颈动脉粥样硬化证候分布规律及益肾活血法干预的研究
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摘要
目的：对颈动脉粥样硬化(CAS)的常见中医证候,证候要素及其分布规律进行回顾性研究。分析颈动脉粥样硬化的相关指标及影响因素等与中医证候的相关性,探讨颈动脉粥样硬化的中医证候分布规律,并进行益肾活血法干预的临床研究,旨在探索该病的中医治疗方法。
方法：以广安门医院近3年收治的颈动脉粥样硬化临床病例资料为研究对象,以中医证候为切入点,运用流行病学和生物统计学的研究思路和方法,试图客观揭示颈动脉粥样硬化的证候分布规律,为该病证候规范化研究提供依据。证候分布规律研究采用回顾性研究方法,对298例颈动脉粥样硬化患者,收集包括一般临床资料和症状资料,统计症状及证候出现的频率,并进行比较分析等,探讨该病的证候分布规律、CAS的相关指标及影响因素等与中医证候的相关性。第三部分是益肾活血法方药对CAS血瘀证+肝肾阴虚证的干预研究。根据颈动脉粥样硬化及中医血瘀证+肝肾阴虚证的诊断标准,收集门诊及住院病例,分为治疗组和对照组,各40例,进行临床疗效观察评价两组的疗效差别。所有数据采用SPSS18.0统计软件进行描述、均数差别性检验、t检验或Mann-Whitney U检验、X2检验、Logistic回归分析等统计。
结果
1.CAS各证型组出现频率依次为痰浊阻遏证+气滞血瘀证+肝肾阴虚证型组合117例(39.3%)、痰浊阻遏证+气滞血瘀证型组85例(28.5%)、气滞血瘀证+肝肾阴虚证型组47例(15.8%)、痰浊阻遏证+肝肾阴虚证型组30例(10.1%),证型多组合出现。
2.痰浊阻遏证与其他型组别间的颈动脉超声、经颅多普勒(TCD)参数,通过独立样本t检验显示,左侧斑块长径、右侧大脑中动脉均值血流速度、右侧大脑前动脉均值血流速度,均为*P<0.05,或*P<0.01,有统计学差异。
3.气滞血瘀证与其他证型组间的相关指标,通过独立样本t检验显示,载脂蛋白B,为*P<0.05,有统计学差异。气滞血瘀证组的载脂蛋白B均值浓度低于其他证型组。
4.肝肾阴虚证与其他证型组别间的颈动脉参数、经颅多普勒(TCD)、相关指标,通过独立样本t检验显示,右侧大脑前动脉均值血流速度、左侧大脑前动脉均值血流速度、右侧颈内动脉虹吸段均值血流速度、左侧颈动脉虹吸段均值血流速度、收缩压、血糖均值浓度,均为*P<0.05,或*P<0.01,有统计学差异。肝肾阴虚证组的TCD均值速度低于其他证型组。肝肾阴虚证的收缩压均值、血糖均值浓度高于其他证型组。
5.痰浊阻遏证+气滞血瘀证组与其他证型组别间的颈动脉超声、TCD参数及相关指标,通过独立样本经t检验,右侧大脑中动脉血流速度、左侧大脑中动脉血流速度,总胆固醇、极低密度脂蛋白、载脂蛋白B均值浓度,均为*P<0.05,有统计学差异。痰浊阻遏证+气滞血瘀证组的TCD均值速度高于与其他证型组。痰浊阻遏证+气滞血瘀证组的血脂均值浓度与其他证型组别指标相比降低。
6.痰浊阻遏证+肝肾阴虚证组与其他证型组别间的颈动脉参数、TCD及相关指标,经独立样本t检验左侧椎动脉均值血流速度、收缩压均值,均为*P<0.05,有统计学差异。痰浊阻遏证+肝肾阴虚证组的左侧椎动脉均值血流速度、收缩压均值高与其他证型组。
7.气滞血瘀证+肝肾阴虚证组与其他证型组别间的颈动脉参数、TCD,经独立样本t检验,右侧大脑前动脉均值血流速度、左侧大脑前动脉均值血流速度、年龄、收缩压均值,均为,*P<0.05,或*P<0.01,有统计学差异。气滞血瘀证+肝肾阴虚证组的TCD均值速度低于其他证型组。气滞血瘀证+肝肾阴虚证组的年龄、收缩压均值高于其他证型组。
8.痰浊阻遏证+气滞血瘀证+肝肾阴虚证组与其他型组别间的颈动脉参数、TCD,经独立样本t检验,左侧椎动脉、年龄、收缩压均值,均为*P<0.05,有统计学差异。痰浊阻遏证+气滞血瘀证+肝肾阴虚证组的椎动脉速度、年龄、收缩压均值高于其他证型组。
9.四个证型组之间的颈动脉参数比较,经ANOVA单因素方差分析,显示P>0.05。关于血糖指标,痰浊阻遏证+气滞血瘀证组与痰浊阻遏证+肝肾阴虚证组间的比较t值呈负值(b>a),显示*P<0.05,有显著性统计学差异。
10.CAS合并病与中医证候的关系,经Logistic回归分析,冠状动脉粥样硬化是痰浊阻遏证的重要影响因素；腔隙性脑梗塞是气滞血瘀证的重要影响因素；高脂血症、腔隙性脑梗塞、冠状动脉粥样硬化是肝肾阴虚证的重要影响因素；腔隙性脑梗塞是痰浊阻遏证+肝肾阴虚证的重要影响因素；冠状动脉粥样硬化、腔隙性脑梗塞是痰浊阻遏证+气滞血瘀证的重要影响因素；年龄、高脂血症是气滞血瘀证+肝肾阴虚证的重要影响因素。痰浊阻遏证+气滞血瘀证+肝肾阴虚证的Logistic回归分析,结果显示所有变量因素OR=1,表示变量因素对该证型的发生不起作用。
11.对颈动脉斑块的临床研究显示,自拟益肾活血汤组的双侧斑块厚度之合及左、右侧斑块厚度的治疗前后相比较,显示呈正值,*P<0.05,有显著性差异。而对照组的双侧斑块之合及左侧斑块厚度的治疗前后相比较,显示呈负值,*P<0.05,有显著性差异。
结论：
1.CAS证候发生频率以痰浊阻遏证+气滞血瘀证+肝肾阴虚证组合发生率最高。
2.颈动脉及脑动脉硬化发生发展显示以实证为主的痰浊阻遏证、气滞血瘀证。
3.增龄或伴高血压病、糖尿病、高血脂症者显示以虚证为主的肝肾阴虚证。
4.证候组合之间,颈动脉斑块的大小无相关性。说明颈动脉斑块以痰浊、血瘀、阴虚为主,是三种病因综合作用下形成的病理变化。
5.痰浊阻遏证的影响因素：冠状动脉粥样硬化。
6.气滞血瘀证的影响因素：腔隙性脑梗塞。
7.肝肾阴虚证的影响因素：糖尿病、高脂血症、冠状动脉粥样硬化、腔隙性脑梗塞。
8.痰浊阻遏证+气滞血瘀证的影响因素：冠状动脉粥样硬化、腔隙性脑梗塞。
9.痰浊阻遏证+肝肾阴虚证的影响因素：腔隙性脑梗塞。
10.气滞血瘀证+肝肾阴虚证的影响因素：增龄、高脂血症。
11.临床研究显示益肾活血法对颈动脉斑块有缩小作用。
本研究设计时,把颈动脉粥样硬化的主要核心证候归纳为痰浊阻遏证、气滞血瘀证、肝肾阴虚证三个证候。提出了针对性强的治疗模式,有利于寻找相应的方药和治则。CAS中医临床证型的单独出现的频率很少见。偶尔可以看到只有一种证候比较突出而其他证候不明显时,能辨证作为先要解决的单独证候。但也不能代表CAS整个病机的演变规律。其实,一个证候不能概括整个CAS病机的过程,只是与其他证候组相比,该证候的表现突出一点,只能作为一个病理阶段的短暂性辨证模式。故临证时,常常根据CAS证候的病理变化,灵活运用相应的辨证模式,才能得到理想的效果。
颈动脉粥样硬化是随年龄增大,通过长期代谢紊乱的干扰下形成的病变。根据中医辨证理论的实践,痰、瘀、虚为CAS核心病因病机,能概括整个CAS发病过程当中的演变规律。该三个代表证候的病因病机,可互相影响转化。故CAS的证候多为两个或以上证候同时出现的频率比较多。本研究表明,痰浊阻遏证+气滞血瘀证+肝肾阴虚证3个证型组合兼见所占比例最大。由此可见,CAS是痰、瘀、虚共同作用的结果。
证候与影响因素的研究结果为通过分析整个证型组合内选出某一、或两个证候组合的总频率后,经Logisitc回归分析得到的影响因素(合并病)。故辨证时,一个影响因素(合并病)的出现,能推测到构成CAS患者的证型组合的某一阶段、或组成部分。又通过望闻问切的结合,能加强辨证论治的正确性。即对证型组合起作用的影响因素也能作为辨证新模式的一部分。另外,有研究报道,痰浊型动脉硬化(AS)患者的血脂指标水平如VLDL及LP明显高于肾虚证。痰浊明确为AS伴高血脂症有密切关系,但本研究表明肝肾阴虚证对高血脂症的影响力高于痰浊阻遏证。这是因为本研究以颈动脉斑块为主分析的证候分布规律,比一般的动脉硬化(AS)更严重状态。故本人认为CAS的痰浊、肝肾阴虚证均能导致高血脂症,但颈动脉斑块形成后的肝肾阴虚证对脂质代谢紊乱比痰浊阻遏证更有密切关系。
自拟益肾活血汤为血瘀证+肝肾阴虚证组成的方剂。为对颈动脉斑块缩小、稳定化,最重要的证型组合。血瘀征象相应的药物有葛根、白蒺藜、地龙、川芎、丹参；而肝肾阴虚征象相应的药物有制首乌、女贞子、枸杞子。这些药物对该辨证模式不但有针对性强,而且现代医学认为这些中药有降血压、降血脂、降血糖等的药理作用。所以该处方的配伍,对辨证思路与现代医学的研究不矛盾。
Objective:This study is to make a retrospective study of carotid atherosclerosis(CAS) TCM syndrome distribution law. Analysis on related indexes and influencing factors of CAS is to find more suitable TCM clincal therapeutic principle for CAS TCM syndrome. Clinical study of nourishing kidney and promoting blood circulation method purport to be about the exploration for TCM treatment.
Method:This study was made with CAS clinical patient history as an investigation object,which were based on TCM syndrome using methods of epidemiology. These are attempts to give objective CAS law of TCM syndrome distribution and give evidence to CAS Syndrome standardization study. Syndrome distribution law study used retrospective method, investigated298cases of CAS patient, collected general clinical data, data of symtoms, and frequency of syndrome, use statistical comparative analysis, explore the CAS of syndrome distribution law and study correlation between related indexes and influencing factors. In the third section of nourishing kidney and promoting blood circulation method is to study etiology and pathogenesis of TCM, which motivate us to find very best therapeutic principle and herbs. Every treatment group and control group collected40cases each, cases were collected treatment group by outpatient and control group by the medical record review. All the data were analysed by descriptive analysis, mean number difference analysis, Mann-Whiteney U test, t-test, X--test, Logistic regression analysis using SPSS18.0statistical software package.
Result:
1. The frequency order of different TCM syndrome group was as follows, sputum stasis syndrome+qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group117cases> sputum stasis syndrome+qi stagnation and blood stasis syndrome group85cases> qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group47cases> sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group30cases,etc.
2. Sputum stasis syndrome group compared with other groups of carotid ultrasound. TCD,related index.using t-test show that left side plaque length. right side middle cerebral artery,right side anterior cerebral artery t-value was positive value (P<0.05or P<0.01)
3. Qi stagnation and blood stasis syndrome group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that apolipoproteinB, t-value was negative-value(P<0.05).
4. Deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that right side anterior cerebral artery, left side anterior cerebral artery, right and left side siphon degment of carotid artery, t-value was negative-value (P<0.05or P<0.01) and about the related index shows that systolic blood pressure and blood glucose t-value was positive-value(P<0.05).
5. Sputum stasis syndrome+qi stagnation and blood stasis syndrome group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that right and left side middle cerebral artery t-value was positive-value(P<0.05) and abut the related index shows that total cholesterol, very low density lipoprotein, apolipoproteinB t-value was negative-value (P<0.05).
6. Sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that left side vertebral artery was positive-value(P<0.05) and about the related index shows that systolic blood pressure t-value was positive-value(P<0.05).
7. Qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that right and left side anterior cerebral artery t-value was negative-value(P<0.05or P<0.01) and about the related index shows that age, systolic blood pressure t-value was positive-value(P<0.05).
8. Sputum stasis syndrome+qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that left side vertebral artery was positive-value(P<0.05) and about the related index shows that age, systolic blood pressure t-value was positive-value(P<0.05).
9. Four different TCM syndrome groups of carotid ultrasound used one-way Anova method to compared each other and show that among the four different types of syndrome groups plaque has no difference (P>0.05), also shows that compare between sputum stasis syndrome+qi stagnation and blood stasis syndrome group with sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group t-value was negative-value(b> a;P<0.05).
10. Sputum stasis syndrome of logistic regression analysis show that coronary atherosclersis P=0.000,OR=4.193, has positive correlation.
11. Qi stagnation and blood stasis syndrome of logistic regression analysis show that lacunar cerebral infarction P=0.012,OR=0.383, has negative correlation.
12. Deficiency syndrome of both liver and kidney yin of logistic regression analysis show that diabetes P=0.020,OR=1.881, hyperlipidemia P=0.046,OR=1.995, lacunar cerebral infarction P=0.006,OR=2.149, has positive correlation and also shows that coronary atherosclersis P=0.001,OR=0.362, has negative correlation.
13. Sputum stasis syndrome+qi stagnation and blood stasis syndrome group of logistic regression analysis show that coronary atherosclersis P=0.002, OR=2.486, has positive correlation and also shows that lacunar cerebral infarction P=0.012,OR=0.480, has negative correlation.
14. Sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group of logistic regression analysis show that lacunar cerebral infarction P=0.023,OR=1.803, has positive correlation.
15. Qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group of logistic regression analysis show that hyperlipidemia P=0.009,OR=2.374,ageP=0.019,OR=1.033, has positive correlation.
16. Sputum stasis syndrome+type of qi stagnation and blood stasis+deficiency syndrome of both liver and kidney yin group of logistic regression analysis show that all the variable factors are OR=1, it means that variable factor have no effect on CAS TCM syndrome group.
17. The clinical effect of nourishing kidney and promoting blood circulation method on CAS patient show that treatment group of before and after treatment of plaque length and thickness t-value was positive-value(P<0.05). control group of before and after treatment of plaque length and thickness t-value was negative-value(P<0.05),showed statistical difference.
Conclusion:
1. Sputum stasis syndrome+qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group117cases has the highest incidence of different TCM syndrome groups.
2. Empirical syndrome's like sputum stasis syndrome or qi stagnation and blood stasis syndrome are mostly have effect on CAS and cerebral arteriosclerosis.
3. Deficiency syndrome's like deficiency syndrome of both liver and kidney yin group are mostly have effect on age, hypertension, diabetes, hyperlipidemia.
4. Among the four different TCM syndrome groups of plaque thickness has no difference each other. It is likely to think that plaque thickness is made of three syndrome factors which is participated by Sputum stasis syndrome, qi stagnation and blood stasis syndrome, deficiency syndrome of both liver and kidney yin group.
5. Influencing factors of sputum stasis syndrome:Coronary atherosclersis.
6. Influencing factors of qi stagnation and blood stasis syndrome:Lacunar cerebral infarction.
7. Influencing factors of deficiency syndrome of both liver and kidney yin:Diabetes, Hyperlipidemia, Coronary atherosclersis, Lacunar cerebral infarction.
8. Influencing factors of sputum stasis syndrome+qi stagnation and blood stasis syndrome:Coronary atherosclersis, Lacunar cerebral infarction.
9. Influencing factors of sputum stasis syndrome+deficiency syndrome of both liver and kidney yin:Lacunar cerebral infarction.
10. Influencing factors of qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin:Age, Hyperlipidemia.
11. Nourishing kidney and promoting blood circulation method can reduce CAS plaque's thickness.
In this study, the main design of carotid atherosclerosis's syndrome concluded to Sputum stasis syndrome,Qi stagnation and blood stasis syndrome and Deficiency syndrome of both liver and kidney yin group, which has therapeutic mode of strong pertinence.It is easier to find a proper herbs and therapeutic principle. It is very rare to see that TCM clinical syndrome shows only one single appearance.When you find to see only one syndrome appear and other syndrome not so obvious,that can be a syndrome differentiation first to be treated. But this can not be representing the whole idea of pathogenesis.In fact,one syndrome can not generalize all the CAS pathogenesis of TCM syndromes,just only compare to other syndromes,when one syndrome show prominent,then this syndrome differentiation is just a temporary medical differential mode of all the pathologic stages. Therefore,when doctors are in a TCM clinic practice,you have to use the proper TCM therapeutic mode to obtain the ideal effect. Generally, CAS gets larger as the increasing of age,which is long-term interference of metabolic disorder.According to TCM syndrome differentiation theory,sputum,blood stasis and deficiency syndromes are summarized as the core evolution law of CAS.These representative three syndromes of etiology and pathogenesis can make mutual transformation. Therefore, CAS syndromes mostly appears in the form of two or three syndromes together. In this research shows the most high requency of the three combination of Sputum stasis syndrome+Qi stagnation and blood stasis syndrome+Deficiency syndrome of both liver and kidney yin. Therefore,CAS is the result of sputum,blood stasis and deficiency syndromes' interaction.
The result of correlation between Sydromes and Influencing factors are made by Logistic retrospective analysis.which is made after analyzing the total frequency of all types of each syndrome combination.Therefore, Influencing factors can indicate a certain stage or composition of CAS syndrome.Also,in the help of inspection, auscultation-olfaction,interrogation and palpation method can strengthen accuracy of syndrome differentiation and treatment.It means that these Influencing factors can make the part of new form of syndrome differentiation method.
In addition, some research reports shows that Sputum stasis syndrome of arteriosclerosis(AS) has much higher concentration of VLDL,LP than Deficiency syndrome of both liver and kidney yin. Sputum stasis syndrome of arteriosclerosis(AS) clearly related to hyperlipidemia,but this research shows that Deficiency syndrome of both liver and kidney yin has more influence on hyperlipidemia.This is because the results are analyzed by CAS distribution rules of manifestation.and this what makes more bigger influences on hyperlipidemia than to Sputum stasis syndrome of arteriosclerosis(AS).Therefore,I think that Sputum stasis syndrome and Deficiency syndrome of both liver and kidney yin all have influence on on hyperlipidemia.but after carotid plaque is formed. Deficiency syndrome of both liver and kidney yin has more correlated to lipid metabolism disorder than Sputum stasis syndrome.
Self-made yishen huoxue decoction is made by blood stasis syndrome+ Deficiency syndrome of both liver and kidney yin combination.It is an effective treatment that can make reduce and stabilize Carotid plaque.
Corresponding herbs to blood stasis syndrome are kudzu,tribulus,lumbricus, rhizomaligusticichuanxiong, salvia and corresponding herbs to Deficiency syndrome of both liver and kidney yin are radix polygoni multiflori preparata,ligustrum lucidum,wolfberry fruit. These herbs are not only have strong pertinence to each syndromes,and also modern medicine holds that these herbs have pharmacological action of lowering blood pressure,reducing blood lipid,hypoglycemic effect etc...Therefore this prescription has no contradiction between TCM thinking of syndrome differentiation and modern medicine.
方法：以广安门医院近3年收治的颈动脉粥样硬化临床病例资料为研究对象,以中医证候为切入点,运用流行病学和生物统计学的研究思路和方法,试图客观揭示颈动脉粥样硬化的证候分布规律,为该病证候规范化研究提供依据。证候分布规律研究采用回顾性研究方法,对298例颈动脉粥样硬化患者,收集包括一般临床资料和症状资料,统计症状及证候出现的频率,并进行比较分析等,探讨该病的证候分布规律、CAS的相关指标及影响因素等与中医证候的相关性。第三部分是益肾活血法方药对CAS血瘀证+肝肾阴虚证的干预研究。根据颈动脉粥样硬化及中医血瘀证+肝肾阴虚证的诊断标准,收集门诊及住院病例,分为治疗组和对照组,各40例,进行临床疗效观察评价两组的疗效差别。所有数据采用SPSS18.0统计软件进行描述、均数差别性检验、t检验或Mann-Whitney U检验、X2检验、Logistic回归分析等统计。
结果
1.CAS各证型组出现频率依次为痰浊阻遏证+气滞血瘀证+肝肾阴虚证型组合117例(39.3%)、痰浊阻遏证+气滞血瘀证型组85例(28.5%)、气滞血瘀证+肝肾阴虚证型组47例(15.8%)、痰浊阻遏证+肝肾阴虚证型组30例(10.1%),证型多组合出现。
2.痰浊阻遏证与其他型组别间的颈动脉超声、经颅多普勒(TCD)参数,通过独立样本t检验显示,左侧斑块长径、右侧大脑中动脉均值血流速度、右侧大脑前动脉均值血流速度,均为*P<0.05,或*P<0.01,有统计学差异。
3.气滞血瘀证与其他证型组间的相关指标,通过独立样本t检验显示,载脂蛋白B,为*P<0.05,有统计学差异。气滞血瘀证组的载脂蛋白B均值浓度低于其他证型组。
4.肝肾阴虚证与其他证型组别间的颈动脉参数、经颅多普勒(TCD)、相关指标,通过独立样本t检验显示,右侧大脑前动脉均值血流速度、左侧大脑前动脉均值血流速度、右侧颈内动脉虹吸段均值血流速度、左侧颈动脉虹吸段均值血流速度、收缩压、血糖均值浓度,均为*P<0.05,或*P<0.01,有统计学差异。肝肾阴虚证组的TCD均值速度低于其他证型组。肝肾阴虚证的收缩压均值、血糖均值浓度高于其他证型组。
5.痰浊阻遏证+气滞血瘀证组与其他证型组别间的颈动脉超声、TCD参数及相关指标,通过独立样本经t检验,右侧大脑中动脉血流速度、左侧大脑中动脉血流速度,总胆固醇、极低密度脂蛋白、载脂蛋白B均值浓度,均为*P<0.05,有统计学差异。痰浊阻遏证+气滞血瘀证组的TCD均值速度高于与其他证型组。痰浊阻遏证+气滞血瘀证组的血脂均值浓度与其他证型组别指标相比降低。
6.痰浊阻遏证+肝肾阴虚证组与其他证型组别间的颈动脉参数、TCD及相关指标,经独立样本t检验左侧椎动脉均值血流速度、收缩压均值,均为*P<0.05,有统计学差异。痰浊阻遏证+肝肾阴虚证组的左侧椎动脉均值血流速度、收缩压均值高与其他证型组。
7.气滞血瘀证+肝肾阴虚证组与其他证型组别间的颈动脉参数、TCD,经独立样本t检验,右侧大脑前动脉均值血流速度、左侧大脑前动脉均值血流速度、年龄、收缩压均值,均为,*P<0.05,或*P<0.01,有统计学差异。气滞血瘀证+肝肾阴虚证组的TCD均值速度低于其他证型组。气滞血瘀证+肝肾阴虚证组的年龄、收缩压均值高于其他证型组。
8.痰浊阻遏证+气滞血瘀证+肝肾阴虚证组与其他型组别间的颈动脉参数、TCD,经独立样本t检验,左侧椎动脉、年龄、收缩压均值,均为*P<0.05,有统计学差异。痰浊阻遏证+气滞血瘀证+肝肾阴虚证组的椎动脉速度、年龄、收缩压均值高于其他证型组。
9.四个证型组之间的颈动脉参数比较,经ANOVA单因素方差分析,显示P>0.05。关于血糖指标,痰浊阻遏证+气滞血瘀证组与痰浊阻遏证+肝肾阴虚证组间的比较t值呈负值(b>a),显示*P<0.05,有显著性统计学差异。
10.CAS合并病与中医证候的关系,经Logistic回归分析,冠状动脉粥样硬化是痰浊阻遏证的重要影响因素；腔隙性脑梗塞是气滞血瘀证的重要影响因素；高脂血症、腔隙性脑梗塞、冠状动脉粥样硬化是肝肾阴虚证的重要影响因素；腔隙性脑梗塞是痰浊阻遏证+肝肾阴虚证的重要影响因素；冠状动脉粥样硬化、腔隙性脑梗塞是痰浊阻遏证+气滞血瘀证的重要影响因素；年龄、高脂血症是气滞血瘀证+肝肾阴虚证的重要影响因素。痰浊阻遏证+气滞血瘀证+肝肾阴虚证的Logistic回归分析,结果显示所有变量因素OR=1,表示变量因素对该证型的发生不起作用。
11.对颈动脉斑块的临床研究显示,自拟益肾活血汤组的双侧斑块厚度之合及左、右侧斑块厚度的治疗前后相比较,显示呈正值,*P<0.05,有显著性差异。而对照组的双侧斑块之合及左侧斑块厚度的治疗前后相比较,显示呈负值,*P<0.05,有显著性差异。
结论：
1.CAS证候发生频率以痰浊阻遏证+气滞血瘀证+肝肾阴虚证组合发生率最高。
2.颈动脉及脑动脉硬化发生发展显示以实证为主的痰浊阻遏证、气滞血瘀证。
3.增龄或伴高血压病、糖尿病、高血脂症者显示以虚证为主的肝肾阴虚证。
4.证候组合之间,颈动脉斑块的大小无相关性。说明颈动脉斑块以痰浊、血瘀、阴虚为主,是三种病因综合作用下形成的病理变化。
5.痰浊阻遏证的影响因素：冠状动脉粥样硬化。
6.气滞血瘀证的影响因素：腔隙性脑梗塞。
7.肝肾阴虚证的影响因素：糖尿病、高脂血症、冠状动脉粥样硬化、腔隙性脑梗塞。
8.痰浊阻遏证+气滞血瘀证的影响因素：冠状动脉粥样硬化、腔隙性脑梗塞。
9.痰浊阻遏证+肝肾阴虚证的影响因素：腔隙性脑梗塞。
10.气滞血瘀证+肝肾阴虚证的影响因素：增龄、高脂血症。
11.临床研究显示益肾活血法对颈动脉斑块有缩小作用。
本研究设计时,把颈动脉粥样硬化的主要核心证候归纳为痰浊阻遏证、气滞血瘀证、肝肾阴虚证三个证候。提出了针对性强的治疗模式,有利于寻找相应的方药和治则。CAS中医临床证型的单独出现的频率很少见。偶尔可以看到只有一种证候比较突出而其他证候不明显时,能辨证作为先要解决的单独证候。但也不能代表CAS整个病机的演变规律。其实,一个证候不能概括整个CAS病机的过程,只是与其他证候组相比,该证候的表现突出一点,只能作为一个病理阶段的短暂性辨证模式。故临证时,常常根据CAS证候的病理变化,灵活运用相应的辨证模式,才能得到理想的效果。
颈动脉粥样硬化是随年龄增大,通过长期代谢紊乱的干扰下形成的病变。根据中医辨证理论的实践,痰、瘀、虚为CAS核心病因病机,能概括整个CAS发病过程当中的演变规律。该三个代表证候的病因病机,可互相影响转化。故CAS的证候多为两个或以上证候同时出现的频率比较多。本研究表明,痰浊阻遏证+气滞血瘀证+肝肾阴虚证3个证型组合兼见所占比例最大。由此可见,CAS是痰、瘀、虚共同作用的结果。
证候与影响因素的研究结果为通过分析整个证型组合内选出某一、或两个证候组合的总频率后,经Logisitc回归分析得到的影响因素(合并病)。故辨证时,一个影响因素(合并病)的出现,能推测到构成CAS患者的证型组合的某一阶段、或组成部分。又通过望闻问切的结合,能加强辨证论治的正确性。即对证型组合起作用的影响因素也能作为辨证新模式的一部分。另外,有研究报道,痰浊型动脉硬化(AS)患者的血脂指标水平如VLDL及LP明显高于肾虚证。痰浊明确为AS伴高血脂症有密切关系,但本研究表明肝肾阴虚证对高血脂症的影响力高于痰浊阻遏证。这是因为本研究以颈动脉斑块为主分析的证候分布规律,比一般的动脉硬化(AS)更严重状态。故本人认为CAS的痰浊、肝肾阴虚证均能导致高血脂症,但颈动脉斑块形成后的肝肾阴虚证对脂质代谢紊乱比痰浊阻遏证更有密切关系。
自拟益肾活血汤为血瘀证+肝肾阴虚证组成的方剂。为对颈动脉斑块缩小、稳定化,最重要的证型组合。血瘀征象相应的药物有葛根、白蒺藜、地龙、川芎、丹参；而肝肾阴虚征象相应的药物有制首乌、女贞子、枸杞子。这些药物对该辨证模式不但有针对性强,而且现代医学认为这些中药有降血压、降血脂、降血糖等的药理作用。所以该处方的配伍,对辨证思路与现代医学的研究不矛盾。
Objective:This study is to make a retrospective study of carotid atherosclerosis(CAS) TCM syndrome distribution law. Analysis on related indexes and influencing factors of CAS is to find more suitable TCM clincal therapeutic principle for CAS TCM syndrome. Clinical study of nourishing kidney and promoting blood circulation method purport to be about the exploration for TCM treatment.
Method:This study was made with CAS clinical patient history as an investigation object,which were based on TCM syndrome using methods of epidemiology. These are attempts to give objective CAS law of TCM syndrome distribution and give evidence to CAS Syndrome standardization study. Syndrome distribution law study used retrospective method, investigated298cases of CAS patient, collected general clinical data, data of symtoms, and frequency of syndrome, use statistical comparative analysis, explore the CAS of syndrome distribution law and study correlation between related indexes and influencing factors. In the third section of nourishing kidney and promoting blood circulation method is to study etiology and pathogenesis of TCM, which motivate us to find very best therapeutic principle and herbs. Every treatment group and control group collected40cases each, cases were collected treatment group by outpatient and control group by the medical record review. All the data were analysed by descriptive analysis, mean number difference analysis, Mann-Whiteney U test, t-test, X--test, Logistic regression analysis using SPSS18.0statistical software package.
Result:
1. The frequency order of different TCM syndrome group was as follows, sputum stasis syndrome+qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group117cases> sputum stasis syndrome+qi stagnation and blood stasis syndrome group85cases> qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group47cases> sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group30cases,etc.
2. Sputum stasis syndrome group compared with other groups of carotid ultrasound. TCD,related index.using t-test show that left side plaque length. right side middle cerebral artery,right side anterior cerebral artery t-value was positive value (P<0.05or P<0.01)
3. Qi stagnation and blood stasis syndrome group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that apolipoproteinB, t-value was negative-value(P<0.05).
4. Deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that right side anterior cerebral artery, left side anterior cerebral artery, right and left side siphon degment of carotid artery, t-value was negative-value (P<0.05or P<0.01) and about the related index shows that systolic blood pressure and blood glucose t-value was positive-value(P<0.05).
5. Sputum stasis syndrome+qi stagnation and blood stasis syndrome group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that right and left side middle cerebral artery t-value was positive-value(P<0.05) and abut the related index shows that total cholesterol, very low density lipoprotein, apolipoproteinB t-value was negative-value (P<0.05).
6. Sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that left side vertebral artery was positive-value(P<0.05) and about the related index shows that systolic blood pressure t-value was positive-value(P<0.05).
7. Qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that right and left side anterior cerebral artery t-value was negative-value(P<0.05or P<0.01) and about the related index shows that age, systolic blood pressure t-value was positive-value(P<0.05).
8. Sputum stasis syndrome+qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group compared with other groups of carotid ultrasound, TCD,related index,using t-test show that left side vertebral artery was positive-value(P<0.05) and about the related index shows that age, systolic blood pressure t-value was positive-value(P<0.05).
9. Four different TCM syndrome groups of carotid ultrasound used one-way Anova method to compared each other and show that among the four different types of syndrome groups plaque has no difference (P>0.05), also shows that compare between sputum stasis syndrome+qi stagnation and blood stasis syndrome group with sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group t-value was negative-value(b> a;P<0.05).
10. Sputum stasis syndrome of logistic regression analysis show that coronary atherosclersis P=0.000,OR=4.193, has positive correlation.
11. Qi stagnation and blood stasis syndrome of logistic regression analysis show that lacunar cerebral infarction P=0.012,OR=0.383, has negative correlation.
12. Deficiency syndrome of both liver and kidney yin of logistic regression analysis show that diabetes P=0.020,OR=1.881, hyperlipidemia P=0.046,OR=1.995, lacunar cerebral infarction P=0.006,OR=2.149, has positive correlation and also shows that coronary atherosclersis P=0.001,OR=0.362, has negative correlation.
13. Sputum stasis syndrome+qi stagnation and blood stasis syndrome group of logistic regression analysis show that coronary atherosclersis P=0.002, OR=2.486, has positive correlation and also shows that lacunar cerebral infarction P=0.012,OR=0.480, has negative correlation.
14. Sputum stasis syndrome+deficiency syndrome of both liver and kidney yin group of logistic regression analysis show that lacunar cerebral infarction P=0.023,OR=1.803, has positive correlation.
15. Qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group of logistic regression analysis show that hyperlipidemia P=0.009,OR=2.374,ageP=0.019,OR=1.033, has positive correlation.
16. Sputum stasis syndrome+type of qi stagnation and blood stasis+deficiency syndrome of both liver and kidney yin group of logistic regression analysis show that all the variable factors are OR=1, it means that variable factor have no effect on CAS TCM syndrome group.
17. The clinical effect of nourishing kidney and promoting blood circulation method on CAS patient show that treatment group of before and after treatment of plaque length and thickness t-value was positive-value(P<0.05). control group of before and after treatment of plaque length and thickness t-value was negative-value(P<0.05),showed statistical difference.
Conclusion:
1. Sputum stasis syndrome+qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin group117cases has the highest incidence of different TCM syndrome groups.
2. Empirical syndrome's like sputum stasis syndrome or qi stagnation and blood stasis syndrome are mostly have effect on CAS and cerebral arteriosclerosis.
3. Deficiency syndrome's like deficiency syndrome of both liver and kidney yin group are mostly have effect on age, hypertension, diabetes, hyperlipidemia.
4. Among the four different TCM syndrome groups of plaque thickness has no difference each other. It is likely to think that plaque thickness is made of three syndrome factors which is participated by Sputum stasis syndrome, qi stagnation and blood stasis syndrome, deficiency syndrome of both liver and kidney yin group.
5. Influencing factors of sputum stasis syndrome:Coronary atherosclersis.
6. Influencing factors of qi stagnation and blood stasis syndrome:Lacunar cerebral infarction.
7. Influencing factors of deficiency syndrome of both liver and kidney yin:Diabetes, Hyperlipidemia, Coronary atherosclersis, Lacunar cerebral infarction.
8. Influencing factors of sputum stasis syndrome+qi stagnation and blood stasis syndrome:Coronary atherosclersis, Lacunar cerebral infarction.
9. Influencing factors of sputum stasis syndrome+deficiency syndrome of both liver and kidney yin:Lacunar cerebral infarction.
10. Influencing factors of qi stagnation and blood stasis syndrome+deficiency syndrome of both liver and kidney yin:Age, Hyperlipidemia.
11. Nourishing kidney and promoting blood circulation method can reduce CAS plaque's thickness.
In this study, the main design of carotid atherosclerosis's syndrome concluded to Sputum stasis syndrome,Qi stagnation and blood stasis syndrome and Deficiency syndrome of both liver and kidney yin group, which has therapeutic mode of strong pertinence.It is easier to find a proper herbs and therapeutic principle. It is very rare to see that TCM clinical syndrome shows only one single appearance.When you find to see only one syndrome appear and other syndrome not so obvious,that can be a syndrome differentiation first to be treated. But this can not be representing the whole idea of pathogenesis.In fact,one syndrome can not generalize all the CAS pathogenesis of TCM syndromes,just only compare to other syndromes,when one syndrome show prominent,then this syndrome differentiation is just a temporary medical differential mode of all the pathologic stages. Therefore,when doctors are in a TCM clinic practice,you have to use the proper TCM therapeutic mode to obtain the ideal effect. Generally, CAS gets larger as the increasing of age,which is long-term interference of metabolic disorder.According to TCM syndrome differentiation theory,sputum,blood stasis and deficiency syndromes are summarized as the core evolution law of CAS.These representative three syndromes of etiology and pathogenesis can make mutual transformation. Therefore, CAS syndromes mostly appears in the form of two or three syndromes together. In this research shows the most high requency of the three combination of Sputum stasis syndrome+Qi stagnation and blood stasis syndrome+Deficiency syndrome of both liver and kidney yin. Therefore,CAS is the result of sputum,blood stasis and deficiency syndromes' interaction.
The result of correlation between Sydromes and Influencing factors are made by Logistic retrospective analysis.which is made after analyzing the total frequency of all types of each syndrome combination.Therefore, Influencing factors can indicate a certain stage or composition of CAS syndrome.Also,in the help of inspection, auscultation-olfaction,interrogation and palpation method can strengthen accuracy of syndrome differentiation and treatment.It means that these Influencing factors can make the part of new form of syndrome differentiation method.
In addition, some research reports shows that Sputum stasis syndrome of arteriosclerosis(AS) has much higher concentration of VLDL,LP than Deficiency syndrome of both liver and kidney yin. Sputum stasis syndrome of arteriosclerosis(AS) clearly related to hyperlipidemia,but this research shows that Deficiency syndrome of both liver and kidney yin has more influence on hyperlipidemia.This is because the results are analyzed by CAS distribution rules of manifestation.and this what makes more bigger influences on hyperlipidemia than to Sputum stasis syndrome of arteriosclerosis(AS).Therefore,I think that Sputum stasis syndrome and Deficiency syndrome of both liver and kidney yin all have influence on on hyperlipidemia.but after carotid plaque is formed. Deficiency syndrome of both liver and kidney yin has more correlated to lipid metabolism disorder than Sputum stasis syndrome.
Self-made yishen huoxue decoction is made by blood stasis syndrome+ Deficiency syndrome of both liver and kidney yin combination.It is an effective treatment that can make reduce and stabilize Carotid plaque.
Corresponding herbs to blood stasis syndrome are kudzu,tribulus,lumbricus, rhizomaligusticichuanxiong, salvia and corresponding herbs to Deficiency syndrome of both liver and kidney yin are radix polygoni multiflori preparata,ligustrum lucidum,wolfberry fruit. These herbs are not only have strong pertinence to each syndromes,and also modern medicine holds that these herbs have pharmacological action of lowering blood pressure,reducing blood lipid,hypoglycemic effect etc...Therefore this prescription has no contradiction between TCM thinking of syndrome differentiation and modern medicine.
引文
[1]陈奇.中药药效研究思路与方法[M].人民卫生出版社,2005：187-189.
[2]孙璐、黄水清.动脉粥样硬化动物模型与中医证候相关性研究[J].现代中西医结合杂志,2009,18(3)：337-339.
[3]王东生、陈方平、等.动脉粥样硬化大鼠“痰瘀”病理演变与血管平滑肌细胞凋亡的相关性研究[J].中国中医药信息杂志,2005,2(2)：38-40.
[4]刘卫红、张琪、颜贤忠、等.高脂血症及动脉粥样硬化痰瘀演变的代谢组学研究[J].中医杂志,2008,49(8)：738-741.
[5]刘仁人、顾耘.颈动脉粥样硬化肾虚证和痰湿证血脂质代谢及动脉病变特点的比较[J].上海中医药杂志,2006,40(11)：20-21.
[6]吴以岭.“脉络-血管系统”相关性探讨[J].中医杂志,2007,48(1)：5-8.
[7]王琴、朱浩、王璇等.半夏白术天麻汤治疗颈动脉粥样硬化斑块疗效观察[J].现代中西医结合杂志,2007,16(13)：1752-1753.
[8]陈冰、宋剑南、牛晓红等.健脾祛痰化瘀方对氧化型低密度脂蛋白诱导血管细胞信号分子钙离子和蛋白激酶C表达的影响[J].中国动脉硬化杂志,2004,12(2)：143-146.
[9]于荣、许平等.疏肝清脂颗粒延缓或消退动脉粥样硬化斑块机制的实验研究[J].中国中西医结合杂志,2007,27(10)：912-915.
[10]张红霞、李广斌、姜希娟、等.调肝导浊中药对动脉粥样硬化家兔PDGF-A及其受体α表达的影向[J].中国杂志,2007,20(5)：61-63.
[11]蒋晓霞、张斌霞、李小龙.补肾泄浊法治疗颈动脉粥样硬化45例[J].中西医结合心脑血管病杂志,2006,4(9)：815-816.
[12]张琪.血脉通颗粒治疗颈动脉粥样硬化斑块42例临床研究[J].国医论坛,2005,20(6)：36-37.
[13]黄小波、李宗信、陈文强等.颈动脉粥样硬化痰浊内阻证与血瘀证主成分的相关分析[J].中国中医结合急救杂志,2008,15(3)：135-137.
[14]陈萍、陈浩、洪泳敦等.温胆泄浊法对痰浊型高血压病患者血管内皮舒张功能与粥样硬化改善作用的超声研究[J].中国中西医结合杂志,2007,27(1)：21-24.
[15]王志强、张学平、张怀印、等.化痰通络法改善颈AS患者血管内皮功能研究[J].辽宁中医药大学学报,2009,8(11)：8.
[16]曾燕静、潘竟霞、刘柯兵等.温胆片治痰浊型高血压患者颈动脉粥样硬化的血流动力改变[J].内蒙古中医药,2008：10-11.
[17]陈可翼、马晓昌.关于传统血瘀证的现代分类[J].中国中西医结合杂志,2008,20(7)：487.
[18]赵明、孙立新、徐素芝等.活血化瘀软胶囊治疗脑梗死伴发颈动脉粥样硬化斑块的临床观察[J].河北中医,2009,2(1)：192-193.
[19]董国菊、刘剑刚、史大卓.气血并治方胶囊治疗颈动脉粥样硬化的临床研究[J].世界中西医结合杂志,2008,3(1)：29-32.
[20]张雪梅.蒲参胶囊治疗颈动脉粥样硬化的临床研究[J].中成药,2008,30(8)：1105-1107.
[21]董会文、刘爱军、韩召展、等.通心络胶囊对高血脂症及颈动脉硬化的影响[J].中西医结合心脑血管病杂志,2007,8(5)：732-733.
[22]刘向敏.脑心通胶囊治疗颈动脉粥样硬化的疗效观察[J].中西医结合心脑血管病杂志,2009,5(7)：5.
[23]仝允军、于首元.复方丹参滴丸对动脉粥样硬化斑块影响的临床分析[J].中华全科医学,2009,7(D)：63.武汉：湖北中医学院,2007
[24]许迎春、王华良、丁晶.动脉粥样硬化从毒论治探讨[J].中医杂志,2004,5(6)：405-407.
[25]毛莉娜.清热解毒法对冠心病患者血脂及C-反应蛋白影响的临床研究[J].中国医药学报,2007,19(6)：341-344
[26]李富玉、李军艳、许彦来、等.解毒活血法治疗颈动脉粥样硬化斑块临床观察[J].山东中医药大学学报,2010,36(1)：42-43
[27]彭哲、王硕仁、李秋梅、等.解毒活血益气方药物血清对兔血管平滑肌细胞增殖及脂质过氧化的影响[J].中国医药学报,2007,19(6)：341-344
[28]吴智春、吴凯、王浩、等.金匮泻心汤抗动脉粥样硬化的实验研究[J].中国老年学杂志,2003,23(7)：461-462.
[29]骆丽娟.益气活血方治疗颈动脉粥样硬化的临床观察[J].辽宁中医杂志, 2011,38(2)：311-312.
[30]吴天敏、陈金水.康欣胶囊对肾虚血瘀型颈动脉粥样硬化的临床观察[J].光明中医,2010,25(8)：1382-1384.
[31]王占奎、王伟志、傅立新等.针灸对颈动脉粥样硬化患者颈动脉形态学和动力学的影响[J].上海针灸杂志,2005,24(6)：8-11.
[32]王伟志、宋平、王占奎.针灸治疗颈动脉粥样硬化斑块的临床观察[J].中国针灸,2005,5(25)：312-314.
[33]戴蓓、程丑夫.降脂消斑片对痰热血瘀型颈动脉粥样硬化的作用[J].中医药导报,2012,18(2)：49-50.
[34]陈明荃、顾耘、徐辉.颈动脉粥样硬化患者中医证候分布探讨[J].中华中医药学刊,2012,30(6)：1394-1396.
[35]陈文强、王芬等.颈动脉粥样硬化中医证候转化的定量分析[J].中国老年学杂志,2010,15(30)：2089-2091.
[36]幺明玉、高学功.清热养阴活血法治疗颈动脉粥样硬化斑块150例临床观察[J].河北中医,2010,32(1)：31-33.
[37]李经华、赵广利.三七通舒胶囊治疗颈动脉粥样硬化斑块30例临床观察[J].甘肃中医,2009,22(2)：31-32.
[38]李孝次.涤痰逐瘀汤治疗颈动脉粥样硬化临床观察[J].中西医结合心脑血管病杂志,2011,9(9)：1059-1061.
[39]汪铁铮、王少杰.原发性高血压病合并颈动脉粥样硬化中医证候学规律研究[J].北京中医药,2011,30(12)：894-897
[40]刘鹏业、黄黄琛、娄翕翕、李思琪、钱海凌.活血化瘀利水中药复方治疗颈动脉粥样硬化的临床研究[J].广西中医药,2012,35(6)：9-12
[41]张春燕、李宗信、黄小波、王芬、陈文强.老年颈动脉硬化患者血清炎症因子与中医证型的关系[J].中国中医药信息杂志,2009,16(7)：19-21
[42]刘仁人.六君子汤加味治疗痰湿型颈动脉硬化的临床观察[J].上海中医药杂志,2008,42(4)：28-29
[1]朱建贵.中医老年病临床实践[M].贵州科技出版社,2001：32.
[2]刘仁人、顾耘.颈动脉粥样硬化肾虚证和痰湿证血脂质代谢及动脉病变特点的比较[J].上海中医药杂志,2006,40(11)：20-21.
[1]池明宇,等.中西医结合血栓病学[M].北京：人民卫生出版社,2004：38-196
[2]卫生部心血管病防治研究中心.中国心血管病报告2008-2009[M].北京：中国大百科全书出版社,2009：33-65
[3,5]何文.颈动脉彩色多普勒超声与临床[M].北京：科学技术文献出版社,2007,第一版：57-58.
[4]Crouse JR,Harpold GH,Kahl FR,et al.Evalua.tion of a scoring system for extracranial carotid atherosclerosis extent with B-mode ultrasound.[J].Stroke,1986, 17:270-274.
[5]徐智障.现代腹部超声诊断学[M].北京：科学出版社,2001,第一版：636-640.
[2]孙璐、黄水清.动脉粥样硬化动物模型与中医证候相关性研究[J].现代中西医结合杂志,2009,18(3)：337-339.
[3]王东生、陈方平、等.动脉粥样硬化大鼠“痰瘀”病理演变与血管平滑肌细胞凋亡的相关性研究[J].中国中医药信息杂志,2005,2(2)：38-40.
[4]刘卫红、张琪、颜贤忠、等.高脂血症及动脉粥样硬化痰瘀演变的代谢组学研究[J].中医杂志,2008,49(8)：738-741.
[5]刘仁人、顾耘.颈动脉粥样硬化肾虚证和痰湿证血脂质代谢及动脉病变特点的比较[J].上海中医药杂志,2006,40(11)：20-21.
[6]吴以岭.“脉络-血管系统”相关性探讨[J].中医杂志,2007,48(1)：5-8.
[7]王琴、朱浩、王璇等.半夏白术天麻汤治疗颈动脉粥样硬化斑块疗效观察[J].现代中西医结合杂志,2007,16(13)：1752-1753.
[8]陈冰、宋剑南、牛晓红等.健脾祛痰化瘀方对氧化型低密度脂蛋白诱导血管细胞信号分子钙离子和蛋白激酶C表达的影响[J].中国动脉硬化杂志,2004,12(2)：143-146.
[9]于荣、许平等.疏肝清脂颗粒延缓或消退动脉粥样硬化斑块机制的实验研究[J].中国中西医结合杂志,2007,27(10)：912-915.
[10]张红霞、李广斌、姜希娟、等.调肝导浊中药对动脉粥样硬化家兔PDGF-A及其受体α表达的影向[J].中国杂志,2007,20(5)：61-63.
[11]蒋晓霞、张斌霞、李小龙.补肾泄浊法治疗颈动脉粥样硬化45例[J].中西医结合心脑血管病杂志,2006,4(9)：815-816.
[12]张琪.血脉通颗粒治疗颈动脉粥样硬化斑块42例临床研究[J].国医论坛,2005,20(6)：36-37.
[13]黄小波、李宗信、陈文强等.颈动脉粥样硬化痰浊内阻证与血瘀证主成分的相关分析[J].中国中医结合急救杂志,2008,15(3)：135-137.
[14]陈萍、陈浩、洪泳敦等.温胆泄浊法对痰浊型高血压病患者血管内皮舒张功能与粥样硬化改善作用的超声研究[J].中国中西医结合杂志,2007,27(1)：21-24.
[15]王志强、张学平、张怀印、等.化痰通络法改善颈AS患者血管内皮功能研究[J].辽宁中医药大学学报,2009,8(11)：8.
[16]曾燕静、潘竟霞、刘柯兵等.温胆片治痰浊型高血压患者颈动脉粥样硬化的血流动力改变[J].内蒙古中医药,2008：10-11.
[17]陈可翼、马晓昌.关于传统血瘀证的现代分类[J].中国中西医结合杂志,2008,20(7)：487.
[18]赵明、孙立新、徐素芝等.活血化瘀软胶囊治疗脑梗死伴发颈动脉粥样硬化斑块的临床观察[J].河北中医,2009,2(1)：192-193.
[19]董国菊、刘剑刚、史大卓.气血并治方胶囊治疗颈动脉粥样硬化的临床研究[J].世界中西医结合杂志,2008,3(1)：29-32.
[20]张雪梅.蒲参胶囊治疗颈动脉粥样硬化的临床研究[J].中成药,2008,30(8)：1105-1107.
[21]董会文、刘爱军、韩召展、等.通心络胶囊对高血脂症及颈动脉硬化的影响[J].中西医结合心脑血管病杂志,2007,8(5)：732-733.
[22]刘向敏.脑心通胶囊治疗颈动脉粥样硬化的疗效观察[J].中西医结合心脑血管病杂志,2009,5(7)：5.
[23]仝允军、于首元.复方丹参滴丸对动脉粥样硬化斑块影响的临床分析[J].中华全科医学,2009,7(D)：63.武汉：湖北中医学院,2007
[24]许迎春、王华良、丁晶.动脉粥样硬化从毒论治探讨[J].中医杂志,2004,5(6)：405-407.
[25]毛莉娜.清热解毒法对冠心病患者血脂及C-反应蛋白影响的临床研究[J].中国医药学报,2007,19(6)：341-344
[26]李富玉、李军艳、许彦来、等.解毒活血法治疗颈动脉粥样硬化斑块临床观察[J].山东中医药大学学报,2010,36(1)：42-43
[27]彭哲、王硕仁、李秋梅、等.解毒活血益气方药物血清对兔血管平滑肌细胞增殖及脂质过氧化的影响[J].中国医药学报,2007,19(6)：341-344
[28]吴智春、吴凯、王浩、等.金匮泻心汤抗动脉粥样硬化的实验研究[J].中国老年学杂志,2003,23(7)：461-462.
[29]骆丽娟.益气活血方治疗颈动脉粥样硬化的临床观察[J].辽宁中医杂志, 2011,38(2)：311-312.
[30]吴天敏、陈金水.康欣胶囊对肾虚血瘀型颈动脉粥样硬化的临床观察[J].光明中医,2010,25(8)：1382-1384.
[31]王占奎、王伟志、傅立新等.针灸对颈动脉粥样硬化患者颈动脉形态学和动力学的影响[J].上海针灸杂志,2005,24(6)：8-11.
[32]王伟志、宋平、王占奎.针灸治疗颈动脉粥样硬化斑块的临床观察[J].中国针灸,2005,5(25)：312-314.
[33]戴蓓、程丑夫.降脂消斑片对痰热血瘀型颈动脉粥样硬化的作用[J].中医药导报,2012,18(2)：49-50.
[34]陈明荃、顾耘、徐辉.颈动脉粥样硬化患者中医证候分布探讨[J].中华中医药学刊,2012,30(6)：1394-1396.
[35]陈文强、王芬等.颈动脉粥样硬化中医证候转化的定量分析[J].中国老年学杂志,2010,15(30)：2089-2091.
[36]幺明玉、高学功.清热养阴活血法治疗颈动脉粥样硬化斑块150例临床观察[J].河北中医,2010,32(1)：31-33.
[37]李经华、赵广利.三七通舒胶囊治疗颈动脉粥样硬化斑块30例临床观察[J].甘肃中医,2009,22(2)：31-32.
[38]李孝次.涤痰逐瘀汤治疗颈动脉粥样硬化临床观察[J].中西医结合心脑血管病杂志,2011,9(9)：1059-1061.
[39]汪铁铮、王少杰.原发性高血压病合并颈动脉粥样硬化中医证候学规律研究[J].北京中医药,2011,30(12)：894-897
[40]刘鹏业、黄黄琛、娄翕翕、李思琪、钱海凌.活血化瘀利水中药复方治疗颈动脉粥样硬化的临床研究[J].广西中医药,2012,35(6)：9-12
[41]张春燕、李宗信、黄小波、王芬、陈文强.老年颈动脉硬化患者血清炎症因子与中医证型的关系[J].中国中医药信息杂志,2009,16(7)：19-21
[42]刘仁人.六君子汤加味治疗痰湿型颈动脉硬化的临床观察[J].上海中医药杂志,2008,42(4)：28-29
[1]朱建贵.中医老年病临床实践[M].贵州科技出版社,2001：32.
[2]刘仁人、顾耘.颈动脉粥样硬化肾虚证和痰湿证血脂质代谢及动脉病变特点的比较[J].上海中医药杂志,2006,40(11)：20-21.
[1]池明宇,等.中西医结合血栓病学[M].北京：人民卫生出版社,2004：38-196
[2]卫生部心血管病防治研究中心.中国心血管病报告2008-2009[M].北京：中国大百科全书出版社,2009：33-65
[3,5]何文.颈动脉彩色多普勒超声与临床[M].北京：科学技术文献出版社,2007,第一版：57-58.
[4]Crouse JR,Harpold GH,Kahl FR,et al.Evalua.tion of a scoring system for extracranial carotid atherosclerosis extent with B-mode ultrasound.[J].Stroke,1986, 17:270-274.
[5]徐智障.现代腹部超声诊断学[M].北京：科学出版社,2001,第一版：636-640.