基于CCU重症病例及现代病理生理机制的真武汤方证条文内涵解读及其治疗心力衰竭、心肾综合征、利尿剂抵抗等急危重症体会

Zhenwu Decoction:connotation interpretation based on severe cases and modern pathophysiological mechanisms and application in treatment of heart failure in critical care unit

真武汤出自汉代医家张仲景的《伤寒论》,具有温阳、化气、利水功效,主治阳虚水泛证。基于急危重症病例及病理生理机制研究发现,真武汤条文描述的是心力衰竭急性期的症状和治疗方案,其方证成因,很可能与临床误诊、误治有关,尤其因心源性呼吸困难与肺源性呼吸困难鉴别困难而误用大剂量麻黄发汗误治,而致形成心力衰竭急性加重,合并水电解质紊乱,伴肺部感染的病理生理状态有关。真武汤方证可能反映出当时医家处理心力衰竭的临证经验不足。“振振欲擗地”本质是心衰的临床表现,是苓桂术甘汤“身为振振摇者”的升级版。真武汤的指征:(1)疾病方面,适用于急慢性心力衰竭、心肾综合征、利尿剂抵抗的治疗,真武汤可用于上述各种类型心力衰竭的治疗,尤其适用于全心衰竭、急性心力衰竭、射血分数降低性心力衰竭、《中国心力衰竭诊断和治疗指南2018》中的“湿冷”型心力衰竭;还可用于Ⅱ型和Ⅳ型心肾综合征的治疗;(2)症状指征方面,方证包括胸闷喘憋,心悸,下肢浮肿,小便不利,小便清长,肢冷怕凉,舌淡,苔薄白,脉沉迟无力;(3)药理机制上,真武汤与现代医学治疗心力衰竭的利尿、扩血管、强心治疗原则保持高度一致。附子为真武汤方中君药,以30~60 g为宜,但大剂量附子尤需慎重,有导致恶性心律失常之弊。真武汤方证常以肾气丸、人参汤(理中汤)、五苓散、防己黄芪汤等健脾益气、温阳利水方药善后。扶阳治法在历史上限于在医疗条件欠缺,临床诊断不清,病情危重之时的不得已而为之,现今尤需客观看待。

Zhenwu Decoction is recorded in Treatise on Febrile Diseases by an outstanding physician ZHANG Zhong-jing in the Han dynasty.With effect of warming yang,transforming Qi,and promoting urination,Zhenwu Decoction is mainly used to treat edema due to yang deficiency.The studies of the severe and critical cases and the pathophysiological mechanisms have demonstrated that the record of Zhenwu Decoction in Treatise on Febrile Diseases describes the clinical symptoms and therapeutic regimen of acute heart failure.The syndrome treated by this formula may be related to the misdiagnosis and wrong treatment.Due to the difficult distinguishing between cardiogenic dyspnea and pulmonary dyspnea,high doses of Ephedrae Herba may be misused for inducing sweating,which may finally lead to the acute aggravation of heart failure,electrolyte disorder,and pulmonary infection.The syndrome treated by Zhenwu Decoction can illustrate the lack of experience of ancient physicians in treating acute heart failure.The description of"trembling and shivering"may be the clinical manifestation of heart failure,which is an upgraded version of"trembling and shaking"treated by Linggui Zhugan Decoction.①In terms of diseases,Zhenwu Decoction is suitable for the treatment of acute or chronic heart failure,cardiorenal syndrome,and diuretic resistance.The decoction is especially suitable for treating whole heart failure,acute h eart failure,heart failure with reduced ejection fraction,and heart failure with the syndrome of sold and dampness.In addition,it can be used to treat both typeⅡand typeⅣcardiorenal syndrome.②In terms of symptoms,Zhenwu Decoction can be used for treating chest tightness,palpitations,lower limb edema,difficult urination or increased urine output,fear of cold,pale fat tongue with teeth marks,white and slippery tongue fur,and deep or slow pulse.③In terms of the pharmacological mechanism,Zhenwu Decoction treats heart failure following the principle of promoting urination,expanding blood vessels,and invigorating heart in modern medicine.Aconiti Lateralis Radix Praparata is the sovereign herb in the formula,with the recommended dosage of 30-60 g.However,arrhythmia may be caused by high doses of Aconiti Lateralis Radix Praparata,which should be used with concern.In addition to Zhenwu Decoction,Shenqi Pills,Renshen Decoction,Wuling Powder,and Fangji Huangqi Decoction with the effect of invigorating spleen,replenishing Qi,warming Yang,and promoting urination can be used in the recovery stage.The therapy of reinforcing Yang was the last choice for critical cases due to the lack of medi cal conditions,unclear clinical diagnosis in history,which should be treated objectively now.