Research On Relevance Of Thenar Eminence Representation And Syndrome Elements Of Traditional Chinese Medicine Of Patients With Coronary Heart Disease Based On Cornary Computed Tomography Angiography

Looking,listening&smelling,asking and feeling the pulse are the methods of diagnosing diseases in Traditional Chinese Medicine(TCM),and the looking is the most important means.The changes in the corresponding internal organs can be inferred through looking and the syndrome elements can be refined so as to realize the clinical diagnosis and treatment guided by the combination of disease and syndrome through the observation of the external symptoms,physical signs and other pathological phenomena."LingShu" has lots of records on the collaterals of heart meridian of hand Shaoyin,pericardium meridian of Jueyin and lung meridian of Taiyin directly passing through thenar.Thenar is closely related to cardiopulmonary function.The heart governs blood&vessel and the lung governs Qi of the whole body which assists the heart in the circulation of blood.Disfunction of heart and lung leads to disorder of Qi and blood,which results in blood stasis and stenosis in heart vessels,and their external expressions can be reflected on the thenar through meridians.The tutor puts forward three dimensions of thenar inspection method through clinical practice for thirty years:The abnormal changes of thenar color,muscle,dermatoglyphics and subcutaneous vessels are closely related to coronary heart disease(CHD)and its syndrome elements,which can guide TCM differentiation of CHD and clinical medication.At present,there is lack of classification standard for the representation of thenar and relevance of thenar eminence representation and syndrome elements of CHD.This study aims to explore the relationship between the representation of thenar and CHD based on classification standard so as to clarify its value in evaluating CHD.Then we analyze the relevance of thenar representation and syndrome elements of CHD which provides evidence for he representation of thenar on assisting TCM syndrome differentiation of CHD.I ObjectiveTo explore the relevance between thenar representation and CHD and its syndrome elements,which provides not only scientific basis for TCM syndrome identification of CHD but evidence for the representation of thenar on assisting TCM syndrome differentiation of CHD.Ⅱ Methods1.Literature analysis on quantification of the representation of thenarUsing field search of "title or key words","Dayuji" or "Yuji" in Chinese National Knowledge Infrastructure(CNKI),Wanfang data(WANFANG)and VIP database(VIP),and "thenar"or "thenar eminence" in English on PubMed database,to analyze the related literature of quantification of thenar representation so as to understand the key operating methods of inspection of thenar representation and current status of research norms of the quantification of thenar representation.2.Expert questionnaire survey on the inspection classification of the representation of thenarFormulate the expert questionnaire of "Inspection classification of thenar representation" according to literature analysis results.Conduct expert questionnaire,using Delphi methods in two rounds,for the normal form and regional definition of thenar,abnormal representation(Color,wrinkles,thenar muscular hypertrophy/flat/concave,green tendon of thenar/thumb root)and classification.Select experts from the field of cardiovascular,with the title of deputy director or above and a certain knowledge of thenar inspection,and 30 experts were invited each round.Reliability and validity of the questionnaire were evaluated by Cronbach a coefficient and construct validity.The positive coefficient of experts for participating in the survey was evaluated by the positive coefficient.Authority degree of experts,concentration degree of opinions and consensus of opinions were evaluated by authority coefficient,mean number of consent degree,cumulative percentage of consent degree and evaluation of variation coefficient respectively.Finally form the expert consensus according to mean number of consent degree>4 and variation coefficient<0.25.3.Relevance of thenar eminence representation and syndrome elements of TCM of patients with CHDAdopt case-control study design,collect the 500 patients checked by Outpatient Department of Radiology of Guang’anmen Hospital of China Academy of Chinese Medical Sciences.Divide the patients into no stenosis group,non-obstructive coronary stenosis group(stenosis<50%),coronary heart disease group(obstructive stenosis,stenosis)50%)according to coronary CTA results.Collect patient demographic data(gender,age,education,occupation,BMI,central obesity),personal life history(smoking,drinking and sleeping situation),past medical history(hypertension,diabetes,hyperlipidemia,hyperuricemia),family history of cardiovascular history of first degree relatives,representations of thenar of two hands(shape,color,wrinkle,green tendon of thenar/thumb root),Frank’s sign,nasal fold sign,tongue manifestation(tongue body.tongue color,tongue coating,sublingual collaterals),syndrome elements of TCM(phlegm turbidity,stasis of blood,Qi stagnation,cold coagulation,blood deficiency,Qi deficiency,Yin deficiency and Yang deficiency).And conduct descriptive analysis among three groups.To judge the thenar representation under the circumstance of left hand,right hand and both hands respectively and consider other factors comprehensively(gender,age,BMI,occupation,smoking,drinking,previous disease,family history,chief complaint).After selecting P<0.2,frequency ratio>15%,exclude collinear variables,the rest variables shall be added into the available analysis variables.Preliminarily screen out the abnormal representation of thenar and other related factors,which are possibly related to non-obstructive coronary stenosis and coronary heart disease according to univariate logistic regression,random Sen data and other statistics and data mining methods.Adopt Logistic regression analysis with multi-class classification(order,disorder)and multiple factors,analyze and determine abnormal representation of thenar used to evaluate classification value of non-obstructive stenosis,coronary heart disease,and analyze relationship between abnormal representation of thenar in CHD group and the number of coronary lesions.Adopt the goodness of fit test,parallelism test to evaluate the classification effect of multivariate logistic regression model.Adopt the association rule data mining based on Apriori algorithm to set minimum threshold support degree>20%,confidence level>40%,lifting degree>1.Find the rules,integrate support and confidence of abnormal representation of thenar and phlegm turbidity,stasis of blood,Qi stagnation,cold coagulation,Qi deficiency,Yin deficiency,Yang deficiency and blood deficiency to extract the effective rule between abnormal representation of thenar and syndrome elements of CHD group,non-obstructive coronary stenosis group.Ⅲ.Research results1.Literature analysis on quantification of the representation of thenarImage collection and artificial observation are the common methods of classification standard for thenar representation,which belong to semi quantitative research.The research indicator of CHD and thenar representation is single with small sample size and different judgement standard of abnormal representation of thenar,so it is necessary to establish the classification specification for the representation of thenar.2.Expert questionnaire survey on the inspection classification of the representation of thenarThe experts came from related fields of 10 top three hospitals and scientific research institutes in 5 provinces and cities with good regional representation.representation classification expert questionnaire of thenar of CHD has good structural validity with 0.966 of Cronbacha coefficient and good reliability.There were 30 questionnaires distributed in each round and the 29 and 28 valid questionnaires were collected respectively and the two rounds of expert positive coefficients are 96.67%and 93.33%respectively,which reflected the high participation degree of experts in the research.The two rounds of expert authority coefficients were 0.80%and 0.86%respectively,which could reflect the good authority of this investigation.Experts’agreement on each item of the questionnairex>4 with the cumulative percentage of consent degrees>90%and good concentration of expert opinions.The CV of each item in two rounds of questionnaires were<0.25 and the Kendall’s W coefficients were 0.419 and 0.536 respectively,which reflected the good consistency,small variation and reliable investigation results of two rounds of expert opinions.Determine the normal forms of thenar through questionnaire investigation.The abnormal representation of thenar can be shown by the three aspects of color,musculocutaneous lines,subcutaneous blood vessels.The abnormal colors of the thenar included red,yellow,blue and white.The abnormal skin pattern of the thenar was skin wrinkles seen by eyes.The abnormal forms of thenar muscle were fat,flat and sunken.The abnormal subcutaneous vascular of the thenar was the green tendon of thenar and thumb root seen by eyes.Classification of thenar abnormal representation:①Morphology of thenar muscle:Classification judgement of thenar hypertrophy was according to the distance reduction level classification of the curve of thenar muscle and thenar with the hypertrophic:levelⅠ—distance reduced to 1cm-0.5cm,Level Ⅱ—distance reduced to 0.5cm,Level Ⅲ—muscle plumpness of thenar colliculus to or beyond thenar curve;Judgement of the flat classification of thenar was according to the reference of palm and small thenar level:Level Ⅰ—palmar level≤thenar level≤small thenar level,Level Ⅱ—thenar level=palmar level,Level Ⅲ thenar level<palmar level;Judgement of the sunken classification of thenar was according to the reference of normal thenar colliculus:Level Ⅰ—slight depression of thenar muscle,which is still the most convex part of palm,Level Ⅱ—thenar muscle depression deepens,which is not the highest point of palm,Level Ⅲ—thenar depression is basin like.② Thenar fold:Wrinkle quantity classification level Ⅰ≤lpeice,1 piece<level Ⅱ≤3 pieces,Level Ⅲ>3 pieces;Wrinkle depth classification:Level I<0.5mm,0.5mm≤level Ⅱ<1mm,Level Ⅲ≥1mm.③Green tendon of thenar:classification of green gluten in thenar<1mm、≥1mm;Length classification:Length classification level Ⅰ≤3cm,3cm<level Ⅱ≤6cm,level>6cm.④The thickness of green tendon at the root of thumb is<1mm&≥1mm,the length is<1cm&≥1cm.3.Relevance of thenar eminence representation and syndrome elements of TCM of Patients with CHD1)This research had 500 patient cases with the elimination of 14 cases so the final patient cases were 486,in which 285 males(58.6%)and 201 women(41.4%)with the age of 51.76±6.72 years old.78 patients’education level were(16.8%)under junior middle school,197 patients’ education level were(40.5%)high school and technical secondary school,and 207 patients’ education level was(42.6%)above junior college The types of occupation were 280 mental workers(57.6%)and 106 manual workers(21.8%),both 72(14.8%),either 28(5.8%).The distribution of syndrome factors in patients:426 phlegm turbidity cases(87.8%),442 stasis of blood cases(98.4%),8 Qi stagnation cases(1.6%),1 cold coagulation cases(0.2%),2 blood deficiency cases(0.4%),275 Qi deficiency cases(56.6%),358 Yin deficiency cases(73.7%)and 192 Yang deficiency cases(39.5%).There were 196 cases without stenosis,132 cases with non-obstructive stenosis of coronary artery and 158 cases with CHD.2)Relevance of thenar representation and non-obstructive coronary stenosis&coronary heart disease:The thenar fold had relevance to non-obstructive coronary stenosis(P<0.05);The red thenar and green tendon of thumb root had relevance to CHD.The incidence of non-obstructive stenosis increased 1.714 times for patients with"thenar fold"(OR=1.714,95%CI:1.02～2.881,P<0.05)compared to no stenosis group.The risk of CHD increased 1.884 times for the patients with "red thenar"(OR=1.884,95%CI:1.089～3.258,P<0.05)compared to no stenosis group.The risk of CHD increased 1.885 times for the patients with "green tendon of thumb root"(OR=1.885,95%CI:1.045～3.291,P<0.05).The risk of coronary heart disease increased 1.884 times for the patients with "green tendon of thumb root"(OR=1.884,95%CI:1.024～3.321,P<0.05)compared to non-obstructive stenosis group3)Relevance of red thenar&green tendon of thumb root and number of coronary lesions.In CHD group,the ratio of patients with thumb root green tendons to those without thumb root tendons increased by 2.583 times(OR=2.583,95%CI:1.106-6.576,P<0.05)and there was no obvious significant correlation between the red thenar and number of coronary lesions.4)The distribution of main syndrome factors in patients with non-obstructive stenosis:122 stasis of blood cases(92.4%),119 phlegm turbidity cases(90.2%),85 Qi deficiency cases(64.4%),90 Yin deficiency cases(68.2%)and 43 Yang deficiency cases(32.6%).The distribution of main syndrome factors in patients with CHD:153 stasis of blood cases(96.8%),153 phlegm turbidity cases(96.8%),92 Qi deficiency cases(58.2%),119 Yin deficiency cases(75.3%)and 57 Yang deficiency cases(36.1%).Association rule analysis results showed that the thenar fold in patients with non obstructive stenosis was related to the syndrome element of "Qi deficiency" and "stasis of blood"(support degree:43.20%,confidence degree:74.03,improvement degree:1.007).The red thenar was related to the "stasis of blood"(support degree:41.77%,confidence degree:43.14,improvement degree:1.007,improvement degree:1.08),"phlegm turbidity and Yin deficiency"(support degree:33.54%,confidence degree:44.83,improvement degree:1.062)in CHD group.The green tendon of thumb root in CHD group was related to the syndrome element of "phlegm turbidity and stasis of blood"(support degree:79.11%,confidence degree:83.89,improvement degree:1.0196).Ⅳ Conclusion1.The establishment of the classification standard for the representation of the thenar lays a foundation for the exploration of relationship between representation of thenar and CHD.2.The thenar fold is the characterization of Qi deficiency and stasis of blood of non-obstructive coronary stenosis group.The red thenar and green tendon of thumb root are the characterization of CHD group with blood stasis and phlegm turbidity and the red thenar is also the characterization of Yin deficiency.The green tendon of thumb root also reflects the multi-vessel disease of CHD,which has more effective reference value compared to Frank’s sign.V Innovation1)First to formulate the classification standard for the representation of the thenar and conduct three level division quantification method for abnormal representation of thenar representation(shape,wrinkle,green tendon).2)Under the guidance of Image Thinking,adopt three dimensions of thenar inspection method.First to find out the relevant abnormal thenar representation of non-obstructive coronary stenosis and CHD.Clarify the value of abnormal thenar representation in evaluating non-obstructive coronary stenosis and CHD.Then we discover the relevance of thenar representation and syndrome elements of CHD,which provides evidence for thenar representation on assisting TCM syndrome differentiation of CHD.