【作者】 刘美霞；

【导师】 张文高；

【作者基本信息】 广州中医药大学 ， 中西医结合临床， 2010， 博士

【摘要】 目的1.临床研究：探讨急性冠脉综合征(ACS)标实证与冠状动脉造影指标及炎症指标的相关性,为瘀毒病机探讨及解毒活血治疗方案的设计提供科学依据。2.实验研究：观察解毒活血中药配伍对载脂蛋白E基因敲除[ApoE(-／-)]小鼠腹腔巨噬细胞泡沫化的影响,探讨其机制。方法1.临床研究：搜集ACS患者50例,按照中医标实证辨证标准,分为痰浊证、血瘀证、气滞证、寒凝证、热毒证。每例患者均进行冠状动脉造影,记录冠脉病变支数、冠脉最大狭窄程度,并计算冠脉病变积分；检测患者炎症指标血清超敏C反应蛋白(hs-CRP)及肿瘤坏死因子(TNF)。将各标实证与冠脉造影指标、炎症指标进行相关性分析。2.实验研究：收集ApoE(-／-)小鼠腹腔巨噬细胞,分为空白组、解毒组(加入虎杖苷)、活血组(加入山楂提取物)、解毒活血配伍组(加入虎杖苷及山楂提取物)、洛伐他汀组(加入洛伐他汀)、罗格列酮组(加入罗格列酮)、模型组。除空白组外,其他各组均同时加入氧化型低密度脂蛋白(ox-LDL)及脂多糖(LPS)。各组在培养箱内共孵育(泡沫化)2天,电镜下观察48小时后空白组、模型组及解毒活血配伍组细胞内超微结构的变化；并分别观察0小时、24小时、48小时三个不同时相各组细胞内游离钙离子浓度的变化,总胆固醇、游离胆固醇及胆固醇酯的变化,过氧化物酶体增殖物激活受体γ(PPARγ)、三磷酸腺苷结合盒转运子Al (ABCAl)、白细胞分化抗原36配体(CD36)的mRNA表达,Toll样受体(TLR4)、核因子-KB(NF-KB)、肿瘤坏死因子-α(TNF-α)及白介素-1β(IL-1β)的表达。结果1.临床研究：ACS标实证中以血瘀证及热毒证最多,且血瘀证与热毒证冠脉病变程度及范围均较重,其病变积分明显高于痰浊证、气滞证及寒凝证；与其它证相比,血瘀证和热毒证的hs-CRP、TNF均明显增高；随着冠脉病变最大狭窄程度加重、病变支数增加,hs-CRP、TNF呈升高趋势；hs-CRP、TNF与冠脉病变积分均呈正相关。2.实验研究：解毒活血中药配伍能够减轻ox-LDL、LPS对细胞内部超微结构的损害；拮抗巨噬细胞内钙离子水平的增高；显著降低巨噬细胞内总胆固醇、游离胆固醇及胆固醇酯的浓度；提高巨噬细胞内PPARγ、ABCAl的mRNA表达,降低CD36的mRNA表达；减少TLR4、NF-KB、TNF-α及IL-1β的表达；其综合作用优于单纯解毒或活血中药,相当于或优于洛伐他汀及罗格列酮。结论1.临床研究：热毒证是ACS的另一重要标实证,瘀毒互结是ACS的主要病机；解毒活血可望成为ACS的重要治法。2.实验研究：解毒活血中药配伍能够通过保护细胞内超微结构,拮抗钙离子水平的增高,改善细胞内胆固醇及胆固醇酯转移,上调PPARy、ABCAl的mRNA表达,下调CD36的mRNA表达,抑制炎症因子分泌等途径干预巨噬细胞泡沫化过程,延缓动脉粥样硬化的发生与发展。更多还原

【Abstract】 Objective1.The clinical research:To discuss the correlation of sthenia syndrome of acute coronary syndrome (ACS) with coronary arteriongraphy and inflammation index, and to provide scientific evidence for pathogenesis of blood stasis and pyretic toxicity and treatment of detoxication and promoting blood flow on ACS.2. The empirical study:To observe the effect of the compatibility of detoxication and promoting blood flow on the peritoneal macrophage foaming of apolipoprotein E gene knock out[ApoE(-/-)] mice, and to discuss its mechanism.Methods1. The clinical research:Fifty patients of ACS were divided in the syndrome of phlegm, the syndrome of blood stasis, the syndrome of stagnation of QI, the syndrome of cold coagulation and the syndrome of pyretic toxicity, according to the differentiation of symptoms and signs standard of chinese medical science sthenia syndrome. Everyone was given coronary arteriongraphy, recorded numbers of coronary artery process and greatest narrow degree of coronary artery, and calculated scores of coronary artery process. Everyone was detected the inflammatory indexes such as highsensitivity C reactive protein(hs-CRP) and tumour necrosis factor(TNF). To analyze the correlation of all sthenia syndromes with coronary arteriongraphy and inflammatory indexes.2. The empirical study:The peritoneal macrophage of ApoE(-/-) mice were divided in seven groups:blank group, detoxication group (add polydatin), promoting blood flow group(add hawthorn extractive), detoxication and promoting blood flow group(add polydatin and hawthorn extractive), lovastatin group(add lovastatin), rosiglitazone group(add rosiglitazone), model group. Except for blank group, other groups were added in oxidized-LDL (ox-LDL) and lipopolysaccharide (LPS).All groups were incubated two days in incubator. To observe the ultrastructural changes in cells of the blank group, model group and detoxication and promoting blood flow group with electron microscope after 48 hours. To observe the changes of intracellular calcium concentration, the changes of intracellular total cholesterol, free cholesterol and cholesteryl esters, the mRNA express of intracellular peroxisome proliferators-activated receptor gamma (PPARγ), ATP-binding cassette transporter Al (ABCA1), cluster of differentiation antigen 36 (CD36), toll-like receptor4 (TLR4), neuclear factor kappa B(NF-κB), tumor necrosis factor-α(TNF-α) and interleukin-1β(IL-1β) in all groups after 0 hour,24 hours and 48 hours respectively.Results1. The clinical research:The syndrome of blood stasis and the syndrome of pyretic toxicity were more than other sthenia syndromes of ACS, their coronary artery process and scope were severer, and their scores of coronary artery process were obviously higher than the syndrome of phlegm, the syndrome of stagnation of QI and the syndrome of cold coagulation. Compared with other sthenia syndromes, the hs-CRP and the TNF of the syndrome of blood stasis and the syndrome of pyretic toxicity all raised up obviously. The hs-CRP and the TNF had a tendency of raise along with the increase of coronary artery process greatest narrow degree and process numbers. The hs-CRP and the TNF had a positive correlation with the scores of coronary artery process.2. The empirical study:The compatibility of detoxication and promoting blood flow could relieve the damage of ox-LDL and LPS on intra-cellular ultrastructure, rivalry the levels of calciumion in macrophage, degrade the concentration of total cholesterol, free cholesterol and cholesteryl esters obviously, elevate the express of PPARγmRNA and ABCA1mRNA, degrade the express of CD36mRNA and decrease the express of TLR4, NF-κB, TNF-αand IL-1β. Its synthetic effect was superior to the simple detoxication medicine or the simple promoting blood flow medicine, and was equal to or superior to the lovastatin and the rosiglitazone.Conclusion1. The clinical research:The syndrome of pyretic toxicity is another significant sthenia syndrome of ACS, the combination of blood stasis and pyretic toxicity is its major pathogenesis, the detoxication and promoting blood flow is hope to become its important treament.2.The empirical study: The compatibility of detoxication and promoting blood flow can obviously interfere in macrophage foaming and delay generation and development of atherosclerosis, which may be because it can protect the intra-cellular ultrastructure, rivalry the rise of calciumion, improve the outflow of cholesterol and cholesterol esters in macrophage, up-regulate the express of PPARymRNA and ABCA1mRNA, down-regulate the express of CD36mRNA and inhibt the secretion of inflammatory factor.更多还原