2型糖尿病合并高血压病患者血管老化的中西医临床特征研究

发布时间：2018-05-21 07:19

本文选题：2型糖尿病 + 高血压　；参考：《中国中医科学院》2017年硕士论文

【摘要】：一、研究目的探讨2型糖尿病合并高血压病患者血管老化的临床特征,研究其血管老化病变的临床特点、中医证候规律以及相关性,从而加深对于血管老化的全面理解,并将有助于丰富和完善中医药防治心血管疾病的途径和靶点。二、研究方法本研究是一个横断面研究,通过专家问卷以及文献调研编制2型糖尿病合并高血压病的临床调查量表,收集2016年5月-2017年4月于西苑医院内分泌科以及心血管内科住院的107例2型糖尿病合并高血压病患者的临床资料,构建临床信息数据库,并将患者按照年龄分为中年组(45-59岁)和老年组(60-80岁),对收集到的资料进行统计分析,同时收集了 14例健康人作为对照组。对纳入的107例患者的一般资料进行频数分析,运用主成分分析-聚类分析等方法统计糖尿病合并高血压病患者的中医证素与中医证型;使用t检验、秩和检验、线性回归探讨2型糖尿病合并高血压病患者的临床特征;使用单因素方差分析结合Logistic回归分析中医证素与血管老化指标之间的相关性;使用独立样本t检验以及秩和检验分析糖尿病合并高血压病患者与健康对照人群之间血管老化指标的异同。三、研究结果:1基线资料107例2型糖尿病合并高血压患者中,男性45例,女性62例;年龄最小45岁,最大80岁,平均年龄62.7±9.2岁;高血压1级患者12人,高血压2级患者38人,高血压3级患者57人;血脂正常53人,血脂轻度升高25人,高脂血症29人;糖尿病较轻患者17人,较重46人,严重44人;41人吸烟,占到患者组的38.32%,早发心血管疾病家族史的患者47人,占患者组的43.93%。对照组来自社会招募的非高血压非糖尿病的健康志愿者,共计14人,最大年龄61岁,最小年龄45岁,平均年龄50.2±5.2岁,其中男性8人,女性6人。其中5人吸烟,占健康对照组的35.7%,3人有心血管病家族史,占健康对照组的21.4%。2不同年龄段、不同性别之间血管老化临床特征的差异性分析中年组与老年组相比,胎球蛋白A(FetuinA)、脉搏波波速(Pulse Wave Velocity,PWV)的差异性明显,中年组的PWV要低于老年组的PWV,中年组的FetuinA要高于老年组的FetuinA,中年组与老年组之间的血管性血友病因子(von Willebrand Factor,vWF)值并无明显差异,提示随着年龄的增加,血管老化程度逐渐加重,钙质沉积出现异常。不同性别之间的血管老化指标差异并不明显,提示随着年龄的增加,不论男女,血管弹性逐渐变差,老化程度逐渐加重。3基础疾病、年龄等因素对血管老化临床特征的影响线性回归分析中可以得出,PWV的回归方程为:Y=1585.316+64.129X1,年龄水平(X1)是影响PWV的主要因素;FetuinA的回归方程为:Y =1.577+0.235X3-0.122X1,高血压水平(X3)、年龄水平(X1)是影响FetuinA的主要因素;vWF的回归方程为:Y =0.233+0.03X4,血脂水平(X4)是影响vWF的主要因素。4糖尿病合并高血压患者中医证素的因子分析将通过临床样表收集到的患者的症状、舌苔、脉象进行因子分析—主成分分析,得到15个公因子,选择最大方差法对因子载荷矩阵中原始的15个公因子进行旋转,旋转在24次迭代后收敛,提取公因子负荷值≥0.5的变量,可以得出每个公因子对应的中医四诊信息;根据因子中载荷系数的大小,决定每个因子中医四诊信息的主次顺序,并结合该因子中其它中医四诊信息,分析每个因子可能提供的病性、病位信息,最终得到15个公因子分别代表气虚、血瘀、热盛、痰湿、阳亢、阳虚、阴虚,涉及的病变脏腑分别为肝、脾、肺、肾、胃。5糖尿病合并高血压患者中医证素的聚类分析将15个公因子作为变量进行聚类,选择最远临元素—欧氏距离的方法进行聚类分析,从结果来看,聚为6类时从中医理论解释相对合理,据此可以初步判断出糖尿病合并高血压患者中医的辨证分型,根据公因子下中医症状的载荷系数的多少,结合中医临床相应的辨证信息,可初步拟定各个证型的辨证依据。最终得到2型糖尿病合并高血压有肝盛克脾、血瘀阻络、阴虚阳亢、阳虚水泛、气阴两虚、肝郁脾虚等六种证型。6糖尿病合并高血压患者病性证素分布情况本试验共收集了糖尿病合并高血压患者39个临床常见症状,舌诊项目15项,脉诊项目9项,107位病人出现该症状记为1,不出现该症状记为0,参照文献中对于相关症状的描述,将患者的临床症状依次录入到EXCEL表格中,参照中医证候辨证标准,将患者满足某项证素描述中50%的症状定义为患者具备该项病性证素。在107例2型糖尿病合并高血压病的患者中,“阳虚”占到的比例最大,达到了 55.2%,“肝阳上亢”占的比例最小,仅为33.39%。7糖尿病合并高血压患者病性证素组合分布情况统计分析得知,在患者中,两类证素相兼的患者最多,有29人,占患者总数的27.6%,七种证素相兼的患者最少,只有2人,占患者总数的1.9%。8不同年龄组别、不同性别之间证素分布的差异中年男性最常见的证素为热盛,病性证素的前三位分别是热盛(77.3%)阳虚(68.2%)阴虚(45.5%);中年女性最常见的证素为痰湿,前三位的病性证素为痰湿(70.6%)阴虚(58.8%)=气虚(58.8%)血瘀(52.9%);老年男性最常见的证素为阳虚和热盛,病性证素前三位的是阳虚(56.5%)=热盛(56.5%)痰湿(43.5%)气虚(34.8%)=肝阳上亢(34.8%);老年女性最常见的证素为阳虚,病性证素的前三位分别是阳虚(51.2%)痰湿(48.8%)=阴虚(48.8%)=气虚(48.8%)血瘀(46.5%)。9病性证素与血管老化之间的关系为探究相应的病性证素与血管损伤指标以及糖化血红蛋白、血脂等生化指标之间的相关性,对107例糖尿病合并高血压的患者进行统计分析。首先进行正态分布检验,选取符合正态分布的项目进行方差检验,不符合正态分布的项目进行秩和检验,提取P≤0.1的项目做进一步的分析。由单因素方差分可知,阳虚组与非阳虚组之间BMI、vWF有差异,阴虚组与非阴虚组之间HDL、TG有差异,热盛组与非热盛组之间年龄、TG、VLDL有差异。再分别以热盛、阴虚、阳虚为因变量,以年龄、FetuinA、vWF、TG、HDL、VLDL、PWV、BMI为协变量,进行Logistic回归分析。对因变量赋值如下:病性证素赋值为:0-否,1-是;协变量赋值为:性别:1-男性,2-女性,方法采用向后LR,结果发现热盛的回归方程中,年龄的OR值是0.941,回归系数是-0.061,表示两者负呈相关,说明患者年龄越大,越不容易出现热盛的症候;在阳虚的回归方程中,vWF的OR值是754.435,回归系数是6.626,提示两者呈正相关,说明当随着vWF的增高,患者出现阳虚证的风险也跟着增大。10糖尿病、高血压对血管老化的影响在糖尿病合并高血压患者组与健康对照组之间,PWV、FetuinA的差异性明显,糖尿病合并高血压患者组的PWV要明显高于健康对照组,说明糖尿病合并高血压患者血管老化程度较为明显;而患者组的FetuinA值要低于健康对照组,说明在糖尿病合并高血压患者体内可能出现了钙质沉积的异常。四、结论1随着年龄的增加,血管弹性逐渐变差,老化程度逐渐加重;中年组血管内钙质的异位沉积要低于老年组,高血脂可加重血管内皮损伤,导致血管老化加重。2糖尿病合并高血压病患者的中医证素为气虚、血瘀、热盛、痰湿、阳亢、阳虚、阴虚;涉及的病变脏腑分别为肝、脾、肺、肾、胃;疾病的证型为:肝盛克脾、血瘀阻络、阴虚阳亢、阳虚水泛、气阴两虚、肝郁脾虚。3中年男性最常见的证素为热盛,中年女性最常见的证素为痰湿,老年男性最常见的证素为阳虚和热盛,老年女性最常见的证素为阳虚。年龄越大,发生热盛的可能性就越低;血管内皮细胞损伤加重时,患者更容易发生阳虚。4高血压合并糖尿病患者的血管老化程度要重于健康对照人群。
[Abstract]:The purpose of this study is to investigate the clinical features of vascular aging in patients with type 2 diabetes and hypertension, to study the clinical characteristics of the vascular aging disease, the regularity of TCM syndrome and the correlation, so as to deepen the comprehensive understanding of the vascular aging, and to enrich and improve the ways and targets for the prevention and treatment of cardiovascular diseases in Chinese medicine. Two Methods a cross-sectional study was conducted in this study. The clinical data of type 2 diabetes combined with hypertension were compiled by the expert questionnaire and literature survey, and the clinical information of 107 patients with type 2 diabetes combined with high blood pressure in the Department of Endocrinology, Xiyuan Hospital, Xiyuan Hospital, and the cardiovascular medicine department in May 2016, -2017 years, was collected and the clinical information was constructed. The patients were divided into middle age group (45-59 years old) and aged group (60-80 years old) according to age. The collected data were statistically analyzed, and 14 healthy people were collected as control group. The general data of 107 patients were analyzed, and diabetes combined with hypertension was analyzed by principal component analysis cluster analysis. TCM syndromes and TCM syndrome types of patients with disease; using t test, rank sum test, linear regression to investigate the clinical characteristics of patients with type 2 diabetes combined with hypertension; use single factor analysis of variance and Logistic regression to analyze the correlation between TCM syndrome and blood vessel aging index, and use independent sample t test and rank sum test to analyze diabetes mellitus The differences and similarities between the blood vessel aging indexes between the patients with hypertension and the healthy controls. Three, the results of the study: 1 baseline data, 107 cases of type 2 diabetes combined with hypertension, 45 cases of male, 62 cases, the age of 45, the maximum 80 years, the average age of 62.7 + 9.2 years, 12 in the patients with high blood pressure 1, hypertensive 2 patients 38, high blood pressure grade There were 57 patients with normal blood lipids, 53 blood lipids, 25 hyperlipidemia, 29 hyperlipidemia, 17 diabetic patients, 46 heavier, 44 serious, 41 smoking, 38.32% in the patient group, 47 in the family history of early cardiovascular disease, and a group of 43.93%. control group from non hypertensive and non diabetic healthy volunteers recruited from the society. A total of 14 people, the maximum age of 61 years, the minimum age of 45 years, the average age of 50.2 + 5.2 years, including 8 men and 6 women, 5 of them smoking, accounting for 35.7% in the healthy control group, 3 people with the family history of cardiovascular disease, accounting for the different age groups of 21.4%.2 in the healthy control group and the difference analysis of the clinical characteristics of blood vessel aging between the different sexes and the aged group and the elderly Compared with the group, the difference of fetal globulin A (FetuinA) and pulse wave velocity (Pulse Wave Velocity, PWV) was obvious. The PWV in the middle age group was lower than the PWV in the elderly group, and the FetuinA in the middle age group was higher than the FetuinA in the elderly group. There was no significant difference between the middle-aged group and the elderly group. With the increase of age, the degree of vascular aging is increasing and the calcareous deposition is abnormal. The difference of blood vessel aging indices between different sex is not obvious. It is suggested that with the increase of age, the vascular elasticity gradually becomes worse, the degree of aging gradually aggravates the basic.3 disease, and the factors of age and other factors affect the clinical characteristics of blood vessel aging. It can be concluded that the regression equation of PWV is Y=1585.316+64.129X1, age level (X1) is the main factor affecting PWV; the regression equation of FetuinA is Y =1.577+0.235X3-0.122X1, the level of hypertension (X3), and the age level (X1) is the main factor affecting FetuinA; vWF regression equation is the main factor of Y, and the blood lipid level is the main influence Factor analysis of factors of TCM syndrome in patients with.4 diabetes combined with hypertension, the symptoms, tongue coating, pulse condition, factor analysis, principal component analysis, 15 common factors are obtained, and the maximum variance method is selected to rotate the original 15 common factors in the factor load matrix, and the rotation is convergent after 24 iterations. Taking the variables of the public factor load value more than 0.5, we can get the four diagnosis information of each public factor, and determine the order of the four diagnosis information of each factor according to the load coefficient in the factor, and combine the four diagnosis information of the other Chinese medicine in the factor, and analyze the possible disease, the disease location information which each factor may provide, and finally get 15 The public factors represent Qi deficiency, blood stasis, heat, phlegm, phlegm, yang hyperactivity, Yang deficiency and yin deficiency. The cluster analysis of the syndrome elements of the liver, spleen, lung, kidney, and gastric.5 diabetes combined with hypertension, cluster analysis of 15 common factors as variables, and select the farthest element Euclidean distance to cluster analysis, from the results. In the 6 class, the interpretation of TCM theory is relatively reasonable. According to this, the syndrome differentiation of diabetic patients with hypertension can be judged preliminarily. According to the load coefficient of the symptoms of traditional Chinese medicine under the common factor, according to the corresponding clinical syndrome differentiation information of traditional Chinese medicine, the syndrome differentiation basis of each type of syndrome can be preliminarily drawn up. Finally, the combination of type 2 diabetes is higher. The blood pressure has the liver Sheng Ke spleen, blood stasis obstructing the collaterals, yin deficiency and yang hyperactivity, Yang deficiency water flooding, Qi Yin deficiency, liver depression and spleen deficiency and other six types of.6 diabetes combined with hypertension, the distribution of the disease syndrome in the patients with diabetes combined hypertension, 39 common symptoms, 15 items of tongue diagnosis, 9 items of pulse diagnosis, and 107 patients with this symptom For 1, the symptoms were not recorded as 0. According to the description of the related symptoms in the literature, the patients' clinical symptoms were entered into the EXCEL form in turn. Referring to the syndrome differentiation standard of TCM syndrome, the patients were satisfied with the symptoms of a certain syndrome, which were defined as the patient with the disease, in 107 patients with type 2 diabetes combined with hypertension. The proportion of "Yang Deficiency" accounted for the largest proportion, reaching 55.2%. The proportion of "liver yang hyperactivity" accounted for the smallest proportion. Only the statistical analysis of the combination distribution of 33.39%.7 diabetes combined with hypertension showed that in the patients, the number of two types of syndrome elements was the most, with 29, accounting for 27.6% of the total number of patients, and the least of the seven types of syndrome elements, only the least, only the patients with the least. There were 2 people, accounting for the 1.9%.8 age group of the total number of patients. The most common syndromes in middle-aged men were hot and hot (77.3%) Yang deficiency (77.3%) Yang deficiency (68.2%) yin deficiency (45.5%), and the most common syndromes in middle-aged women were phlegm dampness and the first three were phlegm dampness (70.6%) yin deficiency (58.8%) = three. Qi deficiency (58.8%) blood stasis (52.9%); the most common syndromes in old men were Yang deficiency and heat flourishing, and the first three were Yang deficiency (56.5%) = hot (56.5%) phlegm dampness (43.5%) Qi deficiency (34.8%) = liver yang hyperactivity (34.8%); the most common syndromes in old women were Yang deficiency, and the first three of the disease syndrome elements were Yang deficiency (51.2%) phlegm dampness (48.8%) = Yin deficiency (48.8%) = Qi deficiency (4) 8.8%) the relationship between blood stasis (46.5%).9 disease and vascular aging is to explore the correlation between the corresponding syndromes and blood vessel damage indexes, glycated hemoglobin, blood lipid and other biochemical indexes, and to make a statistical analysis on 107 patients with diabetes combined with hypertension. First, normal distribution test is carried out to select normal distribution. The project carries on the variance test, does not conform to the normal distribution of the project to carry on the rank sum test, extracts P less than 0.1 of the project to do further analysis. By the single factor variance, the difference between the Yang deficiency group and the non Yang deficiency group BMI, the vWF is different. The difference between the yin deficiency group and the non Yin deficiency group is HDL, the TG is different, the age between the hot and non hot groups, the TG, and the VLDL are different. Do not take heat, yin deficiency and yang deficiency as the dependent variable, take age, FetuinA, vWF, TG, HDL, VLDL, PWV, BMI as co variables to carry out Logistic regression analysis. The values of the dependent variables are as follows: the value of the syndrome factor is 0- no, 1- is: 1- male, 2- female, and method adopts backward regression equation, and the result finds the age value of 0 .941, the regression coefficient is -0.061, indicating the negative correlation between the two, indicating that the older the patient is, the less prone to hot syndrome; in the regression equation of Yang deficiency, the OR value of vWF is 754.435 and the regression coefficient is 6.626, suggesting that the risk of Yang deficiency syndrome with the increase of vWF also increases.10 diabetes and higher blood. The effect of pressure on the aging of blood vessels was significantly different between the diabetic group and the healthy control group. The difference of PWV and FetuinA was obvious. The PWV of the patients with diabetes combined with hypertension was significantly higher than that in the healthy control group, indicating that the blood vessel aging degree of the patients with diabetes combined with hypertension was more obvious; the FetuinA value of the patient group was lower than that of the healthy one. According to the group, the abnormal calcium deposits may appear in the patients with diabetes combined with hypertension. Four, conclusion 1 with the increase of age, the vascular elasticity gradually deteriorated and the aging degree gradually aggravated, and the ectopic deposition of intravascular calcium in the middle age group was lower than that in the elderly group. Hyperlipidemia could aggravate the vascular endothelial damage, and the aging of blood vessels aggravated.2 diabetes. The TCM Syndromes of the patients with hypertension are Qi deficiency, blood stasis, heat, phlegm, yang hyperactivity, Yang deficiency and yin deficiency, the liver, spleen, lung, kidney and stomach are respectively the liver, spleen, lung, kidney and stomach. The syndrome of the disease is liver, blood stasis, yin deficiency and yang hyperactivity, Yang deficiency water flooding, two deficiency of Qi Yin, the most common syndrome of middle aged male.3 men with liver depression and spleen deficiency, the most common middle age female female The common syndromes are phlegm dampness. The most common syndromes in old men are Yang deficiency and heat, and the most common syndrome in old women is Yang deficiency. The older the age is, the lower the possibility of thermal prosperity. When the vascular endothelial cell damage is aggravated, the patient is more likely to have the degree of blood vessel aging in patients with Yang deficiency.4 hypertension and diabetes. Group.
【学位授予单位】：中国中医科学院
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R587.1;R544.1

【参考文献】