logstic回归分析显示脏腑虚证、阳虚寒凝证越严重,冠脉病变程度趋于严重。这一结果与与第一部分描述性统计分析的结果相互印证,与证候与冠心病病变的Logstic回归分析结果一致,并进一步反应了证候要素组合的规律性。因子分析将内部相关联的证候要素归纳在同一公因子中,病机规律是其中潜在的支配因素。更多还原

【Abstract】 BackgroundCoronary Heart Disease(CHD) is a common diseases with seriously harmful to health. Interventional diagnosis and treatment of CHD obtained growing attention in recent years, coronary angiography(CAG) is known as golden criterion of CHD diagnosis.Syndrome is the targetof syndrome differentiation in traditional Chinese medicine(TCM) and the basis of treatment determination.Study of syndrome help to improve the clinical level of prevention and treatment of CHD.In this study,we analysis characteristics of TCM syndromes on CHD patients,and study on the Correlation between TCM syndromes and degree of pathologic changes of the coronary artery(Gensini,number of stenosed coronary artery);use factor analysis for four clinics to summarize the factors to syndromes of CHD, and the relationship between syndrome elements and the extent of coronary artery disease.Method:(1) 502 cases underwent CAG in Chuiyangliu hospital and Dongfang hospital from Mar.2005-Mar.2009 with complete information.(2) Completed TCM symptoms collection within 48h after CAG which has been done by standard method,complete the relevant laboratories test before and after CAG within one week.Develop western medical diagnostic and TCM diagnosis with reference to the relevant standards.(3) Statistical methods:SPSS13.0 statistical software,Measurement data using t-test or analysis of variance,calculators information is chi-squaretest,grading information is rank sum test;To analysis the syndrome of CHD and Correlation with pathologic changes of the coronary artery,use Correlation Analysis of multivariate analysis including Binary Logistic Regression analysis、Liner Regression analysis,Multinominal Logstic Regression analysis; unsupervised data analysis using Factor analysis.Result:(1) Syndromes distribution of CHD:blood stasis syndrome(77.3%) and Qi deficiency syndrome(75.9%) are the most common Chinese medicine syndrome of CHD, followed by phlegm syndrome(42.7%)、Yin deficiency syndrome(37.4%) and Yang deficiency syndrome(31.9%),Qi stagnation and cold are less(11.5%,10.1%);Kidney deficiency syndrome(74.3%) is most common in viscera deficiency syndrome,followed by deficiency of liver(50.9%)、spleen deficiency(22.5%),stomach deficiency(20.1%)、lung deficiency(13.5%).By chi-square test,Qi deficiency,the ratio of blood stasis,phlegm and cold in CHD group was significantly higher than non-CHD group.(2) The characteristics of syndromes combination:three syndromes combination are the most common both in TCM syndrome and viscera deficiency syndrome(42.2%,35.8%),followed by the two syndromes combination(28.7%,20.9%) and four syndromes combination(20.0%, 13.5%).The regulation of syndromes changing are as follows:Qi-deficiency and blood stasis syndrome are the basic combination,heart and kidney Qi deficiency are the basic combination of viscera deficiency syndrome,Qi-deficiency→Yang deficiency→cold is the changing axis of snydrome.(3) Syndrome factors of CHD:The result of Logistic Regression analysis indicates that blood stasis and Qi deficiency,phlegm(relative risk are 2.952 and 2.295,and 2.266 respectively) are important syndrome factors of CHD;patients with blood stasis、Qi deficiency,and phlegm has the tendency of suffering from CHD; kidney and heart deficiency syndromes patients has the tendency of suffering from CHD, (relative risk are 1.844 and 2.184).(4) Correlation between TCM syndromes and degree of pathologic changes of the coronary artery:The result of Linear Regression analysis show that cold,phlegm,blood stasis is correlated with the Gensini score(partial correlation coefficient are 0.219,0.164,0.159 respectively),the order of relevance is cold＞phlegm＞blood stasis.Through Multinominal Logstic Regression analysis,result indicates that phlegm,blood stasis,cold,Qi Deficiency syndromes are all positively related to the number of pathologic changes of the coronary artery associated:Comparing with non-lesion, correlation between single artery stenosis and syndrome have no significant;Blood stasis and Qi deficiency,phlegm related to dual-artery lesions,Probability of double artery stenosis of CAG result is the 3.057 times in patients with blood stasis than patient without blood stasis;2.912 times in patients with Qi deficiency than without Qi deficiency,2.119 times in patients with phlegm than without phlegm;Cold,phlegm and Qi deficiency associated with three artery stenosis.Comparing with non-lesion,Probability of three artery stenosis of CAG result is the 4.565 times in patients with cold snydrome than patient without cold snydrome;2.268 times in patients with phlegm than without phlegm;2.044 times in patients with Qi deficiency than without Qi deficiency.Furthermore,blood stasis syndrome associated with left main artery stenosis,risk of left main tenosis in patients with blood stasis syndrome is 2.3 times than patients without blood stasis syndrome.(5) Syptoms factor analysis:four-diagnositic information reducted to the 15 components,in which 7 components representated deficiency,4 components representated mixed syndrome of deficiency excessiveness,4 components representated syndrome of excessiveness;Factor analysis of syndrome Elements reducted to the 5 components,components 1、2 syndrome representated visceral deficiency,components 3、4、5 representated characteristic of syndrome,in accordance with the set and classification of syndromes.Gensini score is associated with the component 2 and component 5,representing the heart、kidney、liver deficiency and Yang deficiency and cold snydrome.Conclusion:(1) Qi deficiency and blood stasis is the basic TCM pathogenesis of CHD, syndrome characterized by deficiency as the virtual snydrome,visceral is the main syndrome,and Qi deficiency had the most common.(2) Qi deficiency,blood stasis,phlegm, heart and kidney Deficiency Syndromes are important influence factors of CHD,appearing these syndromes have the tendency of suffering frome CHD.(3) The syndromes of cold、phlegm、blood stasis and Qi deficiency associated with the degree of coronary artery disease,with appearance of syndromes,suggesting that the extent of coronary artery disease tends to serious,and reflects a trait of mixed syndrome of deficiency and excess.TCM syndrome barely contribute to single artery stenosis.However,phlegm、blood stasis、cold and Qi deficiency contribute to double-artery and triple artery stenosis comparing with non-stenosis.Blood stasis in patients with coronary heart disease had high-risk of left main artery coronary disease.(4) The trait and number of deficiency or excess components from four diagnostic information factor analysis indicate the trait of deficiency based in CHD,Qi deficiency is most frequently,visceral deficiency existed universally,the combination of four diagnostic information reflects the regulation of pathogenesis.Factor analysis of 13 syndrome elements reducted to five components,which matched the pre-designed structure.Syndrome components reflects the degree of coronary artery and Gensini score.The more seriously visceral efficiency、Yang deficiency and cold, degree of coronary artery disease tend to be serious.This result is consistent with the descriptive statistical analysis,and with coronary heart disease syndromes Logstic Regression analysis results,and further reflects the regularity of combination of syndromes. Factor analysis conclude the elements with internal association into certain components,the pathogenesis is one of the dominant factor in potential.更多还原