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冠心病的中医认识与经方治疗策略

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冠心病为心血管领域的常见疾病,我国约有1 140万例冠心病患者,其患病率与病死率逐年上升,已成为威胁人类健康和公共卫生的重要因素。在现代医学的一级、二级预防,介入,冠状动脉旁路移植术等干预下,其病死率虽有下降,但仍存在阿司匹林等药物抵抗、继发性硝酸甘油失效、介入术后乏力胸闷焦虑、冠心病合并高出血风险等问题,已成为现代医学亟待解决的临床关键科学问题。冠心病属于中医学"胸痹、心痛"范畴。在病因上,包括外感寒邪、情志内伤、禀赋不足、体虚劳伤等,这与现代医学中的交感神经活性、双心疾病状态、家族病史、心血管多代谢紊乱等因素密切相关。在病机上,包括气郁、痰浊、瘀血、火热、寒凝、正虚等证型。结合现代病理,气郁与焦虑抑郁状态等情志因素相关,痰浊与脂质代谢异常相关,瘀血与血液循环与凝血功能异常相关,火热与炎症反应相关,寒凝与免疫反应亢进相关,正虚与后期心力衰竭、合并慢性消耗性疾病或年老体虚相关。在经方治疗策略上,气郁推荐柴胡加龙骨牡蛎汤,痰浊推荐温胆汤、瓜蒌薤白半夏汤,瘀血推荐血府逐瘀汤、桂枝茯苓丸,火热推荐小陷胸汤、三黄泻心汤,寒凝推荐枳实薤白桂枝汤,正虚推荐人参汤等。研究发现,在病机认识上,由于古今疾病谱变化以及体质差异,导致冠心病的核心病机从阳微阴弦的胸阳不振、"寒凝"为主,转变为"气郁""痰浊""痰瘀""火热"等,呈现出由寒到热,由虚到实的转变;在经方合方上,有规律可循,即某疾病的核心方证常固定性地与其他方证合方出现,这可能与疾病内在的病理生理机制的发展变化相关;在现代药理成果的临床运用上,根据团队"病机结合病理,药性结合药理"临证原则,大量经典名方的现代药理学研究有助于现代临床的"靶向"治疗;经方还有助于改善阿司匹林抵抗、氯吡格雷抵抗,介入术后焦虑,易合并高出血风险,冠脉临界病变的缺乏有效阻断、延缓心肌梗死后心力衰竭进展等临床难题。冠心病的病因病机创新认识,有助于进一步提升中医药临床疗效,进而推进经方治疗冠心病临证体系的完善。
Coronary heart disease:innovative understanding from traditional Chinese medicine and treatment by classic formulas
Coronary heart disease is a common cardiovascular disease,attacking about 11.4 million patients in China.With in-creasing prevalence and mortality year by year,coronary heart disease has become a major factor threatening human health and public health.Although primary and secondary prevention,intervention,coronary artery bypass grafting and other interventions have reduced the death rate,there are drug(aspirin)resistance,secondary nitroglycerin failure,post-intervention fatigue,chest tightness,and an-xiety,and complication with a high risk of bleeding,which have become the key clinical and scientific issues needed to be resolved.Coronary heart disease belongs to the category of chest impediment and heart pain in traditional Chinese medicine(TCM).The TCM etiology of this disease includes external contraction of cold,emotional disorders,constitutional insufficiency,physical weakness,and labor injury,which are closely related to sympathetic nerve activity,state of cardiac and psychological diseases,family history,and cardiovascular metabolic disorders in modern medicine.The TCM causes of coronary heart disease include Qi depression,phlegm tur-bidity,blood stasis,fire-heat,cold congealing,and healthy Qi deficiency,which are associated with emotional factors such as anxiety and depression,abnormal lipid metabolism,abnormalities in blood circulation and coagulation,inflammatory responses,hyperactive immune responses,and heart failure,chronic wasting disease,or aging,respectively.Accordingly,the patients with Qi depression should be treated with Chaihu Longgu Muli Decoction,and those with phlegm turbidity should be treated with Wendan Decoction and Gualou Xiebai Banxia Decoction.Xuefu Zhuyu Decoction and Guizhi Fuling Pills are recommended for blood stasis,Xiaoxianxiong De-coction and Sanhuang Xiexin Decoction for fire-heat,Zhishi Xiebai Guizhi Decoction for cold congealing,and Renshen Decoction for healthy Qi deficiency.Due to the changes in the spectrum of diseases from ancient to modern times as well as the differences in physi-cal constitution,the key cause of coronary heart disease has evolved from the chest Yang deficiency and cold congealing to Qi depres-sion,phlegm turbidity,phlegm combined with stasis,and fire-heat,showing a shift from cold to heat and from deficiency to excess.The combination of classic formulas presents a pattern.That is,the core formula-syndrome correspondence of a disease often fixedly ap-pears with other formula-syndrome correspondence,which may be related to the development of the pathophysiological mechanism of the disease.In the clinical application of modern pharmacological results,the research team has formulated the clinical principle of patho-genesis corresponding to pathological changes and medicinal nature corresponding pharmacological effects.The modern pharmacological research on classic formulas is conducive to targeted treatment.Moreover,classic formulas help to ameliorate aspirin resistance,clopi-dogrel resistance,post-intervention anxiety,and high risk of bleeding and address the lack of effective blockade of critical lesions in the coronary artery and the progression of post-infarction heart failure.The innovative understanding of the etiology and pathogenesis of co-ronary heart disease helps to improve the clinical efficacy of TCM and the clinical system for treating coronary heart disease with classic formulas.

coronary heart diseaseclassic formulacorrespondence between formula and syndrometraditional Chinese medicine

蓝宇、罗富锟、于悦、王小雅、王朋倩、熊兴江

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中国中医科学院广安门医院,北京 100053

中国中医科学院中药研究所,北京 100700

冠心病 经方 方证对应 中医药

中央高水平中医医院临床研究和成果转化能力提升项目——医疗机构制剂研发与新药转化专项临床科研一体化人才专项京津冀基础研究合作专项中国中医药科技发展中心(国家中医药管理局人才交流中心)联合攻关项目中国中医科学院科技创新工程项目中国中医科学院中药研究所启航人才项目中国中医科学院中药研究所国家自然科学基金培育专项

HLCMHPP2023081CZ30981CI2021A03804ZXKT21017ZXKT23015

2024

中国中药杂志
中国药学会

中国中药杂志

CSTPCD北大核心
影响因子:1.718
ISSN:1001-5302
年,卷(期):2024.49(13)