慢性心力衰竭中医证候特点的临床研究
摘要
慢性心力衰竭是21世纪危害最大的心血管疾病之一,个体体质的差异性及基础疾病的多样性,致使本病的中医辨证论治复杂化和多样化。因此,对慢性心衰中医证型研究,有助于提高中医药防治慢性心衰的临床水平。本课题拟通过对慢性心衰的证候分布特点及证候组合规律的研究,总结出慢性心衰证型特点,进而为慢性心衰的证型规范化研究提供依据,更好指导临床。
方法：(1)以2009年5月-2010年3月在北京中医药大学东方医院、东直门医院、中日友好医院等心内科住院治疗的122例慢性心衰患者和30例非心衰患者为研究对象。(2)对疑诊心衰的患者由主治医师以上职称人员按2007年中国慢性心力衰竭诊断治疗指南进行评估,排除心衰患者纳入非心衰(对照)组,符合心衰患者初步纳入心衰组,进行纽约心功能(NYHA)分级,再由具有中医师资格医师参照心衰中医辨证分型及脏腑虚证辨证相关标准对心衰患者进行中医辨证,收集患者中医四诊信息和其他病情资料。(3)使用SPSS13.0统计软件进行统计分析。计量资料表示为χ±s的形式。计量资料采用t检验或方差分析,两组计数资料的构成比比较,采用X2检验。
结果：(1)慢性心衰中医证侯分布：心衰组122例中医证候以气虚证出现比例最高(占89.3%),其次为血瘀证(占61.5%),水饮证(27.9%),痰浊证、阴虚证和阳虚证所占比例相对较低。脏腑虚证以心虚证出现比例最高(占92.6%)其次为肾虚证(占82.0%)、肺虚证(占49.2%)及脾虚证(占39.3%),肝虚证也占一定比例(23.8%),胃虚证所占比例较低。经统计分析,心衰组气虚证、血瘀证、水饮证、心虚证、肺虚证、肾虚证、脾虚证构成比高于非心衰组(P<0.05)阳虚证、水饮证、痰浊证在心功能Ⅳ级心衰患者中构成比明显高于心功能ⅡI级和Ⅲ级(P<0.01)。(2)慢性心衰中医证侯组合特点：心衰组122例,以三证组合为最多(占50.8%),其次为两证组合(占32.0%)和四证组合(占9.8%),而五证组合(占4.1%)和单证(占3.3%)少见。以气虚血瘀为基本证候组合,在此基础上合并其他证候。脏腑虚证组合以三证组合最为多见(占43.4%),其次为两证组合(占29.5%)和四证组合(占18.0%),五证组合(占4.9%)及单证(占4.1%)少见。心虚证可单独出现,但心虚证合并其他脏腑虚证的三证组合、二证组合更为常见。二证组合大多为心虚证合并肾虚证或肺虚证,三证组合大多为心、肺、肾虚并见。由此可见,心衰虽是局部之病却是全身之疾。心与五脏之气相连一脉相承。慢性心衰以心气虚为基础,进而损及肺、脾、肾、肝四脏,以致全身阴阳气血紊乱,在此基础上产生痰浊、瘀血、水湿等种种内生实邪,导致一系列的临床危急征象,故其临床表现复杂。
结论：(1)慢性心衰的基本病机特点为本虚标实,气虚、阳虚为本,瘀血阻滞、水饮内停为标,气虚血瘀是慢性心衰最基本证候。(2)气虚证、血瘀证及水饮证可作为心衰的相对特异性证候。(3)心衰发生后,随阳虚证、水饮证及痰浊证出现,心功能将不断恶化,提示阳虚证、水饮证、痰浊证可能在心衰发病之后的病情发展变化中起着重要作用。(4)本研究通过对心衰常见的证候的临床研究,认为气虚血瘀是贯穿于慢性心衰病程中的最基本的病理机制,气虚血瘀进一步发展可致气阳两虚、阳气虚脱、水湿内停、痰浊内阻等一系列虚实夹杂的证候群,成为充血性心力衰竭辨证论治的基础,而这同样体现了充血性心力衰竭的中医证型变化主要特点。
Chronic heart failure is one of the most harmful disease of the 21st century. Individual difference and different basic diseases make the syndrome of HF differentiation and treatment is also complicated and diversified. Therefore, in-depth syndromes research of chronic heart failure helps regulate the TCM syndrome, and then improve the clinical level of TCM. This study attempts to explore syndromes distribution characteristics of chronic heart failure and regularity of syndromes combination so as to provide research basis of chronic heart failure.
Methods:(1) The objects of research are 122 in-patients in department of cardiology from.Dongfang hospital, Dongzhimen hospital, China-Japanese Friendship Hospital who have been diagnosed with chronic heart failure from May 2009 to March 2010. (2) The research has been investigating the potential heart failure patients due to evaluate the 2007 China's chronic heart failure diagnosis and treatment guidelines. And the definite diagnosis patients will be preliminary involved heart failure group. It will classify the patients by New York Heart Association (NYHA) to exclude some patients according to the standards. Then doctors who have TCM certificate will give TCM diagnose and collect other clinical record. (3) Statistical method:Use the Statistical software of SPSS 13.0 for windows. Measurement data use t-test or variance analysis. The comparison of percentages between two groups use X2-test.
Results:(1) Distribution of syndromes:The statistical analysis shows that the most common syndromes is the deficiency-syndrome of qi (89.3% of total). The second are the syndrome of blood stasis (61.5% of total) and water overflowing (27.9% of total), while only a few syndromes are the syndrome of sputum-turbid, the deficiency-syndrome of yin and the deficiency-syndrome of yang. The most common deficiency-syndrome of the viscera are the deficiency-syndrome of the heart(92.6% of total), then is the deficiency-syndrome of the kidney (82.0% of total) and the deficiency-syndrome of the lung(49.2% of total) and the deficiency-syndrome of the spleen (39.3% of total). The deficiency-syndrome of the liver has a little proportion (39.3% of total), while the deficiency-syndrome of the stomach has the lowest proportion. Through the statistical analysis the percentages of the deficiency-syndrome of qi, the syndrome of blood stasis, the syndrome of the water overflowing, the deficiency-syndrome of the heart, the deficiency-syndrome of the lung, the deficiency-syndrome of the kidney and the deficiency-syndrome of the spleen of the group of HF are higher than that of the group of NHF (P< 0.05). The deficiency-syndrome of yang, the syndrome of the water overflowing and the syndrome of sputum-turbid have a higher percent in NYHAⅣthan NYHAⅡandⅢ(P< 0.01). (2) Combination of syndromes:The statistical analysis shows that the most common combination of syndromes among the patients of HF is the combination of three-syndromes (50.8% of total). Besides, the combination of two-syndromes (32.0% of total) and four-syndromes (9.8% of total) are also relatively common combination, while only a few combination are the Combination of five-syndromes (4.1% of total) or single-syndrome (3.3 of total). The combination of the deficiency-syndrome of qi and the syndrome of blood stasis is the basis of the combination of syndrome. The most common combination of the deficiency-syndrome of the viscera is the combination of three-syndromes (43.4% of total). Besides, the combination of two-syndromes (29.5% of total) and four-syndromes (18.0% of total) are also relatively common combination, while only a few combination are the combination of five-syndromes (5.1% of total) and single-syndrome (4.1% of total). The deficiency-syndrome of the heart can be alone, but the deficiency-syndrome of the heart with other deficiency-syndrome of the viscera has more percents.
Conclusion:(1) The basic features of pathogenesis of HF is primary deficiency and secondary excess. The syndrome of deficiency of qi and the blood stasis is the basic syndrome of HF. (2) The deficiency-syndrome of qi, the syndrome of blood stasis and water overflowing can be the characteristics syndrome of HF. (3) After HF has appeared, cardiac function will deteriorate after the appearance of the deficiency-syndrome of yang, the syndrome of the water overflowing and the syndrome of sputum-turbid, and these syndromes play an important role among the changes of the state of HF. (4) This thesis studied on common syndrome of HF by clinical observation, then we make a conclusion that the syndrome of deficiency of qi and the blood stasis is the basic syndrome of HF. From this basis the syndrome of deficiency of qi and deficiency of yang, the syndrome of exhaustion of yangqi, the syndrome of the water overflowing and the syndrome of sputum-turbid will appeare, which will be the basic of treatment based on syndrome differentiation in HF.
方法：(1)以2009年5月-2010年3月在北京中医药大学东方医院、东直门医院、中日友好医院等心内科住院治疗的122例慢性心衰患者和30例非心衰患者为研究对象。(2)对疑诊心衰的患者由主治医师以上职称人员按2007年中国慢性心力衰竭诊断治疗指南进行评估,排除心衰患者纳入非心衰(对照)组,符合心衰患者初步纳入心衰组,进行纽约心功能(NYHA)分级,再由具有中医师资格医师参照心衰中医辨证分型及脏腑虚证辨证相关标准对心衰患者进行中医辨证,收集患者中医四诊信息和其他病情资料。(3)使用SPSS13.0统计软件进行统计分析。计量资料表示为χ±s的形式。计量资料采用t检验或方差分析,两组计数资料的构成比比较,采用X2检验。
结果：(1)慢性心衰中医证侯分布：心衰组122例中医证候以气虚证出现比例最高(占89.3%),其次为血瘀证(占61.5%),水饮证(27.9%),痰浊证、阴虚证和阳虚证所占比例相对较低。脏腑虚证以心虚证出现比例最高(占92.6%)其次为肾虚证(占82.0%)、肺虚证(占49.2%)及脾虚证(占39.3%),肝虚证也占一定比例(23.8%),胃虚证所占比例较低。经统计分析,心衰组气虚证、血瘀证、水饮证、心虚证、肺虚证、肾虚证、脾虚证构成比高于非心衰组(P<0.05)阳虚证、水饮证、痰浊证在心功能Ⅳ级心衰患者中构成比明显高于心功能ⅡI级和Ⅲ级(P<0.01)。(2)慢性心衰中医证侯组合特点：心衰组122例,以三证组合为最多(占50.8%),其次为两证组合(占32.0%)和四证组合(占9.8%),而五证组合(占4.1%)和单证(占3.3%)少见。以气虚血瘀为基本证候组合,在此基础上合并其他证候。脏腑虚证组合以三证组合最为多见(占43.4%),其次为两证组合(占29.5%)和四证组合(占18.0%),五证组合(占4.9%)及单证(占4.1%)少见。心虚证可单独出现,但心虚证合并其他脏腑虚证的三证组合、二证组合更为常见。二证组合大多为心虚证合并肾虚证或肺虚证,三证组合大多为心、肺、肾虚并见。由此可见,心衰虽是局部之病却是全身之疾。心与五脏之气相连一脉相承。慢性心衰以心气虚为基础,进而损及肺、脾、肾、肝四脏,以致全身阴阳气血紊乱,在此基础上产生痰浊、瘀血、水湿等种种内生实邪,导致一系列的临床危急征象,故其临床表现复杂。
结论：(1)慢性心衰的基本病机特点为本虚标实,气虚、阳虚为本,瘀血阻滞、水饮内停为标,气虚血瘀是慢性心衰最基本证候。(2)气虚证、血瘀证及水饮证可作为心衰的相对特异性证候。(3)心衰发生后,随阳虚证、水饮证及痰浊证出现,心功能将不断恶化,提示阳虚证、水饮证、痰浊证可能在心衰发病之后的病情发展变化中起着重要作用。(4)本研究通过对心衰常见的证候的临床研究,认为气虚血瘀是贯穿于慢性心衰病程中的最基本的病理机制,气虚血瘀进一步发展可致气阳两虚、阳气虚脱、水湿内停、痰浊内阻等一系列虚实夹杂的证候群,成为充血性心力衰竭辨证论治的基础,而这同样体现了充血性心力衰竭的中医证型变化主要特点。
Chronic heart failure is one of the most harmful disease of the 21st century. Individual difference and different basic diseases make the syndrome of HF differentiation and treatment is also complicated and diversified. Therefore, in-depth syndromes research of chronic heart failure helps regulate the TCM syndrome, and then improve the clinical level of TCM. This study attempts to explore syndromes distribution characteristics of chronic heart failure and regularity of syndromes combination so as to provide research basis of chronic heart failure.
Methods:(1) The objects of research are 122 in-patients in department of cardiology from.Dongfang hospital, Dongzhimen hospital, China-Japanese Friendship Hospital who have been diagnosed with chronic heart failure from May 2009 to March 2010. (2) The research has been investigating the potential heart failure patients due to evaluate the 2007 China's chronic heart failure diagnosis and treatment guidelines. And the definite diagnosis patients will be preliminary involved heart failure group. It will classify the patients by New York Heart Association (NYHA) to exclude some patients according to the standards. Then doctors who have TCM certificate will give TCM diagnose and collect other clinical record. (3) Statistical method:Use the Statistical software of SPSS 13.0 for windows. Measurement data use t-test or variance analysis. The comparison of percentages between two groups use X2-test.
Results:(1) Distribution of syndromes:The statistical analysis shows that the most common syndromes is the deficiency-syndrome of qi (89.3% of total). The second are the syndrome of blood stasis (61.5% of total) and water overflowing (27.9% of total), while only a few syndromes are the syndrome of sputum-turbid, the deficiency-syndrome of yin and the deficiency-syndrome of yang. The most common deficiency-syndrome of the viscera are the deficiency-syndrome of the heart(92.6% of total), then is the deficiency-syndrome of the kidney (82.0% of total) and the deficiency-syndrome of the lung(49.2% of total) and the deficiency-syndrome of the spleen (39.3% of total). The deficiency-syndrome of the liver has a little proportion (39.3% of total), while the deficiency-syndrome of the stomach has the lowest proportion. Through the statistical analysis the percentages of the deficiency-syndrome of qi, the syndrome of blood stasis, the syndrome of the water overflowing, the deficiency-syndrome of the heart, the deficiency-syndrome of the lung, the deficiency-syndrome of the kidney and the deficiency-syndrome of the spleen of the group of HF are higher than that of the group of NHF (P< 0.05). The deficiency-syndrome of yang, the syndrome of the water overflowing and the syndrome of sputum-turbid have a higher percent in NYHAⅣthan NYHAⅡandⅢ(P< 0.01). (2) Combination of syndromes:The statistical analysis shows that the most common combination of syndromes among the patients of HF is the combination of three-syndromes (50.8% of total). Besides, the combination of two-syndromes (32.0% of total) and four-syndromes (9.8% of total) are also relatively common combination, while only a few combination are the Combination of five-syndromes (4.1% of total) or single-syndrome (3.3 of total). The combination of the deficiency-syndrome of qi and the syndrome of blood stasis is the basis of the combination of syndrome. The most common combination of the deficiency-syndrome of the viscera is the combination of three-syndromes (43.4% of total). Besides, the combination of two-syndromes (29.5% of total) and four-syndromes (18.0% of total) are also relatively common combination, while only a few combination are the combination of five-syndromes (5.1% of total) and single-syndrome (4.1% of total). The deficiency-syndrome of the heart can be alone, but the deficiency-syndrome of the heart with other deficiency-syndrome of the viscera has more percents.
Conclusion:(1) The basic features of pathogenesis of HF is primary deficiency and secondary excess. The syndrome of deficiency of qi and the blood stasis is the basic syndrome of HF. (2) The deficiency-syndrome of qi, the syndrome of blood stasis and water overflowing can be the characteristics syndrome of HF. (3) After HF has appeared, cardiac function will deteriorate after the appearance of the deficiency-syndrome of yang, the syndrome of the water overflowing and the syndrome of sputum-turbid, and these syndromes play an important role among the changes of the state of HF. (4) This thesis studied on common syndrome of HF by clinical observation, then we make a conclusion that the syndrome of deficiency of qi and the blood stasis is the basic syndrome of HF. From this basis the syndrome of deficiency of qi and deficiency of yang, the syndrome of exhaustion of yangqi, the syndrome of the water overflowing and the syndrome of sputum-turbid will appeare, which will be the basic of treatment based on syndrome differentiation in HF.
引文
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