【作者】 朱波；

【导师】 李七一；

【作者基本信息】 南京中医药大学 ， 中医内科， 2009， 博士

【摘要】 背景慢性心力衰竭(Chronic Heart Failure,CHF简称心衰)是由于各种器质性或功能性心脏疾病使心室充盈或射血能力受损的一种综合征。我国心衰住院率占同期心血管病的20%,死亡率却占40%,提示预后严重,因此心力衰竭的治疗的是临床重要课题。传统的强心、扩血管、利尿三联用药在改善患者近期临床情况的同时,却不能降低其死亡,甚至反有可能增加死亡的危险性。究其原因,可能激活了神经内分泌系统,包括交感神经系统(SNS)及肾素-血管紧张素-醛固酮系统(RAAS),未能阻断甚至还可能加速了心肌重构的进程。以血管紧张素转换酶抑制剂(ACEI)为基石的心衰现代治疗方案,通过降低SNS活性,抑制RAAS激活,从而阻断了心肌重构的进展,改善了心功能。传统中医根据心衰时既有心肾阳虚,又有水饮内停和血脉瘀阻的病机特点,拟定了温阳利水,活血化瘀的心衰治疗大法,对于一些中、重症心衰的患者,往往确也能取得良好近期疗效,但是并没有证据表明能摆脱心衰患者的死亡率居高不下的困扰。中医理论认为,物质属阴,功能属阳。在心肌重构的进程中,心肌细胞的凋亡、减少,就是属阴的物质丢失,而属于阴虚,日久则阴损及阳,进而使阳的功能减退:此外,心肌细胞的变性、凋亡、肥大和间质增生,中医则认为是痰、瘀、水气等邪内停的结果。根据以上理论,结合长期临床实践,李七一教授研制出具有益气养阴、活血利水、化痰软坚作用的心衰Ⅰ号配方颗粒剂(简称心衰Ⅰ号),经临床实践证明疗效较好,为进一步深入认识,进行了如下临床试验和动物实验以验证其疗效,探究其作用机理。研究目的一、研究心衰Ⅰ号对慢性心力衰竭患者(简称心衰患者)临床症状、6分钟步行试验及血浆脑钠肽水平的影响。二、研究心衰Ⅰ号改善慢性心力衰竭大鼠(简称心衰大鼠)的血流动力学指标、以及对肾素—血管紧张素—醛固酮系统、心房钠尿肽、内皮素等相关指标的影响,并探讨其机制。研究内容与方法一、临床研究部分1、方法将51例心衰患者随机分为治疗组26例与对照组25例,两组基础治疗参照中华医学会心血管分会关于《慢性收缩性心力衰竭治疗建议》的标准治疗,治疗组口服心衰Ⅰ号,每日1袋,分2次服。对照组口服心衰Ⅰ号安慰剂,每日1袋,分2次服。4周为1个疗程,观察时间为6个疗程。比较两组治疗后症状体征、生活质量评分、脑钠肽、纽约心功能分级、6分钟步行试验的变化和综合疗效。2、结果两组治疗后在症状体征、脑钠肽、6分钟步行试验及综合疗效方面有显著差异。3、结论心衰Ⅰ号对心衰患者具有显著改善临床症状,提高临床疗效,改善血浆脑钠肽水平,改善6分钟步行试验的作用,提示该法对心衰患者长期疗效较好。二、动物试验部分1、造模及分组方法:按Fletcher法,对SD(Sprague Dawley)大鼠行左冠状动脉主干结扎术,假手术组开胸后,不结扎冠状动脉。室内饲养,规律照明,自由进食及饮水,饲养4周。按随机数字表法将造模成功后大鼠随机分为4组,每组15只,另设置正常大鼠15只作为空白对照组及15只的假手术组,共计6组。造模成功后开始实验。具体分组情况为:正常对照组(Con):正常不造模型大鼠,每日灌蒸馏水3ml连续4周。假手术组(Sha):每日灌蒸馏水3ml,连续4周。模型组(CHF):确定造模成功后,每日灌蒸馏水3ml,连续4周。卡托普利组(Cap):确定造模成功后,每日灌卡托普利0.016g/Kg,连续4周。心衰Ⅰ号小剂量组(XS1):确定造模成功后,每日灌中药颗粒12g生药/kg,连续4周。心衰Ⅰ号大剂量组(XS2):确定造模成功后,每日灌中药颗粒36 g生药/kg,连续4周。观察各组动物治疗过程中外观、运动、食欲及水肿、紫绀等症状表现。每日称饲料及水的消耗量。每周称大鼠的体重。给药4周后,对每只大鼠眼眶静脉取血4ml用于放免测定,后进行心功能血流动力学监测。随即将每只大鼠解剖,取完整心脏,生理盐水冲洗后放入液氮罐,保存待测。2、实验方法对实验心衰大鼠进行以下实验并记录结果:血流动力学测定、心肺重量的测定、血浆肾素活性(PRA)测定、血浆血管紧张素Ⅱ(AngⅡ)测定、血浆醛固酮(ALD)测定、血浆心房钠尿肽(ANP)测定、血浆内皮素(ET)测定、对抗苯肾上腺素收缩心衰大鼠离体肠系膜上动脉血管作用测定及心肌纤维化程度的检测。3、研究结果(1)心衰Ⅰ号对心衰大鼠血流动力学的影响与模型组比较,心衰Ⅰ号大剂量组与卡托普利组均能增加心衰大鼠的LVSP、+dp/dtmax(P＜0.01),显著降低LVEDP(P＜0.05～0.01),且心衰Ⅰ号大剂量组与卡托普利组相比无明显差异(P＞0.05)。心衰Ⅰ号大剂量组与卡托普利组均能使t～dp/dt max下降(P＜0.05～0.01),似心衰Ⅰ号大剂量组作用更强(P＜0.05)。心衰Ⅰ号小剂量组心衰大鼠的LVSP明显提高(P＜0.05),t～dp/dt max显著下降(P＜0.01)。同时卡托普利组、心衰颗粒大、小剂量组心衰大鼠的SAP均有明显升高(P＜0.05～0.01),似以心衰Ⅰ号大剂量组作用最强。(2)心衰Ⅰ号对心衰大鼠心、肺的影响与模型组比较,心衰Ⅰ号大剂量组与卡托普利组均能增加心衰大鼠左室重量和LV/BW(P＜0.05～0.01),且以心衰Ⅰ号大剂量组为显著(P＜0.05)。心衰Ⅰ号小剂量组和卡托普利组均能抑制右室肥厚(P＜0.01),且心衰Ⅰ号小剂量组同时能降低肺脏指数(P＜0.05)。(3)心衰Ⅰ号对心衰大鼠肾素—血管紧张素—醛固酮系统、心房钠尿肽、内皮素的影响心衰大鼠RAAS被激活,与正常组比较,血浆PRA、AngⅡ、ALD水平显著提高(P＜0.01)。各给药组治疗后,PRA、AngⅡ、ALD水平明显下降(P＜0.01),其中以心衰Ⅰ号大剂量组下降最为显著。心衰大鼠血浆ANP水平降低,用心衰Ⅰ号与卡托普利治疗后,ANP有所回升,但无统计学意义。心衰大鼠血浆ET水平显著升高(P＜0.01),各给药组治疗后,血浆ET水平平均有下降(P＜0.05～0.01),其中以心衰Ⅰ号大剂量组最为明显。(4)心衰Ⅰ号对抗苯肾上腺素收缩心衰大鼠离体肠系膜上动脉血管作用心衰大鼠肠系膜上动脉血管对苯肾上腺素的反应性增强(P＜0.05),而心衰Ⅰ号与卡托普利均具有明显对抗苯肾上腺素收缩离心体大鼠肠系膜上动脉血管的作用(P＜0.01)。(5)对心衰大鼠心肌纤维化程度的检测结果心衰Ⅰ号大小剂量组及卡托普利组心肌间质纤维化程度均小于模型组,卡托普利组心肌间质纤维化程度小于模型组,大于高剂量组。4、结论心衰Ⅰ号可以明显改善慢性心力衰竭大鼠的血流动力学指标、对肾素—血管紧张素—醛固酮系统、心房钠尿肽、内皮素等相关指标均有不同程度改善,其中以大剂量组更为显著。此外,心衰Ⅰ号可以降低心衰大鼠心肌纤维化的程度。更多还原

【Abstract】 BackgroundChronic Heart Failure(Chronic Heart Failure,CHF referred to as heart failure ) is a complex syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventride to fill with or eject blood.In China,the heart failure hospitalization rates over accounted for 20%of the same period cardiovascular disease,the mortality rate accounted for 40%,suggesting a serious prognosis.Therefore the treatment of heart failure is a clinical important issue.Traditional cardiac,vasodilative,diuretic drugs may be activated neuroendocrine system, failed to block the process of myocardial remodeling,and even likely to accelerate the process of myocardial remodeling,so in the near future to improve the clinical condition of patients at the same time,but should not reduce their death,or even anti-are likely to increase the risk of death.By angiotensin-converting enzyme inhibitor(ACEI) as the cornerstone of modern treatment of heart failure by reducing sympathetic nervous system(SNS) activity,inhibiting the renin - angiotensin - aldosterone system(RAAS) activation,which has impacted off the progress of cardiac remodeling and improve cardiac function results.Traditional Chinese medicine in accordance with the heart failure pathogenesis characteristics,not only the deficiency of heart-Yang and kidney-Yang but also retention of fluid within the body and blood Stagnation,developed Onyang diuresis,huoxuehuayu Dafa treatment of heart failure, for some,the severe heart failure patients can often do a good short-term efficacy.However, there is no long-term treatment in patients with heart failure out of the troubled high mortality rate.Chinese medicine theory holds that material belong to Yin,Yang is function.In the process of cardiac remodeling,myocardial apoptosis,the material reduced Yin lost in the first place,and ultimately Yin impairment involve Yang,,so that the function rreduced Yang dysfunction..Normal decrease in the number of myocardial cells,reflects the Yin impairment, while the remaining myocardial cells hypertrophy,Chinese medicine consider that it is phlegm,stagnant blood,such as fluid vapor suspended in the outcome of evil.Cardiac myocyte apoptosis and cardiac myocyte hypertrophy,myocardial structure and function is the main reason for change.Based on the above theory with long-term clinical practice,Professor Li Qiyi developed XinShuai Formula granulesⅠ(referred to as XinShuaiⅠ) through the overall conditioning,multi-target,multi-link acting on the neuroendocrine system,as well as neurohumoral factors,inhibition ventricular remodeling and the role of anti-heart failure. Research purposesFirst,to study XinShuaiⅠin patients with chronic heart failure(referred to as heart failure rats) on clinical symptoms,6-minute walk test and plasma brain natriuretic peptide levels. Second,to study XinShuaiⅠin rats with chronic heart failure(referred to as heart failure rats) to improve hemodynamic parameters,as well as the renin - angiotensin - aldosterone system, atrial natriuretic peptide,endothelin and other related indicators,and explore its mechanism, so as to clinical application XinShuaiⅠto provide experimental basis,better services for the vast number of patients with heart failure.Research contents and methodsFirst,.the part of clinical research1,methods51 cases of heart failure patients will be randomly divided into treatment group 26 cases and 25 cases of the control group,two groups with reference to basic treatment of the Chinese Medical Association of Cardiovascular Branch regarding "Chronic systolic heart failure treatment recommendations," the standard treatment,The treatment group oral XinShuaiⅠ1 bag per day,at 2 times service,the control group oral placebo 1 bag per day,at 2 times service.4 weeks for a course of treatment,observation time of 6 treatments.Compared between the two groups after treatment signs and symptoms,quality of life score,brain natriuretic peptide,New York cardiac function grade,6 minute walking test and general effect.2,resultThe two groups after treatment at signs and symptoms,brain natriuretic peptide,6-minute walk test and general efficacy has significant differences.3,conclusionXinShuaiⅠin patients with heart failure significantly improved clinical symptoms,improve clinical efficacy,improvement in plasma brain natriuretic peptide levels,6 minute walking test to improve the role,suggesting XinShuaiⅠhas better long-term efficacy.in patients with heart failure.Second,the part of animal experiments1.model and group methods:By Fletcher,act of SD rats with left main coronary artery ligation,sham-operated group, after thoracotomy,non-coronary artery ligation.Indoor farming,the law of the lighting,free eating and drinking water,rearing four weeks.Random number table,after the successful model rats were randomly divided into 4 groups,each 15,and the other set of normal rats 15 as blank control group and 15 of the sham-operated group,for a total of 6 groups.After the success of the beginning of model experiments.Specific sub-cases as follows:Normal control group(Con):do not build a normal rat model,daily irrigation 3ml distilled water for 4 weeks.Sham-operated group(Sha):distilled water daily irrigation 3ml,for 4 weeks. Model group(CHF):determined after modeling success,the daily irrigation of distilled water 3ml,for 4 weeks.Captopril group(Cap):determined after modeling success,the daily irrigation captopril 0.016g/Kg,for 4 weeks.XinShuaiⅠof low-dose group(XS1):determined after modeling success,the daily irrigation of XinShuaiⅠ12g crude drug / kg,for 4 weeks.XinShuaiⅠof high-dose group(XS2):determined after modeling success,the daily irrigation of XinShuaiⅠ36g crude drug / kg,for 4 weeks.Observation of animals in each group during the treatment appearance,movement,loss of appetite,and edema,cyanosis and other symptoms.Said daily feed and water consumption. Week that the body weight of rats.After 4 weeks,administration of each rat orbital venous blood 4ml for RIAand then proceed the determination of cardiac function and hemodynamic monitoring.To each rat was dissected,check integrity of the heart,after washing with normal saline add liquid nitrogen cans,preserved under test.2.experimental methodsExperimental rats and recorded the following experimental results:determination of hemodynamic and cardiopulmonary weight,determination of plasma renin activity(PRA), plasma angiotensinⅡ(AngⅡ),plasma aldosterone(ALD),A-type natriuretic peptide(ANP) and plasma endothelin(ET).Against the role of contraction of heart failure rats superior mesenteric artery by phenylephrine and detection of the extent of myocardial fibrosis.3.results(1) XinShuaiⅠon heart failure rats hemodynamicsCompared with model group,XinShuaiⅠof high-dose group and captopril group can increase heart failure in rats LVSP,dp / dt max(P＜0.01),significantly decreased LVEDP(P＜0.05～0.01),and XinShuaiⅠof high-dose group and the captopril group compared with no significant difference(P＞0.05).XinShuaiⅠof high-dose group and captopril group can t～dp / dt max decreased(P＜0.05～0.01),XinShuaiⅠmay granules stronger role in high-dose group(P＜0.05).XinShuaiⅠof low-dose group of heart failure in rats with heart failure LVSP significantly improve(P＜0.05),t～dp / dt max decreased significantly(P＜0.01).At the same time,the captopril group,XinShuaiⅠhigh and low dose groups of heart failure in rats with SAP were significantly higher(P＜0.05～0.01),XinShuaiⅠseems to particles of high-dose group of the strongest role.(2) XinShuaiⅠon heart failure rats in heart,lung impactCompared with model group,XinShuaiⅠof high-dose group and captopril group are able to increase left ventricular weight and LV / BW(P＜0.05～0.01),and XinShuaiⅠ high-dose group was significantly(P＜0.05).XinShuaiⅠof low-dose group and captopril group are able to inhibit the right ventricular hypertrophy(P＜0.01),XinShuaiⅠof low-dose group of particles at the same time can reduce the lung index(P＜0.05).(3) XinShuaiⅠon heart failure rats in renin - angiotensin - aldosterone system,atrial natriuretic peptide,endothelinRAAS is activated in rats with heart failure,compared with the normal group,PRA,AngⅡ,ALD levels was significantly enhance(P＜0.01).Of drug-treated group after treatment, PRA,AngⅡ,ALD levels were significantly decreased(P＜0.01),of which XinShuaiⅠof high-dose group of heart failure the most significant decline.The levels of plasma ANP in Heart failure rats,after treatment of XinShuaiⅠand captopril,the levels of ANP has been picked up,but without statistical significance.Heart failure rats plasma ET levels significantly increased(P＜0.01),after treatment of drug-treated group,plasma ET levels have declined on average(P＜0.05～0.01),of which XinShuaiⅠof high-dose group is most obvious.(4) XinShuaiⅠagainst the contraction of heart failure rats superior mesenteric artery by phenylephrineHeart failure rats superior mesenteric artery response to phenylephrine increased(P＜0.05), and XinShuaiⅠand captopril groups are clearly against the hcontraction of heart failure rats superior mesenteric artery by phenylephrine(P＜0.01).(5) Detection of the extent of myocardial fibrosis in heart failure rats The extent of myocardial fibrosis in XinShuaiⅠof high and low dose groups and the captopril group were all less than model group,the extent of myocardial fibrosis in the captopril group is less than the model group,higher than high-dose group.4.conclusionXinShuaiⅠcan improve hemodynamic parameters significantly in heart failure rats,improve in varying degrees on renin - angiotensin - aldosterone system,atrial natriuretic peptide, endothelin and other related indicators,of the total,the high-dose group is more as significant. In addition,XinShuaiⅠcan can reduce the extent of myocardial fibrosis更多还原