本文關(guān)鍵詞：ACS患者的臨床特點(diǎn)及與“毒”邪致病相關(guān)性探討　出處：《廣州中醫(yī)藥大學(xué)》2016年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 急性冠脈綜合征 不穩(wěn)定性心絞痛 “毒”邪 中藥 因子分析

【摘要】：目的：臨床研究：采用臨床醫(yī)學(xué)統(tǒng)計(jì)法和臨床流行病學(xué)調(diào)查法,在“毒”邪致病特點(diǎn)基礎(chǔ)上,結(jié)合ACS的臨床特點(diǎn)(包括臨床表現(xiàn)、證候要素、理化結(jié)果、冠脈造影等)地分析,試圖為嶺南地區(qū)ACS中醫(yī)“毒”邪證的辨證提供更多客觀科學(xué)的依據(jù)。通過對嶺南地區(qū)ACS的中藥用藥規(guī)律的研究嘗試從中藥解毒方面,反證ACS中“毒”邪的存在,進(jìn)一步闡釋ACS中解毒法的具體內(nèi)涵。方法：臨床研究：本研究自2015年8月至2015年12月,運(yùn)用小樣本、橫斷面、前瞻性的臨床流行病學(xué)調(diào)查方法對廣州中醫(yī)藥大學(xué)第一附屬醫(yī)院100例ACS患者的臨床特點(diǎn)進(jìn)行調(diào)查,臨床特點(diǎn)包括：一般資料、既往病史、西醫(yī)診斷、冠脈造影結(jié)果、實(shí)驗(yàn)室檢查結(jié)果、臨床癥狀、中醫(yī)主癥計(jì)分、舌脈、中藥等,建立數(shù)據(jù)庫：并根據(jù)“毒”邪致病特點(diǎn),對ACS的臨床主癥進(jìn)行評(píng)分,作為ACS中“毒”邪的辨識(shí)依據(jù),將臨床主癥評(píng)分≥9分為“毒”邪患者,9分為非“毒”患者,然后進(jìn)行臨床病例對照研究。統(tǒng)計(jì)方法采用頻數(shù)分析、T檢驗(yàn)、主成分分析、因子分析、相關(guān)分析等多因素分析方法。結(jié)果：1.影響因素因子分析發(fā)現(xiàn),高UA(尿酸)的載荷值最大,說明高UA(尿酸)在本次研究“毒”邪證發(fā)生的最重要的影響因素,其載荷值為：0.670。其他因素按影響程度的大小排列依次是：糖尿病病史高血脂病史陳舊心梗病史高LDL-C高血壓病史飲酒史吸煙史腦卒中病史TNI(+),其載荷值分別為：0.524、0.500,0.396、0.366、0.335、0.309、0.301、0.286、0.109。“毒”邪組中醫(yī)證候因子分析結(jié)果顯示,氣虛的載荷值最大,說明氣虛在本次研究“毒”邪中醫(yī)證候中是影響最大的中醫(yī)證候。所有中醫(yī)證候按影響程度的大小排列依次是：氣虛、血瘀、痰熱、陽虛、氣滯、寒凝、火熱、陰虛,其載荷值分別為：0.911、0.892、0.828、0.558、0.553、0.488、0.403、0.154�！岸尽毙敖M臨床主癥主成分分析得分結(jié)果顯示,胸痛的載荷值最大,說明胸痛是影響本次研究“毒”邪主癥中最重要的臨床癥狀,其得分為：1.644。其他中醫(yī)主癥按影響程度的大小排列依次是：心悸、乏力、氣短、胸悶,其得分分別為:1.399、1.188、1.160、1.104�！岸尽毙敖M臨床兼癥主成分分析得分結(jié)果顯示,寒癥有畏寒(0.642)；熱癥有面紅(0.705)、目赤(0.704)、口干欲飲(0.475)、便秘(0.540)、自汗(0.453)；痰癥有咳嗽(0.646)、咳痰(0.670)；瘀血癥有自汗(0.453)、口干欲飲(0.475)、便秘(0.540)。舌脈的獨(dú)立樣本T檢驗(yàn)結(jié)果,P值為0.000(P值0.05),有統(tǒng)計(jì)學(xué)意義。舌淡紅、舌白的P值0.05,說明在“毒”邪證與非“毒”證中,二者比較均有統(tǒng)計(jì)學(xué)意義；少苔、脈細(xì)、脈弦滑、脈滑數(shù)的P值0.01,說明在“毒”邪證與非“毒”證中,以上舌脈的統(tǒng)計(jì)學(xué)意義高度顯著。“毒”邪證候要素組合方式中比例較多的是：氣滯+血瘀+氣虛、血瘀+痰熱+氣虛、血瘀+寒凝+氣虛、血瘀+火熱+氣虛。2.通過對嶺南地區(qū)100例ACS“毒”邪組與非“毒”組的影響因素、中醫(yī)證候、臨床癥狀、舌脈、證候要素等相關(guān)分析,四診合參,再結(jié)合中醫(yī)臟腑、氣血津液理論,初步得出ACS中“毒”邪證的臨床辨證標(biāo)準(zhǔn)如下。主要指標(biāo)：(1)胸痛(中或重度)、胸悶(中或重度)、心悸、乏力、氣短總積分≥臨床主癥積分總和的60%;(2)舌暗紅、舌下絡(luò)脈紫絳或紫紅。次要指標(biāo)：(1) hs-CRP3 mg/L；(2)心肌酶(肌酸激酶、肌酸激酶同工酶)或肌鈣蛋白超過正常上限的2倍以上；(3)高血壓史2-3級(jí)；(4)糖尿病病史,FBG710 mmol/L;(5)高膽固醇病史；(6)高尿酸血癥；(7)長期吸煙史、飲酒史。ACS病人符合1個(gè)主要指標(biāo)或2個(gè)次要指標(biāo)(至少含1項(xiàng)生化指標(biāo))即可診斷為“毒”邪。其中生活勞累、性格急躁、飲食辛辣油膩咸是主要誘因。3.依據(jù)“毒”邪不同的始動(dòng)邪氣(火熱、血瘀、痰熱、寒凝),結(jié)合以上中醫(yī)證候、證候要素、臨床癥狀、舌脈的統(tǒng)計(jì)結(jié)果,綜合得出“毒”邪證的分類,臨床可分為熱毒證、瘀毒證、痰毒證、寒毒證。熱毒證：熱盛傷氣陰,故呈現(xiàn)熱毒血瘀、氣陰兩虛證,臨床表現(xiàn)為胸痛甚、胸悶、煩躁易怒、便秘、氣短、自汗、乏力、心悸、舌紅苔黃、脈滑數(shù)等熱毒證。瘀毒證：瘀熱互結(jié),氣陰兩傷,二毒常夾雜為患,臨床表現(xiàn)為胸痛甚、胸悶、口干欲飲、便干便秘、氣短、自汗、乏力、舌暗紅、舌下絡(luò)脈紫紅或絳紫,苔黃膩、脈滑等瘀毒證。痰毒證：痰毒內(nèi)盛、心脾兩虛,臨床多表現(xiàn)胸悶甚、胸痛、咳嗽咳痰、便溏、口淡、氣短、乏力、心悸、頭暈、舌白膩、脈滑細(xì)等痰毒證。寒毒證：寒毒凝聚、心陽不展,臨床多表現(xiàn)胸痛劇烈、畏寒肢冷、氣短明顯、冷汗、乏力、心悸、舌淡暗、脈沉細(xì)緩等寒毒證。4.ACS與“毒”邪致病的相關(guān)病機(jī),(內(nèi))邪氣亢極或蘊(yùn)結(jié)不化而化生(內(nèi))毒,依不同的始動(dòng)邪氣,可分為寒毒、(火)熱毒、痰毒、瘀毒等,形質(zhì)受損,臟腑虛損,或者正衰邪盛,亦可從化為毒,邪可化毒,毒可致邪,最終形成毒瘀搏結(jié)、毒損心絡(luò)、毒損臟腑的惡性循環(huán)�！罢摱臼ⅰ笔茿CS的總的病機(jī),瘀毒阻脈是ACS基本的病理變化(以瘀毒為核心),毒損心絡(luò),毒損臟腑是最終病理變化。5.本次研究從100例我院對嶺南地區(qū)ACS的用藥統(tǒng)計(jì)結(jié)果,結(jié)合嶺南地區(qū)土卑地薄,氣候炎熱,暑濕為盛的氣候特點(diǎn),藥類分析結(jié)果：活血藥清熱藥補(bǔ)氣藥化痰藥理氣藥祛濕藥補(bǔ)陰藥。藥頻分析結(jié)果,祛邪藥排列前五味中藥為：川芎、赤芍、紅花、丹參、降香、毛冬青；補(bǔ)虛藥排列前五味中藥為：炙甘草、黃芪、黨參、白術(shù)、茯苓。從中藥藥類、頻數(shù)使用情況,以藥測證,反推得出嶺南地區(qū)ACS患者的主要臨床證候：熱毒血瘀、氣陰兩虛證。6.在ACS“毒”邪致病體系中,分為外毒、內(nèi)毒致病。外毒以疫毒、煙酒毒等為主,以祛邪解毒法為主,祛疫毒、祛或戒煙酒毒等。內(nèi)毒除活血解毒外,還要能夠結(jié)合產(chǎn)生毒邪的始動(dòng)邪氣確立相應(yīng)治法,如清熱解毒、散寒解毒、利濕解毒、祛風(fēng)解毒、潤燥解毒、清營解毒、扶正解毒等。7.根據(jù)本次研究中藥用藥規(guī)律,藥證相應(yīng),以“扶正解毒”為治則,初步整理歸納出嶺南地區(qū)ACS的中醫(yī)解毒方劑—解毒活血湯。結(jié)論：臨床研究：通過數(shù)理統(tǒng)計(jì)的結(jié)果與中醫(yī)理論、臨床經(jīng)驗(yàn)相結(jié)合,可以得出相對客觀的ACS中醫(yī)“毒”邪證的臨床診斷及量化標(biāo)準(zhǔn),前瞻性的臨床調(diào)查與多因素?cái)?shù)理統(tǒng)計(jì)分析相結(jié)合是進(jìn)行ACS中醫(yī)“毒”邪證辨證標(biāo)準(zhǔn)客觀化研究的一種有效方法,值得進(jìn)一步深入研究。中醫(yī)強(qiáng)調(diào)因地制宜,故本研究針對嶺南地區(qū)ACS患者的臨床特點(diǎn)、中藥治療與“毒”邪及相關(guān)病機(jī)的相關(guān)性研究,為以后深入探討提供了研究基礎(chǔ)及參考模式,有利于日后進(jìn)行大樣本、多中心、橫斷面、前瞻性臨床流行病學(xué)的調(diào)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.鈥滄瘨鈥濋偑緇勪復(fù)搴婂吋鐥囦富鎴愬垎鍒嗘瀽寰楀垎緇撴灉鏄劇ず,瀵掔棁鏈夌晱瀵，

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