摘要
冠状动脉粥样硬化性心脏病(简称冠心病)是严重危害人民健康的常见疾病,近年来采用针灸方法治疗冠心病心绞痛日益普遍,并取得满意疗效。本研究通过采用子午流注纳甲法开穴配合辨证取穴治疗冠心病心绞痛患者,为临床治疗冠心病心绞痛提供一种简易有效且具中医特色的治疗方法。
本研究包括理论研究和临床研究两大部分。理论研究
回顾中国历代中医辨治冠心病心绞痛的学术思想,考证胸痹心痛中医学病名源流,探讨胸痹心痛的病因病机和辨证施治的范畴,介绍导师罗陆一教授治疗冠心病的学术观点与科研成果,包括从运气学说论治、从虚劳论治、从肾虚论治、通脉地仙丸、补肾祛瘀汤、通脉液、通心贴、超声波刺激虚里穴位、中频电刺激心腧穴、温肾化痰活血法心腧穴位外治等各个内容。
总结近五年来临床研究针灸治疗冠心病心绞痛的进展概况,介绍各种常用的针灸治疗手段包括单纯针刺、针灸并用、穴位贴敷、针罐结合、电针、穴位注射、激光针灸、超声波、穴位埋线、针药结合等多种疗法。
研究子午流注纳甲法理论的源流,探讨其按时开穴推算方法的重要组成部分,如五输穴与五行及十天干之间的配对关系以及[阳进阴退」、[经生经、穴生穴」、[返本还原」和[气纳三焦、血纳包络]等四个方面,并概述子午流注纳甲法在临床应用上必须注意的几个主要问题如补穴方法、准确推算时辰及临床取穴方法等。
临床研究
目的：
通过子午流注纳甲法开穴配合辨证取穴治疗冠心病心绞痛患者,观察临床疗效,分析子午流注纳甲法在治疗冠心病心绞痛上的可行性和实用性,比较各组针刺治疗方法的疗效,探讨疗效机理,为按时取穴方法治疗冠心病心绞痛提供较完整的临床研究数据及操作建议,提高针刺治疗冠心病的疗效。
方法：
按诊断及病例选择标准,筛选符合观察条件的冠心病心绞痛患者160病例,随机分为4组,每组各40例。各组基础治疗方法基本相同。口服中药以温阳补肾、活血化痰汤剂为基础,随证加减化裁,7天为一个疗程。治疗组T(试验组)：以子午流注纳甲法按时开穴结合治疗冠心病辨证取穴针刺治疗；对照组A(子午流注开穴对照组)以子午流注纳甲法按时开穴针刺治疗；对照组B(辨证取穴对照组)以治疗冠心病辨证取穴针刺治疗；以上3组针刺治疗均为每天1次,每次20分钟；对照组C(空白对照组)未予针刺治疗。观察并记录治疗前和治疗7天后各病例的心绞痛症状评分标准和中医证候疗效判定标准,比较治疗前后各组病例评分变化,通过t-检验和卡方分析,检视各组疗效并考证各组的疗效差异。
结果：
成功采纳治疗组T37例、对照组A39例、对照组B37例及对照组C32例,共145病例。治疗前,对各组病例数据包括性别、年龄、心绞痛症状评分、心绞痛程度分级、中医证候评分、运动平板试验Duke评分、合并症、吸烟史等资料进行统计学分析,结果发现各组资料无显著性差异(P>0.05),具可比性。
治疗前后心绞痛症状评分比较：各组治疗后评分均优于治疗前评分,P<0.001,具统计学意义。
治疗前后心绞痛程度分级比较：各组心绞痛程度均有不同程度的改善,无心绞痛发作病例明显增加,中度心绞痛病例和重度心绞痛病例明显减少。
各组心绞痛症状评分疗效比较：治疗组T与对照组B比较P<0.05,有显著性差异；治疗组T与对照组C比较P<0.001,有非常显著性差异；对照组A与对照组C比较P<0.05,有显著性差异；其余治疗组T与对照组A比较,对照组A与对照组B比较及对照组B与对照组C比较均P>0.05,无显著性差异。
治疗前后中医证候评分比较：各组治疗后评分均优于治疗前评分,P<0.001,具统计学意义。
各组中医证候评分疗效比较：治疗组T与对照组A比较P<0.05,有显著性差异；治疗组T与对照组B比较P<0.001,有非常显著性差异；治疗组T与对照组C比较P<0.001,有非常显著性差异；对照组A与对照组C比较P<0.05,有显著性差异；其余对照组A与对照组B比较及对照组B与对照组C比较均P>0.05,无显著性差异。
各组心电图疗效比较：各组比较均P>0.05,无显著性差异。
治疗前后运动平板试验Duke评分比较：各组治疗后评分均优于治疗前评分,P<0.001,具统计学意义。
治疗前后运动平板试验Duke评分危险分层比较：各组危险分层均有不同程度的改善,低危组病例增加,中危组病例和高危组病例减少。
讨论：
通过对145例子午流注纳甲法治疗冠心病心绞痛的临床研究,结果发现子午流注纳甲法按时开穴结合辨证取穴针刺治疗(治疗组T),比较治疗前后心绞痛症状评分标准和中医证候评分标准,总有效率分别为94.6%和97.3%,具良好的改善冠心病患者临床症状的作用,有非常显著性差异,具统计学意义。
比较治疗前后心绞痛症状评分标准及中医证候评分标准的总有效率,治疗组T较辨证取穴针刺治疗(对照组B)及空白对照组(对照组C)为佳,具统计学意义。比较治疗组T与子午流注纳甲法按时开穴针刺治疗(对照组A),治疗前后心绞痛症状评分标准的总有效率,治疗组T与对照组A的差异并无统计学意义,不能证明治疗组T疗效优于对照组A；反之,在治疗前后中医证候评分标准的总有效率,治疗组T较对照组A为佳,具统计学意义。此外,对照组A较对照组C为佳,具统计学意义；对照组A与对照组B的差异,以及对照组β与对照组C的差异,均无统计学意义,不能证明对照组A优于对照组B,或对照组B优于对照组C。
总结以上结果,本临床研究发现子午流注纳甲法结合辨证取穴,在治疗冠心病心绞痛的疗效上明显较辨证取穴为佳,并具统计学意义,证明纳甲法结合辨证取穴效果较单纯辨证取穴优越。由于单纯纳甲法与单纯辨证取穴治疗冠心病心绞痛的疗效差异没有统计学意义,无法证实两种疗法之优劣。
Coronary atherosclerotic heart disease or coronary heart disease (CHD) is a common disease which harms people's health seriously. In recent years, acupuncture and moxibustion applications to the treatment of CHD angina pectoris have become more popular and have achieved satisfactory results. By adopting Ziuvliuzhu Najia acupuncture with syndrome differentiation acupoints in the treatment of patients with CHD angina pectoris, this study provides a simple and effective TCM treatment method for CHD angina pectoris.
This study contains two main parts:theoretical study and clinical study.
Theoretical Study
This study reviews historical Chinese medicine academic thoughts on syndrome differentiation of CHD angina pectoris, researches on the origin of the name of chest stuffiness and pain in Chinese medicine, investigates the scope of etiology, pathogenesis and syndrome differential treatment of chest stuffiness and pain, introduces professor Lu Yi LUO's academic point of views and achievements in scientific research on CHD including different contents like treatment based on the theory of Yunqi, treatment based on deficiency and tiredness, treatment based on kidney deficiency, Tongmai pill, Bushen Quyu decoction, Tongmai injection, Tongxin plaster, ultrasound wave and Xuli point stimulation, Xiushu point mean frequency current stimulation, and'warm kidney, resolve phlegm and activate blood'external applied to Xinshu point.
By summarizing the progress of clinical researches about acupuncture treatment on CHD angina pectoris in the latest5years, this study introduces different commonly used treatment methods including pure acupuncture, acupuncture with moxibustion, acupoint plaster, acupuncture with cupping, electro-acupuncture, acupoint injection, laser acupuncture, ultrasound wave, acupoint catgut embedding and acupuncture with medicine.
In this study, the origin of Ziwuliuzhu Najia acupuncture theory has been reviewed. Investigation has been concentrated on the important components of time-acupoint projection like paired relationship among the five-shu acupoints, the five elements and the ten heavenly stem, and the four aspects including'yang advance yin retreat','jin born jin, point born point','return and restore'and'triple energizer absorb qi, pericardium absorb blood'. In addition, explanations have been given to several important practical issues of Ziwuliuzhu Najia acupuncture that attention must be paid to such as supplementary acupoint method, accurate time projection, practical methods for acupoint treatment, etc.
Clinical Study
Objective
Throughout adopting Ziwuliuzhu Najia acupuncture with syndrome differentiation acupoints on treatment of patients with CHD angina pectoris, this study observes the respective clinical efficacy, analyses the feasibility and practicality of the treatment method, compares the efficacies of different acupuncture treatment methods, investigates the underlining mechanisms, provides more comprehensive clinical research data and practical recommendations on time-acupoints treatment method for CHD angina pectoris, and improves the efficacy of acupuncture treatment on CHD.
Methodology
According to diagnosis and case selection standards,160cases that complied with observation criteria of patients with CHD angina pectoris are selected. The cases are divided into4groups and each group consists of40cases. The basis treatment methods provided for all groups are basically the same. The oral medicine is based on Chinese medicine prescriptions with effects of enhancing Yang, nourishing kidney, resolving phlegm and activating blood. The prescriptions would be modified depending on syndrome differential of patient. The course of treatment is7-day.
Treatment group T (i.e. testing group) adopts Ziwuliuzhu Na jia acupuncture with syndrome differentiation acupoints on the treatment of patients with CHD angina pectoris. Control group A adopts Ziwuliuzhu Najia acupuncture on treatment only. Control group B adopts syndrome differentiation acupoints on treatment only. All the above3treatment methods apply once daily and each time lasts20minutes. No acupuncture treatment is applied to control group C. Angina pectoris symptom score and Chinese medicine syndrome score have been taken and recorded on both before treatment and after7-day treatment for each case. The results of different groups are used for comparison. By using t-test and Chi-square test, the efficacies of different groups and the respective efficacy differences are investigated.
Result
145cases are successfully adopted in this study which treatment group T has37cases, control group A has39cases, control group B has37cases, and control group C has32cases. By comparing data including sex, age, angina pectoris symptom score, angina pectoris severity level, Chinese medicine syndrome score, Duke treadmill score, comorbidities and smoking history of different groups before treatment statistically, the results support that there is no significant difference among different groups of data (i. e. P>0.05) and so those groups of samples would be comparable.
By comparing angina pectoris symptom scores of the same group between before and after treatment, it is observed that the score of each group after treatment is superior to that of the same group before treatment (i. e. P<0.001) and the result has statistical significance.
By comparing angina pectoris severity level of the same group between before and after treatment, it is found that the severity levels of angina pectoris of all groups show different degrees of improvement. The number of cases with no angina attack increases significantly and the number of cases with moderate and severe angina reduces significantly.
By comparing angina pectoris symptom scores among groups, there are significant difference between the score of treatment group T and that of control group B (i.e. P<0.05), very significant difference between the score of treatment group T and that of control group C (i. e. P<0.001), and significant difference between the score of control group A and that of control group C (i.e. P<0.05). There is no significant difference between the score of treatment group T and that of control group A, the score of control group A and that of control group B, and the score of control group B and that of control group C (i. e. P>0.05).
By comparing Chinese medicine syndrome score of the same group between before and after treatment, it is observed that the score of each group after treatment is superior to that of the same group before treatment (i. e. P<0.001) and the result has statistical significance.
By comparing Chinese medicine syndrome score among groups, there are significant difference between the score of treatment group T and that of control group A (P<0.05), very significant difference between the score of treatment group T and that of control group B (i. e. P<0.001), very significant difference between the score of treatment group T and that of control group C (i.e. P<0.001), and significant difference between the score of control group A and that of control group C (i.e. P<0.05). There is no significant difference between the score of control group A and that of control group B, and the score of control group B and that of control group C (i.e. P>0.05).
By comparing ECG efficacy among groups, there is no significance difference (i.e. P>0.05).
By comparing Duke treadmill score of the same group between before and after treatment, it is observed that the score of each group after treatment is superior to that of the same group before treatment (i.e. P<0.001) and the result has statistical significance.
By comparing Duke treadmill score using risk stratification of the same group between before and after treatment, it is found that the risk levels of all groups show different degrees of improvement. The number of cases with low risk level increases and the number of cases with moderate and high risk levels reduces.
Discussion
Throughout145cases clinical research of Ziwuliuzhu Najia acupuncture on treatment of patients with CHD angina pectoris, it is observed that Ziwuliuzhu Najia acupuncture with syndrome differentiation acupoints on the treatment of patients with CHD angina pectoris (i.e. treatment group T) achieves total effective rate of94.6%and97.3%on comparison of angina pectoris symptom score and Chinese medicine syndrome score respectively between before and after treatment. The results show very significant difference (i. e. P>0.001) and had statistical significance. It supports that the treatment has positive effect on improving the clinical symptoms of CHD patients.
By comparing total effective rates of angina pectoris syndrome score and Chinese medicine syndrome score between before and after treatment, Ziwuliuzhu Najia acupuncture with syndrome differentiation acupoints treatment (i.e. treatment group T) outperforms syndrome differentiation acupoints treatment (i.e. control group B) and no acupuncture treatment (i.e. control group C) and the results have statistical significance. By comparing total effective rates of angina pectoris syndrome score between before and after treatment, the difference between treatment group T and Ziwuliuzhu Najia acupuncture treatment (i. e. control group A) has no statistical significance and could not support that treatment group T outperforms control group A. However, in view of total effective rates of Chinese medicine syndrome score between before and after treatment, treatment group T outperforms control group A and the result has statistical significance. Besides, control group A outperforms control group C and the result has statistical significance. There is no statistical significance between the differences in total effective rates of control group A and control group B as well as of control group B and control group C. Therefore, the results could not support either control group A outperforming control group B, or control group B outperforming control group C.
Summarizing the above findings, this clinical research discovers that Ziwuliuzhu Najia acupuncture with syndrome differentiation acupoints treatment outperforms syndrome differentiation acupoints treatment significantly in respect of the efficacy of CHD angina pectoris and the difference has statistical significance. This result supports that Najia acupuncture with syndrome differentiation acupoints treatment outperforming pure syndrome differentiation acupoints treatment. On the other hand, the difference in the efficacy of CHD angina pectoris between pure Najia acupuncture and pure syndrome differentiation acupoints treatment shows no statistical significance. The result could not support either treatment would be better than the other.
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