【作者】 徐伟；

【导师】 陈可冀； 王承龙；

【作者基本信息】 北京中医药大学 ， 中西医结合临床， 2010， 博士

【摘要】 急性冠脉综合征(ACS)是冠心病中的危重症,其发病率呈上升趋势,具有很高的死亡率,为社会和经济发展带来沉重的负担。现代医学对本病的诊断、治疗取得了较大进展,然而ACS的治疗成本日益增加,死亡率、复发率仍然较高。本研究结合传统中医理论以及现代医学研究成果,对ACS与稳定性冠心病(SCHD)的临床症状、证候及现代医学检测、检查结果规律性做一些有价值的探讨。其中第一部分为文献研究,对目前冠心病的辨证规律研究进展以及急性冠脉综合征与炎症因子的变化研究进展进行总结；第二部分为临床研究,通过多中心的临床试验,对ACS的“瘀毒”表征进行分析,为ACS中医“瘀毒”病因病机的探索以及针对性的预防、治疗奠定基础。目的假设急性冠脉综合征(ACS)患者(病例组)为中医“瘀毒”证组,稳定性冠心病患者(对照组)作为非“瘀毒”证组,比较两组患者在宏观指标及微观指标的差异,总结出ACS“瘀毒”表征,为中医“瘀毒”病因学提供依据和冠心病中医“瘀毒”证的早期识别、预防、干预奠定基础。方法本研究自2008年1月1日至2009年12月30日,运用多中心、横断面的现代临床流行病学现场调查研究方法,依托于国家重点基础研究项目(973计划)一心血管血栓性疾病“瘀毒”病因学的系统研究及国家“十一五”国家科技支撑计划重大项目—中西医综合干预介入后急性冠脉综合征的临床研究,对中国中医科学院西苑医院、卫生部中日友好医院、首都医科大学附属安贞医院、首都医科大学附属同仁医院、北京军区总医院、上海复旦大学附属中山医院六家大型综合性三甲医院冠心病患者进行现场调查研究,其中ACS患者230例(包括不稳定型心绞痛111例,占48.0%,非ST段抬高心肌梗死6例,占3.0%,ST段抬高心肌梗死113例,占49.0%),稳定性冠心病患者510例(包括稳定型心绞痛患者306例,占60.0%；无心绞痛症状患者204例,占40.0%)。调查内容包括两组患者病史、症状、体征、中医主症、中医兼症、血瘀证、舌象、脉象、实验室检查、冠状动脉造影等。利用中国中医科学院西苑医院冠心病数据管理系统建立统一数据库,采用描述性分析、卡方检验、Logistic回归分析、主成分分析等统计学方法进行分析。并对ACS组患者进行亚组分析,分别将不稳定性心绞痛与急性心肌梗死和稳定性冠心病以性别、年龄、糖尿病史、心梗病史住院为匹配因素,按1：2比例匹配,结合临床实践,提取中医“瘀毒”表征的宏观指标及微观指标。结果1根据本试验研究结果,可以初步确定ACS表现为本虚标实,以实证为主。疾病特点为发病急,进展快,病情重。2ACS患者“瘀毒”主症为胸痛、胸闷发作突然及程度的加重,包括发作次数多,持续时间长,心绞痛计分、中医主症计分、血瘀证计分均较高。伴随兼症头痛、口苦、口臭、心悸等,舌脉特征性表现为舌质暗红,舌下络脉粗胀,色紫,脉象细弱或细涩。而舌苔腻,冠状动脉造影表现为三支病变可能是急性心肌梗死的瘀毒表征。3急性冠脉综合征兼症多表现为心肾阳虚证症候群(畏寒、气短、心悸、乏力、头晕、浮肿、耳鸣或耳聋伴口臭)。而稳定性冠心病主要表现为心脾阳虚证症候群(畏寒、肢凉、气短、自汗、乏力、心悸、恶心或呕吐、腹胀伴口臭)。由脾阳虚证到肾阳虚证,可能是反映冠心病患者病情加重,以及“瘀”和“瘀毒”区别的表征之一。4 Logistic回归分析发现吸烟、糖尿病史与“瘀毒”证呈正相关,比值比分别为2.642、1.792；实验室微观表征为白细胞及中性粒细胞百分比明显升高,相应淋巴细胞百分比下降。红细胞计数及血红蛋白含量、红细胞压积偏低,血小板体积分布宽度较低,甘油三酯偏低,心肌坏死标记物升高。炎症因子hsCRP明显增高。冠状动脉造影可能较多表现为三支病变。结论本研究找出了ACS的相关危险因素及“瘀毒”表征,提取出“瘀毒”表征的宏观指标及微观指标。为ACS中医“瘀毒”病因学提供科学依据,将为下一步冠心病“瘀毒”证的早期识别、预防、干预研究奠定基础。更多还原

【Abstract】 Acute coronary syndrome (ACS) is a severe and critical disease in coronary heart diease (CHD), whose incidence is rising. With high mortality and disablity rate, it has brought a heavy burden for the social development and family harmony. Modern medical diagnosis and treatment of the disease has made substantial progress; However, ACS treatment costs more and mortality as well as recurrence rates remains high. This study is based on traditional Chinese medicine theory and modern medical research, discussing ACS incidence and etiological factors. The first part of this study is ACS-related reference review exploring the current regularity of Chinese medicine syndrome and objective assessment indexes for progress in coronary heart disease and summing up the relationship between inflammatory factors and clinical syndrome.The second part is about large and multi-centeral clinical trials analyzing ACS’s "Toxin-stasis" characteristics and exploring pathogenesis of Chinese "Toxin-stasis" for further prevention and treatment research.Objective:The ACS patients (case group) were considered as Chinese medicine "Toxin-stasis" syndrome group, The stable coronary heart diease(SCHD) patients (control group) were considered as non-"Toxin-stasis" syndrome group, two groups were compared difference at the macro and micro indexes, for summing up the ACS Chinese "Toxin-stasis" characteristics, providing the basis for etiology of Chinese medicine "Toxin-stasis", laying a foundation for early prevention,identification, intervention of "Toxin-stasis".Methods:This study is execute since January 1,2008 to December 30,2009, and is a multi-center, cross-sectional study of modern clinical epidemiology, including Xiyuan Hospital of China Academy of Traditional Chinese Medicine, China-Japan Friendship Hospital, Anzhen Hospital, Tongren Hospital affiliated to Capital Medical University, Beijing Military General Hospital, Zhongshan Hospital affliated to Shanghai Fudan University.All the CHD patients,including 230 cases of ACS patients,510 cases of patients with stable coronary heart disease were investigated. The questionnaire included two sets of medical history, symptoms, signs, main symptoms of chinese, Subcardinal synptoms of chinese medicine, blood stasis syndrome, tongue, pulse, laboratory tests, coronary angiography,etc. We Established a database, using descriptive analysis, chi-square test, Logistic regression analysis, principal component analysis, multivariate analysis of statistical methods. combinating clinical practice of Chinese medicine extracted "Toxin-stasis" characteristics of macro indicators and micro indicators. Results:According to the results of this study, the initial results of coronary heart disease "Toxin-stasis" can be deficiency of Ben and repletion of Biao. Disease characterized by onset and fast progress; main symptoms were chest pain, chest tightness, increased the occurrence and extent, including the more often attacks, lasted longer, high angina scoring,high Chinese main symptoms scoring, and high blood stasis scoring. And patients with headaches, mouth bitter, bad breath, difficulty falling asleep, the performance of the tongue is dark red tongue and pulse, rough sublingual up, color purple, thin or weak astringent pulse. Merge main blood stasis syndrome, and patients whose symptoms were kidney yang deficiency syndrome (chills, shortness of breath, dizziness, edema, fatigue, tinnitus or deafness, heart palpitations, bad breath). The stability of the main coronary artery disease showed spleen yang deficiency syndrome (chills, cold limbs, shortness of breath, fatigue, palpitations, nausea or vomiting, spontaneous sweating, bloating, bad breath). Deficiency of the spleen yang deficiency syndrome to the conversion of the kidney yang deficiency patients with coronary heart disease is increasing, the condition from the "stasis" to "Toxin" change with characteristics.Logistic regression analysis of smoking, history of diabetes was positively associated with ACS onset, odds ratio was 2.642,1.792; laboratory microscopic characteristics showed the percentage of leukocytes and neutrophils significantly increased, the corresponding percentage of lymphocytes decreased. Red blood cell count and hemoglobin, low hematocrit, low platelet volume distribution width.low triglycerides,elevated serum alanine aminotransferase, hsCRP was significantly higher. Coronary lesions are mainly three more.Conclusion:Through the use of modern clinical epidemiology and statistical analysis to identify the risk factors associated with ACS and the Chinese "Toxin-stasis" characteristics, extracted Chinese medicine "Toxin-stasis" characteristics of macro indicators and micro indicators. providing the scientific basis for Chinese medicine for the ACS "Toxin-stasis" etiology and early identification, prevention, intervention of CHD "Toxin-stasis".更多还原