本文選題：介入后冠心病 + 辨證用藥��； 參考：《中國中醫(yī)科學(xué)院》2017年碩士論文

【摘要】：經(jīng)皮冠狀動(dòng)脈介入治療(percutaneous coronary intervention,PCI)是冠狀動(dòng)脈狹窄或閉塞后改善心肌血流灌注的有效方法,從1977年對(duì)冠狀動(dòng)脈粥樣硬化狹窄病變進(jìn)行經(jīng)皮冠狀動(dòng)脈腔內(nèi)成形術(shù),至今已有40年的歷史。我國從1984年開展PCI到2013年,由每年幾十例增至每年45萬例左右。冠脈支架植入的血運(yùn)重建機(jī)制主要是血管重塑,但只能解決血管病變部位狹窄,并不能解決心臟所有動(dòng)脈的狹窄病變,更沒有消除引起動(dòng)脈粥樣硬化狹窄的原因,且同時(shí)存在再狹窄、血栓形成、心肌組織無復(fù)流等問題,影響了臨床預(yù)后。中藥可作用于PCI后相關(guān)病理改變的多個(gè)病理環(huán)節(jié),對(duì)改善預(yù)后有重要意義。史大卓教授在“病證結(jié)合”治療介入后冠心病方面,形成了自己的診療特色。本研究在對(duì)導(dǎo)師診療介入術(shù)后冠心病臨床經(jīng)驗(yàn)學(xué)習(xí)總結(jié)的基礎(chǔ)上,應(yīng)用數(shù)理統(tǒng)計(jì)學(xué)方法和數(shù)據(jù)挖掘技術(shù),從理、法、方、藥方面,對(duì)導(dǎo)師治療介入后冠心病的遣方用藥特點(diǎn)進(jìn)行了系統(tǒng)研究。一.文獻(xiàn)綜述:益氣活血解毒法治療冠狀動(dòng)脈支架術(shù)后進(jìn)展通過對(duì)益氣活血解毒方藥治療冠狀動(dòng)脈支架術(shù)后相關(guān)文獻(xiàn)的綜述分析,發(fā)現(xiàn)血瘀和氣虛是PCI后冠心病的主要證候要素,氣虛血瘀是冠心病PCI術(shù)后的基本病機(jī),益氣活血是介入后冠心病主要治法,瘀血阻滯脈絡(luò)、日久蘊(yùn)積化毒、因毒致變是發(fā)生心血管病事件的關(guān)鍵。二.經(jīng)驗(yàn)總結(jié):史大卓教授治療介入后冠心病的臨床經(jīng)驗(yàn)史大卓教授治療PCI后冠心病,擅于中醫(yī)個(gè)體化宏觀辨證和病理生理變化相結(jié)合,中藥的寒熱溫涼屬性和現(xiàn)代藥理研究成果相結(jié)合,具體表現(xiàn)為以下幾個(gè)方面:(1)通陽宣痹注重豁痰化痰、散寒通痹;(2)在活血化瘀的基礎(chǔ)上和解毒藥有機(jī)結(jié)合:(3)補(bǔ)氣強(qiáng)調(diào)不但要補(bǔ)心氣、補(bǔ)宗氣,還要注意補(bǔ)中氣、補(bǔ)元?dú)?(4)補(bǔ)益肝腎強(qiáng)調(diào)甘溫補(bǔ)腎;(5)圓機(jī)活法,注意結(jié)合通絡(luò)、安神、活血利水等法。三.臨床研究:基于數(shù)據(jù)挖掘技術(shù)研究史大卓治療介入后冠心病遣方用藥規(guī)律目的:挖掘分析史大卓教授辨治介入后冠心病的遣方用藥特點(diǎn)和規(guī)律。方法:利用中國中醫(yī)科學(xué)院信息研究所開發(fā)的名老中醫(yī)臨床診療共享系統(tǒng),進(jìn)行臨床信息的采集、存儲(chǔ),利用ETL工具進(jìn)行數(shù)據(jù)管理,利用SPSS13.0軟件進(jìn)行統(tǒng)計(jì)分析,利用中醫(yī)臨床科研信息共享系統(tǒng)對(duì)中藥性味歸經(jīng)進(jìn)行聯(lián)機(jī)分析(OLAP),關(guān)聯(lián)規(guī)則分析藥對(duì)特點(diǎn),聚類分析方劑組合,復(fù)雜網(wǎng)絡(luò)分析配伍規(guī)律。對(duì)史大卓教授治療介入后冠心病的遣方用藥特點(diǎn)進(jìn)行挖掘分析。結(jié)果:1.共計(jì)入選317例患者,1165診次,其中男性208例,占65.62%;女性109例,占34.38%。年齡23-88歲,平均年齡60.545歲。發(fā)病年齡主要分布在40至80歲之間。2.臨床合并病以高脂血癥(122例,占7.58%)最常見,其后依次是高血壓(85例,占5.28%)、糖尿病(40例,占2.49%)慢性心力衰竭(27例,占1.68%)、腦血管病(21例,占1.31%)失眠(19例,占1.18%)等。3.中醫(yī)證候分布情況以血瘀最多占67.04%,其后依次是氣虛占10.53%、痰濁占6.45%、陰虛占6.45%、氣滯占3.29%、郁熱占2.50%、血虛占0.72%、肝陽上亢占0.59%等。4.使用中藥250種,使用頻次共計(jì)14334次,用藥頻次前十的中藥依次是丹參、川芎、赤芍、生黃芪、薤白、莪術(shù)、金銀花、白蒺藜、醋香附、陳皮。按功效進(jìn)行分類顯示,主要以活血、止痛、和血、清熱、安神、祛風(fēng)、涼血、養(yǎng)血、祛瘀、消癰、解毒、燥濕、行氣、健脾為主。中藥性味以辛味藥最多,1192頻次,其次為甘味藥(1191次)、苦味藥(1178次)、微寒味藥(1158次)、溫性藥(1158次)、平性藥(1129次),之后依次是寒酸咸濕性藥、澀性藥、熱性藥�；颊呤褂弥兴幍臍w經(jīng)以脾經(jīng)最多,為1858次,其次為肺經(jīng)、心經(jīng)、肝經(jīng)、胃經(jīng)、心包經(jīng)、膽經(jīng)、大腸經(jīng)、腎經(jīng)、膀胱經(jīng)、三焦經(jīng)、小腸經(jīng)。5.關(guān)聯(lián)規(guī)則定義SUP40%,CON90%,結(jié)果顯示常用的中藥配伍有:莪術(shù)配丹參、赤芍配丹參、黃連配丹參、莪術(shù)配赤芍、川芎配丹參、生黃芪配丹參、莪術(shù)配川芎;常用的藥組有:川芎、莪術(shù)、赤芍和丹參;莪術(shù)、赤芍和丹參;川芎、黃連、赤芍和丹參;莪術(shù)、川芎和丹參;莪術(shù)、川芎和赤芍;赤芍、生黃芪、川芎和丹參;黃連、丹參和赤芍;赤芍、川芎和丹參;黃連、川芎和丹參等。6.聚類結(jié)果顯示,聚成14類后,指標(biāo)數(shù)相對(duì)合理,能較好體現(xiàn)史教授中醫(yī)辨證中與藥組方用藥特點(diǎn)。每一類包含一組中藥群,每組中藥群均與臨床診治過程中的主病主證相對(duì)應(yīng)。人機(jī)結(jié)合,在史教授參與指導(dǎo)下,對(duì)14類中藥群解析如下:第一類藥物組成功效可歸納為“清熱化濁、益氣活血”;第二類藥物組成功效可歸納為“化痰祛濁、活血化瘀”;第三類藥物組成功效可歸納為“益氣活血、散結(jié)通絡(luò)”;第四類藥物組成功效可歸納為“活血化瘀、理氣行滯”;第五類藥物組成功效可歸納為“活血化瘀、調(diào)和氣機(jī)”;第六類藥物組成為史教授益氣活血利水的經(jīng)驗(yàn)方;第七類藥物組成功效可歸納為“平肝潛陽、活血解毒”;第八類藥物組成功效可歸納為“益氣養(yǎng)陰、活血化瘀”;第九類藥物組成功效可歸納為“活血化瘀、清熱解毒、潤腸通便”;第十類藥物組成功效可歸納為“滋補(bǔ)肝腎、清心安神”;第十一類藥物組成功效可歸納為“疏肝健脾、益氣活血”;第十二類藥物組成為史教授益氣養(yǎng)陰、活血解毒的自擬方;第十三類藥物組成功效可歸納為“滋補(bǔ)肝腎、活血解毒”;第十四類藥物組成功效可歸納為“活血祛瘀、清熱解毒散結(jié)”。由此可以看出,史教授在治療介入后冠心病時(shí),常根據(jù)合并病的不同選用具有益氣活血、滋補(bǔ)肝腎、活血通絡(luò)、清熱解毒等功效的藥物。7.復(fù)雜網(wǎng)絡(luò)分析顯示:(1)以中藥為節(jié)點(diǎn)進(jìn)行分析,在過濾節(jié)點(diǎn)≥10時(shí),能較好地展現(xiàn)中藥之間的配伍關(guān)系,按節(jié)點(diǎn)度由大到小依次為丹參、生黃芪、川芎、莪術(shù)、赤芍、黃連、三七粉、金銀花、白蒺藜、醋香附、薤白、茯苓、天麻、鉤藤、川牛膝、黨參、葛根、紅花、陳皮、當(dāng)歸、法半夏、生白術(shù)、黃芩。過濾節(jié)點(diǎn)度≥30時(shí),使用中藥的前4味關(guān)聯(lián)是丹參、川芎、赤芍、生黃芪;(2)以證候-中藥為節(jié)點(diǎn)進(jìn)行分析,按節(jié)點(diǎn)度由大到小依次是血瘀對(duì)應(yīng)的中藥是赤芍、丹參、莪術(shù)、川芎、紅花、三七粉,氣虛對(duì)應(yīng)的中藥是生黃芪、黨參、西洋參,痰濁對(duì)應(yīng)的中藥是瓜蔞、薤白、半夏、陳皮、茯苓,熱毒對(duì)應(yīng)的中藥是黃連、金銀花、黃芩。過濾節(jié)點(diǎn)度≥32時(shí),藥物與冠心病主要證候的節(jié)點(diǎn)分布較為清晰明確,冠心病核心證候?yàn)檠鲎C,核心藥物組成以生黃芪、川芎、赤芍、丹參為主,核心證候與核心藥物功效相符合,體現(xiàn)了史教授臨證以補(bǔ)氣、活血為主的用藥特點(diǎn);(3)冠心病使用中藥-功效分析顯示,在過濾節(jié)點(diǎn)度≥42時(shí),能較好地展示使用中藥功效之間的關(guān)聯(lián)關(guān)系,包含的中藥功效有活血、清熱、止痛、安神、和血。結(jié)論:(1)史大卓教授治療介入后冠心病的核心組方配伍是丹參、赤芍、黃連、川芎、生黃芪。(2)史大卓教授治療介入后冠心病以益氣、活血、破血、化痰、解毒、安神為主要治法。(3)史大卓教授治療介入后冠心病的用藥規(guī)律體現(xiàn)了介入后冠心病虛、瘀、痰、毒的病機(jī)特點(diǎn)。
[Abstract]:Percutaneous coronary intervention (percutaneous coronary intervention, PCI) is an effective method to improve myocardial perfusion after coronary artery stenosis or occlusion. The percutaneous coronary angioplasty for coronary atherosclerotic stenosis in 1977 has been 40 years old. From 1984 to 2013, China developed from PCI to 2013. The blood transport reconstruction mechanism of coronary stent implantation is mainly vascular remodeling, but it can only solve the stenosis of vascular lesions, and can not solve the stenosis of all arteries of the heart. It does not eliminate the cause of atherosclerotic stenosis, and there is restenosis, thrombosis and myocardial tissue at the same time. No reflux and other problems affect the clinical prognosis. Chinese medicine can play a role in the pathological changes of the pathological links after PCI, and it is of great significance to improve the prognosis. Professor Shi Dazhuo has formed his own diagnosis and treatment characteristics in the treatment of coronary heart disease after the "combination of disease and syndrome" treatment. The clinical experience of coronary heart disease after the interventional therapy of tutor diagnosis and treatment is studied. On the basis of the summing up, using mathematical statistics and data mining techniques, this paper systematically studies the characteristics of the recreational drugs for coronary heart disease after the intervention of the tutor treatment. 1. The literature review: the progress of the treatment of coronary artery stenting after the treatment of coronary artery stenting by the method of invigorating qi and activating blood circulation and detoxifying the coronary artery is to treat the coronary artery by the prescription of Invigorating Qi and activating blood and detoxifying the coronary artery The review and analysis of related literature after stenting, found that blood stasis and Qi deficiency are the main syndromes of coronary heart disease after PCI, Qi deficiency and blood stasis are the basic pathogenesis of coronary heart disease after PCI. The main treatment of coronary heart disease after interventional therapy is the main treatment of coronary heart disease after intervention, blood stasis block choroid, persistent accumulation of poison, and the key to the occurrence of cardiovascular events because of toxic changes. Two. Experience summary Professor Shi Dazhuo's clinical experience in the treatment of coronary heart disease after intervention, Professor Shi Dazhuo treated coronary heart disease after the treatment of coronary heart disease. He was unauthorized to combine the macroscopic syndrome differentiation and pathophysiological changes of traditional Chinese medicine. The cold and warm cold properties of traditional Chinese medicine and modern pharmacological research results were combined, and the following aspects were shown in the following aspects: (1) Tongyang Xuan Bi paid attention to phlegm and phlegm and scattered cold. (2) to reconcile the organic combination of toxic drugs on the basis of activating blood and removing blood stasis: (3) supplementing Qi emphasizes not only to fill the heart, make up the sect gas, but also pay attention to supplementing the middle Qi and nourishing the Qi; (4) tonifying the liver and kidney to emphasize the tonifying of the kidney; (5) circular machine activities, pay attention to the combination of dredging collaterals, Anshen, blood circulation, and other methods. Three. Clinical research: Based on data mining technology to study the intervention intervention of Shi Dazhuo intervention The objective of drug use for post coronary heart disease is to excavate and analyze the characteristics and laws of Professor Shi Dazhuo's medicine for treating coronary heart disease after intervention. Methods: the clinical information sharing system of the famous old Chinese medicine developed by the Information Research Institute of the Chinese Academy of science of traditional Chinese medicine (Chinese Academy of science of traditional Chinese Medicine) was used to collect and store the clinical information and to use the ETL tool to manage the data and use SPSS13.0 The software was analyzed by the statistical analysis, and the traditional Chinese medicine scientific research information sharing system was used to analyze the traditional Chinese medicine flavour meridian (OLAP). The association rules were used to analyze the characteristics of the drugs, the combination of the cluster analysis and the combination of the complex network analysis. The characteristics of the medication for the coronary heart disease after the intervention of Prof Shi Da Zhu were analyzed. Results: 1. There were 317 patients and 1165 times, of which 208 cases were male, 65.62%, and 109 women were 34.38%. age 23-88 years old and the average age was 60.545 years old. The onset age was mainly between 40 and 80 years old with hyperlipidemia (122 cases, 7.58%), followed by hypertension (85, 5.28%), and chronic heart disease. Stress failure (27 cases, 1.68%), cerebrovascular disease (21 cases, 1.31%) insomnia (19 cases, 1.18%), the distribution of.3. TCM syndromes with blood stasis was 67.04%, followed by qi deficiency and 10.53%, phlegm in 6.45%, yin deficiency in 6.45%, qi stagnation up 3.29%, stasis heat occupy 2.50%, blood deficiency occupy 0.72%, liver yang hyperactivity occupied 0.59%.4. and other kinds of traditional Chinese medicine. 14334 times, the first ten of the traditional Chinese medicine were Salvia miltiorrhiza, Ligusticum chuanxiong, Radix Paeoniae, Radix Astragalus, Radix Astragalus, rhizome, rhizome, Rhizoma rhizome, zedoary turmeric, honeysuckle, Tribulus terrestris, vinegar pericarp, and tangerine peel. According to the efficacy, it was mainly used to activate blood, relieve pain, blood, heat, dispel wind, and dispel carbuncle, detoxification, dampness, Qi and spleen. More, 1192 frequency, followed by sweet medicine (1191), bitter medicine (1178 times), micro cold medicine (1158 times), thermo sexual medicine (1158 times), flat drug (1129), followed by cold acid salt wet medicine, astringent medicine, and thermal medicine. The patients used Chinese medicine were the most abundant, 1858 times, followed by lung, meridian, stomach, pericardium, bile meridian, large intestine meridian, kidney. SUP40% and CON90% are defined by the.5. association rules of the bladder meridian, tri focal meridian and small intestine. The results show that zedoary turmeric with Salvia miltiorrhiza, red peony root with Salvia miltiorrhiza, Rhizoma miltiorrhiza with Rhizoma miltiorrhiza, rhizome of Rhizoma Chuanxiong with Salvia miltiorrhiza, Radix Astragali with Salvia miltiorrhiza, zedoary rhizome and Salvia miltiorrhiza; zedoary turmeric root, red peony root and Salvia miltiorrhiza; Ligusticum chuanxiong, Rhizoma Coptidis, Radix Paeoniae and Salvia miltiorrhiza; zedoary rhizome, Rhizoma Chuanxiong and Salvia miltiorrhiza; zedoary turmeric, Rhizoma Chuanxiong and Radix Paeoniae radix; Radix Paeoniae radix, Radix Astragalus, Rhizoma Chuanxiong and Radix Salviae Miltiorrhizae; Rhizoma Coptidis, Salvia miltiorrhiza and Radix Paeoniae radix; Radix Paeoniae Paeoniae, Rhizoma Chuanxiong and Salvia miltiorrhiza; Rhizoma Coptidis, Ligusticum chuanxiong and Salvia miltiorrhiza; after the aggregation of the index number is reasonable, it can better reflect the characteristics of medicine in TCM syndrome differentiation and medicine. One group includes a group of Chinese medicine groups, each group of Chinese medicine should be corresponding to the main main syndrome in the process of clinical diagnosis and treatment. Under the guidance of Professor Shi, the 14 kinds of Chinese medicine groups are analyzed as follows: the first kind of drug composition can be summed up as "clearing heat and activating blood and promoting blood circulation", and the second kinds of drugs can be summed up as "phlegm dispelling turbidity, activating blood circulation" The effect of the composition of the third kinds of drugs can be summed up as "Invigorating Qi and activating blood, removing the collaterals and collaterals"; the composition of the fourth kinds of drugs can be summed up as "activating blood to dissipate blood stasis and regulating qi stagnation"; the efficacy of the fifth types of drugs can be summed up as "activating blood to remove stasis and harmonization of Qi"; the sixth group of drugs became the experience of Professor Shi Yiqi Huoxue Li Shui, and the seventh kind of medicine. The efficacy of the eighth kinds of drugs can be summed up as "Nourishing Qi and nourishing Yin, activating blood and removing blood stasis", and the ninth kinds of drugs can be summed up as "activating blood and removing stasis, clearing heat and detoxifying, moistening intestines and bowel movement", and the efficacy of the tenth kinds of drugs can be summed up as "nourishing liver and kidney, clearing heart and mind"; eleventh types of drugs. The efficacy of drug composition can be summed up as "liver nourishing and invigorating the spleen, invigorating qi and activating blood circulation"; the composition of the twelfth kinds of drugs is the self-made prescription of Professor Shi Yiqi nourishing yin and activating blood to detoxify; the thirteenth kinds of drugs can be summed up as "nourishing the liver and kidney, activating blood and detoxifying", and the efficacy of the fourteenth kinds of drugs can be summed up as "activating blood and removing stasis, clearing heat and detoxification and dispersing the knot". In the treatment of coronary heart disease after intervention, Professor Shi is often used in the complex network analysis of.7. complex network analysis of the effects of combining Qi and activating blood and kidney, nourishing the liver and kidney, activating blood and dredging collaterals, clearing heat and detoxifying and so on. (1) the traditional Chinese Medicine is used as the node to analyze, and when the filter node is more than 10, it can better display the compatibility relationship between the Chinese medicine and press the node. From large to small, the order of Radix Salviae Miltiorrhizae, Radix Astragalus, Rhizoma Chuanxiong, Rhizoma Chuanxiong, Radix Paeoniae, Rhizoma Coptis, Rhizoma Coptidis, 37 powder, honeysuckle, Tribulus terrestris, vinegar incinction, xeba, tuckahoe, Rhizoma rhizome, Radix Achyranthes, Radix Codonopsis, kudzu, kudzu, tangerine, Radix Angelicae, Radix pellucidae, Radix Scutellariae, and scutellaria. The first 4 flavors of traditional Chinese medicine are Salvia miltiorrhiza, Ligusticum chuanxiong, Radix Paeoniae and Astragalus membranaceus; (2) The traditional Chinese medicine is Radix Paeoniae, Salvia miltiorrhiza, Rhizoma Rhizoma Rhizoma, Rhizoma Chuanxiong, red flower, 37 powder, and the corresponding Chinese medicine of qi deficiency, Radix Codonopsis, Panax quinquefolium and phlegm is the gualosanus, and the Chinese herbs of xebai, Pinellia ternata and tuckahoe are the Chinese herbal medicine of Huanglian, honeysuckle and scutellaria. When the degree of filtering node is more than 32, the distribution of main syndromes of drugs and coronary heart disease is clear and clear. The core syndrome of coronary heart disease is blood stasis syndrome. The core drugs are composed of Astragalus membranaceus, Ligusticum chuanxiong, red peony root and Salvia miltiorrhiza. The core syndromes are in accordance with the core drug efficacy, which embodies the characteristics of the history teaching and clinical syndrome to supplement qi and promote blood circulation; (3) coronary heart disease (CHD) The use of traditional Chinese Medicine - efficacy analysis shows that when the degree of filtering nodes is more than 42, it can show the relationship between the efficacy of traditional Chinese medicine and the efficacy of traditional Chinese medicine including activating blood, clearing heat, relieving pain, relieving pain, and blood. Conclusion: (1) the compatibility of Professor Shi Dazhuo in the treatment of coronary heart disease after intervention is Salvia miltiorrhiza, radix paeoniae rubra, Rhizoma Chuanxiong, and Astragalus membranaceus. (2) Shi Dazhuo After the treatment of interventional therapy, coronary heart disease is the main treatment of Qi supplementing, activating blood, breaking blood, eliminating phlegm, detoxification, and Anshen. (3) the rule of medicine for the treatment of coronary heart disease after the intervention of Professor Shi Dazhuo embodies the pathogenesis of coronary heart disease, blood stasis, phlegm and poison after intervention.
【學(xué)位授予單位】：中國中醫(yī)科學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R249;R259

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