基于QUEST算法的高血压辨病对症治疗中药的重要性分析

An analysis on importance of drugs in traditional Chinese medicine for treatment of complications and symptoms of hypertension by QUEST algorithms

目的探讨祝光礼教授针对高血压合并症、并发症和症状的辨病治疗及随症加减用药规律。方法选择2012年9月至2015年1月浙江中医药大学附属广兴医院，浙江省杭州市中医院首次就诊、资料完整的原发性高血压（EH）患者，以高血压合并症、并发症和症状为目标变量，以所使用的中药为自变量，通过QUEST算法分析不同目标变量中药的重要性贡献率。结果共获得9种合并症、并发症（包括高脂血症、冠心病、心律失常、高血糖、微量蛋白尿、腔隙性脑梗死、血肌酐升高、肝功能异常、心功能不全）和39种症状（头晕、心悸、胸闷、夜寐不安、乏力、腰膝酸软、口干、便溏、疲劳、自汗、头痛、气短、大便干结、脘痞、视物模糊、肢体麻木、情绪不畅、胸痛、纳差、腹胀、多梦、耳鸣、潮红、项强、烘热、口苦、咳嗽、嗳气、夜尿增多、肢体震颤、叹息、咽痛、头重、盗汗、尿频、咳痰、形寒、口腔溃疡、流涎）的QUEST决策模型。将全部病例755次就诊所使用的全部中药进行汇总、并记录药物出现的频次。研究共涉及中药171味、10620频次，每处方平均（14．07±1．53）味。用药频次前10位中药是茯苓（588）、山药（551）、枸杞子（496）、白芍（442）、石决明（405）、天麻（395）、麦冬（325）、淮小麦（293）、郁金（281）、灯芯草（277），占总频次的38．16％，出现频次〉100的中药33种，占总频次的74．65％。针对合并症和并发症的加减用药进行分析，重要性贡献率〉5％的药物有：腔隙性脑梗死中僵蚕和益智仁的用药频率分别为50．74％和32．69％；冠心病中太子参、黄芪、檀香、炙葶苈子的用药频率分别为23．05％、17．70％、15．31％、5．06％；心律失常中黄芪、苦参、淮小麦、龙齿、龙骨的用药频率分别为46．65％、11．56％、7．56％、7．13％、6．28％；心功能不全中炙葶苈子、白扁豆的用药频率分别为92．97％、7．03％；高脂血症中决明子、檀香、生地黄、红藤的用药频率分别为24．26％、12．47％、10．51％、5．81％；高血糖中天花粉、生山楂的用药频率分别为51．02％、30．18％；微量蛋白尿中六月雪的用药频率为83．33％；血肌酐升高中藤梨根、六月雪、女贞子、积雪草的用药频率分别为81．37％、6．21％、6．21％、6．21％；肝功能不全中平地木、荷包草、垂盆草的用药频率分别为86．37％、6．82％、6．82％。以症状为目标变量，前3位常见症状重要性贡献率〉5％的中药有：血压升高用桑寄生（89．59％）；头晕用天麻、石决明（分别为46．96％、33．61％）；头痛用川芎、藁本、秦艽（分别为85．77％、7．11％、7．11％）。结论祝光礼教授辨病治疗和随症加减用药的基本思路是在辨证论治原则的指导下，以中医经典理论为依据，优先选择经临床和（或）实验研究证实疗效可靠的药物。

Objective To approach Professor Zhu Guangli＇s regular pattern of differentiation of symptoms and signs in patients with hypertension accompanied by complications and in accord with the individual manifestations to add or subtract the ingredients in the prescription. Methods The patients with essential hypertension selected were those who the first time came to the Affiliated Guangxing Hospital of Zhejiang Chinese Medical University or Hangzhou Hospital of Traditional Chinese Medicine （TCM） of Zhejiang Province from September 2012 to January 2015, and were continuously followed up in the hospitals having their clinical data comprehensive. The complications, combination diseases and symptoms of hypertension were conducted as dependent variables, while the applied Chinese medicines were acted as independent variables. QUEST algorithms were employed to analyze the different dependent variables to evaluate the importance contribution rate （ICR） of every kind of Chinese medicine. Results There were 9 types of complications or combination diseases [including hyperlipemia, coronary heart disease, cardiac arrhythmia, hyperglycemia, trace albuminuria, lacunar cerebral infarction, elevation of creatinine in blood （azotemia）, liver dysfunction and cardiac dysfunction] and 39 types of symptoms obtained （including dizziness, palpitation, chest oppression, insomnia, lack of strength, soreness of the waist and knees, dry mouth, loose stool, fatigue, apontaneous sweating, headache, shortness of breath, coprostasis, fullness in the stomach, blurred vision, limb numbness, low spirit, chest pain, poor appetite, abdominal distension, excessive dreaming, tinnitus, flush of the face, neck rigidity, hectic fever, bitterness in the mouth, cough, ructus, nocturia, fremitus, stenagma, pharyngalgia, heaviness in head, nocturnal sweating, frequent urination, coughing of sputum, chillness and cold limbs, aphthous stomatitis and sialosis） being the QUEST decision models. All kinds of the TCM employed in all the patients paying visits for 755 times were summed up, and the individual drug frequency of presentation in the prescription was recorded. In the study, 171 sorts of TCM and 10620 of cumulative frequency （freq.） were involved in 755 prescriptions. The average sorts of TCM was 14.07 ± 1.53 per prescription. The top ten kinds of TCM the most commonly used （freq.） were as follows： tuckahoe （588）, Chinese yam （551）, wolfberry fruit （496）, white peony root （442）, abalone shell （405）, gastrodia tuber （395）, lilyturf root （325）, Huai wheat （293）, curcuma root （281）, rush pith （277）, accounting for 38.16% in the total frequency. There were 33 kinds of TCM with frequency 〉 100, accounting for 74.65% in the total frequency. By the analyses of QUEST algorithms directing to the complications and combination diseases to add or subtract the items of TCM, it was discovered that the drugs with ICR 〉 5% were as follows： in lacunar cerebral infarction, the drug application frequencies or ICRs of batryticated silkworm and bitter cardamom were 32.69% and 50.74% resoectively; in coronary heart disease, the ICRs of pseudostellaria root,astragalus root, white sandal wood and lepidium seed were 23.05%, 17.70%, 15.31% and 5.06% respectively; in cardiac arrhythmia, the ICRs of astragalus root, flavescent sophora root, Huai wheat and dragon tooth and dragon bone were 46.65%, 11.56%, 7.56%, 7.13% and 6.28% respectively; in cardiac dysfunction, the ICRs of lepidium seed and white hyaciath bean were 92.97% and 7.03%; in hyperlipemia, the ICRs of cassia seed, white sandal wood, dried rehmannia root and sargentgloryvine stem were 24.26%, 12.47%, 10.51% and 5.81% respectively; in hyperglycemia, the ICRs of triehosanthes root and dried hawthorn fruit were 51.02% and 30.18%; in trace albuminuria, the ICR of snow in June herb was 83.33%, in elevation of creatinine in blood, the ICRs of Chinese actinidia root, herb of snow in June, glossy privet fruit and eentella were 81.37%, 6.21%, 6.21% and 6.21% respectively; in liver dysfunction, the ICRs of coral ardisia root, purse grass and herb of stringy stonecrop were 86.37%, 6.82% and 6.82% respectively. When the symptoms were used as the dependent variables, for the top 3 commonly seen symptoms, in the prescription, the items of TCM used with ICR 〉 5% were as follows： in cases with elevation of blood pressure, parasitic loranthns （ICR 89.59%） was used; with dizziness, gastrodia tuber （ICR 46.96%） and/or abalone shell （ICR 33.61%） were added; laeadache, rhizome of Chinese ligusticum and/or rhizome of Sichuan lovage and/or large gentian with ICR at 85.77%, 7.11% and 7.11% respectively. Conehtsion Professor Zhu＇s essential thought in differentiation of disease and expectant treatment of hypertension in accord with the individual manifestations to add and subtract drugs in TCM is under the guidance of TCM principle of differentiation of symptoms and signs for treatment, and based on the classical theories in TCM, the reliable drugs whose actions are demonstrated clinically and experimentally are preferentially selected.