【作者】 张彬；

【导师】 曹晓岚；

【作者基本信息】 山东中医药大学 ， 中西医结合临床， 2009， 博士

【摘要】 目的:探讨在中医臧象理论与整体观念指导下,“心脑同治”理论的框架构建;分析老年心脑共病这一临床常见疾病现象的证候特点;观察中药益气心脑宁治疗老年心脑共病的临床疗效,以期为临床提供理论依据、有效组方及新的科研模式与思路。方法:1.理论研究:以整体观念为指导思想,在藏象体系结构与功能完整统一的基础上,将心与脑看做一个整体,对心与脑的结构与功能及二者之间的相关关系进行系统性剖析。将发生于同一个老年个体的缺血性心血管病合并缺血性脑血管病看作一个整体——老年心脑共病,探讨老年心脑共病的病机、病位,并阐释心脑同治理论的内涵与外延。为对老年心脑共病的回归性研究与前瞻性研究提供理论依据。2.回顾性研究:对山东中医药大学附属医院保健科老年心脑共病病例112例进行研究,对年龄、性别、病史、中医证候等进行相关分析,研究在老年心脑共病中,是否存在有据可循的中医证候方面的规律。以期为心脑同治理论与研究提供临床流行病学证据。3.前瞻性研究:以80例老年心脑共病患者为研究对象,治疗组(40例)予以口服中药汤剂益气心脑宁,对照组(40例)予以口服通心络胶囊。按积分记录症状体征并检测疗效指标:中医证候疗效、神经功能缺损水平(NIHSS积分)、认知功能障碍水平(MMSE积分)、同常生活活动能力(Barthel指数)、左心室功能(SV、EF、FS)、心电图、血压、颈总动脉内膜-中膜厚度(IMT)、颈总动脉血流量、血脂水平(TC、TG、HDL-C、LDL-C)、内皮功能(ET-1、NO)、纤维蛋白原(Fib)等。同时监测血、尿、大便常规、肝、肾功能等安全性指标。治疗4周后,进行分析与比较。结果:1.理论研究:在减象学说与中医整体观念理论基础上,心与脑在结构与功能诸多方面密切相关。血脉是心脑相关的内在物质基础,神是心脑相关的外在表现,脉络是老年心脑相关的结构基础。这是心脑共病的理论基础。老年心脑共病的基本病机是正气亏虚、痰瘀阻滞。脉络是老年心脑共病的关键发病部位。2.回顾性研究:在理论研究指导下进行。研究发现,心脑共病是老年临床常见的疾病现象;年龄与气虚证、痰浊阻滞证、瘀血阻滞证呈高度正相关。气虚证伴随老年心脑共病的整个阶段,并随增龄而比重增大。气虚证、瘀血阻滞证与痰浊阻滞证之间呈高度正相关,是老年心脑共病最常见的证候类型。老年心脑共病病史与瘀血阻滞证、痰浊阻滞证之间存在显著的线性正相关关系。3.前瞻性研究:根据前两部分研究结论,心脑密切相关,正气亏虚、痰瘀阻滞是老年心脑共病的基本病机。因此,对老年心脑共病采取辨病与辨证相结合的治疗原则,确立补虚、化瘀、祛痰、通络的治疗方法,使用益气心脑宁进行心脑同治。治疗后,中医证候、临床症状、实验室指标均有明显改善,具体表现在:改善老年心脑共病患者的中医证候:临床治愈7例,显效17例,有效14例,总有效率95.0%;改善循环系统的症状与体征:减少心绞痛发作频率(P＜0.01),减少心绞痛发作持续时间(P＜0.01),增加左心室每分钟搏出量(P＜0.05),升高左室射血分数(P＜0.01),升高左室短轴缩短率(P＜0.01),降低血压(P＜0.01),改善心电图;改善神经系统的症状与体征:显著降低NIHSS积分(P＜0.05),升高MMSE积分(P＜0.01),升高Barthel指数(P＜0.01);增加颈总动脉血流量(P＜0.01);降低总胆固醇(P＜0.05),降低低密度脂蛋白胆固醇(P＜0.05),升高高密度脂蛋白胆固醇(P＜0.01);降低血浆内皮素(P＜0.01),升高一氧化氮(P＜0.05);降低纤维蛋白原(P＜0.05)。结论:藏象体系下心脑密切相关。心脑相关是心脑共病的理论基础,是心脑同治的理论依据。正气亏虚,痰瘀阻滞脉络是老年心脑共病常见的中医证候类型。正气亏虚,痰瘀阻滞与老年心脑共病呈高度正相关。益气心脑宁对老年心脑其病有较好的临床疗效,安全可靠,无不良反应,是治疗老年心脑共病的有效方剂。心脑同治理论是藏缘理论指导下的关于心与脑的生理、病理、诊断与治疗的理论创新,基于临床,并经得起临床实践的检验。心脑同治理论的提出为中医藏象理论内涵与外延的创新与发展提供了新的思路。以理论研究-回顾性研究-前瞻性研究三部分组成的临床科研模式值得在临床进一步推广。更多还原

【Abstract】 Objective: Studying the theoretical frame of treatment heart and brain with common theory and methods under the guidance of viscera theory doctrine and the concept of organic wholeness. We analyze the syndrome’s characteristic of the old people who are sick in heart together with brain which is a familiar disease phenomenon in clinic practice. We investigate the clinical therapeutic effect of Yiqixinnaoning on patients suffered from ischemic cardiovascular and cerebrovascular diseases so that we can provide a new theoretical basis or effective recipe, new pattern of scientific research and thinking.Methods: 1. Theories investigation: To study deeply on doctrine of viscera state and holism concept, the structure and function of viscera theory are analysed systematically. It is found that heart and brain are closely related to the relationship between them. The olderly individuals who suffer from both ischemic cardiovascular and cerebrovascular disease are considered as a whole study, so that we could investigate their etiology, pathogenesis and disease-bit. 2. Retrospectively research: To analyse retrospectively the characteristical syndrome of older who suffer from both heart and brain which are collected from Shandong University of TCM Affiliated Hospital. The total number are 112 and the time are limited within two years. Using the method of correlation analysis, the disciplines or characteristics in patients who are old and have two kinds of diseases at the same time are researched. 3. Clinical research: 40 cases with ischemic cardiovascular and cerebrovascular disease are taken as objects treated with Chinese medicine Yiqixinnaoning. By means of comparing the therapeutic effect of patients before and after the therapy between treatment group and control group which treated with Tongxinluo Capsule, the observations on effects are made. The whole course is 4 weeks. The indexes of therapeutic effects include such as: clinical symptoms integrals; nerves dysfunctions system(NIHSS), the level of cognitive dysfunction(MMSE), activities of daily living(Barthel index), cardiac function(SV, EF, FS), ECG, blood pressure, Carotid artery intimae-media thickness(IMT), blood flow of Carotid artery, blood- lipid(TC, TG, LDL-C, HDL-C), vascular endothelial (ET-1, NO), and fibrinogen, etc. The safety evaluation are monitored at the same time.Results: 1. Theoretical results: The result shows heart and brain are related closely in many aspects, such as structure and function. Vein and meridian are the disease-bit of ischemic cardiovascular and cerebrovascular disease. Qi asthenia, blood stasis and phlegm block are the common pathogenesis. 2. Retrospective research results: It is found that it is common in the clinic of olderly suffered from both ischemic cardiovascular and cerebrovascular disease in healthy care section office. Age and qi-deficiency, stagnation of phlegm-stasis, congestion block are positively correlated. Qi asthenia accompanied the entire period of old age. High positive correlation is showed among Qi asthenia, stagnation of phlegm-stasis, congestion block. 3. Clinical reach results: The conclusions are that the distinctly improved symptoms are observed after the end of treatment. Clinical symptoms and signs of ischemic cardiovascular and cerebrovascular disease are improved, in particular Yiqixinnaoning. In the treatment group, the indexes of NIHSS are reduced(P<0.05), the indexes of MMSE and the indexes of Barthel index are rised(P<0.01), compared with Tongxinluo. Frequencies and duration of angina pectoris decraese all(P<0.01) when cardiac function is improved(P<0.05). Blood pressure decreases(P<0.01), too. At the same time, it is found that Yiqixinnaoning can adjust blood lipid levels in TC, HDL-C, LDL-C, protect endothelial function(P<0.05), reduce fibrinogen (P<0.05) and increase carotid blood flow of CCA (P<0.05).Conclusions: Based on the doctrine of viscera state, heart relates to brain cosely. It is just this kind of relationship between them which construct the theoretical basis of heart and brain to be sicked together. It is the theoretical basis of curing them together, too. Through researching the theory of zangxiang, the pathogenesis of qi asthenia, blood stasis and phlegm block is explained clearly which are important to the old. Qi asthenia, stagnation of phlegm-stasis, congestion block are correlated positively with the old who is ill both in heart and in brain. Yiqixinnaoning is effective and safe in clinical research. Arised from the clinic, the theory of treating heart and brain with common theory and methods is constructed under the framework of doctrine of viscera state, including the physiologic, pathologic, diagnosis and treatment about this kind of special disease phenomenon. New ideas and methods are provided for the development of doctrine of viscera state in the respects of connotation and denotation. The clinical research pattern can be promoted further,which are constructed by three parts: investigation on the theory-retrospective study- prospective study.更多还原