保元养心方治疗胸痹心痛病（冠心病心绞痛）经验的研究

发布时间：2018-09-11 11:11

【摘要】：目的:导师袁海波教授近五十年来从事中医药研究以及诊疗工作,善于运用中医药理论防治内科心血管疾病及相关脏腑疾患,在继承和发扬前人治疗心血管疾病经验的基础上,结合自身治疗本病的临证经验,创立保元养心方,临证应用时灵活加减变化,取得了显著的临床疗效。本课题通过跟师随诊、与师交流、收集和整理总结医案,总结了导师对胸痹心痛病的理论认识,创立保元养心方的基本背景及理论基础,探索保元养心方的组成、方义及临证应用的加减用药。通过对医案的研究,总结了常见的症状、舌象、脉象、兼证、用药频次、药物功能分类等,为中医的经验传承,和中医药的继承发展提供助力。方法:一、学术思想研究1.充分利用网络资源及报纸刊物,在中国知网、万方数据库,翻阅查询中医药杂志、中医研究等刊物,收集详读导师著作文章及著作等,反复阅读、研究思考、标注重点,不懂之处请教导师,体会导师诊病经验,初步总结导师对胸痹心痛病的总体认识及保元养心方创立的基本背景、思路。2.跟师期间,侍其左右抄方随诊,随时记录笔记,包括导师用药的经验及谈医话,时常翻阅回忆,对重点难点标注后请教导师,及时与导师进行学术探讨与沟通,精心记录学习内容,并进一步进行修改、补充、完善。二、病案研究1.收集2015年4月至2015年12月期间导师运用保元养心方治疗的胸痹心痛的,理、法、方、药完善的医案76例。2.在导师指导下,依据第七版中医内科学(中医类专业用,周仲英主编)对胸痹心痛病进行诊断,依据第五版中药学教材对医案中出现的药物进行分类,教材中未出现的中药材依据《中药大辞典》(第二版,南京中医药大学编著)进行统一规范。3.依据第七版中医诊断学(中医类专业用,朱文锋主编),参考“十一五”国家科技支撑计划课题,袁海波教授学术思想及临证经验医案观察表,将原始医案术语规范化,把原始医案转化为规范医案。4.建立Excel医案数据库,将收集到的医案按患者编号、性别、年龄、症状、舌象、脉象、证型、治法、方药完整地录入,反复核对数据库信息确保信息的准确性。5.运用SPSS19.0软件,对Excel医案数据库的数据采用频数统计分析,统计应用了保元养心方诊疗的胸痹心痛病患者的性别、年龄、症状、舌象、脉象、证型、治法、方药等分布情况。同时进行保元养心方药物加减组成的分析。结果:一、学术思想研究结果1.导师认为,胸痹心痛病应独立命名,其病位在心,相似于现代医学中的冠心病心绞痛,临证中注重轻症与重症的区分,导师认为胸痹心痛病的病因主要有四个方面:寒湿侵袭、损阳伤正;饮食不节、痰湿内生;七情内伤、气血瘀滞;劳逸无度、伤心损脾。证分四型:气阴两虚型;痰湿阻滞型;气滞血瘀型;心阳虚脱型。2.导师认为胸痹心痛病的病程分期可分为三期,其中第二期时心正常的生理功能减弱,自我调节恢复功能受限,患者自觉症状明显,通过休息、调养及生活方式的改变不能缓解病症,通常选择就医治疗,此阶段是胸痹心痛病治疗的关键阶段,也是保元养心方形成的基础及背景。3.导师创立的保元养心方,由保元汤、生脉散、丹参饮、四物汤四方化裁加减而成,主要药物有:太子参(西洋参或党参)、黄芪、麦冬、五味子、黄精、赤芍、川芎、丹参、檀香、砂仁、桂枝、炙甘草组成,功用保元益气,养阴生津,活血化瘀。临床应用于气阴两虚兼血瘀证型的胸痹心痛病较多,临证加减用药灵活多变。二、医案研究结果1.收集医案中胸痹心痛病的患者,男性26人,女性50人,发病人群以中老年(50~70岁共64人)居多。2.收集的医案中,出现的主要症状有:胸闷、气短、胸痛、失眠、烦躁、乏力倦怠、心慌、头晕、头痛、耳鸣、脘腹胀满、纳呆、多汗、便干、四肢麻木、便溏、下肢浮肿、颈项痛、嗳气、腰膝酸软、畏寒怕冷。3.主要舌象分为以下几种:舌质暗淡苔薄白、舌质暗淡苔厚腻、舌质暗红苔薄白、舌质暗红苔厚腻、舌质暗红苔薄腻、舌质暗紫有瘀斑苔薄腻、舌质暗紫有瘀斑苔薄白、舌质淡红苔薄白、舌质暗边尖红舌苔薄腻、舌质暗边尖红苔薄白。以舌质暗淡苔薄白最多,占总数的60.5%。4.主要脉象包括以下几种:脉弦细、脉沉细、脉弦沉细、脉弦细滑、脉弦沉、脉弦细结、脉沉、脉弦滑、脉弦细涩、脉弦、脉细数、脉沉滑、脉沉细结、脉沉细涩。以脉弦细及脉沉细最多见,分别占总数的32.4%、22.4%。5.导师运用保元养心方治疗的胸痹心痛病基本证型为气阴两虚兼血瘀型,兼证证型按由多到少可见气滞型、痰湿型、瘀热型、心阳虚弱型、胃气逆型。6.根据76例医案中出现的药物统计,共出现药物106味,出现频次共1216次,出现频次最多的药物是太子参(或以人参、党参、北沙参、南沙参等代之)、黄芪、麦冬、五味子、檀香、丹参、甘草、茯苓、郁金、白术、延胡索、广木香、枳实、焦山楂。7.根据76例医案中出现的药物分类统计,导师治疗气阴两虚证型时以补气药、活血化瘀药、理气药、补阴药频次较高。结论:1.导师认为胸痹心痛病的病机在于本虚标实,“本虚”是指心脏虚弱受损,外邪侵袭,心脉阻滞而致心痛;“标实”表现为寒凝、气滞、痰湿、血瘀等,气阴两虚贯穿发病始终。2.在胸痹心痛病的治疗过程中以益气养阴活血为原则贯穿始终,但对病程中存在的其他兼加证型,有针对地加减用药治疗,用药平缓。3.倡导基本病机、基本治法、基本方药的统一。4.“不离乎心,不止乎心”注重胸痹心痛病的发生与肺、脾、肝、肾的关系,整体把握,统筹兼顾。5.医嘱调护,关怀病人,顺应自然,不妄作劳。
[Abstract]:Objective: Professor Yuan Haibo has been engaged in the research and treatment of traditional Chinese medicine in the past 50 years. He is good at using the theory of traditional Chinese medicine to prevent and treat cardiovascular diseases and related visceral diseases in internal medicine. On the basis of inheriting and carrying forward the experience of predecessors in the treatment of cardiovascular diseases, combining with his own clinical experience in the treatment of this disease, he has established the prescription of protecting the Yuan and nourishing the heart and applied it in clinical practice. This topic through follow-up, exchanges with the teacher, collects and summarizes the medical records, summarizes the tutor's theoretical understanding of chest pain, the establishment of the basic background and theoretical basis of Baoyuan Yangxin Formula, explore the composition of Baoyuan Yangxin Formula, prescription justice and clinical application of the drug. The study of medical records summarizes common symptoms, tongue symptoms, pulse symptoms, concurrent syndromes, frequency of drug use, classification of drug functions, etc., which can help to inherit and develop traditional Chinese medicine. Medical research and other publications, collect detailed reading of the tutor's works and articles, repeated reading, research and thinking, focus on the point, do not know where to consult the tutor, experience the tutor's experience in the diagnosis of chest pain, a preliminary summary of the tutor's general understanding of chest pain and maintenance of the basic background of the heart. Record notes, including tutor's medication experience and talk about the doctor's words, often read the memories, after the key and difficult points are marked, consult the tutor, timely academic discussion and communication with the tutor, carefully record the learning content, and further revise, supplement, improve. 2, medical record research 1. Collection of April 2015 to December 2015 during the period of the tutor's use of the maintenance of the Yuan heart recipe treatment. Under the guidance of the tutor, the seventh edition of internal medicine of traditional Chinese medicine (specialty of traditional Chinese medicine, edited by Zhou Zhongying) was used to diagnose chest pain and heartache, and the medicines appearing in the medical records were classified according to the fifth edition of traditional Chinese medicine textbooks. According to the seventh edition of diagnostics of traditional Chinese medicine (specialty of traditional Chinese medicine, edited by Zhu Wenfeng), referring to the National Science and Technology Support Program of the Eleventh Five-Year Plan, Professor Yuan Haibo's academic thinking and clinical experience observation table, standardize the terminology of original medical records, and transform them into norms. 4. Establish Excel medical records database, according to patient number, sex, age, symptoms, tongue, pulse, syndrome type, treatment, prescriptions and medicines intact input, check the database information repeatedly to ensure the accuracy of information. 5. Use SPSS19.0 software, Excel medical records database data using frequency statistical analysis, statistical application of the insurance element. The distribution of sex, age, symptoms, tongue, pulse, syndrome types, treatment methods, prescriptions and medicines of the patients with chest pain caused by Yangxin Recipe were analyzed. Pathogenic angina pectoris, clinical syndrome focus on the distinction between mild and severe, the tutor thinks that the main causes of chest pain are four aspects: invasion of cold and dampness, damaging Yang injury; diet is not good, phlegm and dampness endogenous; seven internal injury, Qi and blood stasis; fatigue and leisure, loss of spleen. Teachers believe that the course of the disease can be divided into three stages, the second stage of heart normal physiological function weakened, self-regulation recovery function limited, patients with obvious symptoms, through rest, recuperation and lifestyle changes can not alleviate the disease, usually choose medical treatment, this stage is the key stage of the treatment of chest pain, but also Baoyuan Yangxin Formula is the foundation and background of Baoyuan Yangxin Square. 3. The Baoyuan Yangxin Formula is made up of Baoyuan Tang, Shengmai San, Danshen Yin and Siwu Tang. The main medicines are Radix Pseudostellariae (Radix Codonopsis), Radix Astragali, Radix Ophiopogonis, Fructus Schisandrae Chinensis, Radix Paeoniae Rubra, Salvia Miltiorrhizae, Sandalwood Seed, Cinnamomum Cassia Branch and Radix Glycyrrhizae. Yangyin Shengjin, Huoxue Huayu. Clinical application in Qi and Yin deficiency and blood stasis syndrome of chest pain more flexible and changeable. 2, medical records 1. Collection of medical records of chest pain patients, 26 men, 50 women, the incidence of elderly people (50 to 70 years old 64 people) in the majority. 2. Collection of medical records, the main emergence of the main. Symptoms are: chest tightness, shortness of breath, chest pain, insomnia, irritability, fatigue and tiredness, panic, dizziness, headache, tinnitus, abdominal distention, nausea, sweating, dry, numb limbs, stool, lower extremities edema, neck pain, belching, lumbar and knee soreness, chills and chills. 3. The main tongue is divided into the following: dull fur thin white, dull fur thick and greasy tongue, dull red fur thin and white tongue, tongue numbness. The dark red fur is thick and greasy, the dark purple of the tongue has the ecchymosis fur thin and delicate, the dark purple of the tongue has the ecchymosis fur thin and white, the light red fur of the tongue is thin and white, the dark edge of the tongue is pointed red fur thin and delicate, the dark edge of the tongue is pointed red fur thin and white. Pulse string is slippery, pulse string sink, pulse string sink, pulse string slippery, pulse string is astringent, pulse string, pulse number, pulse sink slippery, pulse sink fine knot, pulse sink fine and astringent. The most common type is pulse string and pulse sink fine, accounting for 32.4% and 22.4% of the total respectively. 5. The basic syndrome type of chest pain treated by tutor Baoyuan Yangxin Fang is Qi-Yin Deficiency and blood stasis type. According to the statistics of 76 medical cases, 106 kinds of medicines appeared, 1216 times in total, and the most frequently used medicines were Radix Pseudostellariae (or ginseng, Codonopsis pilosulae, Radix Astragali, Radix Ophiopogonis, Fructus Schisandrae, Sandalwood, Radix Salviae Miltiorrhizae miltiorrhizae, Licorice, Poria, etc.). Ling, Tulip, Atractylodes macrocephala, Corydalis yanhusuo, Hibiscus japonicus, Fructus Aurantii, Hawthorn Jiaoshan. 7. According to the drug classification statistics in 76 cases of medical records, the tutor in the treatment of Qi and Yin deficiency syndrome with Qi-tonifying drugs, blood stasis drugs, Qi-regulating drugs, Yin-tonifying drugs frequency is higher. Conclusion: 1. The tutor believes that the pathogenesis of chest pain is in the deficiency of the real, "this deficiency" refers to the damage of the heart weakness. "Bishi" is characterized by cold coagulation, Qi stagnation, phlegm dampness, blood stasis, etc. Qi and Yin deficiency runs through the onset of the disease from beginning to end. 2. In the treatment of thoracic arthralgia and heartache, the principle of Invigorating Qi and nourishing yin and activating blood circulation runs through the whole process, but for other concurrent syndromes existing in the course of the disease, it is necessary to add and subtract medication, and medication is relieved. 3. Basic pathogenesis, basic treatment, the unification of basic prescriptions and medicines. 4. "Do not leave the heart, not only the heart" pay attention to the occurrence of chest pain and heart disease and lung, spleen, liver, kidney relationship, overall grasp, overall consideration. 5. Medical advice care, care for patients, comply with nature, do not rush to work.
【学位授予单位】：河南中医药大学
【学位级别】：硕士
【学位授予年份】：2016
【分类号】：R256.22

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