曹玉山教授学术思想与辨治冠心病的临床经验研究

发布时间：2017-12-30 23:49

  本文关键词：曹玉山教授学术思想与辨治冠心病的临床经验研究　出处：《中国中医科学院》2016年博士论文　论文类型：学位论文

  更多相关文章： 曹玉山 学术思想 冠心病 临床经验研究 通冠汤

【摘要】：冠心病是目前全球范围内严重危害人们身体健康的常见病、多发病,尽管现代医学在治疗冠心病方面取得了很大进步,但因患者长期服用药物的副作用和耐药性等问题使得冠心病的防治仍是当今医学的难点。中医药在防治冠心病方面有其独特的优势,值得临床研究与推广本论文分为三个部分,第一部分是中医药诊治冠心病的文献综述,详绌介绍了历代中医药学家对冠心病在中医学中的病名、病因、病机和治疗的认识及现代中医学者对冠心病病因、病机及中医药诊治的研究进展。第二部分详细介绍老师学术思想和临床诊治冠心病的经验。老师的学术思想可以概括总结为以下八个方面：勤研经典、衷中参西；辨病辨证、病证合参；天人合一、整体调治：痰瘀相关、痰瘀同治：气血同调、尤重益气；谨遵古训、继承创新；未病先防、有病早治；善用药对、疗效显著。老师认为冠心病在中医学中属“胸痹、心痛”范畴,但中医学“胸痹”还包括除了冠心病之外的呼吸、消化等其它系统疾病。老师认为冠心病中医病因主要有劳逸失度伤气,气虚血瘀;年迈体弱肾虚,阴阳不足；阳虚风寒入侵,心脉痹阻：热邪内舍于心,心脉郁闭；情志失调伤心,气滞血瘀；饮食失宜伤脾,痰瘀互结。特别强调痰饮、瘀血致病。对于冠心病的病机,老师认为其属本虚标实之证,病变之本,在于气血亏虚,以气虚为主,心脉失养,不荣则痛,尤其注重宗气不足在冠心病发病中的作用。病变之标,在于三焦气化失司,痰饮、瘀血痹阻心脉,不通则痛,虚实二端互为影响,相互致病。治疗时谨守病机、通补兼施,标本兼顾,治病之本,注重调补宗气(补宗气,生心血,安心神；调宗气,行心脉,止痹痛)：治病之标,以通利三焦为主。审因论治,痰瘀同化贯穿整个冠心病病程始终。第三部分为老师临床经验方通冠汤治疗冠心病稳定型心绞痛(气血亏虚、痰瘀互阻)的临床研究。目的：通过观察通冠汤治疗冠心病稳定型心绞痛(气血亏虚、痰瘀互阻)的临床疗效和安全性,探讨通冠汤治疗冠心病稳定型心绞痛可能的作用机制,为临床中医药治疗冠心病提供安全有效的方法。方法：收集甘肃中医药大学附属医院名中医工作站门诊或住院部的冠心病稳定型心绞痛(气血亏虚、痰瘀互阻)患者60例,依据随机对照原则将其分为治疗组和对照组,每组患者各30例。冠心病中西医诊断标准及其他试验标准参考国际国内统一标准,并结合老师临床经验综合制定。对照组给以西医基础治疗,治疗组在西医治疗的基础上给以通冠汤,早晚饭后半小时温服,每日2次,观察疗程为4周。期间观察指标为：(1)安全性指标：血常规、尿常规、肝肾功能、不良反应；(2)疗效性指标：心绞痛疗效、中医症状、中医证候、心电图、血脂四项、凝血系列、血液流变学、同型半胱氨酸、D-二聚体。数据统计分析采用SPSS19.0统计软件分析,所有计量资料用均数±标准差(x±s)表示,一般组间比较用t检验,等级资料采用秩和检验,计数资料采用χ2检验,不服从χ2检验条件用Fisher确切概率法,P0.05为有统计学意义。结果：治疗观察4周后,(1)两组患者治疗前后心绞痛疗效比较：治疗组显效19例(63.33%)、有效7例(23.33%),总有效26例(86.67%),对照组显效18例(60%)、有效6例(20%),总有效24例(80%),两组患者治疗前后的比较采用四格表卡方检验得,χ2=0.48,P=0.49,按α=0.05水准,由此可得两组患者治疗前后心绞痛疗效比较无统计学意义,故认为两组患者治疗前后心绞痛疗效比较无差别。(2)两组患者治疗前后中医症状疗效比较：治疗组患者治疗后胸闷、胸痛、心悸、气短、倦怠疲乏、自汗明显改善,症状积分均明显下降,对照组患者胸闷、胸痛症状较治疗前改善,症状积分下降。由于中医症状所整理的数据为等级资料,故对两组患者治疗前后中医症状的差值进行两独立样本的秩和检验得：P0.05,可知两组患者治疗前后中医症状积分差值的差异有统计学意义,并且治疗组治疗前后中医症状差值的秩均值均大于对照组治疗前后中医症状差值的秩均值,故可认为治疗组疗效优于对照组。(3)两组患者治疗前后中医证候疗效比较：治疗组显效13例(43.33%),有效12例(40%),总有效率为83.33%;对照组显效8例(26.67%),有效10例(33.33%),总有效率为60%。两组患者治疗前后的比较采用四格表卡方检验得,χ2=4.02,P=-0.04,按α=0.05水准,可知治疗组和对照组中医证候疗效差别有统计学意义。(4)两组患者治疗前后心电图疗效比较：治疗组显效14例(46.67%)、有效8例(26.67%),总有效22例(73.33%),对照组显效8例(26.67%)、有效8例(26.67%),总有效16例(53.33%),两组患者治疗前后心电图疗效的比较采用四格表卡方检验得,χ2=2.58,P=0.11,按α=0.05水准,可知治疗组和对照组心电图疗效差异无统计学意义,故不能认为两组患者心电图疗效有差别。(5)两组患者治疗前后消心痛停、减情况比较：治疗组消心痛停药12人、减量14人,总停减26例,总有效率86.67%,对照组消心痛停药7人、减量11人,总停减18例,总有效率是60%,对两组患者治疗前后消心痛减率的比较采用四格表卡方检验得,χ2=5.46,P=0.02,按α=0.05水准,可知治疗组和对照组消心痛停减率差别有统计学意义,且治疗组有效率(86.67%)高于对照组有效率(60%)。(6)两组患者治疗前后血脂代谢改善疗效比较：两组患者治疗后LDL-C均降低,HDL-C升高,对两组患者治疗前后血脂代谢的差值进行两独立样本t检验得：P0.05,可知两组患者治疗前后血脂代谢差值的差异有统计学意义,又因为治疗组治疗前后血脂代谢差值的绝对值均大于对照组治疗前后血脂代谢差值的绝对值,故可认为治疗组的疗效优于对照组。(7)两组患者治疗前后凝血指标变化比较：治疗组在治疗后APTT、TT明显延长,Fib含量明显下降,对两组患者治疗前后凝血指标的差值进行两独立样本t检验得：P0.05,可知两组患者治疗前后凝血指标差值的差异有统计学意义,又因为治疗组在治疗前后凝血指标差值的绝对值均大于对照组治疗前后凝血指标差值的绝对值,故可认为治疗组的疗效优于对照组。(8)两组患者治疗前后血液流变学指标变化比较：治疗组在治疗后全血黏度1、全血黏度5、全血黏度30、全血黏度200、血浆黏度、红细胞聚集指数明显降低,对两组患者治疗前后上述血液流变学指标变化的差值进行两独立样本t检验得：P0.05,可知两组患者治疗前后血液流变学指标变化差值的差异有统计学意义,又因为治疗组在治疗前后血液流变学指标变化差值的绝对值均大于对照组治疗前后血液流变学指标变化差值,故可认为治疗组的疗效优于对照组。(9)两组患者治疗前后D-二聚体、HCY指标变化比较：治疗组在治疗后D-二聚体、HCY含量均明显下降,对两组患者治疗前后HCY和D-二聚体含量的差值进行两独立样本t检验得：P0.05,可知两组患者治疗前后D-二聚体和HCY的差异有统计学意义,且因为治疗组在治疗前后D-二聚体和HCY差值的均值大于对照组在治疗前后D-二聚体和HCY差值的均值,故可认为治疗组的疗效优于对照组。结论：在西医基础治疗上加服通冠汤可以明显减轻冠心病患者心绞痛发作时的胸闷、胸痛、心悸、气短、疲乏、自汗等症状,减少硝酸酯类药物的使用量,改善患者心电图和血脂代谢紊乱,改善患者凝血系列指标和血液流变学指标,并能降低冠心病患者血浆D-二聚体和血清HCY水平。治疗前后患者肝、肾功能及血、尿常规无明显变化,无明显不良反应。说明通冠汤在治疗冠心病稳定型心绞痛(气血亏虚、痰瘀互阻)时临床疗效显著,用药安全可靠。
[Abstract]:Coronary heart disease is a worldwide common disease seriously harming human health, disease, while modern medicine has made great progress in the treatment of coronary heart disease, but because of side effects in patients with long-term medication and drug prevention and treatment of coronary heart disease is the difficulty of making medicine. Traditional Chinese medicine has its unique advantages in the prevention of coronary heart disease it is worthy of clinical promotion and research, this paper is divided into three parts, the first part is the literature review of Chinese medicine in the treatment of coronary heart disease, and introduces the details of traditional Chinese medicine experts name of disease, etiology of coronary heart disease in TCM, understanding the pathogenesis and treatment of TCM and modern scholars on coronary heart disease etiology, pathogenesis and research progress TCM diagnosis and treatment. The second part introduces the academic thought and clinical experience of coronary heart disease. The teacher's academic thought can be summarized into the following eight aspects. Surface: Qinyan classic, full participation in the West; disease syndrome combination; the harmony between man and nature, the overall treatment of phlegm and blood stasis, phlegm and blood stasis, Qi and blood coherence, especially Qi; follow the ancient precept, inheritance and innovation; disease prevention, disease and treatment; medication of good curative effect. The teacher considered significant. Coronary heart disease in TCM is a "xiongbi, heartache" category, but the traditional Chinese medicine "chest" also includes in addition to coronary heart disease besides respiratory, digestive and other system disease. The main causes are coronary heart disease in Chinese teachers believe that the maladjustment of work and rest of Qi, Qi deficiency and blood stasis; frail elderly kidney deficiency, deficiency of yin and Yang; Yang deficiency cold invasion, heart vessel blockage: Geza Hei Sh in the heart, heart closed; emotional disorders sad, qi stagnation and blood stasis; improper diet injured spleen, phlegm and blood stasis phlegm and blood stasis. Especially, for the disease. The pathogenesis of coronary heart disease, the teachers believe that this standard is false evidence, the disease is deficiency of Qi and blood, The deficiency, Qi deficiency, heart pulse dystrophy, not glory pain, with particular emphasis on the role of Zong Qi deficiency in the pathogenesis of coronary heart disease. The disease is standard, Sanjiao dysfunction of Qi and blood stasis phlegm, heart, no pain, and the two end of the mutual influence, mutual treatment and disease pathogenesis. Machine, through supplementation, both specimens, the cure, pay attention to tune up the Zong Qi (pectoral Qi, student effort, peace of mind of God; regulating gas case, heart vein, Zhibitong): treatment of the standard, to Tongli. The trial due on the treatment of phlegm and blood stasis throughout the course of coronary heart disease always assimilation the third part is the teacher. The clinical experience of Tongguan Decoction in treating coronary heart disease with stable angina (Qi and blood deficiency, phlegm and blood stasis) clinical research. Objective: To observe the Tongguan Decoction in the treatment of coronary heart disease with stable angina pectoris (deficiency of Qi and blood, phlegm and blood stasis) the clinical efficacy and safety of the crown, Tong Decoction Treatment of stable angina pectoris of coronary heart disease may The mechanism of action, to provide a safe and effective method for clinical medicine in the treatment of coronary heart disease. Methods: the collection of Gansu University of TCM Affiliated Hospital of traditional Chinese medicine workstation of outpatient or inpatient department of the coronary heart disease with stable angina (Qi and blood deficiency, phlegm and blood stasis) in 60 patients, according to the principle of random photos were divided into the treatment group and the control group, there were 30 cases in each group. Coronary heart disease diagnostic criteria of Western medicine and other domestic and international test standard reference standard, combined with the clinical experience of comprehensive teacher making. The control group were given the basic treatment of Western medicine, the treatment group was given on the basis of Western medicine treatment of Tongguan Decoction, sooner or later, half an hour after a meal day, 2 times a day, the observation lasted for 4 weeks. During the observation index: (1) safety index: blood, urine, liver and kidney function and adverse reactions; (2) the efficacy index: angina pectoris, TCM symptoms, syndromes, electrocardiogram, blood lipid 鍥涢」,鍑濊��绯诲垪,琛，

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