王承龙治疗精神应激性心肌缺血的辨证思路

WANG Chenglong′s Syndrome Differentiation in Treatmentof Mental Stress Myocardial Ischemia

随着美国Engel.G L教授提出的生物心理社会医学模式,在新时代经济发展模式下,精神因素相关的微血管性心绞痛、焦虑、失眠使心血管疾病及其并发症的诊疗更加复杂,且呈现年轻化趋势[1]。部分病人存在情绪激动引发的胸闷胸痛,普通心电图难以捕捉到心肌缺血改变,临床常用的冠脉血管造影常提示轻度狭窄或者冠脉短暂痉挛,心肺运动试验结果亦多呈阴性,不能构成冠心病的诊断标准。根据相关临床试验研究,该类患者属于精神应激性心肌缺血,可增加未来心血管不良事件发生率[2-3]。目前通过心肌灌注成像的心肌缺血节段计分来诊断该类疾病[4-5],在治疗方面,5-羟色胺再摄取抑制剂类药物艾司西酞普兰应用较多,但临床疗效仍需大样本试验进一步验证[6]。中医讲"心主血脉、心藏神明""肝主疏泄、调节情志",因此心肝功能协调,有利于维持血液正常运行、情志舒畅、精神饱满。依据脏腑气血辨证,可以充分发挥中医药治疗优势。文章将具体阐述王承龙教授对精神应激性心肌缺血的中医病机和辨证治则思路,并结合典型病案深层剖析。

With the bio-psychosocial medical model put forward by Professor Engel.GL in the United States,in the new era of economic development,microvascular angina pectoris,anxiety and insomnia related to mental factors makes the diagnosis and treatment of cardiovascular disease and its complications more complicated,showing a younger trend[1].Some patients have chest tightness and chest pain caused by emotional agitation,and it is difficult to capture myocardial ischemic changes by ordinary ECG.Coronary angiography commonly used in clinic often indicates mild stenosis or transient coronary spasm,and the results of cardiopulmonary exercise test are mostly negative,which does not constitute the diagnostic criteria of coronary heart disease.According to the relevant RCT studies,these patients belong to mental stress myocardial ischemia,which can increase the incidence of future cardiovascular adverse events[2-3].At present,the myocardial ischemic segment score of MPI myocardial perfusion imaging is used to diagnose this kind of disease[4-5].Escitalopram,a serotonin reuptake inhibitor,is widely used in treatment,but the clinical efficacy still needs to be further verified by large sample trials[6].Traditional Chinese medicine says that "the heart governs the blood,the heart stores the spirit" and "the liver governs the catharsis and regulates the emotion".Therefore,the coordination of the heart and liver function is conducive to maintaining the normal operation of the blood,feeling comfortable and energetic.According to the syndrome differentiation of Zang-Fu organs,Qi and blood,the advantages of traditional Chinese medicine can be brought into full play.This articleelaborated Professor WANG Chenglong′s thoughts on the pathogenesis of traditional Chinese medicine and the principles of syndrome differentiation and treatment of MSIMI,combining withthe in-depth analysis of typical medical records.