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中醫藥干預冠脈介入術后再狹窄大有作為

醫案日記 2023-06-19 15:03:38

以(yi)冠(guan)脈內支架(jia)置入(ru)術(shu)(shu)為基礎的冠(guan)心病(bing)(bing)介(jie)入(ru)治(zhi)(zhi)療(liao)技術(shu)(shu)(PCI)目前已成為冠(guan)心病(bing)(bing)血(xue)運重建治(zhi)(zhi)療(liao)的重要手段。據統計(ji),2001年全(quan)世界(jie)(jie)范圍(wei)內開展(zhan)的各種(zhong)PCI治(zhi)(zhi)療(liao)約260萬(wan)例。我國2000年完(wan)成1.2萬(wan)例,2001年完(wan)成1.6萬(wan)例,每(mei)年都在(zai)以(yi)30%~40%的速度增(zeng)長。盡管(guan)(guan)數量與國外相差甚遠,但(dan)發(fa)展(zhan)十分迅(xun)速。但(dan)是(shi),術(shu)(shu)后(hou)再(zai)狹窄(zhai)(RS)問題一直(zhi)困擾著冠(guan)心病(bing)(bing)介(jie)入(ru)治(zhi)(zhi)療(liao)的發(fa)展(zhan)。對此(ci),世界(jie)(jie)中(zhong)醫藥(yao)學(xue)會(hui)(hui)聯合(he)會(hui)(hui)心血(xue)管(guan)(guan)病(bing)(bing)專業委員(yuan)會(hui)(hui)副會(hui)(hui)長、廣東省(sheng)中(zhong)醫院張(zhang)敏(min)州教(jiao)授(shou)在(zai)日前召開的第八次全(quan)國中(zhong)西(xi)醫結合(he)心血(xue)管(guan)(guan)病(bing)(bing)學(xue)術(shu)(shu)會(hui)(hui)議(yi)上介(jie)紹說,PCI術(shu)(shu)側重于冠(guan)脈局部病(bing)(bing)變的干(gan)預,術(shu)(shu)后(hou)可誘發(fa)斑塊不穩(wen)定和(he)血(xue)小板、凝血(xue)系統激活,而(er)中(zhong)醫藥(yao)長于對患者(zhe)整體調節,二者(zhe)互相補(bu)充、有機結合(he),可為冠(guan)心病(bing)(bing)的中(zhong)西(xi)醫結合(he)研究(jiu)帶來新的發(fa)展(zhan)契機。那么,中(zhong)醫藥(yao)在(zai)冠(guan)心病(bing)(bing)介(jie)入(ru)治(zhi)(zhi)療(liao)中(zhong)可發(fa)揮哪些積極作(zuo)用,在(zai)此(ci)領域取(qu)得了(le)哪些關(guan)鍵(jian)進展(zhan)呢(ni)?日前,記者(zhe)就此(ci)采訪了(le)張(zhang)敏(min)州教(jiao)授(shou)。

問:自1977年9月Gruentzig開展(zhan)了世界上第一(yi)例(li)經皮冠狀動脈(mo)腔內成形術以來,冠心病(bing)的介(jie)入治療迅速推廣,但術后再狹窄一(yi)直是臨床(chuang)面臨的一(yi)大(da)難題,中醫藥(yao)干(gan)預對(dui)防治再狹窄能起到(dao)哪些積極的作用?

答:近年(nian)來,冠(guan)心(xin)病介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療的(de)適(shi)應證(zheng)不(bu)(bu)(bu)斷(duan)拓寬、復雜病變介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療成(cheng)功率不(bu)(bu)(bu)斷(duan)提(ti)高、急性(xing)心(xin)肌(ji)梗死急診介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療得到廣(guang)泛應用。無論是(shi)(shi)(shi)(shi)冠(guan)心(xin)病介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療的(de)器械還是(shi)(shi)(shi)(shi)介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療的(de)手段都有了很(hen)大程度的(de)改(gai)進(jin),介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療方(fang)面的(de)經驗日益(yi)豐(feng)富。但是(shi)(shi)(shi)(shi),應該(gai)引起重(zhong)(zhong)視的(de)是(shi)(shi)(shi)(shi),介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療并不(bu)(bu)(bu)是(shi)(shi)(shi)(shi)萬(wan)能(neng)的(de),PCI術(shu)只能(neng)處(chu)理局(ju)部(bu)的(de)冠(guan)狀動脈(mo)粥樣(yang)硬化病變,而不(bu)(bu)(bu)能(neng)阻止(zhi)冠(guan)狀動脈(mo)粥樣(yang)硬化的(de)進(jin)展(zhan),因而PCI術(shu)不(bu)(bu)(bu)能(neng)替(ti)代藥(yao)物(wu)(wu)治(zhi)(zhi)(zhi)(zhi)療,患者術(shu)后更應加(jia)強藥(yao)物(wu)(wu)治(zhi)(zhi)(zhi)(zhi)療。冠(guan)脈(mo)介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療注重(zhong)(zhong)局(ju)部(bu)干預(yu),整(zheng)體關注不(bu)(bu)(bu)足(zu)是(shi)(shi)(shi)(shi)其缺點,而整(zheng)體治(zhi)(zhi)(zhi)(zhi)療、整(zheng)體調節是(shi)(shi)(shi)(shi)中醫藥(yao)的(de)優(you)勢之一,術(shu)后用中藥(yao)調整(zheng)陰(yin)陽(yang),調暢氣(qi)血,使陰(yin)平陽(yang)秘,氣(qi)血調和(he),恰好(hao)可彌補介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療的(de)不(bu)(bu)(bu)足(zu)。因此,積(ji)極開(kai)展(zhan)冠(guan)心(xin)病的(de)介(jie)(jie)入(ru)(ru)(ru)(ru)治(zhi)(zhi)(zhi)(zhi)療和(he)中醫藥(yao)研究(jiu)具有重(zhong)(zhong)要意義。

自首例(li)冠(guan)脈(mo)腔內成(cheng)形術(shu)開展以來,術(shu)后再狹窄(zhai)問題(ti)(ti)一直(zhi)困擾著(zhu)冠(guan)心(xin)病(bing)PCI治療的(de)發展,成(cheng)為國內外心(xin)血管研(yan)究領域的(de)重(zhong)要難點。單純球囊(nang)擴張術(shu)后再狹窄(zhai)的(de)發生率(lv)高達30%~50%,金屬裸支(zhi)(zhi)架的(de)置入(ru)將(jiang)再狹窄(zhai)的(de)發生率(lv)降低(di)至20%~30%左(zuo)右。藥(yao)(yao)物(wu)(wu)洗脫(tuo)支(zhi)(zhi)架(DES)通過攜(xie)帶抑制(zhi)平滑肌細胞增生的(de)藥(yao)(yao)物(wu)(wu)到病(bing)變(bian)血管,直(zhi)接抑制(zhi)血管重(zhong)建(jian)術(shu)后新生內膜的(de)增生,從(cong)而有效降低(di)再狹窄(zhai)的(de)發生。然而,SIRIUS試(shi)驗中胰島素依(yi)賴的(de)糖尿病(bing)患者使用藥(yao)(yao)物(wu)(wu)洗脫(tuo)支(zhi)(zhi)架12個(ge)月后再狹窄(zhai)的(de)發生率(lv)高達35%。而且(qie),DES的(de)安全性問題(ti)(ti)(如遲發性血栓事件、支(zhi)(zhi)架貼壁不全、動脈(mo)瘤(liu)等)令人擔憂。

問(wen):中醫藥治療(liao)冠脈(mo)介(jie)入(ru)術后再(zai)狹窄的研究已(yi)獲得哪些進展?

答:近年來,中醫(yi)藥(yao)界眾多(duo)(duo)學者(zhe)圍繞再(zai)(zai)(zai)(zai)(zai)狹(xia)窄(zhai)的(de)(de)病(bing)(bing)因、病(bing)(bing)機、證候(hou)演變規律和中醫(yi)藥(yao)防治(zhi)進(jin)行(xing)了許多(duo)(duo)有(you)益的(de)(de)探索,其(qi)中以陳可冀(ji)院士(shi)對(dui)芎(xiong)芍(shao)膠囊(由血(xue)府逐瘀湯提取)的(de)(de)抗再(zai)(zai)(zai)(zai)(zai)狹(xia)窄(zhai)作(zuo)(zuo)用(yong)研究最為(wei)突(tu)出(chu)。實驗(yan)(yan)研究證明,芎(xiong)芍(shao)膠囊具有(you)調(diao)控血(xue)管平滑(hua)肌細胞增殖凋亡(wang)、膠原(yuan)代(dai)謝,抑制內膜增厚(hou)、改善病(bing)(bing)理性(xing)血(xue)管重(zhong)構等作(zuo)(zuo)用(yong),可作(zuo)(zuo)用(yong)于(yu)術后(hou)(hou)再(zai)(zai)(zai)(zai)(zai)狹(xia)窄(zhai)形(xing)成(cheng)的(de)(de)多(duo)(duo)個(ge)(ge)病(bing)(bing)理環節。其(qi)主(zhu)持的(de)(de)國家(jia)“十五”攻關課題“冠(guan)心(xin)病(bing)(bing)介(jie)(jie)入(ru)(ru)治(zhi)療(liao)后(hou)(hou)再(zai)(zai)(zai)(zai)(zai)狹(xia)窄(zhai)的(de)(de)中醫(yi)干(gan)預治(zhi)療(liao)方案”是第一個(ge)(ge)按照前瞻(zhan)性(xing)、隨(sui)(sui)(sui)機、雙(shuang)盲(mang)和安慰劑對(dui)照原(yuan)則設計的(de)(de)探討中藥(yao)對(dui)PCI術后(hou)(hou)再(zai)(zai)(zai)(zai)(zai)狹(xia)窄(zhai)發生(sheng)率的(de)(de)多(duo)(duo)中心(xin)臨床(chuang)試(shi)驗(yan)(yan),廣(guang)東省中醫(yi)院心(xin)臟中心(xin)作(zuo)(zuo)為(wei)分(fen)(fen)中心(xin)單位參與(yu)。該研究納入(ru)(ru)335例(li)(li)成(cheng)功行(xing)冠(guan)狀(zhuang)動(dong)脈(mo)介(jie)(jie)入(ru)(ru)治(zhi)療(liao)的(de)(de)冠(guan)心(xin)病(bing)(bing)患(huan)者(zhe),隨(sui)(sui)(sui)機分(fen)(fen)為(wei)治(zhi)療(liao)組(zu)(芎(xiong)芍(shao)膠囊)和對(dui)照組(zu)(安慰劑),兩組(zu)均(jun)服用(yong)藥(yao)物6個(ge)(ge)月,而后(hou)(hou)行(xing)冠(guan)狀(zhuang)動(dong)脈(mo)造影隨(sui)(sui)(sui)訪,并在(zai)介(jie)(jie)入(ru)(ru)治(zhi)療(liao)術后(hou)(hou)的(de)(de)1個(ge)(ge)月、3個(ge)(ge)月和6個(ge)(ge)月進(jin)行(xing)臨床(chuang)隨(sui)(sui)(sui)訪。主(zhu)要終點(dian)事件(jian)為(wei)冠(guan)脈(mo)造影證實的(de)(de)再(zai)(zai)(zai)(zai)(zai)狹(xia)窄(zhai)事件(jian)。次要終點(dian)事件(jian)為(wei)死亡(wang)、非致死性(xing)心(xin)肌梗死、再(zai)(zai)(zai)(zai)(zai)次血(xue)運重(zhong)建術和冠(guan)狀(zhuang)動(dong)脈(mo)旁(pang)路搭橋術的(de)(de)聯(lian)合終點(dian)事件(jian)。結果308例(li)(li)(91.9%)患(huan)者(zhe)完成(cheng)隨(sui)(sui)(sui)訪,其(qi)中145例(li)(li)患(huan)者(zhe)(47.1%)進(jin)行(xing)冠(guan)脈(mo)造影隨(sui)(sui)(sui)訪。治(zhi)療(liao)組(zu)的(de)(de)再(zai)(zai)(zai)(zai)(zai)狹(xia)窄(zhai)發生(sheng)率顯著(zhu)低于(yu)對(dui)照組(zu)(26.0%對(dui)47.2%,P

廣東省(sheng)中(zhong)醫(yi)院的課(ke)題組對冠心(xin)病介入術后(hou)中(zhong)醫(yi)證候分布規律和(he)中(zhong)醫(yi)治(zhi)療(liao)(liao)的最佳(jia)方案進行(xing)(xing)了深入探討,結果發(fa)現PCI術后(hou)中(zhong)醫(yi)證型(xing)以(yi)(yi)氣(qi)(qi)虛(xu)血(xue)(xue)(xue)瘀和(he)氣(qi)(qi)虛(xu)痰瘀證型(xing)為(wei)主,因而治(zhi)療(liao)(liao)應以(yi)(yi)益(yi)氣(qi)(qi)活(huo)血(xue)(xue)(xue)和(he)益(yi)氣(qi)(qi)活(huo)血(xue)(xue)(xue)化痰為(wei)主。在(zai)此基礎上,科研(yan)人員(yuan)研(yan)制(zhi)(zhi)出由黃芪、丹參等(deng)藥(yao)組成的中(zhong)藥(yao)復(fu)方制(zhi)(zhi)劑,以(yi)(yi)用于(yu)(yu)冠心(xin)病介入術后(hou)的整體調節。方中(zhong)北芪甘(gan)溫善補中(zhong)氣(qi)(qi),益(yi)氣(qi)(qi)以(yi)(yi)助血(xue)(xue)(xue)行(xing)(xing),取“氣(qi)(qi)為(wei)血(xue)(xue)(xue)帥,氣(qi)(qi)行(xing)(xing)則血(xue)(xue)(xue)行(xing)(xing)”之(zhi)義,為(wei)君藥(yao);丹參性苦,歸心(xin)、肝經,功擅(shan)活(huo)血(xue)(xue)(xue)化瘀,療(liao)(liao)血(xue)(xue)(xue)瘀之(zhi)心(xin)胸疼痛之(zhi)要藥(yao),為(wei)臣(chen)藥(yao),組方藥(yao)簡(jian)力宏(hong),共起益(yi)氣(qi)(qi)活(huo)血(xue)(xue)(xue)通脈(mo)之(zhi)功效。該制(zhi)(zhi)劑用于(yu)(yu)PCI術后(hou)患者,與(yu)西醫(yi)常規治(zhi)療(liao)(liao)組相比,可降低PCI術后(hou)再(zai)狹(xia)窄發(fa)生率(P

問:目前,臨床在(zai)急(ji)性心(xin)梗的急(ji)診搶救(jiu)中尚存在(zai)一些問題(ti),請您談談醫院開道”的必要性與實(shi)施中醫藥綜合干預所(suo)能起到的積(ji)極作(zuo)用。

答:“時(shi)間(jian)(jian)就是(shi)生(sheng)(sheng)命,時(shi)間(jian)(jian)就是(shi)心(xin)(xin)(xin)(xin)肌(ji)”。盡早、充分(fen)、持久地開(kai)通(tong)(tong)(tong)(tong)梗(geng)(geng)(geng)(geng)死(si)靶血管(guan)是(shi)急(ji)(ji)(ji)性(xing)心(xin)(xin)(xin)(xin)梗(geng)(geng)(geng)(geng)搶救(jiu)治(zhi)療(liao)的(de)關鍵。再(zai)灌(guan)注治(zhi)療(liao)能(neng)夠挽救(jiu)瀕死(si)心(xin)(xin)(xin)(xin)肌(ji),減少梗(geng)(geng)(geng)(geng)死(si)范圍,降低死(si)亡(wang)率。其理想目(mu)標(biao)是(shi)患者就診(zhen)(zhen)(zhen)后30分(fen)鐘(zhong)內(nei)開(kai)始溶栓治(zhi)療(liao),90分(fen)鐘(zhong)內(nei)行直接PCI治(zhi)療(liao)。然而,目(mu)前的(de)醫療(liao)體制與管(guan)理模式,使急(ji)(ji)(ji)性(xing)心(xin)(xin)(xin)(xin)肌(ji)梗(geng)(geng)(geng)(geng)死(si)的(de)再(zai)灌(guan)注理想時(shi)間(jian)(jian)難(nan)以(yi)實現。主要的(de)問題(ti)(ti):一是(shi)急(ji)(ji)(ji)診(zhen)(zhen)(zhen)接診(zhen)(zhen)(zhen)醫生(sheng)(sheng)是(shi)各科(ke)(ke)(ke)(ke)(ke)(ke)輪轉醫生(sheng)(sheng),不(bu)是(shi)心(xin)(xin)(xin)(xin)血管(guan)專(zhuan)科(ke)(ke)(ke)(ke)(ke)(ke)醫生(sheng)(sheng),可能(neng)延遲心(xin)(xin)(xin)(xin)肌(ji)梗(geng)(geng)(geng)(geng)死(si)的(de)診(zhen)(zhen)(zhen)斷(duan)及(ji)鑒別診(zhen)(zhen)(zhen)斷(duan);二是(shi)急(ji)(ji)(ji)診(zhen)(zhen)(zhen)科(ke)(ke)(ke)(ke)(ke)(ke)與心(xin)(xin)(xin)(xin)內(nei)科(ke)(ke)(ke)(ke)(ke)(ke)之間(jian)(jian)的(de)協調(diao)不(bu)力可能(neng)導(dao)致丟失(shi)“戰機(ji)”;三是(shi)“先(xian)收費,后治(zhi)療(liao)”的(de)“規矩”為及(ji)早救(jiu)治(zhi)帶(dai)來了(le)阻(zu)礙;四(si)是(shi)心(xin)(xin)(xin)(xin)內(nei)科(ke)(ke)(ke)(ke)(ke)(ke)與導(dao)管(guan)室之間(jian)(jian)的(de)協調(diao)存在(zai)問題(ti)(ti)。針對這些問題(ti)(ti),廣東(dong)省(sheng)中醫院心(xin)(xin)(xin)(xin)臟中心(xin)(xin)(xin)(xin)與急(ji)(ji)(ji)診(zhen)(zhen)(zhen)科(ke)(ke)(ke)(ke)(ke)(ke)、介入科(ke)(ke)(ke)(ke)(ke)(ke)等相(xiang)關科(ke)(ke)(ke)(ke)(ke)(ke)室合(he)作開(kai)通(tong)(tong)(tong)(tong)急(ji)(ji)(ji)性(xing)心(xin)(xin)(xin)(xin)肌(ji)梗(geng)(geng)(geng)(geng)死(si)“綠(lv)色(se)通(tong)(tong)(tong)(tong)道”,從而實現了(le)心(xin)(xin)(xin)(xin)內(nei)科(ke)(ke)(ke)(ke)(ke)(ke)醫生(sheng)(sheng)24小(xiao)時(shi)“全(quan)天(tian)候”應(ying)診(zhen)(zhen)(zhen);各項(xiang)檢查立即(ji)進行;先(xian)開(kai)通(tong)(tong)(tong)(tong)血管(guan),補(bu)辦其它手續;急(ji)(ji)(ji)診(zhen)(zhen)(zhen)科(ke)(ke)(ke)(ke)(ke)(ke)、心(xin)(xin)(xin)(xin)內(nei)科(ke)(ke)(ke)(ke)(ke)(ke)、放射科(ke)(ke)(ke)(ke)(ke)(ke)協同(tong)作戰。AMI患者就診(zhen)(zhen)(zhen)到球(qiu)囊擴(kuo)張時(shi)間(jian)(jian)(DTB),反映了(le)手術組全(quan)體成(cheng)員的(de)集(ji)體反應(ying)速度和(he)“綠(lv)色(se)通(tong)(tong)(tong)(tong)道”的(de)作用,自開(kai)通(tong)(tong)(tong)(tong)急(ji)(ji)(ji)性(xing)心(xin)(xin)(xin)(xin)梗(geng)(geng)(geng)(geng)“綠(lv)色(se)通(tong)(tong)(tong)(tong)道”以(yi)來,由(you)于各科(ke)(ke)(ke)(ke)(ke)(ke)室急(ji)(ji)(ji)救(jiu)意識不(bu)斷(duan)加強,并(bing)保證了(le)每日有手術組成(cheng)員值班,使得DTB時(shi)間(jian)(jian)由(you)開(kai)通(tong)(tong)(tong)(tong)“綠(lv)色(se)通(tong)(tong)(tong)(tong)道”前的(de)平均(104.85±12.09)分(fen)鐘(zhong)縮短至(75.49±14.05)分(fen)鐘(zhong),取得了(le)顯著成(cheng)效。

急性(xing)(xing)心(xin)(xin)(xin)梗(geng)再(zai)灌(guan)(guan)注治療后,再(zai)灌(guan)(guan)注損傷可引起心(xin)(xin)(xin)肌頓抑和(he)微循環(huan)障礙,心(xin)(xin)(xin)功能(neng)低(di)下,甚至心(xin)(xin)(xin)源性(xing)(xing)休克,中(zhong)(zhong)(zhong)醫(yi)辨(bian)證(zheng)多屬于陽虛痰瘀(yu)阻絡,通(tong)(tong)(tong)過(guo)(guo)益(yi)氣溫陽、化(hua)痰活血中(zhong)(zhong)(zhong)藥的(de)(de)運(yun)用,能(neng)夠防治再(zai)灌(guan)(guan)注治療后的(de)(de)缺(que)血-再(zai)灌(guan)(guan)注損傷,改善心(xin)(xin)(xin)肌微循環(huan)障礙,改善心(xin)(xin)(xin)肌頓抑,促(cu)進(jin)心(xin)(xin)(xin)功能(neng)的(de)(de)恢復,從而減(jian)少患(huan)者住(zhu)(zhu)院(yuan)時間(jian)(jian),降(jiang)低(di)住(zhu)(zhu)院(yuan)費用。通(tong)(tong)(tong)過(guo)(guo)實(shi)施“綠色通(tong)(tong)(tong)道(dao)”和(he)中(zhong)(zhong)(zhong)醫(yi)藥綜合干預,可使行(xing)急診PCI術的(de)(de)急性(xing)(xing)心(xin)(xin)(xin)梗(geng)住(zhu)(zhu)院(yuan)時間(jian)(jian)由11.8天(tian)降(jiang)至7.40天(tian)(P<0.05),住(zhu)(zhu)院(yuan)費用較前也降(jiang)低(di)15%(P<0.05)。國外文獻(xian)報(bao)道(dao)急性(xing)(xing)心(xin)(xin)(xin)肌梗(geng)死行(xing)直接PCI患(huan)者的(de)(de)住(zhu)(zhu)院(yuan)時間(jian)(jian)為8.9天(tian),國內文獻(xian)報(bao)道(dao)平均(jun)時間(jian)(jian)為11.60天(tian),廣東省中(zhong)(zhong)(zhong)醫(yi)院(yuan)行(xing)PCI術的(de)(de)急性(xing)(xing)心(xin)(xin)(xin)梗(geng)患(huan)者住(zhu)(zhu)院(yuan)時間(jian)(jian)低(di)于這(zhe)些文獻(xian)報(bao)道(dao),這(zhe)與術后中(zhong)(zhong)(zhong)醫(yi)藥的(de)(de)辨(bian)證(zheng)運(yun)用密(mi)不可分。

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