从气血相关和“通则不病”探讨冠心病微血管新生机理的实验研究

【作者】 李耀辉；

【导师】 姜良铎；

【作者基本信息】 北京中医药大学 ， 中医内科学， 2010， 博士

【摘要】 临床研究目的：探讨气血相关及“从通论治”、“通脉可以生脉”与冠心病微血管新生的关系。方法：回顾性收集导师门诊病例,对纳入病例的证候诊断采用1990年的中国中西医结合学会修订的冠心病中医辨证标准。提取的证候要素主要依据王永炎院士等所确定的29中证候要素为依据。对符合标准的111例医案依次录入Excel 2007表中,采用频数统计方法.结果：①,发生在39岁以下的胸痹患者仅占8.1%,在40岁～79岁之间占到88.2%；②,89%的胸痹患者兼有基础病变,57%患者兼有3种以上基础病变；③,胸痹患者主诉以胸闷、气短、胸部不适为主；④,患者的舌质以暗红舌、舌红为主,二者在所有病例的舌象里占到69.3%；⑤,薄白苔、黄腻苔、薄黄苔、白腻苔加在一起占77%；⑥,单一脉象以弦脉和滑脉为主(77.8%),复合脉象以弦滑脉、弦细脉为主(63%)；⑦,胸痹心痛的完整病机分解为单一证候因素,频率最高的有血瘀、气虚、肝旺、阴虚、肾虚、三焦不畅、气滞等7种；所有的病例的完整病机多由2个或者2个以上证候因素组成,以3个证候因素和4个证候因素组成的辩证证型为最多；⑧,药物使用频次在前16名的依次是：瓜蒌、枳壳实、郁金、赤白芍、丹参、旋复花、全蝎、黄芩、天麻、三七、熟大黄、麦冬、羚羊粉、柴胡、黄芪、葛根；⑨,以此组药物构成导师治疗冠心病的基本方药,适用于中老年冠心病患者属于气虚血瘀、肾虚肝旺证型者。结论：“从通论治”、“通脉即可以生脉”的思路不仅重视心脉痹阻、心气不足的局部问题,更着眼于人体的整体性而言,强调全身气机的通畅运行,“气为血帅”,气行则血行,这就是“通脉即可以生脉”的机理。导师治疗冠心病不仅仅局限于胸痹心痛气虚血瘀的基本病机,还同时从整体上把握患者的完整病机,强调五脏六腑的气机特别是三焦气机的通畅是治疗冠心病的前提。胸痹心痛不仅仅是心气不足、心脉痹阻的问题,也与其他脏腑气血密切相关,尤其对于具有一定内伤基础的中老年冠心病患者而言,其病机更具有复杂性。“从通论治”、“通脉即可以生脉”的观点具有临床意义。实验研究目的：主要从促血管新生角度探讨活血益气法治疗冠心病的作用机理。方法：通过构建大鼠急性心肌梗死模型,采用免疫组化染色和RT-PCR技术,从心梗大鼠梗塞边缘区心肌血管面密度、梗塞边缘区VEGF及其mRNA、bFGF及其mRNA的表达的角度,结合冠心病气虚血瘀的基本病机,观察活血法、益气法、活血益气法的干预作用。结果：实验研究包括四个部分。实验一,主要是成功建立心肌梗死的模型,造模后模型与假手术组大鼠术前术后心电图比较,假手术组大鼠手术前、术后心电图未见明显变化。模型组大鼠术后即刻心电图Ⅰ导、Ⅱ导ST段可见弓背抬高；肉眼观察：假手术组大鼠心脏体积正常,颜色鲜红,表面光滑,无任何斑点；模型组大鼠心脏体积明显变大,左心室部分有灰白色的室壁瘤；HE染色普通光镜观察,假手术组心肌细胞排列整齐,未见心肌细胞肥大现象；模型组部分心肌细胞核较假手术组明显增大,心肌纤维增粗,胞浆着色深。从而证明心梗模型是成功。实验二,用Ⅷ因子阳性染色免疫组化法检测活血益气方药对心肌梗死模型大鼠梗塞边缘区微血管密度的影响,结果假手术组、模型组、倍他乐克组、活血益气方及其拆方各组均可看到新生的微血管。假手术组微血管增生不明显,模型组可见少量微血管增生,倍他乐克组和活血益气方及活血方组可见较多增生的微血管。模型组与假手术组比较,有统计学差异(P∠0.01)；倍他乐克组、活血方组和活血益气方组与模型组比较,有统计学差异(P∠O.01)。实验三,通过免疫组化法检测活血益气方药对心肌梗死模型大鼠梗塞边缘区VEGF、bFGF的影响,结果假手术组、模型组、倍他乐克组、活血益气组、活血组、益气组都有bFGF的表达。假手术组bFGF的表达量最少,模型组有bFGF少量表达,气血组与倍他乐克组bFGF表达量最多。模型组与假手术组相比,具有统计学意义(P∠0.05)；气血组与倍他乐克组与模型组相比,具有统计学意义(P∠0.05)。益气组、活血组bFGF的表达量也明显增加,但与模型组无统计学意义。与模型组相比,气血组、益气组、活血组、西药组的VEGF的表达水平均有显著性差异,都可以使VEGF的表达上调,有统计学意义(P∠0.05)；气血组、西药组二者与活血组、益气组相比,在VEGF的表达水平上也有显著性差异,都较活血组、益气组的表达水平高,具有统计学意义(P∠0.05)；气血组与西药组相比,VEGF的表达水平更高,具有统计学意义(P∠0.05)；益气组和活血组在VEGF的表达水平上无显著性差异,二者之间不具有统计学意义；假手术组和模型组相比,二者之间有统计学意义(P∠0.05)。实验四,用RT-PCR技术检测活血益气方药对心肌梗死模型大鼠梗塞边缘区VEGFmRNA、bFGFmRNA表达的影响,结果假手术组VEGFmRNA的表达最少,气血组、活血组、模型组与之相比均具有统计学意义(P∠0.05)；活血益气组、活血组与模型组相比VEGFmRNA的表达显著提高,具有统计学意义。益气组VEGFmRNA的表达量和模型组相比无统计学意义；模型组、活血组与假手术组相比,bFGF mRNA表达量显著提高,具有统计学意义(P∠O.05)；模型组和活血组之间虽无统计学意义,但是活血组的bFGF mRNA表达量还是高于模型组；而益气组、活血益气组与模型组的bFGF mRNA表达量无统计学意义。结论：①,活血益气方药促使冠心病治疗性微血管新生的疗效确切,其理论依据是“通脉即可以生脉”：作为血管新生的物质基础,气血具有相关性,气血的通畅是微血管新生的前提条件；气血的通畅不仅包括胸痹心痛局部的问题,也包括全身气机的运行通畅,特别是“通行诸气”的三焦气机的通畅。②,活血益气方药促使冠心病微血管新生的机理是：活血益气方药能够持续上调促血管新生因子VEGF、bFGF基因与蛋白的表达,以及VEGF基因的表达,提高缺血心肌毛细血管密度,促进心肌侧支循环的形成。创新点：本文通过气血相关从“从通论治、通脉即可以生脉”角度探讨了冠心病治疗性微血管新生的理论与临床,具有临床研究的创新性；运用免疫组化方法和RT-PCR技术从气血相关探讨了活血益气法治疗冠心病微血管新生的机理,具有实验研究的新颖性。更多还原

【Abstract】 Clinical ResearchObjective:Study of therapeutic angiogenesis mechanism in coronary heart disease according to the relationship between qi and blood and according to "treatment of transporting qi and blood"Method:Based on the TCM four diagnostic methods, Information of 111 out-patient cases with coronary cardiopathic angina pectoris was collected from clinic of Professor Jiang Liang Duo, and was typed by extracting common factors, the information is processed by frequency-statistical method in Excel 2007 tabulation.Result:1,In 111 coronary heart disease casese,88.2% patients aged from 40-79 yeas old; 2,89% patients had other base lesions,57% patients even had 3 kind of other basic lesions.3, Chief complaint included chest tightness、short of breath、chest discomfort; 4, Primary tongue, including dull tongue、reddish tongue, accounted for 69.3%; 5, Thin white coating, yellow sticky coating, thin yellow coating and greasy coating accounted for 77%; 6, Mainly Single pulse inlcuded wiry pulse, slippery pulse, which accounted for 77.8%, while wiry-slippery and wiry-thin pulse accounted for 77.8% in mainly complex pulse.7,The most frequency elements of a single syndrome factor included blood stasis syndrome factor,Qi deficiency syndrome factor,syndrome factor of liver yang haperactivity, Yin asthenia syndrome factor, Qi stagnation syndrome factor, and the triple energizer Congestion syndrome factor; 8, Complete pathogenesis in all of 111 out-patient cases, wer made up of over two single syndrome factors, and most cases had three or four single syndrome factors.9,Based on syndrome differentiation and treatment. the most frequency basic Chinese medicine composed of:Gualou, Zhjiaoshi, Yujin, Chibaishao, Danshen, Xuanfuhua, Quanxie, Huangqin, Tianma, Sanqi, Shudahua, Maidong, Lingyangjiaofen, Chaihu, Huangqi, Gegen.10, The basic prescription is clinical applied for Qi deficiency and blood stasis syndrome, accompanied by syndrome factor of liver yang haperactivity.Conclusion:The method, bsaed on "treatment of transporting qi and blood "and "smooth ing meridian means meridian Regeneration", not only emphasizes on stagnation of heart blood, deficiency of heart Qi, but also streeses on concept of integrity, itemphasizes on Qi and blood ransporting easy and smooth in our body. normal flow of qi ensures normal circulation of blood, and it is the mechanism of "smoothing meridian means meridian Regeneration". my tutor emphasizes on complete pathogenesis of the patients, and emphasizes on the fluency of qi in five zang organs and the six fu-organs, especially streeses on the fluency of qi in the triple energizer. The method, "treatment of transporting qi and blood"and"smoothing meridian means meridian Regeneration", has its clinical significance.Experimental studyObjective:To investigate the mechanism of therapeutic angiogenesis mechanism in coronary heart disease by replenishing qi,and activating blood circulation.Method:After successfully established rats myocardial infarction model,I introduced immunohistochemistry staining methods and RT-PCR technique into experimental study to measure rats myocardial infarction size,MVD in infarct marginal zone, VEGF and VEGFmRNA in infarct marginal zone, bFGFand bFGFmRNA in infarct marginal zone, then.based on the basic pathogenesis of Qi deficiency and blood stasis syndrome in coronary heart disease, I observated different intervention effect of the three methods:activating blood circulation, replenishingqi,replenishing qi and activating blood circulation.Result:Experimental study had four parts.In experimental study 1, I mainly established rats myocardial infarction model successfully. Compared with the preoperative, ECG of rats in sham group had no change, whi le ECG of rats in myocardial infarction model had significant changes:ECG leadⅠ,Ⅱlead ST segment arched upward elevation abnormally. Under naked eye,Heart volume of rats in sham group were normal, and their heart color was red, and their heart surface was smoothly and had no spot. while Heart volume of rats in myocardial infarction model were significant larger,and there was gray aneurysm in left ventricular.After HE staining methods, under ordinary light microscope, myocardial cells of rats in sham group lined normally, and had no largement, while myocardial cells of rats in myocardial infarction model was significant larger,and their myocardial fiber thickenned significantly, and their cytoplasm color Deepened. these signes verified establishment of rats myocardial infarction model successfully.In experimental study 2, I measured MVD in rats infarct marginal zone throughⅧ factor immunohistochemistry staining methods, the groups, including rats in sham group, rats in myocardial infarction model, rats in Betaloc group, rats in activating blood circulation group, rats in replenishing qi group,rats in replenishing qi and activating blood circulation group, had neovascularization.however,rats in sham group had least few neovascularization,rats in myocardial infarction model had few neovascularization, the two had Significant difference (P<0.01); Compared with model group,rats in Betaloc group,rats in activating blood circulation group, rats in replenishing qi group,rats in replenishing qi and activating blood circulation group had more neovascularization, the result had Significant difference (P<0.01).Experimental study 3 concentrated on effect on expression of VEGF、bFGF in myocardial infarction model by medcine, which was made of replenishing qi and activating blood circulation, through immunohistochemistry staining methods. the groups, including rats in sham group,rats in myocardial infarction model,rats in Betaloc group,rats in activating blood circulation group, rats in replenishing qi group,rats in replenishing qi and activating blood circulation group, had expression of bFGF. however,rats in sham group had least few expression of bFGF,rats in Betaloc group and rats in replenishing qi and activating blood circulation group had the most expression of bFGF. Compared with sham group, modelgroup had more expression of bFGF, both had Significant difference (P <0.05); Compared with modelgroup, Betaloc group and replenishing qi and activating blood circulation group had more expression of bFGF,they had Significant difference (P< 0.05);Compared with Betaloc group,replenishing qi and activating blood circulation group had more expression of bFGF, both had Significant difference (P<0.05); Compared with modelgroup,replenishing qi group and activating blood circulation group had a little more expression of bFGF,however,they had no Significant difference.Compared with sham group,model group had more expression of VEGF, both had Significant difference (P<0.05); Compared with modelgroup, Betaloc group, replenishing qi and activating blood circulation group, replenishing qi group and activating blood circulation group had more expression of VEGF, they had Significant difference (P< 0.05); Compared with replenishing qi group and activating blood circulation group,Betaloc group replenishing qi and activating blood circulation group had more expression of VEGF, they had Significant difference (P<0.05); replenishing qi group and activating blood circulation group had no Significant difference.In experimental study 4, I investigated effect on expression of VEGFmRNA、bFGFmRNA in myocardial infarction model by replenishing qi and activating blood circulation medcine through RT-PCR technique. Compared with sham group, modelgroup, replenishing qi and activating blood circulation group, and ctivating blood circulation group had more expression of VEGFmRNA, they had Significant difference (P<0.05); Compared with model group, replenishing qi group and activating blood circulation group and ctivating blood circulation group had more expression of VEGFmRNA,they had Significant difference (P <0.05); replenishing qi group and model group had no Significant difference.Compared with sham group, ctivating blood circulation group and model group had more expression of FGFmRNA, they had Significant difference (P<0.05), whlie between ctivating blood circulation group and model group, there was no Significant difference. replenishing qi and activating blood circulation group replenishing qi group had no Significant difference compared with model group on expression of FGFmRNA.Conclusion:1, treatmen of coronary heart disease trough replenishing qi and activating blood circulation medcine has curative effect. The theoretical basis is the relationships among qi and blood and Treatment of transporting qi and blood, ie, "smoothing meridian means meridian regeneration",Qi and blood ransporting affluent not only means qi and blood in heart, but also means the fluency of qi in five zang organs and the six fu-organs, especially the fluency of qi in the triple energizer.2, the mechanism of therapeutic angiogenesis mechanism in coronary heart disease trough replenishing qi and activating blood circulation medicine is:replenishing qi and activating blood circulation medicine can improve expression of VEGF、bFGF,can improve expression of VEGFmRNA,can improve myocardial ischemia zone MVD, can promote conformation of myocardial collateral circulation.Innovation:According to the relationships between qi and blood and according to the view of "treatment of transporting qi and blood" and"smoothing meridian means meridian Regeneration", this artical investicated therapeutic angiogenesis mechanism in coronary heart disease by replenishing qi and activating blood circulation medicine it has clinical innovation;According to the relationship between qi and blood, this artical investicated therapeutic angiogenesis mechanism in coronary heart disease by replenishing qi and activating blood circulation medicine through immunohistochemistry staining methods and RT-PCR technique.更多还原