【作者】 莫莉；

【导师】 袁肇凯；

【作者基本信息】 湖南中医药大学 ， 中医诊断学， 2008， 博士

【摘要】 目的本研究以临床最常见的冠心病气虚血瘀证为研究对象,从文献、临床和实验三方面探讨其证候的临床特征及益气活血法干预机制,为提高临床辨证治疗水平提供研究依据。方法1.文献研究：采用文献搜集、整理、分析和总结的方法,对冠心病气虚血瘀证病机、辨证(包括辨证标准、计量诊断、客观化)、气虚血瘀证动物模型及冠心病气虚血瘀证证治等多方面进行研究。2.临床研究：(1)通过对冠心病中医证候展开流行病学调查,应用主成分分析、Logistic回归模型及分析等方法,归纳冠心病心气虚血瘀证证型分布特征,并比较其与心血瘀阻证、心气亏虚证的临床症征组成特点；应用逐步回归多因素分析方法对冠心病气虚血瘀证相关危险因素进行分析。(2)以健康人和冠心病气滞血瘀证病人为对照,从临床实验指标(包括面色、舌质、甲色和脉象及其微观指标)方面对冠心病气虚血瘀证进行同步对照观察分析。3.实验研究：(1)制作鸡胚绒毛尿囊膜(CAM)模型,以模组和空白组为阴性对照,以碱性成纤维细胞生长因子(bFGF)组和麝香保心丸组为阳性对照,设五个时间点连续观察,比较同一时间点各组药物干预后CAM血管生成数目,并分别比较各药物组在不同时间点CAM血管生成数。(2)采用溴化二甲噻唑二苯四氮唑(MTT)比色法测定各药物组对大鼠血管内皮细胞的增殖率,观察MTT法作用于大鼠血管内皮细胞时的增殖情况,计算增殖率并进行组间比较。(3)用划痕愈合实验观察内皮细胞迁移率,倒置显微镜下观察各药物组于划痕后0-24小时对心气虚血瘀证大鼠模型内皮细胞迁移情况并计数,了解益气活血法对内皮细胞迁移的影响。(4)通过检测血管内皮细胞管腔结构的形成,进行管腔计数：光镜下观察,内皮细胞连接呈C形即算一个管腔,每张玻片在低倍镜下选取3处管腔密集的视野,在每个放大(×100)的视野计数管腔数。每组随机获取10个图像,取平均值,比较各药物组间差异,了解益气活血法对内皮细胞的成管影响。结果第一部分冠心病气虚血瘀证的文献研究(1)胸痹心痛的产生是多因素复合作用的结果,其中阳微阴弦是冠心病的关键病机,气虚血瘀是阳微阴弦的最新释义,是冠心病发生发展的病理基础。(2)气虚血瘀证是冠心病主要证型之一,其辨证标准及客观化研究、动物模型等研究均有一定的进展,益气活血是CHD气虚血瘀证主要治法,探索中医药的促血管生成作用是一个有意义的研究方向。第二部分冠心病气虚血瘀证特征的临床研究(1)冠心病气虚血瘀证兼具心气虚和心血瘀阻的临床表现,与冠心病常见危险因素密切相关,尤其与患者年龄、体重指数、甘油三脂、高密度脂蛋白胆固醇等关系密切(均P<0.01)。(2)冠心病气虚血瘀证和冠心病气滞血瘀证在面、舌、甲、脉诊上都有一定的证候特征,如面青、舌紫、甲瘀、脉涩等,均具有“心血瘀阻”的共性。但两证型在临床症征和多项微观指标方面均存在统计学意义(p<0.01或p<0.05)。心气虚血瘀证患者面部主波波幅(Hb)、快速充盈系数(Hb／Tab)、脉图的心搏系数([t4-t1]／t)、心功系数(t1／t)及反映心脏功能的4项指标恻值(Sv、Co、Si、Ci)均明显减低,其微循环管袢短小、模糊,血管充盈不良,血色较淡。第三部分益气活血法促血管新生的实验研究(1)益气活血法促鸡胚绒毛尿囊膜血管新生实验①0小时和24小时,各药物组与模组和空白组比较无统计学意义(p>0.05)；且各药物组组间比较亦无统计学意义(p>0.05)。②48小时,各药物组与模组、空白组比较均有统计学意义(均p<0.05)；各药物组组间比较无统计学意义(p>0.05)。③72小时,各药物组与模组、空白组比较均有统计学意义(均p<0.05)；养心通脉方Ⅰ组(YTⅠ)与麝香保心丸组(SXBXW)组间比较无统计学意义(p>0.05)；YTⅠ组与bFGF组比较有统计学意义(p<0.05)；养心通脉方Ⅱ组(YTⅡ)与SXBXW组比较有统计学意义(p<0.05)；YTⅡ组与bFGF组比较无统计学意义(p>0.05)；YTⅠ组与YTⅡ组比较有统计学意义(p<0.05)。各组促血管新生数目由大至小依次为bFGF组>YTⅡ组>YTⅠ组>SXBXW组>模组>空白组。96小时,各药物组与模组、空白组比较均有统计学意义(均p<0.05)；各药物组组间比较结果同72小时。④各药物组促血管新生作用随时间的推移而逐渐增强。模型组和空白组在五个时间点血管虽也逐步增加,但其增长幅度均远不及各药物组。YTⅡ组和bFGF组在96时后回归曲线仍保持上升趋势不变,两组间无统计学意义(p>0.05),而其它各组96时后回归曲线呈下降趋势。(2)益气活血法促大鼠血管内皮细胞增殖实验各药物组与生理盐水组(NS组)和空白血清组比较均有统计学意义(均P<0.05),但NS组与空白血清组比较无统计学意义(P<0.05)。各药物组均具有促大鼠血管内皮细胞增殖作用。其中,YTⅡ组与YTⅠ组、SXBXW组比较均有统计学意义(均P<0.05),但bFGF组与YTⅡ组比较无统计学意义(P>0.05)。YTⅠ组与SXBXW组之间比较亦无统计学意义(P>0.05)。各组促内皮细胞增殖作用由大至小依次为：重组碱性成纤维细胞生长因子组(bFGF)>养通Ⅱ组(YTⅡ)>养通Ⅰ组(YTⅠ)>麝香保心丸组(SXBXW)>生理盐水组(NS)>空白血清组(KX)。(3)益气活血法促大鼠血管内皮细胞迁移实验各药物组与NS组和空白血清组比较均有统计学意义(均P<0.05),但NS组与空白血清组比较无统计学意义(P>0.05)。各药物组均具有促大鼠血管内皮细胞迁移作用。各药物组组间比较结果同增殖实验。各组促内皮细胞迁移作用由大至小为：bFGF组>YTⅡ组>YTⅠ组>SXBXW组>NS组>空白血清组。(4)益气活血法促大鼠血管内皮细胞成管实验各药物组与NS组和空白血清组比较均有统计学意义(均P<0.05),但NS组与空白血清组比较无统计学意义(P>0.05)。各药物组均具有促大鼠血管内皮细胞成管作用。各药物组组间比较结果同增殖实验。各组促内皮细胞成管作用由大至小为：bFGF组>YTⅡ组>YTⅠ组>SXBXW组>NS组>空白血清组。结论1.气虚血瘀是冠心病发生的关键病机,气虚血瘀证是CHD中医证型的主要证型之一,益气活血是冠心病气虚血瘀证的重要治法,其治疗冠心病气虚血瘀证具有坚实的理论依据、临床和实验基础。2.冠心病气虚血瘀证兼具心气虚和心血瘀阻的表现,在各微观指标上有一定的证候特征,本实验研究结果为CHD气虚血瘀证的临床诊断及与气滞血瘀证的鉴别提出了客观微观化指标。3.以益气活血法立方的YTⅠ和YTⅡ均能促进鸡胚绒毛尿囊膜模型新生血管的生成,提示益气活血法有促血管新生作用。4.益气活血法能促血管新生,防治冠心病气虚血瘀证与其对血管内皮细胞的保护作用密切相关,这些保护作用主要表现为它能促进血管内皮细胞增殖、迁移和细胞成管。5.YTⅡ和YTⅠ虽同为益气活血法组方,但YTⅡ促血管新生作用及促细胞增殖、迁移和成管作用显著优于YTⅠ。更多还原

【Abstract】 Objective:This paper mainly research on the most common heart Qi Deficiency and Blood stasis symptom of coronary heart disease (CHD). Three syndromes of literature, clinical and experimental, and the clinical intervention mechanism of Activating Blood & Removing Blood Stasis, have offered basis for research to improve clinical differential diagnosis and treatment.Methods:1.Literature:Adopting methods of literature collection, collation, analysis and summary of, we carried out studies on the blood stasis for coronary heart disease Qi Syndrome standards, the objective of the model and measurement diagnosis, and etc.2.Clinical Research:(1) passes the investigation developing an epidemiology to coronary heart disease doctor of traditional Chinese medicine syndrome, method such as model and analysis applying the host be accomplished analysis, Logistic return, the certificate certificate type summing up coronary heart disease heart blood lacking in vital energy stagnating distributes a characteristic, and the clinical disease comparing the person with painstaking effort stagnating to hinder the certificate, the false ambition wane certificate collects the composition characteristic; The certificate relevance danger factor applying many factors of successive steps return analysis method stagnating to blood of coronary heart disease lacking in vital energy carries out analysis.(2) stagnates blood with the healthy people and the coronary heart disease gas stagnating for the certificate patient contrasting, from clinical experiment index (include complexion, tongue quality, A color and pulse condition and their microcosmic index), aspect stagnates to blood of coronary heart disease lacking in vital energy to verify the synchro collation being in progress observing analysis.3. Experimental study:(1) produced chicken chorioallantoic membrane (CAM) model, and take blank modules to the negative control group, basic fibroblast growth factor (bFGF) group and Shexiangbaoxin pill as a positive control group, make Continuous observation at a five time points, comparing drug CAM angiogenesis figure with intervention from different groups at the same time, and comparing CAM angiogenesis figure from the drug group and look at Yiqihuoxue Law Group’s Tablet and Yang Xin-Pulse whether there is a valid position to promote angiogenesis.(2) produced heart Qi blood stasis rat model using brominated diphenyl dimethyl thiazole tetrazolylazo (MTT) assay to detect the drug group on the cardiac blood stasis Qi rat vascular endothelial cell proliferation rate, NS group and blank serum as a negative control group, bFGF group and Shexiangbaoxin pill as a positive control group, observed by MTT assay role in rat vascular endothelial cells proliferation, and proliferation rate of between group, understanding Yiqihuoxue law Group’s YTⅠand YTⅡon vascular endothelial cell proliferation in vitro.(3) with scratches Experimental observation of the healing rate of endothelial cell migration, observing of the drug group scratches 0～24 hours after endothelial cell migration under inverted microscope and counting, compared to promote migration rate, to understand Yiqihuoxue law on endothelial cell migration affected.(4) making lumen count by detecting the formation of the lumen of vascular endothelial cells:observing under optical microscopy, connecting with endothelial cells that is a C-shaped lumen, low times in each glass microscope (×40) select three lumen intensive vision in each amplification (×100) lumen count the vision of a few. We obtain 10 images randomly from each group and calculating average value, comparing differences of each drug group, to understand Yiqihuoxue method’s influence on endothelial cells.Results: The first part:research literature on Qi blood stasis coronary heart disease Despite the heartache:(1)Chest is a combined effect of multiple factors, but Yang Yin-string is the key pathogenesis of coronary heart disease, blood stasis Qi Yin-Yang is the latest string interpretation of the development of coronary heart disease and the pathological basis.(2)Qi and blood stasis is a main type of coronary heart disease, its dialectical study of objective standards has certain development, Yiqihuoxue law is the treatment of Chest heartache Qi blood stasis.The second part:the clinical research of coronary heart disease and its characteristics——Qi blood stasis:(1)Qi blood stasis of non-coronary heart disease heart blood deficiency and heart-card portfolio simple, the main risk factors associated with age, smoking, body mass index, triglyceride, high-density lipoprotein cholesterol, such as plasma endothelin closely related.(2)Qi blood stasis and Qichixieyu card in the face, tongue, A, has its pulse on certain characteristics of the syndrome. Two patients of a certain proportion of blue, purple tongue, a stasis, pulse Shibuya levy, but Qi blood stasis patients face, tongue color, more TANSEI or whitish, thin and astringent chord pulse. The results showed that the microscopic detection, Qi blood stasis CHD patients than healthy control group, blood flow around the face resistance index (He/Hb) increased dynamic torsion plans to watch drag coefficient (h4/hl), cardiovascular, peripheral resistance (RT) were significantly increased microcirculation of red blood cell aggregation loop, loop top bleeding, slow-speed flow. CHD Qi blood stasis and Qichixieyu card, the card of the two micro indicators of the existence of a number of statistical significance (p<0.01 or p<0.05). Qi blood stasis with facial wave amplitude (Hb), rapid filling coefficient (Hb/Tab), the Pulse of the cardiac index ([t4-t1]/t), heart reactive coefficient (t1/t) and the cardiac function The four indicators Ce values (Sv, Co, Si, Ci) were significantly reduced its microcirculation of the loop short, fuzzy, vascular filling undesirable, such as hemochromatosis than desalination.The third part:Yiqihuoxue Qi blood stasis of promoting angiogenesis experimental study: (1)Yiqihuoxue law promoting chicken chorioallantoic membrane experimental angiogenesis:①0 hours and 24 hours, the drug group and the modules and gaps group was not significant (p>0.05) and the drug group no comparison group was significant (p>0.05).②48 hours, the drug group and the modules blank group are statistically significant (all p<0.05) between the drug group, compared with no statistical significance (p>0.05).③Every medicine has statistics meaning 72 hours, set without exception comparing with the model group, the blank space group (equal p<0.05); The nourishing heart exchanges the square I pulse group (YTI) and musk guarantees the group of heart ball group (SXBXW) there being no statistics significance comparatively (p>0.05); YT I has statistics meaning set comparing with bFGF group (p<0.05); The nourishing heart exchanges square II pulse group (YTⅡ) having statistics meaning comparing with SXBXW group (p <0.05); YTⅡhas no statistics significance set comparing with bFGF group (p> 0.05); YT I has statistics meaning set comparing with YTⅡgroup (p<0.05). Every urges the newborn number of blood vessel to form> the blank space group by forming> a model greatly till being bFGF group> YTⅡgroup> YT I group> SXBXW for a short time in proper order set. Every medicine has statistics meaning 96 hours, set without exception comparing with the model group, the blank space group (equal p<0.05); Every medicine group bears fruit comparatively with 72 hours.④every medicine urges the newborn effect of blood vessel to follow time fading away set but strengthens gradually. The model group and the blank space group count a blood vessel in five time though increasing by also step by step, the person increases but the group of extent without exception far inferior to every medicine. The YTⅡgroup and the bFGF group still keep an uptrend in queen return curve for 96 points invariable, two set of rooms have no statistics significance (p>0.05), but other every group queen return curve for 96 points memorial comes down trend.(2) benefit gases invigorate the circulation of blood following short rat blood vessel bast proliferation of cells experiment Every medicine has statistics meaning set without exception comparing with the normal saline group (NS group) and the blank space serum group (equal p<0.05), but NS has no statistics significance set comparing with blank space serum group (p> 0.05). Every medicine has the short rat blood vessel bast proliferation of cells effect set equally. Among them, YTⅡhas statistics meaning set without exception comparing with the YTI group, the SXBXW group (equal p<0.05), but bFGF has no statistics significance set comparing with YTⅡgroup (p>0.05). YTI has no comparatively also statistics significance between the group and the SXBXW group (p>0.05). Every urges the bast proliferation of cells effect reason to be greatly extremely for a short time in proper order set:Re-organize basicity becoming the fibre cell growth factor group (bFGF)> supports the throughⅡgroup (YTⅡ)> supports theⅠgroup (YTI)> musk guarantees the heart ball group (SXBXW)> normal saline group (NS)> blank space serum group (KX).(3) benefit gases invigorate the circulation of blood following short rat blood vessel bast cell removing an experimentEvery medicine has statistics meaning set without exception comparing with the NS group and the blank space serum group (equal p<0.05), but NS has no statistics significance set comparing with blank space serum group (p> 0.05). Every medicine is had set equally urging the rat blood vessel bast cell to remove an effect. Every medicine group bears fruit comparatively and proliferates an experiment. Every urges the bast cell to remove big extremely minor effect reason by:set BFGF forms> the YTⅡgroup> YTI group> SXBXW group> NS group> blank space serum group.(4) benefit gases invigorate the circulation of blood following short rat blood vessel bast cell Cheng being in charge of an experimentEvery medicine has statistics meaning set without exception comparing with the NS group and the blank space serum group (equal p<0.05), but NS has no statistics significance set comparing with blank space serum group (p> 0.05). Every medicine is had set equally urging the rat blood vessel bast cell to become the tube effect. Every medicine group bears fruit comparatively and proliferates an experiment. Every urges the bast cell to become big extremely minor tube effect reason By:set BFGF forms> the YTⅡgroup> YTI group> SXBXW group> NS group> blank space serum group. Conclusions:1. Qi Deficiency and Blood Stasis is the key to coronary heart disease pathogenesis, Qi Deficiency and Blood Stasis of CHD is the main type of TCM, Activating Blood & Removing Blood Stasisis is an important treatment method for coronary heart disease Qi blood stasis, which has solid theoretical, clinical and experimental basis.2. Qi Deficiency and Blood Stasis of CHD includes the symptom of qi deficiency and blood stasis, which reflect on the face, tongue and etc. This laboratory reaserch result have objective and micro indicators for clinical diagnosis and distinguishing of Qi deficiency and blood stasis of CHD.3. Coming into being invigorating the circulation of blood with benefit gas following cubic YTI and YTⅡbeing able to promote the newborn blood vessel of chicken embryo fine hair urine bag film model without exception, the law pointing out that the benefit gas invigorates the circulation of blood has urging the newborn effect of blood vessel.4. The benefit gas invigorates the circulation of blood following can urge the blood vessel freshman, prevention and cure coronary heart disease blood lacking in vital energy stagnates the certificate is that it can promote blood vessel bast proliferation of cells, migration and the cell ready-made a tube than the cell’s protection effect goes hand in hand, these protection effects show mainly to blood vessel bast.5. YTI of YTⅡbetter than composing in reply YTI though the effect is notable with being that method, but YTⅡurges the newborn effect of blood vessel and urges proliferation of cells, migration and ready-made tube benifit a gas invigorating the circulation of blood following set.更多还原