發(fā)布時間：2017-12-30 23:49

  本文關(guān)鍵詞：曹玉山教授學(xué)術(shù)思想與辨治冠心病的臨床經(jīng)驗研究　出處：《中國中醫(yī)科學(xué)院》2016年博士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 曹玉山 學(xué)術(shù)思想 冠心病 臨床經(jīng)驗研究 通冠湯

【摘要】：冠心病是目前全球范圍內(nèi)嚴(yán)重危害人們身體健康的常見病、多發(fā)病,盡管現(xiàn)代醫(yī)學(xué)在治療冠心病方面取得了很大進(jìn)步,但因患者長期服用藥物的副作用和耐藥性等問題使得冠心病的防治仍是當(dāng)今醫(yī)學(xué)的難點。中醫(yī)藥在防治冠心病方面有其獨(dú)特的優(yōu)勢,值得臨床研究與推廣本論文分為三個部分,第一部分是中醫(yī)藥診治冠心病的文獻(xiàn)綜述,詳絀介紹了歷代中醫(yī)藥學(xué)家對冠心病在中醫(yī)學(xué)中的病名、病因、病機(jī)和治療的認(rèn)識及現(xiàn)代中醫(yī)學(xué)者對冠心病病因、病機(jī)及中醫(yī)藥診治的研究進(jìn)展。第二部分詳細(xì)介紹老師學(xué)術(shù)思想和臨床診治冠心病的經(jīng)驗。老師的學(xué)術(shù)思想可以概括總結(jié)為以下八個方面：勤研經(jīng)典、衷中參西；辨病辨證、病證合參；天人合一、整體調(diào)治：痰瘀相關(guān)、痰瘀同治：氣血同調(diào)、尤重益氣；謹(jǐn)遵古訓(xùn)、繼承創(chuàng)新；未病先防、有病早治；善用藥對、療效顯著。老師認(rèn)為冠心病在中醫(yī)學(xué)中屬“胸痹、心痛”范疇,但中醫(yī)學(xué)“胸痹”還包括除了冠心病之外的呼吸、消化等其它系統(tǒng)疾病。老師認(rèn)為冠心病中醫(yī)病因主要有勞逸失度傷氣,氣虛血瘀;年邁體弱腎虛,陰陽不足；陽虛風(fēng)寒入侵,心脈痹阻：熱邪內(nèi)舍于心,心脈郁閉；情志失調(diào)傷心,氣滯血瘀；飲食失宜傷脾,痰瘀互結(jié)。特別強(qiáng)調(diào)痰飲、瘀血致病。對于冠心病的病機(jī),老師認(rèn)為其屬本虛標(biāo)實之證,病變之本,在于氣血虧虛,以氣虛為主,心脈失養(yǎng),不榮則痛,尤其注重宗氣不足在冠心病發(fā)病中的作用。病變之標(biāo),在于三焦氣化失司,痰飲、瘀血痹阻心脈,不通則痛,虛實二端互為影響,相互致病。治療時謹(jǐn)守病機(jī)、通補(bǔ)兼施,標(biāo)本兼顧,治病之本,注重調(diào)補(bǔ)宗氣(補(bǔ)宗氣,生心血,安心神；調(diào)宗氣,行心脈,止痹痛)：治病之標(biāo),以通利三焦為主。審因論治,痰瘀同化貫穿整個冠心病病程始終。第三部分為老師臨床經(jīng)驗方通冠湯治療冠心病穩(wěn)定型心絞痛(氣血虧虛、痰瘀互阻)的臨床研究。目的：通過觀察通冠湯治療冠心病穩(wěn)定型心絞痛(氣血虧虛、痰瘀互阻)的臨床療效和安全性,探討通冠湯治療冠心病穩(wěn)定型心絞痛可能的作用機(jī)制,為臨床中醫(yī)藥治療冠心病提供安全有效的方法。方法：收集甘肅中醫(yī)藥大學(xué)附屬醫(yī)院名中醫(yī)工作站門診或住院部的冠心病穩(wěn)定型心絞痛(氣血虧虛、痰瘀互阻)患者60例,依據(jù)隨機(jī)對照原則將其分為治療組和對照組,每組患者各30例。冠心病中西醫(yī)診斷標(biāo)準(zhǔn)及其他試驗標(biāo)準(zhǔn)參考國際國內(nèi)統(tǒng)一標(biāo)準(zhǔn),并結(jié)合老師臨床經(jīng)驗綜合制定。對照組給以西醫(yī)基礎(chǔ)治療,治療組在西醫(yī)治療的基礎(chǔ)上給以通冠湯,早晚飯后半小時溫服,每日2次,觀察療程為4周。期間觀察指標(biāo)為：(1)安全性指標(biāo)：血常規(guī)、尿常規(guī)、肝腎功能、不良反應(yīng)；(2)療效性指標(biāo)：心絞痛療效、中醫(yī)癥狀、中醫(yī)證候、心電圖、血脂四項、凝血系列、血液流變學(xué)、同型半胱氨酸、D-二聚體。數(shù)據(jù)統(tǒng)計分析采用SPSS19.0統(tǒng)計軟件分析,所有計量資料用均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,一般組間比較用t檢驗,等級資料采用秩和檢驗,計數(shù)資料采用χ2檢驗,不服從χ2檢驗條件用Fisher確切概率法,P0.05為有統(tǒng)計學(xué)意義。結(jié)果：治療觀察4周后,(1)兩組患者治療前后心絞痛療效比較：治療組顯效19例(63.33%)、有效7例(23.33%),總有效26例(86.67%),對照組顯效18例(60%)、有效6例(20%),總有效24例(80%),兩組患者治療前后的比較采用四格表卡方檢驗得,χ2=0.48,P=0.49,按α=0.05水準(zhǔn),由此可得兩組患者治療前后心絞痛療效比較無統(tǒng)計學(xué)意義,故認(rèn)為兩組患者治療前后心絞痛療效比較無差別。(2)兩組患者治療前后中醫(yī)癥狀療效比較：治療組患者治療后胸悶、胸痛、心悸、氣短、倦怠疲乏、自汗明顯改善,癥狀積分均明顯下降,對照組患者胸悶、胸痛癥狀較治療前改善,癥狀積分下降。由于中醫(yī)癥狀所整理的數(shù)據(jù)為等級資料,故對兩組患者治療前后中醫(yī)癥狀的差值進(jìn)行兩獨(dú)立樣本的秩和檢驗得：P0.05,可知兩組患者治療前后中醫(yī)癥狀積分差值的差異有統(tǒng)計學(xué)意義,并且治療組治療前后中醫(yī)癥狀差值的秩均值均大于對照組治療前后中醫(yī)癥狀差值的秩均值,故可認(rèn)為治療組療效優(yōu)于對照組。(3)兩組患者治療前后中醫(yī)證候療效比較：治療組顯效13例(43.33%),有效12例(40%),總有效率為83.33%;對照組顯效8例(26.67%),有效10例(33.33%),總有效率為60%。兩組患者治療前后的比較采用四格表卡方檢驗得,χ2=4.02,P=-0.04,按α=0.05水準(zhǔn),可知治療組和對照組中醫(yī)證候療效差別有統(tǒng)計學(xué)意義。(4)兩組患者治療前后心電圖療效比較：治療組顯效14例(46.67%)、有效8例(26.67%),總有效22例(73.33%),對照組顯效8例(26.67%)、有效8例(26.67%),總有效16例(53.33%),兩組患者治療前后心電圖療效的比較采用四格表卡方檢驗得,χ2=2.58,P=0.11,按α=0.05水準(zhǔn),可知治療組和對照組心電圖療效差異無統(tǒng)計學(xué)意義,故不能認(rèn)為兩組患者心電圖療效有差別。(5)兩組患者治療前后消心痛停、減情況比較：治療組消心痛停藥12人、減量14人,總停減26例,總有效率86.67%,對照組消心痛停藥7人、減量11人,總停減18例,總有效率是60%,對兩組患者治療前后消心痛減率的比較采用四格表卡方檢驗得,χ2=5.46,P=0.02,按α=0.05水準(zhǔn),可知治療組和對照組消心痛停減率差別有統(tǒng)計學(xué)意義,且治療組有效率(86.67%)高于對照組有效率(60%)。(6)兩組患者治療前后血脂代謝改善療效比較：兩組患者治療后LDL-C均降低,HDL-C升高,對兩組患者治療前后血脂代謝的差值進(jìn)行兩獨(dú)立樣本t檢驗得：P0.05,可知兩組患者治療前后血脂代謝差值的差異有統(tǒng)計學(xué)意義,又因為治療組治療前后血脂代謝差值的絕對值均大于對照組治療前后血脂代謝差值的絕對值,故可認(rèn)為治療組的療效優(yōu)于對照組。(7)兩組患者治療前后凝血指標(biāo)變化比較：治療組在治療后APTT、TT明顯延長,Fib含量明顯下降,對兩組患者治療前后凝血指標(biāo)的差值進(jìn)行兩獨(dú)立樣本t檢驗得：P0.05,可知兩組患者治療前后凝血指標(biāo)差值的差異有統(tǒng)計學(xué)意義,又因為治療組在治療前后凝血指標(biāo)差值的絕對值均大于對照組治療前后凝血指標(biāo)差值的絕對值,故可認(rèn)為治療組的療效優(yōu)于對照組。(8)兩組患者治療前后血液流變學(xué)指標(biāo)變化比較：治療組在治療后全血黏度1、全血黏度5、全血黏度30、全血黏度200、血漿黏度、紅細(xì)胞聚集指數(shù)明顯降低,對兩組患者治療前后上述血液流變學(xué)指標(biāo)變化的差值進(jìn)行兩獨(dú)立樣本t檢驗得：P0.05,可知兩組患者治療前后血液流變學(xué)指標(biāo)變化差值的差異有統(tǒng)計學(xué)意義,又因為治療組在治療前后血液流變學(xué)指標(biāo)變化差值的絕對值均大于對照組治療前后血液流變學(xué)指標(biāo)變化差值,故可認(rèn)為治療組的療效優(yōu)于對照組。(9)兩組患者治療前后D-二聚體、HCY指標(biāo)變化比較：治療組在治療后D-二聚體、HCY含量均明顯下降,對兩組患者治療前后HCY和D-二聚體含量的差值進(jìn)行兩獨(dú)立樣本t檢驗得：P0.05,可知兩組患者治療前后D-二聚體和HCY的差異有統(tǒng)計學(xué)意義,且因為治療組在治療前后D-二聚體和HCY差值的均值大于對照組在治療前后D-二聚體和HCY差值的均值,故可認(rèn)為治療組的療效優(yōu)于對照組。結(jié)論：在西醫(yī)基礎(chǔ)治療上加服通冠湯可以明顯減輕冠心病患者心絞痛發(fā)作時的胸悶、胸痛、心悸、氣短、疲乏、自汗等癥狀,減少硝酸酯類藥物的使用量,改善患者心電圖和血脂代謝紊亂,改善患者凝血系列指標(biāo)和血液流變學(xué)指標(biāo),并能降低冠心病患者血漿D-二聚體和血清HCY水平。治療前后患者肝、腎功能及血、尿常規(guī)無明顯變化,無明顯不良反應(yīng)。說明通冠湯在治療冠心病穩(wěn)定型心絞痛(氣血虧虛、痰瘀互阻)時臨床療效顯著,用藥安全可靠。
[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緋誨垪,琛，

本文編號：1357112