王永炎学术思想与经验总结及养阴熄风复脉汤治疗室早的临床研究

发布时间：2018-05-31 11:09

本文选题：王永炎 + 学术思想　；参考：《中国中医科学院》2017年博士论文

【摘要】：王永炎教授是我国著名的中医内科学、神经内科学专家,主要以运用中医手段预防和诊治心脑血管疾病为研究方向,先后承担了国家的多项重大课题,作为中医内科的学术带头人,对中风、痴呆进行了更深入、更系统化地临床与基础研究,使我国的中医药脑病防治水平有了更大的提升。我有幸作为王永炎教授的学术继承人跟师学习,对王永炎教授的学术思想尤其是其防治心血管疾病的经验进行了总结。本论文主要从以下四个方面对王永炎教授的学术思想以及临证经验进行总结:1.王永炎教授学术渊源;2.王永炎教授学术思想;3.王永炎教授诊治心血管病经验整理与总结;4.养阴熄风复脉汤治疗心阴不足、风动心络证室性早搏的临床研究。1第一部分:探究王永炎教授的学术渊源。王永炎教授出生于中医世家,幼承家训,师从于中医名家董建华老师,学术思想深得其真传,继承了董先生许多宝贵经验,并擅于发展创新,又熟读经典,勤于临证,从医数十年,积累了丰富的学术经验,不仅在以中风病为主的中医脑病理论和临床方面形成了自己的主要学术方向,并且在中医药标准化规范化、方剂组分配伍、临床评价、中药资源、临床中药学等方面培养了大量的人才。2第二部分:挖掘王永炎教授的学术思想。王永炎教授创立了较为完整的中风病的中医诊疗体系,其中首推的便是“证候规范化”研究。导师多年来着力于中风病的诊疗发展,制定创立了“中风病中医诊断、疗效评定标准”,其中明确提出了中风病的名称、病类以及证类的诊断标准、疗效判定标准和其相应的治则治法,使中风病的临床诊疗更加规范和系统化,为后来的众多学者提供了清晰的临床诊疗思路及易行有效的中医药治疗方法,更是对我国临床其他各科建立中医药的规范化系统化诊疗体系起到了一定启示及模范带头作用。王永炎教授初次对病络的涵义给出了明确定义:病络是络脉的病理过程和病机环节,是病证产生的根源。强调通过深入分析病络的发生机制,对寻求其共同的病机、制定治法方药、评估预后均具有重要的意义。在此基础上,发展创新,将其理论与实践结合,用于心血管病的治疗,提出心阴不足、风动心络为室性早搏的病机之一,在临床上根据本病的基本病机形成治疗本病的经验方:养阴熄风复脉汤。3第三部分:王永炎教授诊治心血管病经验整理与总结。本部分通过重点选取心血管病,包括高血压、冠心病、房颤、室性早搏,系统整理分析王永炎教授防治此类心血管疾病的临床经验和学术思想,以期为临床医师运用中医药预防和治诊心血管疾病提供一定的学术经验。高血压:王永炎教授认为高血压病的治疗应注重五脏一体,脏腑并重,其主要病因为:情志失调、饮食失节、内伤虚损,主要的发病机理为:早期多标实,如肝阳上亢、瘀血内停、外感风邪等;中期由于肾水不足,肝阳上亢,尤其是年迈精衰者,往往转化为肾精亏虚或气血不足之证,病机复杂,病情较重,变证丛生。辨证要点:西医辨病与中医辨证相结合,辨病是前提,辨证是核心,强调辨证论治。冠心病:王永炎教授认为冠心病总病机为“阳微阴弦”,病位在心及心络。其发病机理本虚标实,其中,本为气、血、阴、阳的虚损,标为痰、瘀、风冷、毒热,中医治疗总原则为:急则治其标,缓则治其本。强调在冠心病的诊治中应遵循“五脏六腑整体调节”,治疗上分清疾病的轻重缓急,分证论治,标本兼顾。同时指出,冠心病的预防应放在首要位置,中医药应当发挥其应有的优势,注重针药并施。房颤:在房颤的治疗中,王永炎教授在多年的临证中,总结出本病常见的方证及主治规律。总结发现炙甘草汤、桂枝加龙骨牡蛎汤、温胆汤等为主要方证。导师认为肾虚是导致本病的重要病机,临证时强调补肾。室性早搏:王永炎教授认为“心阴不足,风动心络”是阴虚证室性早搏的基本病机,指出风邪致病具有起病急而变化快的特性,而心悸之“悸动”、“心中突兀不宁”、“时轻时重”、“时发时止”等症类似于“风邪”为病的表现。在治疗上也体现了“以风治风”的思想,风类药质地轻清,可起到疏解宣透的作用,特点多为辛、散、窜、透、动等,一方面能发散祛邪、化湿、祛痰;另一方面其仍可发散开郁、温通走窜、滋养血脉、行气化瘀。养阴熄风复脉汤:王永炎教授在多年临证实践中,重视风邪在本病发病中的作用,强调风药止悸对提高室性早搏阴虚证疗效尤其重要。认为“心阴不足,风动心络”是阴虚证室性早搏的基本病机,并在临床上根据本病的基本病机形成治疗本病的经验方:养阴熄风复脉汤。药物组成为:北沙参、玄参、丹参、黄连、麸炒僵蚕、蝉蜕、全虫、生龙骨、生牡蛎、酸枣仁、甘松等。方中北沙参、玄参二者相伍,养阴润燥、滋阴降火、培元固本而共为君药;僵蚕祛风定惊、化痰散结,蝉蜕疏散风热、透邪外出,全虫走窜,搜风通络、攻毒散结,三药相合,搜风通络而共为臣药;丹参活血化瘀、祛瘀生新,黄连苦寒,清热解毒,生龙牡潜敛心神、安神定志,酸枣仁酸甘收敛,伍龙牡而共奏养心安神之效,五药相合,兼顾标实,配合君臣以竟佐助之功;甘松味辛,其气芳香,开郁醒脾,引导方中药物直到病所,为使药。诸药相合,标本兼顾,完切病机,而共奏养阴熄风、安神复脉之功。4第四部分:养阴熄风复脉汤治疗心阴不足风动心络证室早的临床研究。研究目的:观察养阴熄风复脉汤治疗心阴不足风动心络证室早的临床疗效。研究方法:使用随机对照设计方法,将符合纳入标准的室性早搏(心阴不足、风动心络证)患者随机分为中药治疗组和西药对照组,治疗组与对照组各纳入70例。中药治疗组给予“养阴熄风复脉汤”加减治疗,西药对照组给予美托洛尔25mg,2/日治疗,疗程均为28±2天。比较两组患者治疗前、后的临床疗效、中医证候积分、24h动态心电图室性早搏次数及心率变异性的变化差异。研究结果:入组的受试者中,治疗组脱落1例,对照组脱落2例。1.中医证候疗效:两组患者经治疗后,①中医证候总疗效分别为:治疗组89.9%,对照组72.1%,治疗组明显优于对照组,差异具有统计学意义(P0.05);②中医证候总积分均有所减少,两组治疗前后自身比较,差异均具有统计学意义(P0.05);治疗后组间比较,治疗组明显优于对照组,差异具有统计学意义(P0.05);③中医单项症状积分均有所改善,其中,心悸、易惊善恐、气短乏力、心烦不安、失眠症状的改善,治疗组明显优于对照组,差异具有统计学意义(P0.05)。2.室性早搏次数疗效:两组患者经治疗后,24h动态心电图室性早搏次数均有所减少,两组治疗前后自身比较,差异均具有统计学意义(P0.05),组间比较,差异不具有统计学意义(P0.05);两组24h动态心电图有效率分别为,治疗组73.9%,对照组67.6%,组间比较,差异不具有统计学意义(P0.05)。3.心率变异性HRV的影响:主要观察指标有SDNN、SDANN、PNN50、RMSSD,两组患者治疗前后自身对比,治疗后四项指标均有所升高,差异均具有统计学意义(P0.05);治疗后组间比较,其中,SDNN、SDANN、RMSSD的变化,治疗组优于对照组,差异具有统计学意义(P0.05)。研究结论:1.本研究表明养阴熄风复脉汤能明显改善心阴不足、风动心络证室性早搏患者的临床症状及体征,间接佐证了心阴不足、风动心络是室性早搏的病机之一。2.养阴熄风复脉汤可减少患者动态心电图的室性早搏总数,通过其对心室变异率各项指标的影响,考虑室性早搏的发生可能与患者的交感神经兴奋有关,本方可能通过抑制交感神经活性,提高迷走神经张力,改善自主神经功能,从而有效缓解患者症状。3.养阴熄风复脉汤对室性早搏患者最慢心率变化及肝肾功能均无明显影响,无毒副作用,具有良好的安全性。本论文的创新点:1.系统归纳、总结王永炎教授治疗心血管疾病的学术思想及临床经验。2.首次提出“心阴不足,风动心络”是阴虚证室性早搏的基本病机,立养阴熄风复脉法,并在临床上根据本病的基本病机形成治疗本病的经验方:养阴熄风复脉汤。3.进一步验证王永炎教授经验方养阴熄风复脉汤加减治疗室性早搏的临床疗效及安全性,探讨其可能的作用机制,为中医药治疗室性早搏提供新的治疗方法和研究思路。
[Abstract]:Professor Wang Yongyan is a famous expert in internal medicine and neurology in China. It mainly takes the use of traditional Chinese medicine to prevent and treat cardiovascular and cerebrovascular diseases as the research direction. It has undertaken a number of major issues in the country. As the academic leader of the medical department of traditional Chinese medicine, it has carried out a deeper, more systematic clinical and basic research on stroke and dementia. In order to improve the level of cerebral disease prevention and cure of Chinese medicine, I have been lucky to learn from Professor Wang Yongyan's academic successor and teacher, and summarize the academic thought of Professor Wang Yongyan, especially his experience in preventing and controlling cardiovascular disease. This paper mainly discusses the academic thought and the experience of Professor Wang Yongyan from the following four aspects. Summary: 1. professor Wang Yongyan academic origin; 2. professor Wang Yongyan academic thought; 3. professor Wang Yongyan's diagnosis and treatment of cardiovascular disease experience collation and summary; 4. Yangyin Xifeng complex pulse soup treatment of yin deficiency, the clinical study of ventricular premature beat of wind and cardio collateral syndrome: Part 1: To explore the academic origin of Professor Wang Yong Yan. Professor Wang Yongyan was born in traditional Chinese medicine. Professor Wang Yongyan was born in traditional Chinese Medicine The family, the family training, the family training, the teacher from the famous Chinese traditional Chinese medicine Dong Jianhua, has a profound academic thought, inherits many valuable experiences of Mr. Dong, and is good at developing and innovating. He is also familiar with the classics. He has accumulated rich academic experience for decades, and has formed himself not only in the theory and clinical aspects of Chinese traditional Chinese medicine, but also on the theory and clinical aspects of Chinese traditional Chinese medicine. The main academic direction, and in the standardization of traditional Chinese medicine, prescription components and compatibility, clinical evaluation, traditional Chinese medicine resources, clinical pharmacy, and other aspects of training the second parts of.2: to excavate professor Wang Yongyan's academic ideas. Professor Wang Yongyan established a more complete system of TCM diagnosis and treatment of stroke, the first of which is " For years, the tutor focused on the development of diagnosis and treatment of apoplexy, established the establishment of a "TCM diagnosis of stroke, the standard of evaluation of curative effect", which explicitly proposed the name of the stroke, the diagnosis standard of the disease and the syndromes, the criterion of the curative effect and the corresponding treatment method, so that the clinical diagnosis and treatment of the stroke are more standardized and more standardized. Systematization has provided a clear idea of clinical diagnosis and treatment for many later scholars and effective treatment methods of traditional Chinese medicine. It also plays a certain inspiration and exemplary role in standardizing and systematized diagnosis and treatment system of Chinese medicine in other departments of our country. Professor Wang Yongyan gave a clear definition of the meaning of disease collaterals for the first time: disease Collaterals are the pathological process and pathogenesis of the collaterals, which are the root causes of the disease. It is emphasized that through the in-depth analysis of the pathogenesis of the disease and collaterals, it is of great significance to seek their common pathogenesis, formulate prescription drugs and evaluate the prognosis. Foot, wind dynamic heart and collaterals is one of the pathogenesis of ventricular premature beat. According to the basic pathogenesis of this disease, according to the basic pathogenesis of this disease, third parts of the treatment of this disease: Yin Yangfeng Fu Mai Decoction.3: Professor Wang Yongyan's experience in the diagnosis and treatment of cardiovascular diseases. This part focuses on cardiovascular disease, including hypertension, coronary heart disease, atrial fibrillation, ventricular premature beat, and system The clinical experience and academic thoughts of Professor Wang Yongyan in prevention and treatment of such cardiovascular diseases are analyzed and analyzed in order to provide a certain academic experience for clinicians to use traditional Chinese medicine to prevent and treat cardiovascular diseases. Hypertension: Professor Wang Yongyan believes that the treatment of hypertension should pay attention to the integration of the five Zang organs and the viscera, whose main disease is because of the loss of emotion. The main pathogenesis is: early multi - scale, such as liver yang hyperactivity, stagnation of blood stasis, exogenous wind evil and so on; in the middle period, the deficiency of kidney water, hyperactivity of liver Yang, especially the aged and senile, often converted to deficiency of kidney essence or deficiency of Qi and blood, the pathogenesis is complex, the condition is heavier, and the syndrome is clustered. Differentiation points of Western medicine: differentiation of disease and middle syndrome differentiation in Western Medicine Medical syndrome differentiation is the premise, differentiation is the premise, syndrome differentiation is the core, emphasis on syndrome differentiation and treatment. Coronary heart disease: Professor Wang Yongyan thinks that the total disease machine of coronary heart disease is "Yang micro Yin chord", the disease position is in the heart and heart collateral. The pathogenesis of the disease is true, which is the deficiency of Qi, blood, yin and Yang, the standard is phlegm, blood stasis, wind cold, toxic heat, the general principle of TCM treatment is to cure its standard by urgent rule, In the diagnosis and treatment of coronary heart disease, we should follow the "overall regulation of the five viscera and six organs" in the diagnosis and treatment of coronary heart disease. The treatment should distinguish the urgency of the disease, the syndrome differentiation and treatment and the consideration of the specimen. At the same time, it is pointed out that the prevention of coronary heart disease should be put in the first place, the traditional Chinese medicine should give full play to its due advantages, pay attention to the acupuncture and the application of the atrial fibrillation: in the treatment of atrial fibrillation, Wang Yongyan The professor summed up the common syndromes and rule of treatment of the disease in many years. It was found that the decoction of licorice, Guizhi, dragon bone and oyster soup, and Wendan soup were the main syndromes. The tutor thought that kidney deficiency was an important pathogenesis of this disease. The basic pathogenesis of ventricular premature beat indicates that the pathogenic pathogenic wind is characterized by rapid onset and rapid change, and the "throbbing" of palpitations, "sudden and unpleasant" in the heart, "time light weight", "time of hair time" are similar to the manifestation of "wind evil" for the disease. In the treatment, the idea of "wind treatment with wind" is also reflected, and the texture of wind like medicine is light and clear. On the one hand, it can diverge and dispel evil spirits, change dampness and dispel phlegm, on the other hand, it can still be diverged and dispel phlegm. On the other hand, it can be diverged and stagnated, nourishing blood circulation, nourishing blood stasis and removing blood stasis. In the practice of years, Professor Wang Yongyan attaches great importance to the effect of wind evil in the disease, and emphasizes the improvement of wind palpitation. The effect of the ventricular premature beat Yin deficiency syndrome is especially important. It is considered that "heart Yin deficiency, wind moving heart and blood" is the basic pathogenesis of premature ventricular beat of yin deficiency syndrome. According to the basic pathogenesis of this disease, it forms the experience of treating the disease according to the basic pathogenesis of this disease: Nourishing Yin and extinguishing the wind complex pulse soup. Oysters, Zizyphus jujube kernel, Gansu pine and so on. In the north and the north of Radix sastiais and Radix sasphanus, the two groups are compatible, nourishing yin and moistening dryness, nourishing yin and reducing fire, and making a total of monarch medicine; the silkworm dispelling wind and dispelling the wind, dispersing the wind, dispersing the wind and heat, passing the whole worm, searching the wind and dredging the collaterals, combining the three drugs and collecting the wind and collaterals, and removing blood stasis, removing stasis Sheng Xin, Huanglian Bitter cold, heat and detoxification, living dragon and hide the heart, calm the spirit, sour jujube benevolence and astringent, wu long and sour sweet and sour, Wu Long Mu together play the effect of heart and mind, five drugs coincide, give consideration to the subject matter, cooperate with the gentleman and minister to help it. The fourth part of nourishing yin and extinguishing the wind and restoring pulse work: the fourth part: the clinical study of Yangyin Xifeng Fu Mai Decoction in the treatment of Xinyin insufficiency wind dynamic heart and collateral syndrome. Objective: To observe the clinical effect of Yangyin Xifeng Fu Mai Decoction in the treatment of Xinyin insufficiency wind dynamic heart and collateral syndrome. The patients were randomly divided into the Chinese medicine treatment group and the western medicine control group. The treatment group and the control group were included in 70 cases. The Chinese medicine treatment group was given the treatment of "Yangyin quifeng Fu Mai Decoction", the western medicine control group was given metoprolol 25mg, 2/ day treatment, the course of treatment was 28 + 2 days. The clinical curative effect of the two groups before and after treatment was compared. Medical syndrome score, 24h dynamic electrocardiogram room sex early beat times and heart rate variability of variation. Results: in the group of subjects, the treatment group dropped 1 cases, the control group shedding 2 cases of.1. TCM syndrome effect: the two groups of patients after treatment, the total effect of TCM syndrome was 89.9%, the control group 72.1%, the treatment group was obviously better than the control group. Group, the difference was statistically significant (P0.05); the total scores of TCM syndromes were reduced, and the difference between the two groups before and after treatment was statistically significant (P0.05); the treatment group was significantly better than the control group after treatment, and the difference was statistically significant (P0.05); (3) the symptom scores of Chinese medicine were improved, palpitation, easy to be surprised. Good fear, shortness of breath, upset, insomnia symptoms improved, the treatment group was significantly better than the control group, the difference was statistically significant (P0.05).2. ventricular premature beat frequency effect: two groups of patients after treatment, the number of 24h dynamic electrocardiogram room sexual premature beat decreased, the two groups before and after treatment, the difference was statistically significant (P0.05). The difference was not statistically significant (P0.05); the two groups of 24h dynamic electrocardiogram were effective, 73.9% and 67.6% in the control group. The difference was not statistically significant (P0.05).3. heart rate variability HRV: the main observation indexes were SDNN, SDANN, PNN50, RMSSD, two groups of patients were compared before and after treatment, and four items after treatment. The difference was statistically significant (P0.05), and the changes of SDNN, SDANN and RMSSD after treatment, the treatment group was better than the control group, the difference was statistically significant (P0.05). The 1. studies showed that Yangyin Xifeng Fu Mai decoction could obviously improve the insufficiency of the heart and Yin, and the clinical symptoms of the patients with ventricular premature beat of the wind and the heart and the collateral syndrome. The form and sign indirectly confirm the insufficiency of the heart Yin, the wind moving heart and the collaterals is one of the pathogenesis of the ventricular premature beat..2. nourishing yin and extinguishing the pulse soup can reduce the total number of ventricular premature beat of the patient's dynamic electrocardiogram, and the occurrence of ventricular premature beat may be related to the sympathetic excitement of the patient. Making sympathetic nerve activity, improving vagus nerve tension, improving autonomic nerve function, thus effectively relieving the symptom.3. nourishing yin and extinguishing the wind complex pulse soup on the most slow heart rate change and liver and kidney function of patients with ventricular premature beat, non toxic side effect and good safety. The innovation of this paper: 1. systematic induction and summary of Professor Wang Yongyan The academic thought and clinical experience for the treatment of cardiovascular disease.2. first proposed that "the insufficiency of heart Yin, the wind and the heart and the collaterals" is the basic pathogenesis of the premature ventricular beat of yin deficiency syndrome, and the method of nourishing yin and extinguishing the wind to recover the pulse, and to form the experience in the treatment of the disease according to the basic pathogenesis of this disease in clinic: the nourishing Yin extinguishing vein soup.3. further verifies professor Wang Yongyan's experience. The clinical efficacy and safety of Yangyin Xifeng Fu Mai Decoction in the treatment of sexual premature beat in therapeutic room, the possible mechanism of action is discussed, and new treatment methods and research ideas are provided for the traditional Chinese medicine in the therapeutic room sex premature beat.
【学位授予单位】：中国中医科学院
【学位级别】：博士
【学位授予年份】：2017
【分类号】：R249;R259

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