【作者】 王晓艳；

【导师】 杨侃； 孙明；

【作者基本信息】 中南大学 ， 心血管内科学， 2009， 博士

【摘要】 慢性心力衰竭为临床常见病及多发病,是各种心脏病发展至晚期的结局,手术和介入治疗的适应症很少,最主要的仍是药物治疗。尽管ACEI和β受体阻滞剂的应用,改善了心衰患者的运动耐量和生活质量,然而其预后仍然非常差,年死亡率高达10%-50%,所以开展药物治疗慢性心力衰竭方面的研究具有重要意义。应用中医药治疗心力衰竭是祖国医学的一大特色,临床报道并非少见,但系统的临床与实验研究尚不多见,有关中医药治疗心力衰竭的作用机制研究仍不够深入。健心汤是我院心内科治疗慢性心力衰竭的经验方,已在临床上应用并证实有效,但其治疗心力衰竭的机制尚不十分清楚,仍有待进一步探讨。因此,本研究从临床和基础两方面探讨健心汤的抗心衰作用及其可能机制,为心力衰竭的防治和健心汤的进一步临床应用奠定基础。第一部分临床研究目的:观察健心汤治疗慢性心力衰竭的临床疗效及安全性,并初步探讨其作用机制。方法:选取NYHA心功能分级Ⅱ-Ⅲ级的心力衰竭患者50例,随机分为对照组（25例）和治疗组（25例）。对照组给予常规西药治疗,治疗组在常规西药治疗基础上加用健心汤治疗6周。观察患者用药期间心功能的改善及安全性、不良反应,评估健心汤对心衰患者运动耐量和生活质量的影响,ELISA法检测治疗前后NT-proBNP和和肽素（Copeptin）的水平。结果:1.对照组和治疗组均可改善心力衰竭患者心功能,对照组总有效率80%,治疗组92%,两组总疗效比较有显著性差异（P＜0.05）。2.治疗后两组的NYHA分级和Lee氏心衰计分均较治疗前降低（P＜0.05）,治疗组比对照组降低更明显（P＜0.05）。3.两组患者治疗前后超声各参数比较:LVEF、FS较治疗前升高（P＜0.05）,LVESV较治疗前降低（P＜0.05）;治疗组LVEDV较治疗前降低（P＜0.05）。治疗后两组间比较:LVEF、FS较对照组升高（P＜0.05）,LVESV较对照组降低（P＜0.05）。4.治疗后两组的6分钟步行距离较治疗前延长（P＜0.05）,且两组间比较有显著性差异（P＜0.05）,治疗组6分钟步行距离更长。5.治疗后两组NT-proBNP和Copeptin水平均较治疗前降低（P＜0.05）,治疗组降低更明显（P＜0.05）。6.治疗后两组明尼苏达心衰生活质量积分均较治疗前降低（P＜0.05）,治疗组降低更明显（P＜0.05）。7.治疗组和对照组均未发生明显的肝肾损害等不良反应。结论:1.在常规西药治疗的基础上,健心汤能够进一步增强疗效、改善心功能、提高心衰患者的运动耐量和生活质量,与常规西药治疗有协同作用。2.健心汤可降低心衰患者NT-proBNP和Copeptin的水平,提示健心汤是治疗慢性心衰的有效制剂。3.健心汤治疗慢性心衰6周内无明显毒副作用,安全性较好。第二部分基础研究目的:观察健心汤对心功能及左室重构的影响,并探讨其可能机制,为临床治疗心衰提供理论依据。方法:结扎SD大鼠冠状动脉前降支建立心梗后心衰模型,将76只心衰大鼠随机分成4组:健心汤低剂量组（低剂量组）,健心汤高剂量组（高剂量组）,培垛普利组,心衰对照组;另取15只大鼠只穿线不结扎冠状动脉前降支为假手术组。分别给予健心汤7.65g/kg和15.30g/kg、雅施达0.72mg/kg灌胃治疗共6周。假手术组、心衰对照组灌服等剂量纯净水。6周后观察:（1）大鼠一般情况、死亡率、体重、全心重量指数（THMI）和左室重量指数（LVMI）变化;（2）超声心功能参数;（3）心肌组织HE染色;（4）Masson染色法观察胶原含量,并计算胶原容积份数（CVF）;免疫组化法测定心肌组织Ⅰ型和Ⅲ型胶原水平;（5）放免法检测心肌组织AngⅡ、ET水平,ELISA法检测血浆NT-proBNP水平;RT-PCR法检测心肌组织ET、NT-proBNP mRNA的表达;（6）Western Blot法测定心肌组织p-ERK_1/2、p38-MAPK蛋白的表达。结果:1.健心汤治疗后,心衰大鼠的死亡率降低,体重增长,THMI和LVMI降低（P均＜0.05）,但低剂量组、高剂量组、培垛普利组间比较无显著性差异（P＞0.05）。2.健心汤治疗后,心衰大鼠的LVEDD降低、FS和LVEF升高（P均＜0.05）,且FS和LVEF在高剂量组与培垛普利组升高较低剂量组更明显（P＜0.05）:3.健心汤可改善心衰大鼠病理形态结构,高剂量组和培垛普利组较低剂量组更佳。4.健心汤治疗后,心衰大鼠的Ⅰ型胶原含量、Ⅰ/Ⅲ型胶原比值、CVF降低（P＜0.05）,且在高剂量组与培垛普利组较低剂量组降低更明显（P＜0.05）。5.健心汤治疗后,心衰大鼠AngⅡ、ET和NT-proBNP水平均降低（P均＜0.05）,但培垛普利组AngⅡ水平较低剂量组和高剂量组更低（P＜0.05）;ET和NT-proBNP水平在高剂量组和培垛普利组无显著性差异（P＞0.05）,均低于低剂量组（P＜0.05）。6.健心汤治疗后,p-ERK_1/2、p38-MAPK蛋白水平较心衰对照组降低（P＜0.05）,且在高剂量组与培垛普利组较低剂量组降低更明显（P＜0.05）。结论:1.健心汤可改善心衰大鼠的心功能、心肌形态结构,是治疗心衰的有效制剂。2.健心汤降低了心衰大鼠Ⅰ型胶原、Ⅰ/Ⅲ胶原比值、CVF水平,提示健心汤可能通过调节胶原的表达抗心肌重塑。3.健心汤降低了心衰大鼠AngⅡ、ET、NT-proBNP水平,提示健心汤可以拮抗心衰大鼠神经内分泌系统的过度激活。4.健心汤下调了心衰大鼠p-ERK_1/2、p38-MAPK蛋白表达水平,提示健心汤可能通过干预了细胞信号转导系统的ERK、p38通路,通过相关的级联信号分子达到抗心肌重塑的作用。5.高剂量健心汤对心功能的改善和抗心肌重塑的作用在6周内与培垛普利大致相当。更多还原

【Abstract】 Congestive heart failure （CHF） is a common disease, and has become one of the most important public sanitary problems. CHF is the end-stage of various heart diseases. Operation and invention treatment are not widely used, and the major one is still drug treatment. Although the application of ACEI andβ-blocker could improve the life quality and exercise tolerance of patients with heart failure, the prognosis is so poor that the mortality is as high as 10 to 50 percent.The treatment with traditional Chinese medicine for congestive heart failure is a major feature of traditional Chinese medicine. Clinic reports are not unusual, but systemic reports on both clinic and laboratory are not yet common. The Study that is associated with the treatment with traditional Chinese medicine for congestive heart failure is lack of depth. Jian Xin Soup has been used in clinic and be testified effectively to treat heart failure. However, the exact mechanism of anti-heart failure treatment is not yet known and need to be explored further. The possible mechanism of Jian Xin Soup curing congestive heart failure from both clinical and experimental sides will be explored in further study. Part 1: Clinical ResearchObjective: To investigate the effect and safety of Jian Xin Soup on CHF and to study its probable mechanism.Methods: 50 Patients with CHF and NYHA grade II-III were studied, and randomly divided into the treatment group （n=25） and control group （n=25）. The control group was treated with conventional western medicine, while the treatment group was treated with Jian Xin Soup twice a day for 6 weeks as well as western medicine. Side-effects and heart function were recorded during drug administration. 6 minute walk test （6MWT） and Minnesota living with heart failure questionnaire （MLHFQ） were also used to estimate exercise performance and life quality. The level of plasma NT-proBNP and Copeptin was investigated by ELISA assay.Results: 1. The total effective rate in treatment group was 92%, while in control group was 80%, there was significant difference between the two groups （P<0.05） .2. Lee’s marks of CHF and NYHA classification was decreased significantly in both groups after treatment （P<0.05） ,and with even better decrease in treatment group than that in control group （P<0.05） .3. The LVEF, LVESV and FS was improved significantly in both groups after treatment （P< 0.05）,but the improvement in treatment group was more significant than that in control group （P<0.05） . After treatment, there was significant difference in treatment group with LVEDV than that before treatment （P<0.05） , but with no significant difference in control group （P>0.05） .4. After treatment, the distance of 6MWT was increased signifieantly in both groups （P<0.05） ,and with even better increase in treatment group than that in control group （P<0.05） .5. After treatment, the concentration of NT-proBNP and Copeptin was decreased significantly in both groups （P<0.05） ,and with even better decrease in treatment group than that in control group （P<0.05） .6. After treatment, the marks of MLHFQ was decreased significantly in both groups （P<0.05） ,and with even better decrease in treatment group than that in control group （P<0.05） .7. No side-effects such as the liver and kidney function damage were recorded in both groups.Conclusions: 1. Jian Xin Soup could strengthen the therapeutic effects, improve heart function, enhance exercise performance and life quality, and it has cooperative function with conventional western medicine on CHF treatment.2. Jian Xin Soup could decrease the level of NT-proBNP and Copeptin, and it may suggest that Jian Xin Soup is effective in the treatment of CHF.3. Jian Xin Soup has no side effects, and it is very safe in six weeks. Objective: To investigate the effects of Jian Xin Soup on heart function and left ventricular remodeling in order to find some possible mechanism and provide evidence to clinical application.Methods: 76 model rats with CHF were randomly divided into 4 groups, that is, Jian Xin Soup low dose group, Jian Xin Soup high dose group, HF control group, and Perindopril group, 19 in each group. Another 15 rats are the sham operation group. In Jian Xin Soup low dose group, each rat is fed with 7.65g/kg; in Jian Xin Soup high dose group with Jian Xin Soup 15.30g/kg, and in Perindopril group with Perindopril 0.72mg/kg, Sham operation group and the control group is fed with 1ml/kg water. All rats were fed twice a day for 6 weeks. The measurement included: （1） mortality, body weight, total heart mass indexes（THMI）,and left ventricular mass indexes（LVMI） were observed; （2） before and after the treatment, the IVST, LVPWT, LVEDD, FS, LVEF were recorded by Echocardiography; （3） pathologic changes of left ventricular myocardium were viewed with HE staining method; （4） collagen volume fraction （CVF） was done with patho-image analytical system; Expression of collagen type I and III was measured by immuno-hisochemical method, and the ratio of collagen type I and III was calculated; （5） concentration of AngII and ET in left ventricular myocardium was measured by radio-immunity method, the level of plasma NT-proBNP was measured by ELISA assay. The levels of ET and NT-proBNP mRNA in left ventricular myocardium were measured by RT-PCR; （6） the expression of p-ERK_1/2 and p38-MAPK in left ventricular myocardium was measured by Western blot.Results: 1. After the medication treatment, the mortality, THMI and LVMI were significantly decreased in those of all treatment groups （P< 0.05） , but there was no obvious difference among the treatment groups （P>0.05） .2. Compared to sham operated group, in HF control group LVEDD was obviously increased and FS LVEF was decreased （P<0.05） ; After treatment, heart function improved compared to that of HF control group（P<0.05） , FS and LVEF were better in Jian Xin Soup high dose group and Perindopril group than those in Jian Xin Soup low dose group.3. After the treatment of Jian Xin Soup, the pathomorphology of myocardium had been improved with dose-dependence, they were better in Jian Xin Soup high dose group and Perindopril group than those in Jian Xin Soup low dose group, but there was no obvious difference between Jian Xin Soup high dose group and Perindopril group.4. After the medication treatment, the levels of type I collagen, ratio of collagen type I and III and CVF were significantly decreased in all treatment groups （P<0.05）, lower in Jian Xin Soup high dose group and Perindopril group than that in Jian Xin Soup low dose group.5. After the medication treatment, the level of AngII, ET and NT-proBNP were significantly decreased in all treatment groups （P< 0.05）, but the level of AngII was the lowest in Perindopril group compare to that in the other two groups （P<0.05） . The levels of ET and NT-proBNP were lower in Jian Xin Soup high dose group and Perindopril group than those in Jian Xin Soup low dose group, but there was no obvious difference between Jian Xin Soup high dose group and Perindopril group （P>0.05） .6. After the medication treatment, the levels of p-ERK_1/2 and p38-MAPK were significantly decreased in all treatment groups （P< 0.05） , but the levels of p-ERK_1/2 and p38-MAPK were lower in Jian Xin Soup high dose group and Perindopril group than those in Jian Xin Soup low dose group, but there was no obvious difference between Jian Xin Soup high dose group and Perindopril group （P>0.05） .Conclusions: 1. Jian Xin Soup may be effective in the treatment of CHF through improving the CHF rats’ heart function and tissue morphology.2. Jian Xin Soup could decrease the level of type I collagen, ratio of collagen type I and III and CVF, it may regress ventricular remodeling through reversing collagen remodeling.3. Jian Xin Soup could decrease the level of AngII, ET and NT-proBNP, it may regress ventricular remodeling through restraining over-excitation of nerve endocrine system.4. Jian Xin Soup could decrease the level of p-ERK_1/2 and p38-MAPK, it may regress ventricular remodeling through regulating the abnormal signal pathway of ERK and p38.5. Jian Xin Soup could improve heart function and regress ventricular remodeling. There was no obvious difference in therapeutic effects between Jian Xin Soup and Perindopril in six weeks.更多还原