慢性心力衰竭心气虚、心阳虚、心肾阳虚3个不同病程阶段中医药干预临床研究

Clinical Study on TCM Intervention on Heart-Qi deficiency,Heart-Yang Deficiency and Heart-Kidney Yang Deficiency of Chronic Heart Failure

目的:通过对慢性心力衰竭(CHF)的心气虚、心阳虚、心肾阳虚三个不同病程阶段,运用益心气、温心阳、补心肾三种不同治法进行中医药干预,旨在观察不同病程阶段中医药干预治疗前后的临床表征和相关生物学信息变化情况。方法:90例明确诊断为CHF的心气虚、心阳虚、心肾阳虚型患者,每个证型各30例。由上海中医药大学附属曙光医院、上海中医药大学附属岳阳医院、上海中医药大学附属龙华医院3个中心共同完成。入选患者均给予标准化治疗,再根据中医辨证给予不同中药治疗:心气虚者予以独参汤(人参)加减;心阳虚者予以芪附(黄芪、附子)汤加减;心肾阳虚者给予真武汤合鹿角丸(茯苓、白芍、白术、附子、生姜、鹿角、桂心、甘草)加减。随访4周。观察患者治疗前后脑利钠肽(BNP)、血浆凝血酶原、肾素、血管紧张素II(AngⅡ)、醛固酮、左室射血分数(LVEF)、左房内径(LAD)、左心室舒张末期内径(LVDD)、左心室收缩期内径(LVSD)、心功能分级、中医证候积分等变化。结果:治疗4周后,3组患者左心功能分级、中医证候积分均有显著改善(P<0.05)。心气虚组患者LVDD、BNP、血管紧张素II、醛固酮较治疗前有显著改善(P<0.05)。心阳虚患者BNP、肾素、血管紧张素较治疗前有显著改善(P<0.05)。心肾阳虚患者BNP较治疗前有显著改善(P<0.05)。心气虚、心阳虚、心肾阳虚3组患者治疗后心衰疗效分别为66.67%、76.67%、66.67%,中医证候疗效分别为76.67%、80.00%、80.00%,3组间均无显著性差异(P>0.05)。结论:针对CHF的不同病程阶段给予中医药干预治疗能显著改善患者心功能及中医证候,有较好的近期疗效。对于病程初期心气虚阶段患者,应早期中医药干预治疗,可通过改善神经-内分泌水平,抑制RAAS激活,从而抑制早期心室重塑,延缓CHF进一步恶化,有利于CHF患者的预后转归。

Objective： The use of three different ways of TCM interventions,including enriching the heart-qi,warming the heartyang and mending the heart-kidney in three different stages of chronic heart failure aims to observe the clinical manifestation and the related biological information change around the intervention of traditional Chinese medicine at different stages. Methods： 90cases of patients with definitive diagnosis of heart-qi deficiency,heart-yang deficiency and heart-kidney yang deficiency（ every syndrome 30 cases） were accomplished collectively by three medical centers： Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine,Yueyang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine and Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine. Patients received standardized treatment and then were treated with different TCM treatments according to TCM syndrome differentiation： modified Dushen Decoction（ ginseng） for patients with heart-qi deficiency; modified Qifu Decoction（ Astragalus and monkshood） for patients with heart-yang deficiency;Zhenwu Decoction and Lujiao Pills（ Poria cocos,white peony root,white atractylodes rhizome,monkshood,ginger,antler,shaved cinnamon bark and licorice） for patients with heart-kidney yang deficiency. Four weeks＇ follow-up,we observed changes of patients＇ BNP,plasma prothrombin,renin,AngⅡ,aldosterone,LVEF,LAD,LVDD,LVSD,cardiac function classification and TCM syndrome scoring in before and after treatment. Results： After four weeks＇ treatment,both left cardiac function classification and TCM syndrome scoring of three groups of patients had significant improvements（ P 0. 05）. LVDD,BNP,AngⅡ and aldosterone of the patients with heart-qi deficiency had significant improvements after the treatment（ P 0. 05）. BNP,renin and Angiotensin of the patients with heart-yang deficiency had significant improvements after the treatment（ P 0. 05）. BNP of the patients with heart-kidney yang deficiency has significant improvement after the treatment（ P 0. 05）. The curative effects of heart failure after the treatment of heart-qi deficiency,heart-yang deficiency and heart-kidney yang deficiency groups were 66. 67%,76. 67%and 66. 67%. The efficacies of TCM syndrome were 76. 67%,80. 00% and 80. 00%. There were no significant differences among the three groups（ P 0. 05）. Conclusion： Intervention treatment of traditional Chinese medicine to different stages of CHF can significantly improve patients＇ cardiac function and TCM syndrome,and has a good curative effect. Patients at the early stage of heart-qi deficiency should receive intervention treatment of traditional Chinese medicine,which can restrain ventricle remodeling at its early stage and delay further deterioration of CHF by improving the nerve-endocrine level and restraining the activation of RAAS. It is conducive to prognosis of CHF patients.