Coronary artery disease is a heart disease caused by coronary atherosclerosis that narrows or spasms the lumen of blood vessels, resulting in myocardial ischemia and hypoxia, while arrhythmias are caused by nutritional disorders and atrophy of myocardial tissue on top of the disease, resulting in fibrous tissue hyperplasia. Arrhythmia can be the first or only symptom of coronary artery disease. Severe arrhythmia can damage the pumping function of heart and even endanger life, which is one of the high-risk types of coronary artery disease. Arrhythmias in coronary artery disease are very common in clinical practice, and can manifest as either tachyarrhythmias (such as premature ventricular beats, ventricular tachycardia, ventricular fibrillation, etc.) or slow arrhythmias (such as bradycardia, atrioventricular block, etc.), which can increase the death rate of patients with coronary artery disease and reduce their quality of life. Although many new antiarrhythmic therapies have emerged in recent years, pharmacotherapy is still the main treatment method. Although chemically synthesized antiarrhythmic drugs can quickly control arrhythmias, long-term use has a serious risk of arrhythmogenesis and increased mortality. Therefore, it is necessary to analyze the current research status of coronary arrhythmias and discuss the strategy of combining Chinese and Western medicine to prevent and treat coronary arrhythmias, so as to better utilize the advantages of combining Chinese and Western medicine.
I. Current status and progress of modern medical research on arrhythmias
1, arrhythmia detection means and basic research has made progress
The application of three-dimensional cardiac marker system and/or intra-cardiac ultrasound and/or magnetic resonance imaging or spiral CT imaging to guide transcatheter ablation in the treatment of large fold tachycardia, atrial fibrillation and organic heart disease combined with ventricular tachycardia has made great progress. In-depth studies of cardiomyocyte ion channels will help to understand the mechanisms of arrhythmogenesis and develop more effective therapeutic drugs.
2. Advances in cardiac electrophysiology and transcatheter ablation for arrhythmias
Transcatheter radiofrequency ablation is a treatment for arrhythmias by introducing radiofrequency current into the heart through a cardiac catheter to ablate localized myocardial cells in specific areas to melt off the foldback loops or eliminate abnormal lesions. This technology was born in the mid-1980s of the 20th century, and was introduced in China in the early 1990s, and is now being performed in all major hospitals across the country, with tens of thousands of cases completed. At present, radiofrequency ablation is technically mature, and the indications have developed from simple paroxysmal supraventricular tachycardia (mainly atrioventricular bypass, atrioventricular node double pathway) to idiopathic ventricular tachycardia, frequent premature ventricular beats, atrial flutter, atrial tachycardia, atrial fibrillation, and so on. The cure rate for paroxysmal supraventricular tachycardia is more than 90%, and the cure rate for ventricular tachycardia is about 50%. Radiofrequency ablation of atrial tachycardia, atrial flutter, and atrial fibrillation is in clinical trials, and in April 2009, the Heart Rhythm Society of America (HRS) and the European Heart Rhythm Society published the first consensus on radiofrequency ablation procedures for ventricular tachycardia, which includes three main aspects.
(1) The range of patients and ventricular tachycardias involved in radiofrequency ablation of ventricular tachycardia.
(2) The technique of radiofrequency ablation of ventricular tachycardia.
(3) Criteria for evaluating ventricular tachycardia radiofrequency ablation procedures.
It is also recommended that.
(1) despite the rapid development of ventricular tachycardia radiofrequency ablation techniques, the first-line therapy for most ventricular tachycardias should be antiarrhythmic drug therapy.
(2) Cardiomyopathy induced by high-frequency ventricular premature contractions is officially listed as an indication for ventricular tachycardia radiofrequency ablation surgery for the first time.
3. The understanding of pacemaker pacing site, mode, and indications has gradually advanced
With the progressive understanding of cardiac pacing, right ventricular apical pacing has been proven to promote the development of heart failure and atrial fibrillation. In order to pursue a more physiologically compatible pacing site, studies such as His bundle pacing and right ventricular outflow tract septal pacing have been conducted at home and abroad, which initially proved that ventricular septal pacing is safe and feasible, but its further efficacy has yet to be confirmed by research. Permanent pacing for the prevention and treatment of AF is a hot topic in the research of AF treatment. The treatment may be achieved by shortening the P-wave time frame and reducing the atrial nonstop dispersion through pacing at different sites. Studies have shown that septal pacing can reduce the frequency of symptomatic atrial tachycardia episodes and prevent the occurrence of AF. the Leclercq study found that dual-site pacing of the right atrium was safe, effective, and well tolerated. mirza et al. and Prakash et al. observed that dual-site pacing prevented the occurrence of AF. However, some studies have shown a gradual increase in the recurrence rate of AF in the long term with these methods, and their long-term efficacy needs to be observed in more studies. Pacing modalities continue to be optimized. In patients with sick sinus node syndrome (SSS), the new pacemaker with managedventricularpacing (MVP) reduces the absolute risk of ventricular asynchronous pacing and persistent AF by 41.8% and the relative risk by 40% compared to those with dual-chamber pacemakers, thus minimizing ventricular pacing. It also established the optimal mode of single-chamber atrial pacemaker-double-chamber atrial sequential pacemaker (AAIR-DDDR) interconversion with MVP, marking a new era of physiological pacing.
In 2007, the European Society of Cardiology (ESC) pacing guidelines included “adenosine sensitive syncope” in the pacing guidelines for reflex syncope.
In 2007, the ESC pacing guidelines included “adenosine sensitive syncope” in the guidelines for the pacing of reflex syncope. Clinical studies in anti-tachyarrhythmia have shown that pacing therapy is effective in preventing tip-twisting ventricular tachycardia (TdP) in patients with long QT syndrome by shortening or eliminating long intervals, and it has been reported that drug-ineffective adrenergic-dependent TdP in infants can be suppressed by rapid atrial pacing. In addition to cardioverter-defibrillator (ICD) therapy, cardiac pacing will become an effective treatment against tachyarrhythmias. Cardiac resynchronization therapy (CRT) is an important tool in the treatment of congestive heart failure, and in 2007 the ESC upgraded patients with chronic heart failure in sinus rhythm, cardiac function class III-IV, and QRS waves ≥120 ms to category I indications for CRT. ICDs are an effective means of preventing sudden cardiac death. In 2007, ESC recommended patients with LVEF ≤ 35% and cardiac function class III-IV as Class I indications for ICD treatment.
4. Progress in safer antithrombotic therapy for atrial fibrillation
The PROTECTAF study is considered a landmark clinical trial. Although numerous studies have shown that warfarin therapy for patients with AF can significantly improve prognosis, its use is low in clinical practice, one of the main reasons being physician and/or patient concerns about the increased risk of bleeding complications with the drug. The PROTECTAF study showed that left-ear occlusion for such patients was no less effective than warfarin in preventing thrombotic events, but significantly reduced the incidence of hemorrhagic stroke. The RE-LY study was designed to evaluate the efficacy and safety of two doses of dabigatran, a new oral direct thrombin inhibitor, in patients with atrial fibrillation and its comparison with warfarin. The results showed that the efficacy of dabigatran (150 mg), a new direct thrombin inhibitor, was superior to warfarin in patients with atrial fibrillation, with similar rates of bleeding complications, thus strongly demonstrating the efficacy and safety of dabigatran and providing a new option for the treatment of patients with atrial fibrillation.
5. Some consensus was achieved in the pharmacological treatment of arrhythmias
(1) Most arrhythmias occur at the basis of some kind of cardiac structural abnormality or cardiac insufficiency, or have abnormal expression of channel genes, and thus basically have a tendency to recur, and only those arrhythmias that cause serious complications or are fatal require treatment.
(2) Artificial pacing, RFCA, ICD/CRT-D, or pharmacotherapy may be used depending on the nature of the arrhythmia, underlying disease, patient status, and desires.
(3) Pharmacological treatment focuses on aborting the acute attack of arrhythmia and applying drugs to assist in the long term to reduce the recurrence of arrhythmia. β-blockers can be applied in the long term to reduce all-cause mortality.
(4) In principle, the choice of drugs is for those with no structural abnormalities of the heart and normal cardiac function, and for those with structural abnormalities of the heart and cardiac insufficiency, amiodarone is safe. However, amiodarone has more extracardiac side effects, so its long-term application is also limited to severe arrhythmias.
(5) The main obstacle of drug treatment is proarrhythmia and aggravation of heart failure. Proarrhythmia susceptibility depends not only on the drug but also on the state of the heart itself; myocardial ischemia, heart failure, electrolyte disorders, and channel abnormalities can increase the sensitivity of antiarrhythmic drugs, therefore, although there are guidelines for arrhythmia treatment and drug application, they should be individualized.
(6) The main manifestations of proarrhythmia, Class IC drugs for causing restless VT, Class III drugs for TdP, digitalis can manifest a variety of arrhythmias, and the patient’s tolerance to the drug should be considered before use.
6. The role of amiodarone in the treatment of antiventricular arrhythmias has been further recognized and emphasized
Ventricular arrhythmias include ventricular tachycardia and ventricular fibrillation. Most tachyarrhythmias and ventricular fibrillation are malignant or fatal ventricular arrhythmias, which are often associated with severe hemodynamic disturbances and can easily lead to sudden death if not treated promptly. Therefore, timely and effective treatment is extremely important, and even every second counts.
The 2006 ACC/AHA/ESC guidelines for the treatment of ventricular arrhythmias and prevention of sudden cardiac death suggest that amiodarone is the most effective antiarrhythmic drug and is widely used. There are two types of recommendations, Class I and Class IIa. Class I recommendations: ① for recurrent polymorphic ventricular tachycardia without QT interval prolongation, a loading dose of amiodarone should be given; ② patients with recurrent or restless ventricular tachycardia due to myocardial ischemia should be given intravenous amiodarone after coronary revascularization and beta-blockers. Class IIa recommendations: ① persistent monomorphic ventricular tachycardia with hemodynamic instability should be treated with amiodarone when resuscitation is unsuccessful and other medications are ineffective; ② recurrent monomorphic ventricular tachycardia associated with coronary artery disease should be treated with intravenous amiodarone; ③ in symptomatic ventricular tachycardia with old infarction and left ventricular insufficiency, the combination of amiodarone and β-blockers can be effective in treating ventricular tachycardia that is ineffective with β-blockers alone; ④ Ventricular tachycardia that should be treated with ICD implantation, and in patients who cannot or refuse to implant an ICD, amiodarone can be used as an alternative treatment.
The main advantages of amiodarone application are.
(1) Treating both the symptoms and the root cause: the causes of many malignant ventricular arrhythmias are related to coronary artery disease, myocardial infarction and heart failure. When amiodarone is applied, it can not only effectively control malignant ventricular arrhythmias and play the role of treating the symptoms, but also have the effects of anti-myocardial ischemia, vasodilatation and improvement of cardiac function, playing the role of treating the root cause of ventricular tachycardia.
(2) The total efficiency of treatment of ventricular tachycardia and ventricular fibrillation is high: In 1995, Scheinman summarized 324 cases of recurrent, hemodynamically unstable ventricular tachycardia and ventricular fibrillation, and the total efficiency of treatment with amiodarone reached 78%. This shows that its effect on the treatment of malignant ventricular arrhythmias is better than other drugs.
(3) Amiodarone has obvious efficacy in both primary and secondary prevention of ventricular tachycardia or ventricular fibrillation. It was effective in reducing mortality in the primary treatment of patients with severe heart failure, with a mortality rate of 33.5% in the amiodarone group (41.6% in the placebo group). Secondary prevention of sudden death survivors with amiodarone resulted in 78% survival compared to 52% survival in the other drug treatment groups. The loading and maintenance doses applied for the treatment of severe ventricular arrhythmias are the same as those for ventricular tachycardia.
Second, the status and progress of modern medical research on the treatment of coronary heart disease
1.On the primary and secondary prevention of coronary heart disease
As the research on the pathophysiological mechanism of coronary heart disease has been intensified, people have moved forward the prevention of coronary heart disease in recent years and strengthened the primary and secondary prevention of coronary heart disease. In the newly revised guidelines, the importance of a healthy lifestyle (smoking cessation, moderate exercise, etc.) has been more emphasized, and stricter control targets have been set for underlying diseases, such as blood pressure levels, glycated hemoglobin and low-density lipoprotein concentrations. Statins are widely used in various types of coronary heart disease due to their effects beyond lipid regulation such as anti-inflammation, plaque stabilization, and inhibition of intimal hyperplasia, and are supported by a large body of evidence-based medical evidence in clinical studies. In addition, the research results of early-onset coronary heart disease susceptibility genes and characteristic inflammatory factors have made the large-scale screening of coronary heart disease susceptibility population possible, which is also conducive to the advancement of coronary heart disease prevention, which is one of the hot spots of research at home and abroad in recent years.
2.Discussion on the treatment strategy of coronary heart disease
With the emergence of a large number of new technical devices, the clinical application of percutaneous coronary intervention (PCI) has been further expanded to complex lesions that used to be considered classic indications for coronary artery bypass grafting (CABG), such as unprotected left main coronary artery (left main) lesions, chronic completely occluded lesions, multi-branch lesions, etc. lesions, etc. At the same time, the pharmacological treatment of coronary artery disease has also made great progress, and the long-term prognosis and quality of survival of patients with coronary artery disease have been greatly improved after further emphasis on antithrombotic, plaque stabilization, improvement of myocardial remodeling and underlying disease treatment. Therefore, to explore the appropriate treatment strategy for specific patient groups has been a hot topic of research in recent years, and many large-sample, multicenter randomized controlled clinical studies with far-reaching impact have emerged as a result. For example, the OAT study compared the long-term efficacy of optimal drug therapy with PCI for opening infarct-related arteries in stable patients after ST-segment elevation myocardial infarction (STEMI); the COURAGE study focused on the superiority of PCI and optimal drug therapy in patients with stable coronary artery disease; the ARTS and ARTS-2 studies compared metal stents (BMS), drug-eluting stents ( The ARTS and ARTS-2 studies compared the efficacy of metallic stents (BMS), drug-eluting stents (DES), and CABG in the treatment of multiple lesions; the SYNTAX study provided further insight into the long-term outcomes of DES versus CABG in patients with multiple lesions, left main lesions, and combined diabetes mellitus. These studies have greatly enriched the evidence-based evidence on various treatment strategies for coronary artery disease and have helped to understand the major benefits and risks of different treatment strategies. In addition, the results of subgroup and multifactorial analyses based on these studies have revealed a large number of risk factors that are closely related to prognosis, providing a theoretical basis for clinicians to effectively avoid risks and make rational individualized treatment decisions. The accumulation of the above clinical evidence has, on the one hand, led to the development and promulgation of applicable standards for coronary revascularization by domestic and international industry associations, further standardizing the indications for PCI and CABG, and on the other hand, promoting the integration of various therapeutic strategies to achieve complementary advantages, such as combining PCI with optimal drug therapy and one-stop revascularization with PCI and CABG, all of which contribute to further enrich the treatment of coronary artery disease and achieve better long-term prognosis and efficacy ratio.
3. Awareness of the long-term efficacy and safety of DES
Questions about the late in-stent thrombosis, noncardiac death, and late catch-up (late restenosis) of DES peaked in 2006 with the publication of BASKET-LATE and some meta-analysis studies, and caused the proportion of clinical use of DES to fall back in response. As a result, a large number of clinical and basic studies on the long-term efficacy and safety of DES have become a hot topic in the field of coronary artery disease treatment. First, the incidence of delayed stent thrombosis and risk factors for DES have been clearly established in published meta-analyses of randomized clinical studies or registry data worldwide. The current findings suggest that the incidence of stent thrombosis after DES ranges from 0.5% to 2.0%, suggesting that there is no significant increase in the incidence of in-stent thrombosis when DES is used within the indications, and that factors such as premature discontinuation of dual antiplatelet agents and nonindicated use of DES may be important causes of late in-stent thrombosis. In view of this, the American Heart Association/American Heart Association (ACC/AHA) and other five major societies issued a consensus on avoiding premature discontinuation of dual antiplatelet therapy after DES, and extending dual antiplatelet therapy after DES to 1 year after surgery has become the current standard for clinical application. Second, a large number of studies have focused on the improvement of the stent platform, coating and drugs of DES to overcome the limitations of the first-generation DES and improve the long-term efficacy and safety of DES from the root, among which the more studied ones include degradable DES, uncoated DES, degradable-coated DES, and endothelial growth-promoting DES, etc. However, there is a lack of sufficient clinical evidence to date to confirm the In China, the research and clinical studies on new DES are also very active, and many kinds of domestic degradable coated DES and uncoated DES have been marketed.
4.Research on antithrombotic treatment of coronary artery disease
Coronary artery atherosclerosis thrombosis is the most dangerous complication of coronary artery disease, and with the continuous development of interventional technology in recent years, the thrombotic complications related to interventional operations are gradually increasing. On the one hand, new antithrombotic drugs and antithrombotic regimens have emerged and accumulated a large amount of clinical evidence, such as the introduction of new antiplatelet agents clopidogrel, cilostazol, prasugrel, ticagrelor, new anticoagulants bivalirudin and vindaparin sodium, and the exploration of their clinical indications. In the treatment of acute coronary syndrome (ACS) and PCI, studies such as CURE and CREDO have established the cornerstone of dual antiplatelet therapy with aspirin and clopidogrel, but there are still many debates on the dose (loading and maintenance doses), duration of therapy, and the combination of other antiplatelet drug regimens. Many studies on triple antiplatelet therapy with aspirin, clopidogrel, and cilostazol have been conducted in Japan, Korea, and China, and the results have shown that the long-term efficacy of triple antiplatelet therapy in high-risk patients is superior to that of conventional dual therapy. On the other hand, recent studies have shown that there are differences in the response to antiplatelet drug therapy in the population, with 25-30% of patients responding poorly to conventional doses of antiplatelet therapy, referred to as antiplatelet resistance, and this group of patients is at significantly higher risk of thrombotic events. In recent years, the diagnostic method of antiplatelet resistance has evolved from a single optical turbidimetric method to rapid bedside diagnostic methods such as thromboelastography, whole blood impedance method and even VerifyNow method, whose practicality, simplicity and reproducibility have been improving, providing convenient conditions for the screening of patients with antiplatelet resistance. On this basis, the screening of susceptibility genes (such as CYP2C19, CYP3A4, etc.), individualized antiplatelet regimen adjustment (such as increasing dose, increasing drugs, alternative drugs, etc.) and its efficacy monitoring have also been developed, which will become the main direction of antithrombotic therapy research for coronary artery disease in the next stage.
5.Research on myocardial regeneration therapy
For patients with acute myocardial infarction or ischemic cardiomyopathy, promoting myocardial regeneration is one of the most effective ways to improve cardiac function. In the past few years, stem cell transplantation has been highly promising, but to date, there is still no consensus on the pathophysiological mechanisms and clinical means to achieve various types of stem cell transplantation. A pooled analysis of the limited clinical studies found that stem cell transplantation has little effect on improving cardiac function. Based on the current findings, the clinical application of stem cell transplantation for myocardial regeneration is still immature, and many questions regarding indications, transplantation time, type and number of transplanted cells, transplantation method, long-term efficacy and safety cannot be answered, therefore, it is necessary to return to the laboratory and concentrate on basic research in order to build up a strong foundation. Finding new seed cells (such as cardiac stem cells, induced multipotential stem cells, minimal embryonic-like stem cells), improving the microenvironment, and increasing the survival rate of stem cells may be the direction of future efforts.
6.Advances in coronary imaging methods
Coronary imaging has made great progress in the past few years. Intravascular ultrasound (IVUS) is not only an important reference value for determining the degree of coronary lesion, whether the plaque is stable, lumen size, and whether intervention is needed, but also a major means for determining whether the stent is well adherent to the wall, the degree of lesion coverage, and whether there is tearing after intervention, and the significance of guidance for PCI is being increasingly emphasized. IVUS is increasingly used in the interventional treatment of adventitial lesions, bifurcation lesions, and chronic completely occluded lesions. In the DES series, IVUS findings are an important basis for studying the long-term efficacy and safety of DES. Intracoronary optical coherence tomography (OCT) is a new high-resolution tomographic imaging modality with good correlation between imaging results and histological structures under light and electron microscopy, which is mainly used to determine the thickness of unstable coronary plaques, especially the fibrous cap, and lipid nuclei, but also to determine thrombotic lesions, intimal tears and the degree of stent apposition after placement, the coverage of the stent exposed to the intima of the vessel lumen and the relationship of the stent wire to the intima. With the increase of scanning speed and the advancement of imaging technology, coronary CT has played an important role in the diagnosis of coronary artery disease in recent years, and as a non-invasive tool, its imaging quality, stability and accuracy are comparable to the gold standard coronary angiography. In addition, further improvement of coronary CT technology in recent years, such as reducing the bulb voltage (from 120V to 100V) and changing the image acquisition mode (spiral to trigger), can reduce the radiation during coronary CT examination by more than 40%, which further improves its application value.
Third, the research status of Chinese medicine to prevent and treat coronary arrhythmias
There is no name of coronary arrhythmia in Chinese medicine, but the symptoms and onset of the disease belong to “chest paralysis”, “palpitation”, “palpitation”, “palpitation”, “palpitation”, “palpitation”, “palpitation”, “palpitation”, “palpitation”, “palpitation”, “palpitation” and “palpitation” in Chinese medicine. However, the symptoms and onset of the disease belong to the categories of “chest paralysis”, “palpitation”, “palpitation”, “palpitation” and “syncope” in Chinese medicine. From most clinical data reports, the diagnosis of coronary arrhythmias in TCM treatment tends to be more and more organic combination of disease identification, type identification and evidence identification, and most data use ECG, dynamic ECG, cardiac electrophysiological examination, and coronary angiography to diagnose coronary arrhythmias, distinguish types, and combine with TCM evidence identification, so that TCM treatment of coronary arrhythmias is gradually standardized.
1.The Chinese medicine etiology and pathogenesis of coronary arrhythmia
The occurrence of coronary heart disease arrhythmia is mostly due to old age and physical weakness, poor diet, emotional and mental disorders, and internal invasion of external evil, resulting in poor operation of the heart and blood, and loss of nourishment of the heart and mind, causing the heart and mind to shake and palpitate. This disease is located in the heart, and its onset is also related to the dysfunction of the liver, spleen and kidney. Zhang Zhongjing pointed out in The Essentials of the Golden Horoscope that the pathological mechanism of this disease is “when the pulse is taken too much and too little, Yang is weak and Yin is string, that is, chest paralysis and pain, so it is because of its extreme deficiency”, which in one word reveals that the pathological mechanism of this disease is based on the deficiency and the standard, and the mixture of deficiency and reality. Professor Deng Tietao’s “phlegm and stasis-related” theory innovatively developed the etiology and pathogenesis of chest paralysis in traditional Chinese medicine, believing that both phlegm and stasis are pathologies of fluid, and that there are similarities between the two: the common origin of phlegm and stasis is dampness, that is, when dampness is a problem, it can cause the body’s qi to become unstable, and dysfunction of fluid distribution, transit, and excretion, leading to The accumulation of fluid, the transformation of dampness into phlegm, the coalescence of turbid phlegm, the poor flow of qi and blood, the astringent seepage of fluid, and the development of blood stasis, so both are pathological products. At the same time, they are both pathogenic factors, with phlegm and stagnant phlegm blocking each other, paralyzing the heart and the chest, resulting in chest paralysis. According to Chen Jinghe, the disease is based on spleen deficiency and is complicated by the real evil and the real evil is mainly caused by the six depressions. Li Shiwen, through years of clinical practice, believes that there are two main causative factors for this disease: one is “deficiency” and the other is “stasis”; for “deficiency”, there is a deficiency of qi, blood, yin and yang, spleen and kidney. The “deficiency” includes deficiency of qi, blood, yin and yang, deficiency of spleen and kidney, mostly heart yang qi deficiency, while “stasis” includes cold, phlegm, qi depression, stasis of blood; in short, the two main factors of the disease are heart yang qi deficiency and paralysis of heart veins. However, China is a vast country with great differences in geography, climate and living customs. In the southern region, rapid arrhythmia is characterized by phlegm, heat, stasis and deficiency, while slow arrhythmia is characterized by deficiency, stasis and phlegm.
2. Chinese medicine classification of coronary arrhythmias
The classification of coronary arrhythmias has not been unified. For example, in 1987, the National Acute Care Society of Traditional Chinese Medicine revised the diagnosis and treatment standard for chest paralysis and heart pain into 6 types of evidence: deficiency of Qi and Yin, deficiency of Heart-Yang, deficiency of Heart-Blood, occlusion of Phlegm, stasis of Heart-Blood and stagnation of Cold-Qi. In 1992, the Collaborative Group of the Medical Secretary of the State Administration of Traditional Chinese Medicine proposed 6 types of evidence: deficiency of Heart-Qi, deficiency of Heart-Yin, deficiency of Heart-Yang, occlusion of Phlegm, stasis of Heart-Blood and stagnation of Cold-Qi. 6 types of evidence. The Guidelines for Clinical Research on New Chinese Medicines classifies the disease into heart-blood stasis, qi deficiency and blood stasis, qi stagnation and blood stasis, phlegm obstruction of heart veins, yin-cold stagnation, qi-yin deficiency, heart-kidney yin deficiency, and yang deficiency. Feng Hengji classified the disease into 5 types: deficiency of heart yang, cold clotting of heart veins, wind-heat occlusion, fire-heat knot, liver qi stagnation, stagnation of heart veins, phlegm-dampness congestion, paralysis of veins and collaterals, and deficiency of spleen and kidney, deficiency of both qi and yin. Zhang Liping divided the disease into 5 types of evidence: Yang deficiency and blood stasis, Qi deficiency and blood stasis, Yin deficiency and blood stasis, heart and blood stasis, and phlegm and blood stasis. Wang Lianshun summarized the experience of Ma Lianzhen’s teacher and divided the disease into 3 types: Yang deficiency and water flooding type, Yin and Yang deficiency type, and Qi stagnation and blood stasis type. Sun Jianzhi classified the disease into 8 types of symptoms: Qi stagnation and blood stasis, p Qi deficiency and blood stasis, p phlegm and blood stasis, p blood deficiency and blood stasis, p liver and gallbladder stagnation, p liver and kidney yin deficiency, p cold condensation and qi stagnation, p death and Yang desires to be removed.
3.Research on the treatment of arrhythmia in coronary heart disease
(1) Activating blood and resolving blood stasis method: An important clinical feature of coronary heart disease angina pectoris is fixed pain in the posterior sternum or precordial region, combined with a purple and dull tongue, which is a manifestation of blood stasis in Chinese medicine. This is a manifestation of blood stasis in Chinese medicine. Activating blood and resolving blood stasis is designed for this identification. Modern research suggests that the action of blood-stasis activating drugs is directed at blood, mainly by inhibiting platelet function, preventing arterial thrombosis, inhibiting blood coagulation, preventing venous thrombosis, enhancing fibrinolytic activity, and promoting thrombus dissolution. For cardiovascular is through improving blood circulation, increasing blood supply to tissues, reducing myocardial oxygen consumption, increasing metabolism, lowering blood lipids, reducing atherosclerosis, and achieving the purpose of treating angina pectoris of coronary heart disease. These effects are well targeted to coronary heart disease blood stasis evidence, and the application of blood-activating and stasis-transforming drugs to treat coronary heart disease blood stasis evidence is consistent with both TCM theory and modern medicine. The mechanism of action involves regulation of dyslipidemia (lowering total serum cholesterol and LDL-C), inhibition of platelet adhesion, and inhibition of VSMC proliferation and migration through gene regulation, etc. Blood-flow and blood-stasis-removing agents can significantly reduce the intimal plaque area as well as its ratio to intima-media area and the incidence of coronary lesions in experimental AS rabbits.
(2) The method of dispelling phlegm through Yang: phlegm is mostly caused by the lack of Yang in the upper jiao chest, the lack of Yang in the heart and lungs, and the lack of distribution of fluids and fluids, resulting in the internal growth of phlegm, blocking the chest and stagnating the heart veins. It is especially common in obese people with phlegm-damp body. Total cholesterol and triglycerides are often significantly higher in patients with this condition than in those with non-phlegm-damp conditions. The treatment is to clear Yang and drain turbidity, expel phlegm and subdue rebellion. This formula is based on the formula of Gua Gua Bai Bai Han Xia Tang (Gua Gua Bai, Allium, Han Xia, white wine) with reduction. In this formula, Gua Gua expels phlegm and disperses knots to open the chest, while Allium sativum warms and smooths, passes Yang and moves Qi to relieve pain. Radix Panax notoginseng, Yunling, Zhu Ru, Citrus aurantium and Chen Pi dry dampness and move Qi, resolve phlegm and subdue rebellion. Danshen and Angelica sinensis resolve blood stasis and open the channels, while Baijiu warms Yang and lightens and leads the medicine upward. It strengthens the effect of warming Yang, dispelling blood stasis and moving Qi to relieve pain. Modern pharmacology believes that Salvia miltiorrhiza and Angelica sinensis have the effect of increasing coronary blood flow and improving myocardial contractility.
(3) Benefit Qi, warm Yang and invigorate Blood: Heart Yang deficiency, Yang does not control Yin, Yin cold is generated internally; or Heart Qi is internally deficient, and externally feel the evil of Yin and cold, cold is the main attraction, the veins are constricted, blood clotting and stasis, the heart veins are astringent and do not work, the development of this evidence. It is the main type of spontaneous angina pectoris and worsening exertional angina pectoris, with severe pain, often requiring nitroglycerin, and easily evolving into myocardial infarction. The treatment is to dispel cold and invigorate blood, and to promote paralysis through Yang. Guadua, Allium, Gui Zhi and Hsio Xin are used to broaden the chest, dissolve phlegm and disperse nodules, warm the heart yang, dispel cold and relieve pain, while Radix Angelicae Sinensis and Radix Paeoniae Alba are used to nourish the Blood and invigorate it, slow down the pain. The combination of these drugs can benefit the Qi and warm the Yang to supplement the deficiency of the root, and regulate the Qi, invigorate the Blood, dissolve the phlegm, broaden the chest and disperse the knots to dispel the symptoms of the evil, so that the symptoms of angina can be cured. Modern pharmacological research has proved that Allium, Sinensis and Angelica can inhibit platelet adhesion and aggregation, regulate the balance of plasma thromboxane A2. and prostaglandin I2 (TXA2/PGI2), prevent thrombosis, release coronary artery spasm, slow down heart rate, and increase myocardial tolerance to hypoxia.
(4) Benefit qi and activate blood method: Qi deficiency in coronary heart disease is mostly seen in heart qi deficiency, and the main changes of qi deficiency type are in hemodynamic aspects. Modern pharmacological research shows that qi-enhancing drugs can strengthen myocardial contractility and correct cardiac insufficiency, while it can dilate coronary arteries, increase coronary blood flow and reduce myocardial oxygen consumption, so the application of qi-enhancing drugs in coronary heart disease has good relevance to its pathophysiology. However, modern medicine also believes that the pathogenesis of coronary heart disease is closely related to platelet function, and abnormal platelet function is one of the essential changes of blood stasis, so coronary heart disease mostly has changes of blood stasis, and there are few clinical cases of pure qi deficiency, and many qi deficiency and blood stasis are present at the same time. Qi deficiency and blood stasis is the basic type of coronary heart disease, so the clinical method is mostly used to benefit Qi and invigorate blood.
(5) Benefit qi and nourish yin method: coronary heart disease mostly develops in middle-aged and elderly people, and the duration of the disease is long, often manifesting as deficiency of both qi and yin, with blood stasis. Therefore, it should mainly benefit qi and nourish yin, taking into account the activation of blood. If the emphasis is on invigorating blood and removing blood stasis while ignoring the fact of deficiency, the cart will be put before the horse and the efficacy will be affected. Benefiting qi and nourishing yin aims to treat the root cause. Modern medicine confirms that patients with coronary artery disease have obvious blood rheological changes, which can lead to microcirculatory abnormalities and cause the occurrence of angina pectoris, while the increase in whole blood viscosity is the main factor aggravating coronary artery disease. Pharmacological experiments proved that Astragalus has the effect of strengthening heart contraction, reducing myocardial oxygen consumption, eliminating free radicals and improving microcirculation; certain components of Schisandra have antioxidant effects; ginseng can increase blood flow to the brain and internal organs. Experimental studies have shown that this formula has the effect of elevating blood pressure and strengthening heart, which can enhance the contraction of myocardium and improve the effect of coronary circulation. Therefore, the mechanism of Shengwen San in treating angina pectoris in coronary heart disease is related to its effect of improving microcirculation. Shengwen San is a representative formula of the method of benefiting Qi and nourishing Yin, and the method of benefiting Qi and nourishing Yin is an effective method for treating angina pectoris in coronary heart disease.
(6) Clear the heart and calm the mind method: Coronary heart disease belongs to the category of chest paralysis and heart pain disease in Chinese medicine, mostly caused by evil paralysis of the heart and ligaments and poor circulation of qi and blood, and the evidence is mostly deficient and real. Premature ventricular contraction belongs to the category of heart palpitations in TCM, which is mostly caused by heart displacement or disturbance of the heart and mind resulting in abnormal heartbeat, with evidence of heart deficiency and timidity, heart and spleen deficiency, yin deficiency and fire, and heart blood stasis. From our clinical observation, premature ventricular contractions in middle-aged and old-aged coronary heart disease have the pathological characteristics of mixed deficiency and reality, mixed cold and heat, and long duration of disease. Heart blood stasis and phlegm obstruction can interact with each other to form the evidence of phlegm-stasis interconnection, which is the most common type of premature ventricular contraction in coronary heart disease. Among the 164 cases we observed, 73.17% of the cases were mixed with deficiency and real, with real as the main cause (phlegm and blood stasis, Yin deficiency and fire), and 26.83% were deficiency as the main cause (Qi deficiency and blood stasis, heart deficiency and timidity). The latter were predominantly over 70 years old.
Phlegm and stagnation can turn into heat and consume qi in the long run, resulting in heart deficiency and timidity, and yin deficiency and fire. The deficiency of qi leads to blood stasis and phlegm obstruction, while the deficiency of yin leads to internal heat and fire, disturbing the heart and mind, resulting in heart movement and palpitation. Therefore, in the treatment of ventricular premature beats in middle-aged and old-aged coronary artery disease, we seized the four pathological characteristics of phlegm, stasis, heat and deficiency and composed a formula to clear the heart and calm the mind, with bitter ginseng and Huang Lian, which enter the heart and liver meridians, as the main herbs to clear heat and remove fire and calm the mind; with sour date palm, Fu Ling, Radix Codonopsis and Ganoderma lucidum as supplementary herbs to benefit the qi and calm the mind; with Salvia miltiorrhiza, Panax ginseng, Radix Paeonia lactiflora and Psidium guajava as adjuvant herbs to remove stasis and resolve phlegm. The combination of all the herbs together can clear the heart and tranquilize the mind. The results of the above clinical treatment showed that the efficacy of the observation group was significantly higher than that of the control group. And it can significantly improve the clinical symptoms such as chest tightness and chest pain, palpitation, dizziness, weakness, nausea, heart trouble, insomnia, abdominal distension and constipation in middle-aged and old patients with ventricular premature beats of coronary heart disease, and can better reduce blood lipids, blood pressure and improve microcirculation. It shows that the method of clearing the heart and calming the mind can better play a comprehensive treatment role for ventricular premature beats in middle-aged and old-aged coronary heart disease.
(7) Other treatments: Xu Wenge et al. treated 36 cases of slow arrhythmias, including 24 cases of coronary heart disease, from the kidney theory, with the group formula of Radix et Rhizoma Pseudostellariae, Xian Ling Spleen, Gui Zhi, Astragalus, Ginseng, Hossein, Chuan Xiong, Dan Shen, Mai Dong and Wu Wei Zi, resulting in a total effective rate of 97.2%. Hua Mingzhen believed that the arrhythmia of coronary heart disease is a disease of deficiency of the root and the symptoms of the symptoms of the disease, so the treatment emphasizes tonifying the kidney and activating the blood. Lin Huijuan et al. treated 100 cases of tachyarrhythmia with Heart Disease Ning Capsules (Sheng Di Huang, Angelica Sinensis, Huang Lian, Zhi Mu, Sour Jujube), which nourishes Yin and nourishes blood and calms fire, including 56 cases of coronary heart disease, and the results showed that the effective rate was 81% and the symptom effective rate was 96%, which were very significantly different from the control group (P < 0.05); 56 cases in the treatment group and 48 cases in the control group showed effect at different times (immediately, 30 minutes, 24 hours). The number of effective cases was 21, 15, 20 and 0, 20, 28 in 56 cases in the treatment group and 48 cases in the control group at different times (immediately, 30 minutes, 24 hours later), respectively, with significant differences between the two groups.