孟庆义心血管疾病的活血化淤治疗

1,心血管疾病的活血化瘀治疗,中国人民解放军总医院 解放军医学院 北京301医院 孟庆义,Emergency Department of Chinese PLA General Hospital,2,血压的概念：大动脉的压力,大动脉的压力；小动脉，降压与器官血流,微循环问题；在“血压”这个帽子下,存在许多概念（冰山的一角）;血压是一“表面的，非内在的”，“标的，非本的”，“现象的，非本质性的”概念,3,动脉血压的形成：（一个前提，二个条件）,循环系统内有足够的血液充盈取决于血量和循环系统容量之间的关系 心脏射血 心室每次收缩射出6080 ml血液 外周阻力: 微动脉和小动脉对血流的阻力,4,血压： 物理学四定律,Ohms law:MAP = (heart rate SV SVR) + mRAPSimplified Windkessel model:Compliance = SV/aortic PPMAP = (2/3 DAP) + (1/3 SAP)Laplase Law: P2T/r,收缩压；舒张压，脉压差；心输出量,心率, 全身血管阻力，动脉顺应性,5,1. Ohms公式的意义: MAP = (heart rate SV SVR) + mRAP,SVR is not a measured parameter but is calculated from the measured values of MAP, CO and mRAP.Despite clear limitations in Poiseuilles Law when it is applied to the human circulation, it is generally believed that SVR is inversely proportional to the fourth power of the functional radius of the systemic network (mainly that of the distal resistive arteries). For a given MAP, SVR depends only on the value of CO, regardless of the way in which CO is generated (e.g. low SV/high heart rate or high SV/low heart rate).,6,平均动脉压（MAP)的意义,When MAP falls below the lower limit of autoregulation, regional blood flow becomes linearly dependent on MAP.,7,In some pathological settings, MAP overestimates the true perfusion pressure,because of marked increases in extravascular pressure at the outflow level in specific vascular areas (intracranial hypertension, abdominal compartment syndrome) because of marked increases in systemic venous pressure (right heart failure).,8,MAP:代偿机制受损时,Acute decreases in MAP are counteracted by the sympathetically mediated tachycardia, increases in SV (mediated via positive inotropic effect and veno-constriction) and arterial systemic vasoconstriction. In critically ill patients, especially those with sepsis or who are receiving sedative drugs, these compensatory mechanisms can be either impaired or overwhelmed.,9,2.脉压差(pulse pressure)的意义,Although it remains to be demonstrated, it is widely accepted that peripheral PP at rest depends mainly on SV and arterial stiffness (1/compliance) . In this regard, in older individuals increased arterial stiffness leads to increased PP, and this results in systolic hypertension associated with decreased DAP. On the other hand, in patients with cardiogenic or hypovolaemic shock, decreased SV results in a lower PP.,10,Compliance = SV/aortic PP,The paradoxical finding of a low PP in the elderly and in patients with hypertension or atherosclerosis strongly suggests that SV is markedly low,because arterial stiffness is expected to be increased in these patients.,11,3. 血压指标间的关系MAP = (2/3 DAP) + (1/3 SAP),In clinical practice, differences in mean DAP values are believed to reflect mainly changes in vascular tone, with lower DAP corresponding to decreased vascular tone. As discussed above, and for a given MAP, increased arterial stiffness also tends to be associated with lower DAP (and higher SAP as well). According to the classic MAP empirical formula, and for a given MAP, an increase in arterial stiffness increases SAP twofold more than it decreases DAP. Finally, from a beat-to-beat point of view, prolonged diastolic time is associated with lower DAP and shorter diastolic time with higher DAP.,12,4.Laplace Law,拉普拉斯定律: P2T/r 。 P 代表肺泡回缩力，T代表表面张力，r代表肺泡半径。肺回缩力与表面张力成正比，与肺泡的半径成反比。心室产生的压力取决于心室肌收缩产生的张力.,13,血压的三个主要内涵：,器官血流尤其是重要器官的血流心，脑，肾，和肺，肝压力负荷前负荷后负荷心肌耗氧量：Arnold M, Katz的二重乘积：心率乘收缩压系统匹配左心与右心体循环与肺循环动脉系统与静脉系统,14,“调整血压”只是一种治疗手段，“保护或恢复重要靶器官的功能”，才是“目的”,血压控制概念的内涵：重要器官功能“指向的”治疗Remember to treat patients, not BP numbers.Potent IV agents for the immediate control of elevated blood pressure need to be used cautiously, bearing in mind both the side effects and the hazards of overly rapid control of hypertension. Flanigan JS, et al; Med Clin North Am;2006, 90(3):439-51,15,降压治疗与器官血流,体内每一器官的血流量，取决于主动脉压和中心静脉压之间的压力差，又取决于该器官阻力血管的舒缩状态。 “傻女人给孩子洗澡”的启示,16,含化硝苯地平的启示,Sudden reductions in BP accompanying the administration of nifedipine may precipitate cerebral, renal, and myocardial ischemic events that have been associated with fatal outcomes.JAMA 1996; 276:1328-1331,17,盲目降压与J形曲线,降压治疗过程中血压水平与心血管获益之间存在J形曲线，当血压水平低于某一界值时，患者心血管危险性反而逐渐升高。 Framingham研究、SHEP研究、以及INVEST研究均证实了J形曲线的存在，提示当舒张压水平低于60mmHg左右时患者心脑血管事件危险性逐渐增加。越来越多的学者相信降压过程中的确存在着J形曲线现象。,18,硝普钠剂量依赖性降低脑血流量，增加颅内压。急性心肌梗死早期，冠脉窃血； 产生浓度和时间依赖型毒性。硝酸甘油不是有效的血管扩张药物，只在大剂量时作用于动脉通过降低前负荷和心输出量降压影响肾、脑灌注；,19,2. 体循环与肺循环的匹配,两个泵：左心，右心两个阀门：肺动脉，肺静脉,20,水往低处流肺淤血，肺水肿，肺血肿（CLS)静脉输液速度比总量更重要动脉输液总量比速度更重要,21,肺动脉与静脉的匹配,等比下降心输出量（CO）不变或增加非等比下降心输出量（CO）减少或不变肺动脉高压患者全身应用血管扩张剂引起外周阻力下降,如肺动脉不能同时扩张, 可导致左心回心血流减少。肺静脉高压患者，由于下游存在梗阻，全身应用血管扩张剂可以引起肺动脉扩张导致肺血流量增加和肺水肿。,22,3.肺通气血流比值失调,由慢性肺部疾病或间质性肺部疾病引起的低氧性肺高压患者，慎用血管扩张剂因为血管扩张剂治疗可以引起通气血流比值失调而加重低氧血症。,23,通气血流比值失调在充血性心力衰竭患者，硝普钠，硝酸甘油，和ACEI可抑制因缺氧引起的肺血管收缩,可增加非通气部位的肺组织灌注. Schneeweis A.心血管疾病内科治疗学.人民卫生出版社, 1988,PP34-5.,24,4.影响代谢,副作用的差异扩血管的影响首剂效应戒断综合征继发性耐受代谢的影响应用时间长短的内涵临床应用时间，发明时间,25,5.体液潴留,尼卡地平具有不引起体液潴留和不增加体重的优点。 Nicardipine also appears to be useful as initial monotherapy or in combination with other antihypertensive drugs when used in the treatment of mild to moderate hypertension, and may have some advantages over other vasodilators in this regard in that it may not be as frequently associated with fluid retention or weight gain as other similar drugs. Sorkin EM;Clissold SP; Drugs; 1987;33(4):296-345,26,6.可改善记忆,Hypertension; Dissociation between blood pressure and direct drug effects on CNSCardiovascular Week. Atlanta: Feb 24,2003, pg. 22In conclusion, clonidine induced well-known sedative effects, while nicardipine did not impair CNS activity and may have had some short-term alerting effects in elderly hypertensive patients with memory complaints.,27,博採眾長綜合創造！,中俄法英義籍人士相約以酒來顯示自己民族的文化。中國人拿出釀造精純的茅台。俄國人交出伏特加。法國人的香檳。義大利人亮出葡萄酒。英國人取出威士忌。眾彩紛呈。此時老美不慌不忙將所有的酒都倒出一點兌在一起說：這叫雞尾酒，它體現美國的民族精神。,28,心脉通-活血化瘀 通脉养心,中医认为：高血压主要病机为脏腑、经络、气血、阴阳失调，日久不愈必然有瘀血形成。治疗除调理阴阳气血外，亦重视活血化瘀。高血脂亦属中医瘀症范畴。,心 脉 通 功 效,29,当归 丹参 牛膝 钩藤 决明子,三七 毛冬青 粉葛 槐花 夏枯草,配伍逻辑-君臣佐使,当归丹参三七毛冬青,钩藤,槐花,决明子,牛膝,牛膝,夏枯草,粉葛,功效：活血化瘀，通脉养心，降压降脂,30,30,君药选择,当归,丹参,三七,毛冬青,31,31,臣药选择,牛膝,葛根,32,佐药选择,钩藤,槐花,决明子,夏枯草,33,心脉通胶囊组方合理,方中以善于活血化瘀，善舒冠脉的当归、丹参、三七、毛冬青为君药，直达心包，疏导络脉，舒缓胸痹心痛; 辅以擅逐血气，通利血脉的牛膝，擅解诸痹，除胁痛的粉葛为臣药，君臣配合，使血活气行，血运畅通，宁心安寐； 佐以决明子、夏枯草、槐花、钩藤清热息风，平肝潜阳，解郁降压，宁清窍，祛眩晕。,34,降压、调脂,血黏度 ,调节血脂,纤溶活性 ,血小板聚集率 ,改善血液流变学,心脉通,35,改善血管内皮功能,心脉通,NO、ET、VCAM ,改善流量介导的内皮依赖性舒张功能,减轻组织损伤,注：NO（一氧化氮）、降低ET（内皮素），VCAM（血管细胞黏附分子）,36,心脉通胶囊安全有效降压,广东省人民医院心血管研究所,针对98例-期原发性高血压患者，用药2周后血压明显改善。,治疗前后血压变化比较，P0.05（mmHg）,37,广东省人民医院心血管研究所,临床主要症状比较 P0.05（mmHg）,心脉通胶囊显著改善高血压临床症状,38,心脉通配合类药物治疗高血压,医药前沿，年月,治疗组总有效率为93.9，明显高于对照组的78.8，两组比较差异有统计学意义（P0.05），而且降压效果比较，治疗组