冠心病慢性心力衰竭常见证候、证候要素分布规律的研究
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摘要
中医证候是疾病过程中一定阶段的病位、病因、病性、病势及机体抗病能力的强弱等本质有机联系的反应状态,表现为临床可被观察到的症状、体征等。其信息具有主观性、多样性、隐匿性、模糊性、非线性、及不确定性等特点。用证候的所属症状来规范证候,是证候诊断标准中最常用的方法。但证候所属的症状必须界定于病之下,才能体现证候的共性表现,既可克服既往证候研究的随意性,同时有利于进行临床疗效的判定。本课题基于循证医学(Evidence-Based Medicine,EBM)的思想,以冠心病慢性心力衰竭为切入点,在“病证结合”框架下,从现代文献研究及临床流行病学横断面调查两个角度,并结合多种数学统计方法,初步阐释冠心病慢性心力衰竭常见证候、证候要素及症状的分布特点及规律,以期为初步建立以辨证候要素为核心的冠心病慢性心力衰竭的辨证规范提供一定的理论依据。
一、慢性心力衰竭常见证候、证候要素及症状的现代文献研究
目的：主要通过对有关慢性心力衰竭(Chronic heart failure, CHF)的中医现代文献资料进行回顾性研究,来分析CHF常见症状、证候,然后再将证候按照一定的标准拆分成为证候要素,以期初步探讨CHF下症状、证候及证候要素的分布规律及常见证候、证候要素与症状之间的对应关系,为制定临床研究用临床信息采集表提供参考,并为进一步临床多中心、大样本流行病学调查奠定基础。
方法：检索CNKI中国知网中的中国学术期刊全文数据库、中国生物医学文献数据库、重庆维普中文期刊数据库所收录的1994年1月—2008年1月相关文献。借助NoteExpress2软件中建立CHF文献数据库。严格按照文献纳入、排除标准筛出选出合格文献,并文献中出现的证候、症状名称进行规范,然后将原始资料数据量化处理后,输入计算机EpiData3.1软件,通过SPSS16.0统计软件,采用频数、构成比、Logistic回归分析法进行分析。
结果：通过对近15年CHF相关的中医现代文献进行检索,得出176篇合格的文献,对其回顾性分析,得到如下结论
1. CHF的症状分布特点
对CHF的中医症状进行了名词规范后,并结合专家讨论建议,其症状由规范前的269个缩减为145个,总频数4149次。从频率在1.0%以上的中医症状来看,CHF主要临床症状为：心悸、气短、水肿、乏力、脉细、呼吸困难,而喘息、脉结、脉代亦常见。2. CHF的证候分布特点
CHF现代文献中出现275种证候类型,除去重复的后共有116种不同的证型,经规范后还有43种。证候类型的多样性,一方面说明CHF本身的复杂性,另一方面也表明其临床辨证没有统一性。本研究综合研究了频次和病例数构成比两个方面,证型出现的频次统计与病例数构成比统计在前7-8位基本保持一致。故CHF最常见的证候是心肾阳虚证,气虚血瘀证,心阳气虚证,水饮内停证,气阴两虚证,心气虚证,阳虚血瘀证。比较常见的证候有阳虚水泛证,心阴阳两虚证,心血瘀阻证,痰瘀互阻证。不太常见的证候有瘀热伤络证,肾不纳气证,胆胃不和证等。
3. CH F的证候要素分布特点
CHF证候要素频数出现698次,病例合计17839例,证候要素例数出现34939例。CHF病性类证候要素出现的频次统计与病例数构成比统计在前6位基本保持一致。病位类证候要素出现的频次统计与病例数构成比统计在前3位基本保持一致。故CHF最常见证候要素是阳虚、气虚、血瘀、水停、阴虚、痰;心、肾、肺。
4. CHF常见证候、证候要素对应症状的分布特点
证候排序前七位者,病性类证候要素排序前六位及病位性证候要素前三位者,计算证候下症状的频数分布,症状频数排序在前10位(若频数相同,顺延至相同频数症状末位)认定为常见症状,频数较高的症状基本能反映出与之对应的证候、证候要素的特点；采用二分类Logistic回归分析对CHF常见证候要素进行分析,贡献度较大的症状基本能反映与之对应的证候要素的特点。
二、冠心病慢性心力衰竭常见证候、证候要素、症状的临床流行病学横断面调查
目的：在预调查的基础上,进行全国多中心大样本的临床横断面流行病学调查。利用软件建立冠心病慢性心力衰竭的数据库,探讨冠心病慢性心力衰竭下症状、证候及证候要素的分布规律及冠心病慢性心力衰竭常见证候、证候要素与症状的关系,以期为进一步制定以证候要素为核心的冠心病慢性心力衰竭的诊断规范提供一定的理论参考依据。
方法：在前期文献研究的基础上,结合临床专家的建议,制作冠心病慢性心力衰竭横断面调查信息采集表,经过专家多次论证及课题组反复修改,并通过预调查对采集表信度评价后,确定正式的调查表,然后进行全国多中心大样本的流行病学调查。并利用EpiData3.1软件建立冠心病慢性心力衰竭临床数据的数据库,通过SPSS16.0统计软件,采用频数、Logistic回归分析法、无监督分析法(因子分析法、聚类分析法)对数据进行分析。
结果：
1.冠心病慢性心力衰竭临床横断面信息采集表预调查
预调查采集表中83.33%症状的相关系数值都大于0.8,另5家医院80%以上症状的相关系数都在0.8以上(双侧检验,P<0.01),表明采集表的一致性程度较高,可靠性较好。针对部分症状的r值在4家医院或以上低于0.8,则重点修改,并对采集表在某些结构或内容上存在一些问题进行优化及调整。
2.冠心病慢性心力衰竭症状的分布特点
本次临床流行病学横断面调查,合格病例数为596例,采集到的冠心病慢性心力衰竭症状有170个,其中主要症状14个,全身症状14个,头面症状17个,心胸及胁肋症状35个,脾胃及腹部症状8个,腰部及四肢症状4个,饮食及口味相关症状7个,睡眠相关症状3个,二便相关症状7个,舌象症状43个,脉象症状20个(仅计左手脉)。频率高的症状为乏力(578/96.98%),气短(556/93.29%),神疲(528/88.59%),呼吸困难(467/78.36%),浮肿(331/55.54%),心悸(451/75.67%),胸闷(537/90.10%)等。出现频率在30%以上的症状有：少气懒言、畏寒、自汗、潮热、头晕、目眩、口唇紫绀、胸痛、咳嗽、咳痰、喘息、倚息不能卧、腹胀、腰膝酸软、手足不温、肢体困重、爪甲青紫、食欲不振、口淡、口干、失眠、多梦、夜尿频多、舌下络脉异常、脉沉、脉细、脉无力等。
3.冠心病慢性心力衰竭经验辨证及证候要素的分布特点
规范后的经验辨证的证候名称,共有39类,总频数924次。其中频率大于3%的证候有9类：气虚血瘀证、气阴两虚证、痰瘀互阻证、水饮内停证、痰浊证、心血瘀阻证、血瘀水停证、阳虚水泛证、心阳虚证,它们的合计频率占76.84%;其中气虚血瘀证(174/18.83%)、气阴两虚证(154/16.67%)远多于其它证候类型。
将证候分解成基本的证候要素。提取病性类证候要素16个,出现的总频数为1740次;病位类证候要素9个,出现总频数为1397次。其中频次排在前6位的病性类证候要素是个：气虚、血瘀、阴虚、水停、痰、阳虚,它们的合计频率占95.46%；其中气虚证素(497/28.56%)、血瘀证素(448/25.75%)远多于其它病性类证候要素类型。频次排在前4位的病位类证候要素是：心、肾、脾、肺,它们的合计频率占89.26%；其中心证素(578/41.37%),远多于其它病位类证候要素类型。
4.各医院验辨证及证候要素的分布差异情况
14家医院经验辨证规范后,CC13个证候类型,CZ12个,CD15个,DF10个,DZM 17个,HZ13个,ZZ10个,WH22个,WX14个,XJ15个,YC11个,HN12个,ZR19个,ZB14个。各家医院排序在前五位的证候类型覆盖达17个之多,除气阴两虚证、气虚血瘀证是各家医院较公认外,其它类型的证候的排序均不尽相同。病位类证候要素及病性类证候要素各家医院的公认程度较高,均集中在气虚、血瘀、阴虚、水停、痰、阳虚;心、肾、脾、肺。这些证候要素的频数、频率均显著高于其它类型证候要素。部分医院还认为本病与气滞、湿、血虚、寒、热、内风、内火、阳亢、精亏、毒;肝、胃、胆、络脉、脑等相关。
5.冠心病慢性心力衰竭常见证候、证候要素对应症状的分布特点
证候排序前七位者,病性类证候要素排序前六位及病位性证候要素前三位者,计算证候下症状的频数分布,症状频数排序在前10位(若频数相同,顺延至相同频数症状末位)认定为常见症状,频数较高的症状基本能反映出与之对应的证候、证候要素的特点;采用二分类Logistic回归分析对慢性心力衰竭常见证候要素进行分析,贡献度较大的症状基本能反映与之对应的证候要素的特点。
6.中医理论对因子分析结果的诠释
因子分析法统计分析,提取了39个公因子,分析后反映出的证候要素以以气虚、阳虚、心、血瘀、脾、痰、肾、阴虚为多。7.中医理论对聚类分析结果的诠释
采用0、1、2、3和0、1两种形式,分别对全部症状进行聚类的结果大致一致,聚类后反映出的证候要素以气虚、心、阳虚、肾、脾、阴虚、血瘀、痰为多。
三、冠心病慢性心力衰竭常见证候、证候要素、症状的多种研究的对比研究
目的：从现代文献研究、临床流行病学横断面调查及基于无监督数据分析方法的研究结果三个角度分别进行两两对比分析,以期能进一步探寻冠心病慢性心力衰竭常见证候、证候要素的分布特点及其常见证候、证候要素与症状之间的对应关系。
方法：采用频数、Logistic回归分析法、无监督分析法(因子分析法、聚类分析法)进行分析。
结果：文献研究与临床流行病学横断面调查证候、证候要素的分布特点在频数法、因子分析法、聚类分析法中统计结果一致性较强,尤其是证候要素分布特点的一致性更强;但是证候要素下症状在频数法与Logistic回归法中统计结果的一致性较差,其表现在文献研究与临床研究的频数法、Logistic回归法、频数法与Logistic回归法比较的三种结果均不完全一致,相同的症状可能与之对应的证候要素产生联系,可能是反映症状与之对应的证候要素的核心症状,能用中医学理论进行诠释,但有部分症状尚不能完全解释其与所对应的证候要素之间存在联系。
四、结论
1.现代文献研究出现慢性心力衰竭规范后的症状145个,证候43个,证候要素23个;临床流行病学横断面调查规范后的症状170个,证候39个,证候要素25个;因子分析和聚类分析纳入分析的症状110个,其结果经规范后证候31个,证候要素21个。
2.冠心病慢性心力衰竭的证候、证候要素的分布特点通过频数法、因子分析法、聚类分析法的统计,结果一致性较强,尤其是证候要素分布特点的一致性更强。
3.证候要素下症状在频数法与Logistic回归法中统计结果的一致性较差,其表现在文献研究与临床研究的频数法、Logistic回归法、频数法与Logistic回归法比较的三种结果均不完全一致,
4.通过多种数据统计方法对文献研究与临床流行病学横断面调查的结果的比较分析,可以初步得出
4.1冠心病慢性心力衰竭核心并最常见的证候是：气虚血瘀证、气阴两虚证心阳虚证、水饮内停证亦常见。
4.2冠心病慢性心力衰竭核心并最常见的证候要素是：阳虚、气虚、血瘀、水停、阴虚、痰;心、肾,肺亦常见。
4.3冠心病慢性心力衰竭最常见的核心症状是：心悸、气短、呼吸困难。证候要素相关的可能的核心症状体现如下,阳虚：下肢浮肿、苔白、舌体胖;气虚神疲、乏力;血瘀：舌色暗红、舌有瘀斑、口唇紫绀;水停：下肢浮肿、苔白、泡沫痰；阴虚：盗汗、口干;痰：咳嗽、胸闷;心：心悸、下肢浮肿;肾：少尿。
4.4运用因子分析法、聚类分析法,探讨并证实了症状数据之间是存在一定内在联系的,即症状常以“症状组合”的形式表现,借助中医理论可以对其进行诠释。这些“症状群”可以”通俗”理解为证候或者证候要素。
5.在文献研究的基础上结合了临床流行病学横断面调查,其结果有一定的代表性,在一定程度上冠心病慢性心力衰竭常见证候、证候要素的分布规律,为建立以辨证候要素为辨证核心的冠心病慢性心力衰竭诊断规范提供了一定的参考依据。
6.本研究样本量偏小;还有其它一些数据挖掘的方法,如基于熵聚堆的结果尚未开始;临床理化指标的整理工作也在继续,很多资料尚需进一步挖掘,以上的结果还需要进一步地验证。
Syndrome is evidence of external candidates of traditional Chinese medicine (TCM), which a certain stage of the disease process in the disease location, etiology, disease resistance, disease resistance potential and ability of the body such as the strength of the organic nature of the response to contact state, the performance can be observed for clinical symptoms and so on. Its information has the character of subjectivity, mistiness, invisibility, fuzzification, multilayer, uncertainty and so on. Affiliated with the symptoms of the syndrome to regulate syndrome, syndrome diagnostic criteria is the most commonly used method. However, the symptoms of syndrome belongs in the disease must be defined under the common syndrome in order to reflect the performance of research can overcome the arbitrariness of previous syndrome, is also conducive to determine clinical efficacy. Based on the thinking of evidence-based medicine (EBM), and under the framework of "disease and syndrome", for coronary heart disease with chronic heart failure as the starting point, use two methods of modern literature research and clinical cross-sectional epidemiological survey and combine with a variety of mathematical statistical methods to initial interpretation the characteristics and disciplines of common syndrome, syndrome elements and symptoms of coronary heart disease whit chronic heart failure, so that in order to establish a dialectical syndrome elements regulation as the core norms of coronary heart disease whit chronic heart failure syndrome, and provide a standardized and concise theoretical for clinical differentiation
Objective:Through retrospective study of modern literature to analyze the common syndromes, symptoms of chronic heart failure, and split syndrome into syndrome elements in accordance with certain criteria. So that to preliminary investigate the distribution rule of common syndromes, syndrome elements and symptoms of chronic heart failure, and the relationship between syndromes/ syndrome elements with symptoms. All of these, use to provide reference to formulate a clinical information collection form, and lay the foundation for a further clinical multi-center, large sample epidemiological survey.
Methods:Search the journals from China Academic Journal Full-text Database, Chinese Biomedical Literature Database and VIP Database of Chinese Journals, which the date from January 1994 to January 2008. Use NoteExpress2 software to establish a documentation database of chronic heart failure. Accord strictly to the inclusive and exclusive criterions to screen out qualified literatures. And then specify the name of its syndromes and symptoms. Sort data and enter them into EpiData3.1 software. Through SPSS16.0 statistical software, analyze them by using frequency, proportion, Logistic regression methods.
Results:Through retrospective study of modern literature for past 15 years, there are 176 qualified literatures related to chronic heart failure reviewed, the conclusions as follow:
1. The symptoms distribution of chronic heart failure:
Specify the name of symptoms of chronic heart failure, and combine with experts discussions. The number reduces from pre-specified 269 to 145, and the total frequency is 4149 times. After investigate the symptoms which the frequency up 1.0% of total, which can find out that CHF major clinical symptoms are heart palpitation, shortness of breath, edema, fatigue, thready pulse, breathing difficulties, and pant, irregularly intermittent pulse, regularly intermittent pulse are also common.
2. The syndromes distribution of chronic heart failure:
There are 275 syndromes in modern literature. After removing repeated ones there are still 116 syndromes. Further more, specifying the name of symptoms, there are 43 syndromes. Syndromes diversity, which clearly shows the complexity of chronic heart failure itself, on the other hand also shows that there is no an uniformity criterions for their clinical syndrome. The study investigates both the frequency and constituent ratio of 43 syndromes, and the 7-8 bits stay the same. Therefore, the most common syndromes of CHF are heart-kidney yang deficiency syndrome, qi deficiency and blood stasis syndrome, heart yang deficiency syndrome, fluid retention syndrome, qi and yin deficiency syndrome, heart qi deficiency syndrome, yang deficiency and blood stasis syndrome. The more common syndromes are syndrome of water overflowing due to yang deficiency, syndrome of deficiency of both yin and yang, heart blood stasis syndrome, phlegm and blood stasis syndrome. Less common syndromes are syndrome of stagnant-heat invading collaterals, syndrome of insufficient kidney not accepting qi, syndrome of incoordination between gallbladder and stomach.
3. The syndrome elements distribution of chronic heart failure:
Syndrome elements occur 698 times and 34,939 cases in total 17,839 cases. The 6 bits of characteristic-syndrome elements stay the same, and the 3 bits of bit-syndrome elements stay the same. Therefore, the most common CHF syndrome elements are yang deficiency, qi deficiency, blood stasis, water retention, yin deficiency, phlegm; heart, kidney and lung.
4. The distribution of chronic heart failure commonly syndromes/syndrome elements corresponding to its symptoms.
Count frequency of the top 7 syndromes, the top 6 characteristic-syndrome elements and the top 3 bit-syndrome elements, and to understand its distribution. The symptom's frequency ranking in the top 10 (if the same frequency, extended to the same bottom) identified as common symptoms, the symptoms of high frequency can basically reflect the features of its corresponding syndromes, syndrome elements; by Binary Logistic Regression Analysis, the symptoms with more larger contribution can basically reflect the features of its corresponding syndrome elements.
Objective:Base on the pre-survey, and then start a national multi-center clinical large sample cross-sectional epidemiological investigation. Use software to establish database of coronary heart disease with chronic heart failure. So that to preliminary investigate the distribution rule of common syndromes, syndrome elements and symptoms of chronic heart failure, and the relationship between syndromes/syndrome elements with symptoms. In order to provide reference and basis for the further development of distinguish coronary heart disease with chronic heart failure syndrome elements as the core elements of diagnostic criteria.
Methods:Base on pre-literature study and the recommendations of clinical experts to formulate a clinical information collection form. After a discussion by experts and our team repeatedly revised, through the pre-investigation to estimate the consistency of clinical information collection form and perfect it, so that to formulate a determine one, and then start a clinical multi-center, large sample epidemiological survey. Use EpiData3.1 software to establish a database for clinical data. Through SPSS16.0 statistical software, analyze them by using frequency, proportion, logistic regression, unsupervised analysis (factor analysis, hierarchical cluster analysis)methods.
Results:
1. Pilot investigation of coronary heart disease with chronic heart failure clinical cross-sectional survey
Coefficient correlation values of more than 83.33% of TCM symptoms exceeded 0.8. Values of more than 80% of TCM symptoms in other five hospitals exceeded 0.8(two-sided test, p<0.01),which show the coefficient correlation values about the most of symptoms in information collection form were qualified; some symptoms are lower than 0.8 in four hospitals or above, so modify them. Then optimize and adjust the problems of the form with its structure or content.
2. The symptoms distribution of coronary heart disease chronic heart failure:
There are 596 qualified cases in this clinical cross-sectional survey, and collect 170 symptoms. Among them there are 14 main symptoms,14 systemic symptoms,17 head and face symptoms.35 heart and flank symptoms,8stomach and abdominal symptoms,4 waist and limbs symptoms,7 restaurants and taste symptoms,3 sleep-related symptoms,7 soil-urine-related symptoms,43 tongue symptoms and 20 pulse symptoms(only the left hand pulse meter). High frequency of symptoms are fatigue (578/96.98%), shortness of breath (556/93.29%), spiritlessness (528/88.59%), breath difficult (467/78.36%), edema (331/55.54%), palpitations (451/75.67%), chest tightness (537/90.10%), and so on. The frequency of symptoms up 30% are less qi lazy words, chills, spontaneous sweating, hot flashes, dizziness, blurred vision, lips cyanosis, chest pain, cough, sputum, wheezing, reliance interest is not lying, abdominal distension, soreness and weakness of waist and knees, hands and feet are not warm, sleepy body weight, zhaojia bruising, poor appetite, tastelessness, dry mouth, insomnia, dreaming often, frequent urination at night, sublingual vein abnormalities, deep pulse, thready pulse, and weak pulse.
3. The experience syndromes/syndrome elements distribution of coronary heart disease with chronic heart failure:
Specifying the name of experience syndromes, there are 39 types, and the total frequency is 924 times. There are 9 types syndromes'frequency are up 3%: syndrome of deficiency of qi and blood stasis, syndrome of deficiency of both qi and yin, syndrome of intermingled phlegm and blood stasis, fluid retention syndrome, phlegm syndrome, syndrome of blood stasis, water retention and blood stasis syndrome, syndrome of water overflowing due to yang deficiency, syndrome of heart yang deficiency, which accounted for 76.84% of the total frequency. Among them the frequency of syndrome of deficiency of qi and blood stasis (174/18.83%) and syndrome of deficiency of both qi and yin (154/16.67%) are far more than other syndromes.
Split syndrome into syndrome element. There are 16 characteristic-syndrome elements, and the total frequency is 1740 times. There are 9 bit-syndrome elements, and the total frequency is 1397 times. The top six sequences of characteristic-syndrome elements are:qi deficiency, blood stasis, yin deficiency, water retention, sputum, yang deficiency, which accounted for 95.46% of the total frequency. Among them the frequency of qi deficiency (497/28.56%) and blood stasis(448/25.75%) are far more than other characteristic-syndrome elements. The top four sequences of bit-syndrome elements are:heart, kidney, spleen, lung, which accounted for 89.26% of the total frequency. Among them the frequency of heart (578/41.37%) is far more than other bit-syndrome elements.
4. The differences of experience syndromes/syndrome elements among the 14 hospitals
Specifying the name of experience syndromes, CC hospital has 13 types, CZ hospital has 12 types, CD hospital has 15 types, DF hospital has 10 types, DZM hospital has 17 types, HZ hospital has 13 types, ZZ hospital has 10 types, WH hospital has 22 types, WX hospital has 14 types, XJ hospital has 15 types, YC hospital has 11 types, HN hospital has 12 types, ZR hospital has 19 types, and ZB hospital has 14 types. The top five sequences of syndromes come up to as much as 17 types among the hospitals. Syndrome of deficiency of qi and blood stasis, syndrome of deficiency of both qi and yin are the most commonly syndromes, but the other frequencies of syndromes are not the same. Syndrome elements have a higher degree reorganization among the hospitals, and concentrate in qi deficiency, blood stasis, yin deficiency, water retention, sputum, yang deficiency; heart, kidney, spleen and lung. The frequency syndrome elements are significantly higher than other types. Some hospitals also deem that there are some other syndrome elements related this disease, such as qi stagnation, wet, blood, cold, heat, wind, fire, hyperactivity of yang, sperm loss, drug; liver, stomach, gallbladder, collaterals, cerebral, and so on.
5. The distribution of coronary heart disease with chronic heart failure commonly syndromes/syndrome elements corresponding to its symptoms.
Count frequency of the top 7 syndromes, the top 6 characteristic-syndrome elements and the top 3 bit-syndrome elements, and to understand its distribution. The symptom's frequency ranking in the top 10 (if the same frequency, extended to the same bottom) identified as common symptoms, the symptoms of high frequency can basically reflect the features of its corresponding syndromes, syndrome elements; by Binary Logistic Regression Analysis, the symptoms with more larger contribution can basically reflect the features of its corresponding syndrome elements.
6. TCM theory interpret the results of factor analysis
Factor analysis method to extract 39 common factors, which reflects the main syndrome elements are qi deficiency, yin deficiency, blood stasis, yang deficiency, water retention, heart, kidney, spleen, lung.
7. TCM theory interpret the results of hierarchical cluster analysis
Used two forms of 0,1,2,3 and 0,1, respectively, hierarchical cluster analysis method to cluster all the symptoms, which reflects the main syndrome elements are qi deficiency, yin deficiency, blood stasis, yang deficiency, water retention, heart, kidney, spleen, lung.
Objective:Based on three perspectives of modern literature research, clinical cross-sectional epidemiological survey and findings of unsupervised data analysis methods, in order further to find distribution rule of common syndromes, syndrome elements of chronic heart failure with coronary heart disease, and the corresponding relationship between syndromes/syndrome elements with its symptoms.
Methods:Frequency analysis, logistic regression analysis, unsupervised analysis (factor analysis, hierarchical cluster analysis).
Results:The syndromes, syndrome elements results of modern literature research and clinical cross-sectional epidemiological investigation form frequency analysis, factor analysis, cluster analysis in a strong consistency. Especially, the distribution rule of syndrome elements consistent much more strangely. But the results of symptoms of its syndrome elements in the frequency analysis and logistic regression analysis are in the poor performance. Because three results of frequency analysis, logistic regression analysis, and frequency analysis compared with logistic regression analysis are not exactly the same. The same symptoms of its syndrome elements may be have some contact, which may reflect the core symptoms of its syndrome elements, and can be interpreted by TCM theory. But some symptoms are still can not fully explain the contact between it with its syndrome elements.
1. On modern literature research, specifying the name, there are 145 symptoms,43 syndromes,23 syndrome elements. On clinical cross-sectional epidemiological research, there are 170 symptoms,39 syndromes,25syndrome elements. Factor analysis and hierarchical cluster analysis included 110symptoms, after anglicizing; there are 31 syndromes and 21 syndrome elements.
2. The syndromes, syndrome elements of coronary heart disease with chronic heart failure, whose results of modern literature research and clinical cross-sectional epidemiological investigation form frequency analysis, factor analysis, cluster analysis in a strong consistency. Especially, the distribution rule of syndrome elements consistent much more strangely.
3. The results of symptoms of its syndrome elements in the frequency analysis and logistic regression analysis are in the poor performance. Because three results of frequency analysis, logistic regression analysis, and frequency analysis compared with logistic regression analysis are not exactly the same.
4. Through a comparative study of variety of statistical methods, the rustles as follow:
4.1 The core and most commonly syndromes of coronary heart disease with chronic heart failure are syndrome of deficiency of qi and blood stasis, syndrome of heart yang deficiency, fluid retention syndrome, syndrome of deficiency of both qi and yin.
4.2 The core and most commonly syndrome elements of coronary heart disease with chronic heart failure are yang deficiency, qi deficiency, blood stasis, water retention, yin deficiency, phlegm; heart, kidney and lung.
4.3 The core and most commonly symptoms of coronary heart disease with chronic heart failure are heart palpitations, shortness of breath and difficulty breathing. The core symptoms of its syndrome elements:yang deficiency:lower extremity edema, tongue color white, tongue body fat; qi deficiency:spiritlessness, fatigue; blood stasis:dark red tongue, tongue with petechiae, cyanosis of lips; water retention:leg edema, moss color white, foam sputum; deficiency:night sweats, dry mouth; phlegm:cough, chest tightness; heart:heart palpitations, lower extremity edema; renal:oliguria.
4.4 Using the factor analysis method, clustering analysis, the author discusses and confirmed that there are certain symptoms between data, namely, the inner link with "symptoms symptoms often combination" form, with the aid of the TCM theory can be interpreted. These "symptoms" popular "group" understanding for syndrome or syndrome factor.
5. On the basis of modern literature research with a clinical multi-center, larger sample cross-sectional epidemiological survey, the results of which have certain representativenesses. All these can provide reference and basis for the further development of distinguish coronary heart disease with chronic heart failure syndrome elements as the core elements of diagnostic criteria.
6. The sample size of this research is small; and there are other methods are not yet beginning. The work to compile statistics clinical physical and chemical indicators is continuing, and a lot of information need further explore, so the above result also need to further verification.
一、慢性心力衰竭常见证候、证候要素及症状的现代文献研究
目的：主要通过对有关慢性心力衰竭(Chronic heart failure, CHF)的中医现代文献资料进行回顾性研究,来分析CHF常见症状、证候,然后再将证候按照一定的标准拆分成为证候要素,以期初步探讨CHF下症状、证候及证候要素的分布规律及常见证候、证候要素与症状之间的对应关系,为制定临床研究用临床信息采集表提供参考,并为进一步临床多中心、大样本流行病学调查奠定基础。
方法：检索CNKI中国知网中的中国学术期刊全文数据库、中国生物医学文献数据库、重庆维普中文期刊数据库所收录的1994年1月—2008年1月相关文献。借助NoteExpress2软件中建立CHF文献数据库。严格按照文献纳入、排除标准筛出选出合格文献,并文献中出现的证候、症状名称进行规范,然后将原始资料数据量化处理后,输入计算机EpiData3.1软件,通过SPSS16.0统计软件,采用频数、构成比、Logistic回归分析法进行分析。
结果：通过对近15年CHF相关的中医现代文献进行检索,得出176篇合格的文献,对其回顾性分析,得到如下结论
1. CHF的症状分布特点
对CHF的中医症状进行了名词规范后,并结合专家讨论建议,其症状由规范前的269个缩减为145个,总频数4149次。从频率在1.0%以上的中医症状来看,CHF主要临床症状为：心悸、气短、水肿、乏力、脉细、呼吸困难,而喘息、脉结、脉代亦常见。2. CHF的证候分布特点
CHF现代文献中出现275种证候类型,除去重复的后共有116种不同的证型,经规范后还有43种。证候类型的多样性,一方面说明CHF本身的复杂性,另一方面也表明其临床辨证没有统一性。本研究综合研究了频次和病例数构成比两个方面,证型出现的频次统计与病例数构成比统计在前7-8位基本保持一致。故CHF最常见的证候是心肾阳虚证,气虚血瘀证,心阳气虚证,水饮内停证,气阴两虚证,心气虚证,阳虚血瘀证。比较常见的证候有阳虚水泛证,心阴阳两虚证,心血瘀阻证,痰瘀互阻证。不太常见的证候有瘀热伤络证,肾不纳气证,胆胃不和证等。
3. CH F的证候要素分布特点
CHF证候要素频数出现698次,病例合计17839例,证候要素例数出现34939例。CHF病性类证候要素出现的频次统计与病例数构成比统计在前6位基本保持一致。病位类证候要素出现的频次统计与病例数构成比统计在前3位基本保持一致。故CHF最常见证候要素是阳虚、气虚、血瘀、水停、阴虚、痰;心、肾、肺。
4. CHF常见证候、证候要素对应症状的分布特点
证候排序前七位者,病性类证候要素排序前六位及病位性证候要素前三位者,计算证候下症状的频数分布,症状频数排序在前10位(若频数相同,顺延至相同频数症状末位)认定为常见症状,频数较高的症状基本能反映出与之对应的证候、证候要素的特点；采用二分类Logistic回归分析对CHF常见证候要素进行分析,贡献度较大的症状基本能反映与之对应的证候要素的特点。
二、冠心病慢性心力衰竭常见证候、证候要素、症状的临床流行病学横断面调查
目的：在预调查的基础上,进行全国多中心大样本的临床横断面流行病学调查。利用软件建立冠心病慢性心力衰竭的数据库,探讨冠心病慢性心力衰竭下症状、证候及证候要素的分布规律及冠心病慢性心力衰竭常见证候、证候要素与症状的关系,以期为进一步制定以证候要素为核心的冠心病慢性心力衰竭的诊断规范提供一定的理论参考依据。
方法：在前期文献研究的基础上,结合临床专家的建议,制作冠心病慢性心力衰竭横断面调查信息采集表,经过专家多次论证及课题组反复修改,并通过预调查对采集表信度评价后,确定正式的调查表,然后进行全国多中心大样本的流行病学调查。并利用EpiData3.1软件建立冠心病慢性心力衰竭临床数据的数据库,通过SPSS16.0统计软件,采用频数、Logistic回归分析法、无监督分析法(因子分析法、聚类分析法)对数据进行分析。
结果：
1.冠心病慢性心力衰竭临床横断面信息采集表预调查
预调查采集表中83.33%症状的相关系数值都大于0.8,另5家医院80%以上症状的相关系数都在0.8以上(双侧检验,P<0.01),表明采集表的一致性程度较高,可靠性较好。针对部分症状的r值在4家医院或以上低于0.8,则重点修改,并对采集表在某些结构或内容上存在一些问题进行优化及调整。
2.冠心病慢性心力衰竭症状的分布特点
本次临床流行病学横断面调查,合格病例数为596例,采集到的冠心病慢性心力衰竭症状有170个,其中主要症状14个,全身症状14个,头面症状17个,心胸及胁肋症状35个,脾胃及腹部症状8个,腰部及四肢症状4个,饮食及口味相关症状7个,睡眠相关症状3个,二便相关症状7个,舌象症状43个,脉象症状20个(仅计左手脉)。频率高的症状为乏力(578/96.98%),气短(556/93.29%),神疲(528/88.59%),呼吸困难(467/78.36%),浮肿(331/55.54%),心悸(451/75.67%),胸闷(537/90.10%)等。出现频率在30%以上的症状有：少气懒言、畏寒、自汗、潮热、头晕、目眩、口唇紫绀、胸痛、咳嗽、咳痰、喘息、倚息不能卧、腹胀、腰膝酸软、手足不温、肢体困重、爪甲青紫、食欲不振、口淡、口干、失眠、多梦、夜尿频多、舌下络脉异常、脉沉、脉细、脉无力等。
3.冠心病慢性心力衰竭经验辨证及证候要素的分布特点
规范后的经验辨证的证候名称,共有39类,总频数924次。其中频率大于3%的证候有9类：气虚血瘀证、气阴两虚证、痰瘀互阻证、水饮内停证、痰浊证、心血瘀阻证、血瘀水停证、阳虚水泛证、心阳虚证,它们的合计频率占76.84%;其中气虚血瘀证(174/18.83%)、气阴两虚证(154/16.67%)远多于其它证候类型。
将证候分解成基本的证候要素。提取病性类证候要素16个,出现的总频数为1740次;病位类证候要素9个,出现总频数为1397次。其中频次排在前6位的病性类证候要素是个：气虚、血瘀、阴虚、水停、痰、阳虚,它们的合计频率占95.46%；其中气虚证素(497/28.56%)、血瘀证素(448/25.75%)远多于其它病性类证候要素类型。频次排在前4位的病位类证候要素是：心、肾、脾、肺,它们的合计频率占89.26%；其中心证素(578/41.37%),远多于其它病位类证候要素类型。
4.各医院验辨证及证候要素的分布差异情况
14家医院经验辨证规范后,CC13个证候类型,CZ12个,CD15个,DF10个,DZM 17个,HZ13个,ZZ10个,WH22个,WX14个,XJ15个,YC11个,HN12个,ZR19个,ZB14个。各家医院排序在前五位的证候类型覆盖达17个之多,除气阴两虚证、气虚血瘀证是各家医院较公认外,其它类型的证候的排序均不尽相同。病位类证候要素及病性类证候要素各家医院的公认程度较高,均集中在气虚、血瘀、阴虚、水停、痰、阳虚;心、肾、脾、肺。这些证候要素的频数、频率均显著高于其它类型证候要素。部分医院还认为本病与气滞、湿、血虚、寒、热、内风、内火、阳亢、精亏、毒;肝、胃、胆、络脉、脑等相关。
5.冠心病慢性心力衰竭常见证候、证候要素对应症状的分布特点
证候排序前七位者,病性类证候要素排序前六位及病位性证候要素前三位者,计算证候下症状的频数分布,症状频数排序在前10位(若频数相同,顺延至相同频数症状末位)认定为常见症状,频数较高的症状基本能反映出与之对应的证候、证候要素的特点;采用二分类Logistic回归分析对慢性心力衰竭常见证候要素进行分析,贡献度较大的症状基本能反映与之对应的证候要素的特点。
6.中医理论对因子分析结果的诠释
因子分析法统计分析,提取了39个公因子,分析后反映出的证候要素以以气虚、阳虚、心、血瘀、脾、痰、肾、阴虚为多。7.中医理论对聚类分析结果的诠释
采用0、1、2、3和0、1两种形式,分别对全部症状进行聚类的结果大致一致,聚类后反映出的证候要素以气虚、心、阳虚、肾、脾、阴虚、血瘀、痰为多。
三、冠心病慢性心力衰竭常见证候、证候要素、症状的多种研究的对比研究
目的：从现代文献研究、临床流行病学横断面调查及基于无监督数据分析方法的研究结果三个角度分别进行两两对比分析,以期能进一步探寻冠心病慢性心力衰竭常见证候、证候要素的分布特点及其常见证候、证候要素与症状之间的对应关系。
方法：采用频数、Logistic回归分析法、无监督分析法(因子分析法、聚类分析法)进行分析。
结果：文献研究与临床流行病学横断面调查证候、证候要素的分布特点在频数法、因子分析法、聚类分析法中统计结果一致性较强,尤其是证候要素分布特点的一致性更强;但是证候要素下症状在频数法与Logistic回归法中统计结果的一致性较差,其表现在文献研究与临床研究的频数法、Logistic回归法、频数法与Logistic回归法比较的三种结果均不完全一致,相同的症状可能与之对应的证候要素产生联系,可能是反映症状与之对应的证候要素的核心症状,能用中医学理论进行诠释,但有部分症状尚不能完全解释其与所对应的证候要素之间存在联系。
四、结论
1.现代文献研究出现慢性心力衰竭规范后的症状145个,证候43个,证候要素23个;临床流行病学横断面调查规范后的症状170个,证候39个,证候要素25个;因子分析和聚类分析纳入分析的症状110个,其结果经规范后证候31个,证候要素21个。
2.冠心病慢性心力衰竭的证候、证候要素的分布特点通过频数法、因子分析法、聚类分析法的统计,结果一致性较强,尤其是证候要素分布特点的一致性更强。
3.证候要素下症状在频数法与Logistic回归法中统计结果的一致性较差,其表现在文献研究与临床研究的频数法、Logistic回归法、频数法与Logistic回归法比较的三种结果均不完全一致,
4.通过多种数据统计方法对文献研究与临床流行病学横断面调查的结果的比较分析,可以初步得出
4.1冠心病慢性心力衰竭核心并最常见的证候是：气虚血瘀证、气阴两虚证心阳虚证、水饮内停证亦常见。
4.2冠心病慢性心力衰竭核心并最常见的证候要素是：阳虚、气虚、血瘀、水停、阴虚、痰;心、肾,肺亦常见。
4.3冠心病慢性心力衰竭最常见的核心症状是：心悸、气短、呼吸困难。证候要素相关的可能的核心症状体现如下,阳虚：下肢浮肿、苔白、舌体胖;气虚神疲、乏力;血瘀：舌色暗红、舌有瘀斑、口唇紫绀;水停：下肢浮肿、苔白、泡沫痰；阴虚：盗汗、口干;痰：咳嗽、胸闷;心：心悸、下肢浮肿;肾：少尿。
4.4运用因子分析法、聚类分析法,探讨并证实了症状数据之间是存在一定内在联系的,即症状常以“症状组合”的形式表现,借助中医理论可以对其进行诠释。这些“症状群”可以”通俗”理解为证候或者证候要素。
5.在文献研究的基础上结合了临床流行病学横断面调查,其结果有一定的代表性,在一定程度上冠心病慢性心力衰竭常见证候、证候要素的分布规律,为建立以辨证候要素为辨证核心的冠心病慢性心力衰竭诊断规范提供了一定的参考依据。
6.本研究样本量偏小;还有其它一些数据挖掘的方法,如基于熵聚堆的结果尚未开始;临床理化指标的整理工作也在继续,很多资料尚需进一步挖掘,以上的结果还需要进一步地验证。
Syndrome is evidence of external candidates of traditional Chinese medicine (TCM), which a certain stage of the disease process in the disease location, etiology, disease resistance, disease resistance potential and ability of the body such as the strength of the organic nature of the response to contact state, the performance can be observed for clinical symptoms and so on. Its information has the character of subjectivity, mistiness, invisibility, fuzzification, multilayer, uncertainty and so on. Affiliated with the symptoms of the syndrome to regulate syndrome, syndrome diagnostic criteria is the most commonly used method. However, the symptoms of syndrome belongs in the disease must be defined under the common syndrome in order to reflect the performance of research can overcome the arbitrariness of previous syndrome, is also conducive to determine clinical efficacy. Based on the thinking of evidence-based medicine (EBM), and under the framework of "disease and syndrome", for coronary heart disease with chronic heart failure as the starting point, use two methods of modern literature research and clinical cross-sectional epidemiological survey and combine with a variety of mathematical statistical methods to initial interpretation the characteristics and disciplines of common syndrome, syndrome elements and symptoms of coronary heart disease whit chronic heart failure, so that in order to establish a dialectical syndrome elements regulation as the core norms of coronary heart disease whit chronic heart failure syndrome, and provide a standardized and concise theoretical for clinical differentiation
Objective:Through retrospective study of modern literature to analyze the common syndromes, symptoms of chronic heart failure, and split syndrome into syndrome elements in accordance with certain criteria. So that to preliminary investigate the distribution rule of common syndromes, syndrome elements and symptoms of chronic heart failure, and the relationship between syndromes/ syndrome elements with symptoms. All of these, use to provide reference to formulate a clinical information collection form, and lay the foundation for a further clinical multi-center, large sample epidemiological survey.
Methods:Search the journals from China Academic Journal Full-text Database, Chinese Biomedical Literature Database and VIP Database of Chinese Journals, which the date from January 1994 to January 2008. Use NoteExpress2 software to establish a documentation database of chronic heart failure. Accord strictly to the inclusive and exclusive criterions to screen out qualified literatures. And then specify the name of its syndromes and symptoms. Sort data and enter them into EpiData3.1 software. Through SPSS16.0 statistical software, analyze them by using frequency, proportion, Logistic regression methods.
Results:Through retrospective study of modern literature for past 15 years, there are 176 qualified literatures related to chronic heart failure reviewed, the conclusions as follow:
1. The symptoms distribution of chronic heart failure:
Specify the name of symptoms of chronic heart failure, and combine with experts discussions. The number reduces from pre-specified 269 to 145, and the total frequency is 4149 times. After investigate the symptoms which the frequency up 1.0% of total, which can find out that CHF major clinical symptoms are heart palpitation, shortness of breath, edema, fatigue, thready pulse, breathing difficulties, and pant, irregularly intermittent pulse, regularly intermittent pulse are also common.
2. The syndromes distribution of chronic heart failure:
There are 275 syndromes in modern literature. After removing repeated ones there are still 116 syndromes. Further more, specifying the name of symptoms, there are 43 syndromes. Syndromes diversity, which clearly shows the complexity of chronic heart failure itself, on the other hand also shows that there is no an uniformity criterions for their clinical syndrome. The study investigates both the frequency and constituent ratio of 43 syndromes, and the 7-8 bits stay the same. Therefore, the most common syndromes of CHF are heart-kidney yang deficiency syndrome, qi deficiency and blood stasis syndrome, heart yang deficiency syndrome, fluid retention syndrome, qi and yin deficiency syndrome, heart qi deficiency syndrome, yang deficiency and blood stasis syndrome. The more common syndromes are syndrome of water overflowing due to yang deficiency, syndrome of deficiency of both yin and yang, heart blood stasis syndrome, phlegm and blood stasis syndrome. Less common syndromes are syndrome of stagnant-heat invading collaterals, syndrome of insufficient kidney not accepting qi, syndrome of incoordination between gallbladder and stomach.
3. The syndrome elements distribution of chronic heart failure:
Syndrome elements occur 698 times and 34,939 cases in total 17,839 cases. The 6 bits of characteristic-syndrome elements stay the same, and the 3 bits of bit-syndrome elements stay the same. Therefore, the most common CHF syndrome elements are yang deficiency, qi deficiency, blood stasis, water retention, yin deficiency, phlegm; heart, kidney and lung.
4. The distribution of chronic heart failure commonly syndromes/syndrome elements corresponding to its symptoms.
Count frequency of the top 7 syndromes, the top 6 characteristic-syndrome elements and the top 3 bit-syndrome elements, and to understand its distribution. The symptom's frequency ranking in the top 10 (if the same frequency, extended to the same bottom) identified as common symptoms, the symptoms of high frequency can basically reflect the features of its corresponding syndromes, syndrome elements; by Binary Logistic Regression Analysis, the symptoms with more larger contribution can basically reflect the features of its corresponding syndrome elements.
Objective:Base on the pre-survey, and then start a national multi-center clinical large sample cross-sectional epidemiological investigation. Use software to establish database of coronary heart disease with chronic heart failure. So that to preliminary investigate the distribution rule of common syndromes, syndrome elements and symptoms of chronic heart failure, and the relationship between syndromes/syndrome elements with symptoms. In order to provide reference and basis for the further development of distinguish coronary heart disease with chronic heart failure syndrome elements as the core elements of diagnostic criteria.
Methods:Base on pre-literature study and the recommendations of clinical experts to formulate a clinical information collection form. After a discussion by experts and our team repeatedly revised, through the pre-investigation to estimate the consistency of clinical information collection form and perfect it, so that to formulate a determine one, and then start a clinical multi-center, large sample epidemiological survey. Use EpiData3.1 software to establish a database for clinical data. Through SPSS16.0 statistical software, analyze them by using frequency, proportion, logistic regression, unsupervised analysis (factor analysis, hierarchical cluster analysis)methods.
Results:
1. Pilot investigation of coronary heart disease with chronic heart failure clinical cross-sectional survey
Coefficient correlation values of more than 83.33% of TCM symptoms exceeded 0.8. Values of more than 80% of TCM symptoms in other five hospitals exceeded 0.8(two-sided test, p<0.01),which show the coefficient correlation values about the most of symptoms in information collection form were qualified; some symptoms are lower than 0.8 in four hospitals or above, so modify them. Then optimize and adjust the problems of the form with its structure or content.
2. The symptoms distribution of coronary heart disease chronic heart failure:
There are 596 qualified cases in this clinical cross-sectional survey, and collect 170 symptoms. Among them there are 14 main symptoms,14 systemic symptoms,17 head and face symptoms.35 heart and flank symptoms,8stomach and abdominal symptoms,4 waist and limbs symptoms,7 restaurants and taste symptoms,3 sleep-related symptoms,7 soil-urine-related symptoms,43 tongue symptoms and 20 pulse symptoms(only the left hand pulse meter). High frequency of symptoms are fatigue (578/96.98%), shortness of breath (556/93.29%), spiritlessness (528/88.59%), breath difficult (467/78.36%), edema (331/55.54%), palpitations (451/75.67%), chest tightness (537/90.10%), and so on. The frequency of symptoms up 30% are less qi lazy words, chills, spontaneous sweating, hot flashes, dizziness, blurred vision, lips cyanosis, chest pain, cough, sputum, wheezing, reliance interest is not lying, abdominal distension, soreness and weakness of waist and knees, hands and feet are not warm, sleepy body weight, zhaojia bruising, poor appetite, tastelessness, dry mouth, insomnia, dreaming often, frequent urination at night, sublingual vein abnormalities, deep pulse, thready pulse, and weak pulse.
3. The experience syndromes/syndrome elements distribution of coronary heart disease with chronic heart failure:
Specifying the name of experience syndromes, there are 39 types, and the total frequency is 924 times. There are 9 types syndromes'frequency are up 3%: syndrome of deficiency of qi and blood stasis, syndrome of deficiency of both qi and yin, syndrome of intermingled phlegm and blood stasis, fluid retention syndrome, phlegm syndrome, syndrome of blood stasis, water retention and blood stasis syndrome, syndrome of water overflowing due to yang deficiency, syndrome of heart yang deficiency, which accounted for 76.84% of the total frequency. Among them the frequency of syndrome of deficiency of qi and blood stasis (174/18.83%) and syndrome of deficiency of both qi and yin (154/16.67%) are far more than other syndromes.
Split syndrome into syndrome element. There are 16 characteristic-syndrome elements, and the total frequency is 1740 times. There are 9 bit-syndrome elements, and the total frequency is 1397 times. The top six sequences of characteristic-syndrome elements are:qi deficiency, blood stasis, yin deficiency, water retention, sputum, yang deficiency, which accounted for 95.46% of the total frequency. Among them the frequency of qi deficiency (497/28.56%) and blood stasis(448/25.75%) are far more than other characteristic-syndrome elements. The top four sequences of bit-syndrome elements are:heart, kidney, spleen, lung, which accounted for 89.26% of the total frequency. Among them the frequency of heart (578/41.37%) is far more than other bit-syndrome elements.
4. The differences of experience syndromes/syndrome elements among the 14 hospitals
Specifying the name of experience syndromes, CC hospital has 13 types, CZ hospital has 12 types, CD hospital has 15 types, DF hospital has 10 types, DZM hospital has 17 types, HZ hospital has 13 types, ZZ hospital has 10 types, WH hospital has 22 types, WX hospital has 14 types, XJ hospital has 15 types, YC hospital has 11 types, HN hospital has 12 types, ZR hospital has 19 types, and ZB hospital has 14 types. The top five sequences of syndromes come up to as much as 17 types among the hospitals. Syndrome of deficiency of qi and blood stasis, syndrome of deficiency of both qi and yin are the most commonly syndromes, but the other frequencies of syndromes are not the same. Syndrome elements have a higher degree reorganization among the hospitals, and concentrate in qi deficiency, blood stasis, yin deficiency, water retention, sputum, yang deficiency; heart, kidney, spleen and lung. The frequency syndrome elements are significantly higher than other types. Some hospitals also deem that there are some other syndrome elements related this disease, such as qi stagnation, wet, blood, cold, heat, wind, fire, hyperactivity of yang, sperm loss, drug; liver, stomach, gallbladder, collaterals, cerebral, and so on.
5. The distribution of coronary heart disease with chronic heart failure commonly syndromes/syndrome elements corresponding to its symptoms.
Count frequency of the top 7 syndromes, the top 6 characteristic-syndrome elements and the top 3 bit-syndrome elements, and to understand its distribution. The symptom's frequency ranking in the top 10 (if the same frequency, extended to the same bottom) identified as common symptoms, the symptoms of high frequency can basically reflect the features of its corresponding syndromes, syndrome elements; by Binary Logistic Regression Analysis, the symptoms with more larger contribution can basically reflect the features of its corresponding syndrome elements.
6. TCM theory interpret the results of factor analysis
Factor analysis method to extract 39 common factors, which reflects the main syndrome elements are qi deficiency, yin deficiency, blood stasis, yang deficiency, water retention, heart, kidney, spleen, lung.
7. TCM theory interpret the results of hierarchical cluster analysis
Used two forms of 0,1,2,3 and 0,1, respectively, hierarchical cluster analysis method to cluster all the symptoms, which reflects the main syndrome elements are qi deficiency, yin deficiency, blood stasis, yang deficiency, water retention, heart, kidney, spleen, lung.
Objective:Based on three perspectives of modern literature research, clinical cross-sectional epidemiological survey and findings of unsupervised data analysis methods, in order further to find distribution rule of common syndromes, syndrome elements of chronic heart failure with coronary heart disease, and the corresponding relationship between syndromes/syndrome elements with its symptoms.
Methods:Frequency analysis, logistic regression analysis, unsupervised analysis (factor analysis, hierarchical cluster analysis).
Results:The syndromes, syndrome elements results of modern literature research and clinical cross-sectional epidemiological investigation form frequency analysis, factor analysis, cluster analysis in a strong consistency. Especially, the distribution rule of syndrome elements consistent much more strangely. But the results of symptoms of its syndrome elements in the frequency analysis and logistic regression analysis are in the poor performance. Because three results of frequency analysis, logistic regression analysis, and frequency analysis compared with logistic regression analysis are not exactly the same. The same symptoms of its syndrome elements may be have some contact, which may reflect the core symptoms of its syndrome elements, and can be interpreted by TCM theory. But some symptoms are still can not fully explain the contact between it with its syndrome elements.
1. On modern literature research, specifying the name, there are 145 symptoms,43 syndromes,23 syndrome elements. On clinical cross-sectional epidemiological research, there are 170 symptoms,39 syndromes,25syndrome elements. Factor analysis and hierarchical cluster analysis included 110symptoms, after anglicizing; there are 31 syndromes and 21 syndrome elements.
2. The syndromes, syndrome elements of coronary heart disease with chronic heart failure, whose results of modern literature research and clinical cross-sectional epidemiological investigation form frequency analysis, factor analysis, cluster analysis in a strong consistency. Especially, the distribution rule of syndrome elements consistent much more strangely.
3. The results of symptoms of its syndrome elements in the frequency analysis and logistic regression analysis are in the poor performance. Because three results of frequency analysis, logistic regression analysis, and frequency analysis compared with logistic regression analysis are not exactly the same.
4. Through a comparative study of variety of statistical methods, the rustles as follow:
4.1 The core and most commonly syndromes of coronary heart disease with chronic heart failure are syndrome of deficiency of qi and blood stasis, syndrome of heart yang deficiency, fluid retention syndrome, syndrome of deficiency of both qi and yin.
4.2 The core and most commonly syndrome elements of coronary heart disease with chronic heart failure are yang deficiency, qi deficiency, blood stasis, water retention, yin deficiency, phlegm; heart, kidney and lung.
4.3 The core and most commonly symptoms of coronary heart disease with chronic heart failure are heart palpitations, shortness of breath and difficulty breathing. The core symptoms of its syndrome elements:yang deficiency:lower extremity edema, tongue color white, tongue body fat; qi deficiency:spiritlessness, fatigue; blood stasis:dark red tongue, tongue with petechiae, cyanosis of lips; water retention:leg edema, moss color white, foam sputum; deficiency:night sweats, dry mouth; phlegm:cough, chest tightness; heart:heart palpitations, lower extremity edema; renal:oliguria.
4.4 Using the factor analysis method, clustering analysis, the author discusses and confirmed that there are certain symptoms between data, namely, the inner link with "symptoms symptoms often combination" form, with the aid of the TCM theory can be interpreted. These "symptoms" popular "group" understanding for syndrome or syndrome factor.
5. On the basis of modern literature research with a clinical multi-center, larger sample cross-sectional epidemiological survey, the results of which have certain representativenesses. All these can provide reference and basis for the further development of distinguish coronary heart disease with chronic heart failure syndrome elements as the core elements of diagnostic criteria.
6. The sample size of this research is small; and there are other methods are not yet beginning. The work to compile statistics clinical physical and chemical indicators is continuing, and a lot of information need further explore, so the above result also need to further verification.
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