ACS患者的临床特点及与“毒”邪致病相关性探讨

发布时间：2018-01-02 14:35

  本文关键词：ACS患者的临床特点及与“毒”邪致病相关性探讨　出处：《广州中医药大学》2016年硕士论文　论文类型：学位论文

  更多相关文章： 急性冠脉综合征 不稳定性心绞痛 “毒”邪 中药 因子分析

【摘要】：目的：临床研究：采用临床医学统计法和临床流行病学调查法,在“毒”邪致病特点基础上,结合ACS的临床特点(包括临床表现、证候要素、理化结果、冠脉造影等)地分析,试图为岭南地区ACS中医“毒”邪证的辨证提供更多客观科学的依据。通过对岭南地区ACS的中药用药规律的研究尝试从中药解毒方面,反证ACS中“毒”邪的存在,进一步阐释ACS中解毒法的具体内涵。方法：临床研究：本研究自2015年8月至2015年12月,运用小样本、横断面、前瞻性的临床流行病学调查方法对广州中医药大学第一附属医院100例ACS患者的临床特点进行调查,临床特点包括：一般资料、既往病史、西医诊断、冠脉造影结果、实验室检查结果、临床症状、中医主症计分、舌脉、中药等,建立数据库：并根据“毒”邪致病特点,对ACS的临床主症进行评分,作为ACS中“毒”邪的辨识依据,将临床主症评分≥9分为“毒”邪患者,9分为非“毒”患者,然后进行临床病例对照研究。统计方法采用频数分析、T检验、主成分分析、因子分析、相关分析等多因素分析方法。结果：1.影响因素因子分析发现,高UA(尿酸)的载荷值最大,说明高UA(尿酸)在本次研究“毒”邪证发生的最重要的影响因素,其载荷值为：0.670。其他因素按影响程度的大小排列依次是：糖尿病病史高血脂病史陈旧心梗病史高LDL-C高血压病史饮酒史吸烟史脑卒中病史TNI(+),其载荷值分别为：0.524、0.500,0.396、0.366、0.335、0.309、0.301、0.286、0.109。“毒”邪组中医证候因子分析结果显示,气虚的载荷值最大,说明气虚在本次研究“毒”邪中医证候中是影响最大的中医证候。所有中医证候按影响程度的大小排列依次是：气虚、血瘀、痰热、阳虚、气滞、寒凝、火热、阴虚,其载荷值分别为：0.911、0.892、0.828、0.558、0.553、0.488、0.403、0.154。“毒”邪组临床主症主成分分析得分结果显示,胸痛的载荷值最大,说明胸痛是影响本次研究“毒”邪主症中最重要的临床症状,其得分为：1.644。其他中医主症按影响程度的大小排列依次是：心悸、乏力、气短、胸闷,其得分分别为:1.399、1.188、1.160、1.104。“毒”邪组临床兼症主成分分析得分结果显示,寒症有畏寒(0.642)；热症有面红(0.705)、目赤(0.704)、口干欲饮(0.475)、便秘(0.540)、自汗(0.453)；痰症有咳嗽(0.646)、咳痰(0.670)；瘀血症有自汗(0.453)、口干欲饮(0.475)、便秘(0.540)。舌脉的独立样本T检验结果,P值为0.000(P值0.05),有统计学意义。舌淡红、舌白的P值0.05,说明在“毒”邪证与非“毒”证中,二者比较均有统计学意义；少苔、脉细、脉弦滑、脉滑数的P值0.01,说明在“毒”邪证与非“毒”证中,以上舌脉的统计学意义高度显著。“毒”邪证候要素组合方式中比例较多的是：气滞+血瘀+气虚、血瘀+痰热+气虚、血瘀+寒凝+气虚、血瘀+火热+气虚。2.通过对岭南地区100例ACS“毒”邪组与非“毒”组的影响因素、中医证候、临床症状、舌脉、证候要素等相关分析,四诊合参,再结合中医脏腑、气血津液理论,初步得出ACS中“毒”邪证的临床辨证标准如下。主要指标：(1)胸痛(中或重度)、胸闷(中或重度)、心悸、乏力、气短总积分≥临床主症积分总和的60%;(2)舌暗红、舌下络脉紫绛或紫红。次要指标：(1) hs-CRP3 mg/L；(2)心肌酶(肌酸激酶、肌酸激酶同工酶)或肌钙蛋白超过正常上限的2倍以上；(3)高血压史2-3级；(4)糖尿病病史,FBG710 mmol/L;(5)高胆固醇病史；(6)高尿酸血症；(7)长期吸烟史、饮酒史。ACS病人符合1个主要指标或2个次要指标(至少含1项生化指标)即可诊断为“毒”邪。其中生活劳累、性格急躁、饮食辛辣油腻咸是主要诱因。3.依据“毒”邪不同的始动邪气(火热、血瘀、痰热、寒凝),结合以上中医证候、证候要素、临床症状、舌脉的统计结果,综合得出“毒”邪证的分类,临床可分为热毒证、瘀毒证、痰毒证、寒毒证。热毒证：热盛伤气阴,故呈现热毒血瘀、气阴两虚证,临床表现为胸痛甚、胸闷、烦躁易怒、便秘、气短、自汗、乏力、心悸、舌红苔黄、脉滑数等热毒证。瘀毒证：瘀热互结,气阴两伤,二毒常夹杂为患,临床表现为胸痛甚、胸闷、口干欲饮、便干便秘、气短、自汗、乏力、舌暗红、舌下络脉紫红或绛紫,苔黄腻、脉滑等瘀毒证。痰毒证：痰毒内盛、心脾两虚,临床多表现胸闷甚、胸痛、咳嗽咳痰、便溏、口淡、气短、乏力、心悸、头晕、舌白腻、脉滑细等痰毒证。寒毒证：寒毒凝聚、心阳不展,临床多表现胸痛剧烈、畏寒肢冷、气短明显、冷汗、乏力、心悸、舌淡暗、脉沉细缓等寒毒证。4.ACS与“毒”邪致病的相关病机,(内)邪气亢极或蕴结不化而化生(内)毒,依不同的始动邪气,可分为寒毒、(火)热毒、痰毒、瘀毒等,形质受损,脏腑虚损,或者正衰邪盛,亦可从化为毒,邪可化毒,毒可致邪,最终形成毒瘀搏结、毒损心络、毒损脏腑的恶性循环。“正虚毒盛”是ACS的总的病机,瘀毒阻脉是ACS基本的病理变化(以瘀毒为核心),毒损心络,毒损脏腑是最终病理变化。5.本次研究从100例我院对岭南地区ACS的用药统计结果,结合岭南地区土卑地薄,气候炎热,暑湿为盛的气候特点,药类分析结果：活血药清热药补气药化痰药理气药祛湿药补阴药。药频分析结果,祛邪药排列前五味中药为：川芎、赤芍、红花、丹参、降香、毛冬青；补虚药排列前五味中药为：炙甘草、黄芪、党参、白术、茯苓。从中药药类、频数使用情况,以药测证,反推得出岭南地区ACS患者的主要临床证候：热毒血瘀、气阴两虚证。6.在ACS“毒”邪致病体系中,分为外毒、内毒致病。外毒以疫毒、烟酒毒等为主,以祛邪解毒法为主,祛疫毒、祛或戒烟酒毒等。内毒除活血解毒外,还要能够结合产生毒邪的始动邪气确立相应治法,如清热解毒、散寒解毒、利湿解毒、祛风解毒、润燥解毒、清营解毒、扶正解毒等。7.根据本次研究中药用药规律,药证相应,以“扶正解毒”为治则,初步整理归纳出岭南地区ACS的中医解毒方剂—解毒活血汤。结论：临床研究：通过数理统计的结果与中医理论、临床经验相结合,可以得出相对客观的ACS中医“毒”邪证的临床诊断及量化标准,前瞻性的临床调查与多因素数理统计分析相结合是进行ACS中医“毒”邪证辨证标准客观化研究的一种有效方法,值得进一步深入研究。中医强调因地制宜,故本研究针对岭南地区ACS患者的临床特点、中药治疗与“毒”邪及相关病机的相关性研究,为以后深入探讨提供了研究基础及参考模式,有利于日后进行大样本、多中心、横断面、前瞻性临床流行病学的调查分析。
[Abstract]:Objective: the clinical research: the clinical medical statistics and clinical epidemiology survey, based on the pathogenic characteristics of toxic evil, combined with ACS's clinical characteristics (including clinical manifestations, syndrome factors, physicochemical results, coronary angiography) analysis, trying to provide more scientific basis for TCM syndrome differentiation of ACS in south of the Five Ridges area poison syndrome. Through the study of Chinese medicine rule of ACS in south of the Five Ridges to try from the traditional Chinese medicine detoxification, not ACS poison exists, further explain the specific connotation of detoxification of ACS. Methods: clinical study: from August 2015 to December 2015, the use of small sample, cross-sectional, clinical epidemiology prospective investigation method was used to investigate the clinical characteristics of the First Affiliated Hospital of Guangzhou University of Chinese Medicine, 100 cases of ACS patients, the clinical features including: general information, medical history, western medicine diagnosis, coronary artery Angiographic findings, laboratory findings, clinical symptoms, TCM main symptoms score, tongue and pulse, traditional Chinese medicine, the establishment of database: according to the "toxic" pathogenic characteristics, clinical symptoms of the ACS score, as the identification basis in ACS poison, the main clinical symptom score more than 9 points as "poison" the evil 9 patients, divided into "poison" patients, then the clinical case-control study. Statistical methods using frequency analysis, T test, principal component analysis, factor analysis, multiple factors analysis method. Results: 1. factor analysis found that high UA (uric acid) the maximum load value, indicating high UA (uric acid) factors in this study poison card the most important influence, the load value is: 0.670. other factors according to the degree of influence in the order: a history of diabetes hyperlipidemia history of old myocardial infarction with high LDL-C hypertension smoking drinking history The history of the history of stroke (TNI +), the load values were: 0.524,0.500,0.396,0.366,0.335,0.309,0.301,0.286,0.109. poison group syndrome factor analysis showed that the maximum load of qi deficiency, Qi deficiency in this study shows that TCM toxic evil is the biggest influence of TCM syndrome. All TCM syndromes according to influence degree the size of the arrangement are: Qi deficiency, blood stasis, phlegm heat, Yang deficiency, qi stagnation, cold, hot, yin deficiency, the load values were: 0.911,0.892,0.828,0.558,0.553,0.488,0.403,0.154. poison group main clinical symptom scores of principal component analysis showed that the maximum load value of chest pain, chest pain that is affecting the study "the most important clinical symptoms the main toxic evil disease, the score is 1.644. other principal syndrome according to the influence degree of the arrangement are: palpitations, fatigue, shortness of breath, chest stuffy, the scores are as follows: 1.3 99,1.188,1.160,1.104.鈥滄瘨鈥濋偑缁勪复搴婂吋鐥囦富鎴愬垎鍒嗘瀽寰楀垎缁撴灉鏄剧ず,瀵掔棁鏈夌晱瀵，

本文编号：1369650