【作者】 任毅；

【导师】 陈可冀；

【作者基本信息】 广州中医药大学 ， 中西医结合临床， 2009， 博士

【摘要】 目的探讨冠心病患者冠脉介入术前后的中医证候分布规律,了解介入术前后证型变化规律,介入术对中医证型的影响;分析各证型与冠心病危险因素的相关性和冠脉动脉造影结果的关系;通过患者的证候与血脂、内皮素、C—反应蛋白等实验室指标关系的分析,探讨冠心病证候与血脂、内皮素、C—反应蛋白等实验室指标间的相关性。初步研究冠心病介入治疗前后相对规范的中医证候标准,以提高临床辨证治疗冠心病的疗效,推动冠心病证候客观化研究,丰富冠心病中医理论内涵。方法1文献研究系统回顾古今文献,了解冠心病中医证型分布特点及其研究进展;并采用Meta分析对中药防治冠状动脉介入治疗后再狭窄随机对照试验进行系统评价,分析中药防治冠状动脉介入治疗后再狭窄的临床疗效,为中药防治冠状动脉介入治疗后再狭窄的进一步研究提供循证医学证据,并为临床决策提供依据。2临床研究选择经冠状动脉造影确诊冠心病患者405例,参照1990年中医辨证标准对冠心病患者介入治疗术前后进行中医辨证分型,分析介入治疗术前后的中医证侯分布及变化规律;记录冠心病患者危险因素情况,冠脉病变情况,分析各证型与冠心病危险因素和冠状动脉造影结果的相关性;患者人院24h内,于晨起空腹时采静脉血5ml,检测血脂、C反应蛋白、大内皮素—1、N末端脑钠肽等指标,分析冠心病宏观辩证与微观指标间的关系。结果1文献研究回顾古今研究冠心病的相关文献,发现对冠心病的辨证分型虽多,但认识尚不统一,无统一规范;冠心病现有的各种辫证分型方法和辨证思路对冠心病的临床和科研均具有一定的指导意义。利用RevMan 4.2软件对28篇符合纳入标准的中药防治冠状动脉介入治疗后再狭窄的文献进行进行meta分析,结果显示试验组发生率均低于对照组,且差异有统计学意义(P＜0.01)。2临床研究:通过聚类分析,总结冠心病中医证型分七类,即气虚证、阳虚证、阴虚证、气滞证、寒凝证、血瘀证和痰浊证。介入术前后均以气虚证、血瘀证及痰浊证多见。介入治疗后胸痛、胸闷、脉涩等均显著改善,神疲乏力、纳食减少、脉细等显著性增加;介入治疗后气虚证增加,血瘀证、寒凝证减少。危险因素分析中,年龄和气虚证、阳虚证可能相关,吸烟因素和血瘀证、气滞证可能相关,糖尿病和气虚证、阴虚证可能相关,高脂血症、BMI、喜食油腻和痰浊证可能相关。冠脉病变分析中,冠脉病变支数和阴虚证、气滞证、血瘀证和痰浊证可能相关,冠脉单支病变常见于气滞证,多支病变常见于阴虚证、痰浊证、血瘀证;冠脉狭窄程度和气虚证、寒凝证、气滞证、血瘀证和痰浊证可能相关,冠心病冠脉病变狭窄较轻者常见于气滞证,冠心病冠脉病变狭窄较重者常见于气虚证、寒凝证、血瘀证和痰浊证;冠脉病变类型和血瘀证可能相关,血瘀证B、C型病变较多,A型病变较少;Gensini计分和气虚证、阳虚证、寒凝证、气滞证和血瘀证可能相关,气滞证Gensini计分较低,气虚证、阳虚证、寒凝证、和血瘀证Gensini计分较高。证型与实验室指标关系的分析中,痰浊证、血瘀证和血脂可能密切相关,尤其是TC、TG和LDL三项血脂指标,痰浊证及其兼证的TC、TG和LDL水平显著高于非痰浊证:实证中除气滞证外,血瘀证、痰浊证CRP、ESR水平显著升高,包含两个证型兼证的CRP、ESR水平也显著升高;血瘀及其兼证Big ET—1水平明显增高,血瘀证可能和Big ET一1相关;寒凝证和阳虚证患者NT—proBNP水平显著增高,寒凝证和阳虚证证可能和NT—proBNP相关。结论1对28个研究结果的总体效应进行Mata分析,结果提示中药在防治冠状动脉介入治疗后再狭窄及心绞痛复发率方面有一定疗效。2气虚证、血瘀证及痰浊证是冠心病的常见证型;根据聚类结果可把冠心病的常见证型归纳为以下7类:气虚证、阳虚证、阴虚证、气滞证、寒凝证、血瘀证和痰浊证。介入术对冠心病辩证分型的影响为介入治疗后气虚证增加,血瘀证、寒凝证减少。冠心病介入治疗的中医防治思路应加强对气虚证、血瘀证和痰浊证的干预。3冠心病中医辨证分型与危险因素存在相关性,冠心病危险因素的防治应根据不同中医证型的相关危险因素进行重点干预。冠心病中医辨证与CAG结果存在相关性,CAG多项指标作为CHD证型判定指标有一定临床参考价值。4冠心病痰浊证、血瘀证和血脂可能密切相关,血瘀证、痰浊证和CRP、ESR可能相关,血瘀证可能和Big ET—1相关,寒凝证和阳虚证证可能和NT—proBNP相关,这些实验室检测指标可能是冠心病不同证型之间的生化物质基础。更多还原

【Abstract】 Objective:To explore traditional Chinese medicine(TCM) syndromes distribution and changing rule around percutaneous coronary intervention(PCI),and influence of syndrome on account of PCI.To analyses correlation between TCM syndromes and risk factors for coronary heart disease(CHD),and coronary angiography results.Based on analysis of relationship between TCM syndromes and blood lipid,endothelin,C—reactive pretein,To explore correlation between TCM syndromes of CHD and Laboratory Indexes,such as blood lipid,endothelin, C—reactive pretein,etc,research relative standard TCM syndromes criterion around PCI.To raise therapeutic effect of TCM differentiation of symptoms and signs and treat CHD,promote research on TCM syndromes objectivity,develop TCM theoretical connotation of CHD.Methods:1 Literature researchSystematic Review ancient and contemporary literatures,to understand distribution characteristic about TCM syndromes of CHD,and research progression,Meta-analysis is used to assess the randomized controlled trials of TCM in preventing and treating restenosis after PCI.Clinical therapeutic effect on TCM in preventing and treating restenosis after PCI is analyzed, to provide evidence—based medicine proof for research TCM in preventing and treating restenosis after PCI,and provide evidence for clinical decision.2 Clinical Research445 patients of CHD were selected in the study by coronary angiography. In accordance with TCM differentiation of symptoms and signs criterion in 1990, CHD patients were differentiated for syndrome classification around PCI.TCM syndromes distribution and change rule around PCI were analyzed;Risk factor and coronary artery abnomal information of CHD patients were recorded.The correlation between risk factor and coronary angiography results and TCM symptoms were analyzed.Patients were to draw blood 5ml from vein on an empty stomach within admission 24h,In order to detect blood lipid、CRP、Big ET—1、NT—proBNP etc,and analyze relationship between macroscopic TCM syndromes and microcosmic indexes.Results:1 Literature researchReview ancient and contemporary literatures about CHD,we found it was short of unification specification and cognition although there was much TCM differentiation of Syndromes of CHD,thought existing various kinds of method and thinking of differentiation of syndromes of CHD is significant to clinical and research of CHD.28 literatures that coincide internalize specification TCM in preventing and treating restenosis after PCI was evaluated by the statistical software of RevMan 4.2 and meta—analysis method.The incidence rate of the treatment group is lower than the control group,and differences have statistics significance(P＜0.01).2 Clinical researchTCM syndromes of CHD were divided into 7 classfication by hierarchical Cluster,They are Qi deficiency syndrome,Yang asthenia syndrome,Yin deficiency syndrome,Qi stagnation syndrome,cold coagulation syndrome, blood stasis syndrome and phlegm—turbid syndrome.The most syndrome type are Qi deficiency syndrome,blood stasis syndrome and phlegm—turbid syndrome around PCI.Chest pain,chest distress,hesitant pulse had a significant decrease.Spiritlessness and weadness,anorexia,thready pulse had a significant increase after PCI.Qi deficiency syndrome increased.Blood stasis syndrome and phlegm—turbid syndrome decreased after PCI.In risk factor analysis,age is correlated with Qi deficiency syndrome and cold coagulation syndrome.Smoking was correlated with blood stasis syndrome and Qi stagnation syndrome.Diabetes was correlated with Qi deficiency syndrome and Yin deficiency syndrome.Hyperlipoidemia,BMI and greasiness diet were correlated with phlegm—turbid syndrome.In coronary artery abnormal changes analysis, coronary artery lesion number was correlated with Yin deficiency syndrome. Qi stagnation syndrome,blood stasis syndrome and phlegm—turbid syndrome. One—artery lesion was most existed in Qi stagnation syndrome.Multi—artery lesion constituted the majority in Yin deficiency syndrome,blood stasis syndrome and phlegm—turbid syndrome.Coronary artery stenosis degree was correlated with Qi deficiency syndrome,cold coagulation syndrome,Qi stagnation syndrome,blood stasis syndrome and phlegm—turbid syndrome. Slight—degree stenosis could be seen frequently in Qi stagnation syndrome. Serious—degree stenosis was commonly existed in Qi deficiency syndrome,cold coagulation syndrome,blood stasis syndrome and phlegm—turbid syndrome. Coronary artery stenosis type is correlated with blood stasis syndrome.Blood stasis syndrome have more B、C stenosis type,and less A stenosis type.Gensini score is correlated with Qi deficiency syndrome,Yang asthenia syndrome,cold coagulation syndrome,Qi stagnation syndrome and blood stasis syndrome. Gensini score of Qi stagnation syndrome was lower,Gensini score of Qi deficiency syndrome,Yang asthenia syndrome,cold coagulation syndrome,and blood stasis syndrome are higher.In relationship analysis between TCM syndromes and laboratory indexes,phlegm—turbid syndrome and blood stasis syndrome were markedly correlated with blood lipid,especially TC、TG and LDL. TC、TG and LDL level of phlegm—turbid syndrome and its complex symptoms were higher than those of non—phlegm—turbid syndrome.Except for Qi stagnation syndrome in sthenia syndrome,CRP、ESR level of blood stasis syndrome and phlegm—turbid syndrome had significant raise.CRP、ESR level of blood stasis, CRP、ESN level of their complex symptoms also had notable raised.Big ET—1 level of blood stasis syndrome and their complex symptoms had markedly increased.Blood stasis syndrome possibly had a relationship with Big ET—1.NT—proBNP level of Yang asthenia syndrome and cold coagulation syndrome had a significant raised.Yang asthenia syndrome and cold coagulation syndrome were possibly correlation with NT—proBNP.Conclusions:1 The Meta—Analysis to the total effect of the 28 study results was evaluated, TCM in preventing and treating restenosis and patients’ angina pectoris recurrence rate after PCI could have certain therapeutic effect.2 Qi deficiency syndrome,blood stasis syndrome and phlegm—turbid syndrome were TCM syndromes of CHD could be seen frequently in clinic.In accordance with hierarchical cluster result,TCM syndromes of CHD are divided into 7 classfication:Qi deficiency syndrome,Yang asthenia syndrome,Yin deficiency syndrome,Qi stagnation syndrome,cold coagulation syndrome,blood stasis syndrome and phlegm—turbid syndrome.PCI could have a influence for TCM syndromes of CHD,Qi deficiency syndrome increase,blood stasis syndrome and phlegm—turbid syndrome decreased after PCI.Intervention of Qi deficiency syndrome,blood stasis syndrome and phlegm—turbid syndrome should be reinforced about TCM preventing and treating thinking around PCI.3 There was a correlation between TCM syndromes of CHD and risk factors. Preventing and treating risk factors of CHD should be done according to different risk factor of TCM syndromes.There was a correlation between TCM syndromes of CHD and CAG results,CAG indexes have a certain clinical value as assessment of TCM syndromes of CHD.4 Phlegm—turbid syndrome and blood stasis syndrome of CHD significantly correlated with blood lipid,blood stasis syndrome and phlegm—turbid syndrome correlated with CRP、ESR,blood stasis syndrome possibly had a relationship with Big ET—1,Yang asthenia syndrome and cold coagulation syndrome were possibly correlation with NT—proBNP,these laboratory indexes possibly are biochemistry material base of different TCM syndromes of CHD.更多还原