本文選題：穩(wěn)定型心絞痛 + 虛實(shí)證候��； 參考：《中國(guó)中醫(yī)科學(xué)院》2017年博士論文

【摘要】：目的研究采用反映人體自主神經(jīng)功能狀態(tài)的心率變異性(heart rate variability,HRV)時(shí)域和頻域指標(biāo),觀察穩(wěn)定型心絞痛(stable angina pectoris,SAP)實(shí)證、虛證及虛實(shí)夾雜證患者自主神經(jīng)功能狀態(tài);采用能描述人體生理病理非線性混沌特征及程度的HRV非線性參數(shù)指標(biāo),觀察SAP實(shí)證、虛證及虛實(shí)夾雜證患者自主神經(jīng)功能不同狀態(tài)下的混沌特征,探索揭示SAP實(shí)證、虛證及虛實(shí)夾雜證與自主神經(jīng)功能變化及其非線性特征的關(guān)系。方法共納入231例SAP患者,采用中醫(yī)癥狀及四診信息問(wèn)卷表(見(jiàn)附表)采集SAP患者的辨證信息,依據(jù)《中醫(yī)病證診斷療效標(biāo)準(zhǔn)》、《冠心病中醫(yī)辨證標(biāo)準(zhǔn)》及《中醫(yī)內(nèi)科學(xué)》“胸痹虛實(shí)辨證要點(diǎn)”作為虛實(shí)證候分類標(biāo)準(zhǔn),對(duì)每個(gè)研究對(duì)象進(jìn)行虛實(shí)辨證。依據(jù)中醫(yī)虛實(shí)辨證結(jié)果,分為三組:實(shí)證42例(18.18%),虛證48例(20.78%),虛實(shí)夾雜證141例(61.04%)。采用美國(guó)DMS動(dòng)態(tài)心電圖記錄儀采集患者全天24 h心電信號(hào),計(jì)算全天時(shí)域、頻域及非線性參數(shù)(復(fù)雜度、近似熵和關(guān)聯(lián)維值)指標(biāo)。同時(shí)利用小波變化技術(shù),從全部24 h動(dòng)態(tài)心電數(shù)據(jù)中提取出不同頻段(HF、LF、VLF、ULF)的HRV信息指標(biāo),并將分布在各個(gè)頻段下(全頻段、HF、LF、VLF、ULF)的24h動(dòng)態(tài)心電數(shù)據(jù)的HRV信息,按時(shí)間順序分成每小時(shí)一段,計(jì)算各個(gè)小時(shí)中HRV的復(fù)雜度、近似熵、關(guān)聯(lián)維等非線性參數(shù)。利用SPSS19.0統(tǒng)計(jì)軟件,采用方差分析、非參數(shù)檢驗(yàn)、重復(fù)測(cè)量的方差分析的方法對(duì)不同虛實(shí)證候患者自主神經(jīng)功能狀態(tài)、混沌程度及其在不同頻段下的晝夜動(dòng)態(tài)變化趨勢(shì)特征進(jìn)行分析研究。結(jié)果(1)SAP不同虛實(shí)證候患者的HRV時(shí)域指標(biāo)不同,表現(xiàn)為反映自主神經(jīng)功能總能量的SDNN、反映迷走張力的rMSSD指標(biāo)均呈實(shí)證組虛實(shí)夾雜證組≈虛證組;雜證組與虛證組間雖無(wú)統(tǒng)計(jì)學(xué)差異,但呈雜證虛證的趨勢(shì)。根據(jù)SDNN的正常參考值,SDNN100ms為正常,因此實(shí)證組的SDNN仍在正常范圍內(nèi),而虛實(shí)夾雜證和虛證組的SDNN值均低于正常范圍。(2)與HRV時(shí)域指標(biāo)的結(jié)果近似,本組資料頻域指標(biāo)研究結(jié)果表明:總功率(TP)、高頻(HF)、低頻(LF)指標(biāo)均呈實(shí)證組虛實(shí)夾雜證組≈虛證組;雜證組與虛證組間雖無(wú)統(tǒng)計(jì)學(xué)差異,但呈雜證虛證的趨勢(shì)。(3)本組資料非線性參數(shù)的研究結(jié)果表明:非線性分析采用復(fù)雜度(反映數(shù)據(jù)在時(shí)間序列上的復(fù)雜性,表達(dá)系統(tǒng)非線性變化速度)、近似熵(反映數(shù)據(jù)在結(jié)構(gòu)上的復(fù)雜性,表達(dá)系統(tǒng)變化模式復(fù)雜程度)、關(guān)聯(lián)維(反映系統(tǒng)維度復(fù)雜性)指標(biāo)。復(fù)雜度表現(xiàn)為實(shí)證組虛實(shí)夾雜證組虛證組;近似熵虛實(shí)雜3組間雖無(wú)統(tǒng)計(jì)學(xué)差異,但仍呈實(shí)證組虛實(shí)夾雜證組虛證組的趨勢(shì);而關(guān)聯(lián)維則表現(xiàn)為雜證組虛證組,其余組間無(wú)明顯差異。(4)全頻頻段下HRV非線性指標(biāo)的晝夜動(dòng)態(tài)變化特征:①虛實(shí)雜3組間復(fù)雜度曲線的分布位置呈實(shí)證組雜證組虛證組,3組復(fù)雜度參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;②虛實(shí)雜3組間近似熵曲線的分布位置間無(wú)明顯差異;3組近似熵參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;③虛實(shí)雜3組間關(guān)聯(lián)維曲線的分布位置呈實(shí)證組雜證組虛證組,3組關(guān)聯(lián)維參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致。(5)HF頻段下HRV非線性指標(biāo)的晝夜動(dòng)態(tài)變化特征:①虛實(shí)雜3組間復(fù)雜度曲線的分布位置呈實(shí)證雜證≈虛證,3組復(fù)雜度參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;②虛實(shí)雜3組間近似熵曲線的分布位置呈實(shí)證雜證≈虛證,3組近似熵參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;③虛實(shí)雜3組間關(guān)聯(lián)維曲線的分布位置間無(wú)明顯差異,3組關(guān)聯(lián)維參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致。(6)LF頻段下HRV非線性指標(biāo)的晝夜動(dòng)態(tài)變化特征:①虛實(shí)雜3組間復(fù)雜度曲線的分布位置呈實(shí)證雜證≈虛證,3組復(fù)雜度參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)不一致,實(shí)證復(fù)雜度水平全天的波動(dòng)幅度較大,虛證和虛實(shí)夾雜證復(fù)雜度水平全天的波動(dòng)幅度較小;②LF頻段下虛實(shí)雜3組間近似熵曲線的分布位置間無(wú)明顯差異,近似熵參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;③虛實(shí)雜3組間關(guān)聯(lián)維曲線的分布位置呈實(shí)證組雜證組虛證組,3組關(guān)聯(lián)維參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致。(7)VLF頻段下HRV非線性指標(biāo)的晝夜動(dòng)態(tài)變化特征:①虛實(shí)雜3組間復(fù)雜度曲線的分布位置間無(wú)明顯差異,但呈實(shí)證組≈雜證組虛證組的趨勢(shì);3組復(fù)雜度參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;②虛實(shí)雜3組間近似熵曲線的分布位置間無(wú)明顯差異;3組近似熵參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;③虛實(shí)雜3組間關(guān)聯(lián)維曲線的分布位置呈實(shí)證組≈雜證組虛證組;3組關(guān)聯(lián)維參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致。(8)ULF頻段下HRV非線性指標(biāo)的晝夜動(dòng)態(tài)變化特征:①虛實(shí)雜3組間復(fù)雜度曲線的分布位置間無(wú)明顯差異;3組復(fù)雜度參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;②虛實(shí)雜3組間近似熵曲線的分布位置間無(wú)明顯差異;3組近似熵參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致;③虛實(shí)雜3組間關(guān)聯(lián)維曲線的分布位置間無(wú)明顯差異;3組關(guān)聯(lián)維參數(shù)曲線的晝夜動(dòng)態(tài)變化趨勢(shì)一致。結(jié)論1.實(shí)證患者不伴有明顯的自主神經(jīng)功能損傷,虛證患者伴有明顯的自主神經(jīng)功能損傷。與實(shí)證相比,虛證患者的自主神經(jīng)功能總能量、迷走神經(jīng)張力以及交感神經(jīng)張力均明顯降低。2.證候演變過(guò)程中,由實(shí)證轉(zhuǎn)變?yōu)樘搶?shí)夾雜證時(shí),自主神經(jīng)張力降低,表現(xiàn)為迷走和交感張力活性均降低,可能以迷走張力受損為主;而虛實(shí)夾雜證向虛證轉(zhuǎn)化時(shí),自主神經(jīng)張力降低,主要以交感張力活性降低為主。3.非線性指標(biāo)的分析結(jié)果提示,實(shí)證證候的混沌特征較虛證證候更加明顯,而虛證證候更容易伴有人體混沌特性的衰減和喪失,這符合目前非線性研究領(lǐng)域中對(duì)疾病及預(yù)后不良的定義。4.本研究的觀察結(jié)果顯示,無(wú)論復(fù)雜度、近似熵、關(guān)聯(lián)維這3個(gè)指標(biāo)都呈實(shí)證最大,虛證最小的趨勢(shì),提示非線性參數(shù)的研究結(jié)果與時(shí)域、頻域指標(biāo)的觀察結(jié)果相互支撐。5.不同非線性參數(shù)在不同頻段對(duì)虛實(shí)證候的區(qū)分度和敏感性不一樣,提示復(fù)雜度、近似熵、關(guān)聯(lián)維三個(gè)指標(biāo)可從不同側(cè)面、不同程度反映系統(tǒng)的混沌特征。
[Abstract]:Objective to study the parameters of heart rate variability (HRV) in time domain and frequency domain, which reflect the state of human autonomic nervous function (HRV), and to observe the autonomic nervous function state of patients with stable angina pectoris (stable angina pectoris, SAP), deficiency syndrome and false and real inclusion syndrome, and to describe the characteristics and degree of nonlinear chaos in human body's physiological and pathological characteristics. The HRV nonlinear parameter index was used to observe the chaotic characteristics of the patients with SAP demonstration, deficiency syndrome and false and real inclusion syndrome in different state of autonomic nervous function, and explore the relationship between SAP demonstration, deficiency syndrome and false and real inclusion syndrome and the change of autonomic nervous function and its nonlinear characteristics. Methods 231 cases of SAP patients were included, the symptoms of traditional Chinese medicine and the four diagnosis information questionnaire were adopted. The table (see table) collects the syndrome differentiation information of SAP patients. According to the standard of TCM syndrome diagnosis, TCM syndrome differentiation, TCM internal medicine and TCM internal medicine, the syndrome differentiation criterion of deficiency and actual syndrome is used for the syndrome differentiation. According to the syndrome differentiation results of Chinese medical deficiency and reality, three groups are divided into 42 cases (18.18%), There were 48 cases (20.78%) and 141 cases (61.04%) of false and real inclusion syndrome. The whole day 24 h cardiac electrical signal was collected by DMS dynamic electrocardiogram recorder in the United States. The whole day time domain, frequency domain and nonlinear parameters (complexity, approximate entropy and associated dimension) were calculated. At the same time, the different frequency bands (HF) were extracted from all 24 h dynamic ECG data by using the wavelet transform technique. The HRV information index of LF, VLF, ULF) and HRV information of the 24h dynamic ECG data distributed in each frequency band (all frequency bands, HF, LF, VLF, ULF), divided into each hour in order of time, calculating the complexity, approximate entropy, correlation dimension and other non linear parameters of HRV in each hour. Using the SPSS19.0 statistics software, the variance analysis, non parametric test, The method of variance analysis of repeated measurements was used to analyze the autonomic nervous function status of patients with different deficiency and solid syndromes, the chaotic degree and the trend characteristics of day and night dynamic changes under different frequency bands. Results (1) the HRV time domain index of patients with different deficiency and solid syndrome of SAP was different, showing the SDNN reflecting the total energy of autonomic nerve function, reflecting the vagal walk. The rMSSD indexes of tension were all in the group of false and solid syndrome group, although there was no statistical difference between the group and the deficiency syndrome group, but the normal reference value of SDNN, SDNN100ms was normal, so the SDNN of the positive group was still in the normal range, and the SDNN value of the deficiency and real inclusion complex and the deficiency syndrome group were all lower than that of the normal range. (2) The results of the data frequency domain index of this group showed that the total power (TP), high frequency (HF) and low frequency (LF) index were all the deficiency syndrome group in the empirical group, although there was no statistical difference between the miscellaneous and the false evidence groups, but the trend of the false evidence of miscellaneous evidence was found. (3) the research results of the nonlinear parameters of this group showed that the nonlinearity was nonlinear. The analysis uses complexity (reflecting the complexity of the data in time series, expressing the nonlinear changing speed of the system), the approximate entropy (reflecting the complexity of the data in the structure, expressing the complexity of the system change pattern), the correlation dimension (reflecting the complexity of the system dimension). The complex degree of complexity is represented by the false evidence group of the false and real inclusion group in the empirical group, and the approximate entropy deficiency. Although there was no statistical difference between the 3 groups, there were still the trend of deficiency syndrome group in the positive group, but the correlation dimension was the deficiency syndrome group of the mixed syndrome group, and there was no significant difference between the other groups. (4) the Diurnal Dynamic Change Characteristics of the HRV nonlinear indexes under the full frequency band: (1) the distribution of the complex degree curve between the 3 groups of virtual and solid groups showed the deficiency of the empirical group. The circadian dynamic variation trend of the 3 groups of complex parameter curves is consistent, and there is no obvious difference between the distribution positions of the approximate entropy curves between the 3 groups of virtual and real complex; the trend of the day and night dynamic change of the 3 groups of approximate entropy parameter curves is the same. (3) the distribution position of the correlation dimension curves between the 3 groups of the virtual and solid groups shows the false evidence group of the demonstration group and the 3 groups of correlation dimension parameter curves. The trend of day and night dynamic changes is consistent. (5) the characteristics of the Diurnal Dynamic Changes of the HRV nonlinear indexes under the HF frequency band: (1) the distribution position of the complexity curves between the 3 groups of virtual and real complex is an empirical evidence, and the trend of the day and night dynamic change of the 3 groups of complex parameter curves is consistent; and the distribution position of the approximate entropy curves between the 3 groups of the virtual and solid groups is an empirical miscellaneous evidence The trend of the circadian dynamic changes in the 3 groups of approximate entropy parameter curves is consistent. (3) there is no obvious difference between the distribution positions of the correlation dimension curves between the 3 groups of virtual and solid groups, and the trend of the Diurnal Dynamic Changes of the 3 groups of correlation dimension parameters is consistent. (6) the Diurnal Dynamic Change Characteristics of the HRV nonlinear index under the LF band: (1) the distribution position of the complexity curve between the 3 groups of virtual and solid groups The circadian dynamic variation trend of the 3 groups of complex parameter curves is not consistent, the volatility of the empirical complexity level is larger throughout the day, and the complexity of the deficiency syndrome and the false and real inclusion complex level is smaller throughout the day; there is no obvious difference between the approximate entropy curves between the 3 groups of virtual and real miscellaneous groups under the LF band, and the approximate entropy parameters are not found. The trend of the circadian dynamic change of the curve is consistent; (3) the distribution position of the 3 groups of associated dimension curves between the virtual and solid groups shows the false evidence group of the demonstration group, and the trend of the Diurnal Dynamic Changes of the 3 groups of association dimension parameters is consistent. (7) the Diurnal Dynamic Change Characteristics of the HRV nonlinear index under the VLF band: (1) the distribution of the complex degree curve between the 3 groups of the virtual and solid groups is not clear The trend of the deficiency syndrome group in the 3 groups of complex parameter curves is consistent, and there is no obvious difference between the distribution positions of the approximate entropy curves between the 3 groups of virtual and real complex; the trend of the Diurnal Dynamic Changes of the approximate entropy parameter curves of the 3 groups is the same; (3) the distribution position of the correlation dimension curves between the 3 groups of virtual and real miscellaneous groups is real The diurnal dynamic change trend of the 3 groups of correlation dimension parameter curves in the 3 groups is consistent. (8) the Diurnal Dynamic Change Characteristics of the HRV nonlinear indexes under the ULF frequency band: (1) there is no obvious difference between the distribution positions of the complexity curves between the 3 groups of virtual and solid groups; the trend of the day and night dynamic change of the 3 groups of complex parameter curves is the same; (2) the 3 groups of virtual and real miscellaneous groups are close between the two groups. There is no obvious difference between the distribution positions of the entropy like curve, and the trend of the circadian dynamic changes in the 3 groups of approximate entropy parameter curves is consistent, and there is no obvious difference between the distribution positions of the associated dimension curves between the 3 groups of virtual and solid complex; the trend of the Diurnal Dynamic Changes of the 3 groups of correlation dimension curves is consistent. Conclusion 1. positive patients have no obvious impairment of autonomic nervous function. The total energy of the autonomic nervous function, the vagus nerve tension and the sympathetic nerve tension of the patients with deficiency syndrome significantly reduced the evolution process of.2. syndrome, and the tension of autonomic nerve decreased and the activity of vagus and sympathetic tension decreased. When the syndrome of false and solid inclusion is transformed to the deficiency syndrome, the tension of the autonomic nerve is reduced, and the analysis results of the decrease in the activity of sympathetic tensility mainly based on the.3. nonlinear index indicate that the chaotic characteristic of the syndrome is more obvious than the deficiency syndrome, and the deficiency syndrome is more likely to be accompanied by the attenuation and loss of the human body's chaotic characteristics. This is in line with the current research on the definition of disease and poor prognosis in the field of nonlinear research. The results of the.4. study show that the 3 indexes of complexity, approximate entropy and correlation dimension are the most positive, and the trend of the least false evidence suggests that the results of the nonlinear parameter study and the time domain and the observation results of the frequency domain index support the different nonlinearity of the.5.. The degree and sensitivity of parameters in different frequency bands are different in the area of virtual and real syndrome. It suggests that three indexes of complexity, approximate entropy and correlation dimension can be from different sides, and the chaotic characteristics of the system are reflected in different degrees.

【學(xué)位授予單位】：中國(guó)中醫(yī)科學(xué)院
【學(xué)位級(jí)別】：博士
【學(xué)位授予年份】：2017
【分類號(hào)】：R541.4

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本文編號(hào)：1822963