Dynamic Changes Of TCM Syndrome Elements And Interventional Mechanisms Of Chinese Herbs For Nourishing Qi And Activating Blood Circulation On Acute Coronary Syndrome

1 Objectives1.1 To study distribution of TCM syndrome elements in patients with acute coronary syndromes (ACS) before percutaneous coronary intervention (PCI), and to explore the correlation of ACS risk stratification and TCM syndrome elements, so as to provide the clinical basis for early prevention and intervention of Chinese medicine from adverse outcome of ACS patients.1.2 To observe dynamic changes of TCM syndrome elements in ACS patients after PCI, and effect of Chinese herbs for nourishing qi and activating blood circulation (NQABC) on evolution of TCM syndrome element, so as to provide scientific basis for treatment of Chinese medicine.1.3 From aspects of toll-like receptor (TLR)2,4 and downstream pro-inflammatory cytokines, to observe mechanisms of Chinese herbs of NQABC combined with ischemic postconditioning (IPoC) on rat model of reperfusion injury after acute myocardial infarction, so as to provide experimental evidence for early prevention and treatment of Chinese medicine from reperfusion injury of acute myocardial infarction after revascularization.2 Methods2.1 Clinical investigation of syndrome element regularityThis study is a prospective, randomized, controlled multicenter clinical trial, the 241 qualified ACS patients after PCI from six tertiary hospitals were randomly divided into NQABC intervention group and control group. The control group was treated by western medicine standardized therapy, and NQABC intervention group was treated by Chinese herbs of NQABC on the basis of western medicine standardized therapy, and then to follow up these ACS patients after PCI at four time points, which were respectively before enrolled into group and the 3rd,6th,12th month after enrolled into group. Detailed methods as follows:(1) By cross-sectional research method, to analyze general information of 241 ACS patients through frequency analysis, and to assess the prognosis of these patients through global registry of acute coronary event (GRACE) risk score. Based on the result of GRACE risk score, we assessed the distribution of TCM syndrome elements in ACS high-risk patients through multifactor dimensionality reduction (MDR) and Logistic regression analysis method.(2) By prospective research method, to investigate the four diagnostic information of ACS patients at different time points of 3rd,6th,12th after PCI, and to summarize the main TCM syndrome elements at each time point. At the same time, to observe the dynamic changes of TCM syndrome elements in ACS patients after PCI, and effect of Chinese herbs of NQABC on evolution of TCM syndrome elements. 2.2 Animal experiment researchTo established rat model of acute myocardial infarction reperfusion injury, SD rats were randomly divided into sham group, ischemic reperfusion group, IPoC group, NQABC+IPoC group and fosinopril sodium+IPoC group. By the changes of serum myocardial injury markers, myocardial infarction size, macropathology and ultrastructure changes, to observe the influence of Chinese herbs of NQABC combined with IPoC on rat myocardium with reperfusion injury, and to explore its possible mechanism from aspects of TLR2,4 and its downstream pro-inflammatory cytokines interleukin-1β(IL-1β), interleukin-6 (IL-6), tumor necrosis factor-a (TNF-a) and monocyte chemotactic protein-1 (MCP-1).3 Results3.1 Clinical investigation of syndrome element regularity3.1.1 Cross-sectional analytic results3.1.1.1 The main TCM syndrome elements and combination of syndrome elements in ACS patientsThe proportion of 7 TCM syndrome elements in ACS patients in order from high to low are blood stasis (88.4%)>qi deficiency (62.2%)>yin deficiency (32.8%)> turbid phlegm tending toward cold (20.3%)>turbid phlegm tending toward heat (12.0%)>yang deficiency (8.7%)>qi stagnation (0.8%), the results showed that blood stasis and qi deficiency are main syndrome elements of ACS patients. In the specific TCM syndromes, the proportion of combination of 2 syndrome elements blood stasis+qi deficiency was the highest, accounting for 32.0%, and the second is combination of 3 syndrome elements qi deficiency+yin deficiency+blood stasis, accounted for 11.6%, the two combinations accounted for 43.6% in 241 ACS patients. The proportion of combinations of syndrome elements which include root vacuity and tip repletion accounted for 86.4%, which demonstrated that the syndrome features of ACS patients are root vacuity and tip repletion and deficiency complicated with excess.3.1.1.2 The distribution of TCM syndrome elements in ACS high-risk patients241 ACS patients were evaluated by GRACE risk score, and 21 patients were high-risk,220 patients were low-risk and mediate-risk. Based on the results of GRACE risk score, the analytic results of MDR and Logistic regression analysis method demonstrated that the adverse outcomes of the patients with blood stasis, turbid phlegm tending toward cold and yang deficiency were 7.17 times as much as that of the patients without blood stasis, turbid phlegm tending toward cold and yang deficiency, so probability of all-cause death in the ACS patients with blood stasis, turbid phlegm tending toward cold and yang deficiency during six months were higher than that of the patients without blood stasis, turbid phlegm tending toward cold and yang deficiency.3.1.2 Prospective analytic results3.1.2.1 The natural dynamic changes of TCM syndrome elements and their combinations in ACS patients after PCIACS patients in the control group were treated by western medicine standardized therapy method, blood stasis and turbid phlegm tending toward heat reduced significantly after PCI, qi deficiency and yang deficiency increased gradually, the proportion of qi deficiency and yang deficiency increased significantly at the 12th month, accounted for 63.8%, at the same time blood stasis decreased somewhat, but still accounted for a large proportion, which demonstrated that the feature of ACS patients in the later period after PCI was that deficiency syndrome is primary and repletion pattern is subordinate.The combinations of TCM syndrome elements before and after PCI also had a significant change, the main combinations of TCM syndrome elements before PCI was compound syndrome elements, the proportion of combination of 2 syndrome elements or more accounted for 86%. With the extension of revascularization time, the type of more combinations of syndrome elements turned to the type of less combinations of syndrome elements, the proportion of 1 syndrome element or less accounted for 54.2% at the 12th month, blood stasis and yang deficiency were main syndrome elements in the 1 syndrome element, which showed the feature of root deficiency syndrome.3.1.2.2 The dynamic changes of TCM syndrome elements and their combinations in ACS patients taking Chinese herbs after PCIOn the basis of western medicine stantardized therapy, the proportion of the TCM syndrome elements blood stasis, qi deficiency, yin deficiency and yang deficiency in NQABC intervention group had different downward trends in four time points, particularly downward trends of blood stasis and yin deficiency were larger, the proportion of turbid phlegm tending toward heat also had a downward trend at the 3rd after enrolled into group, but had not significant downward trend at the 6th and the 12th. The proportion of turbid phlegm tending toward heat in the whole course of disease had not significant change, which demonstrated that the effect of Chinese herbs of NQABC on turbid phlegm is ineffective.About the combinations of TCM syndrome elements, both the combination of 2 syndrome elements and the combination of 3 syndrome elements reduced significantly at the 3rd month after enrolled into group, while 0 syndrome element and 1 syndrome element increased significantly at the 3rd month after enrolled into group. At 12th month, symptoms as well as tongue and pulse presentations in 49 patient were improved, accounted for 45.8% in NQABC intervention group, the 1 syndrome element and the combination of 2 syndrome elements accounted for 31.8% and 16.8% respectively, the combination of 3 syndrome elements and the combination of 4 syndrome elements were rare. These results demonstrated that the evolutional time from more combinations of syndrome elements to less combinations of syndrome elements in NQABC intervention group is shorter than that of control group, and the ACS patients taking Chinese herbs of NQABC has the trend to good prognosis.3.1.2.3 The comparison of TCM syndrome elements in NQABC intervention group and control group at different time pointsEach syndrome element between two groups was compared at the 3rd,6th,12th month. The results show that the proportions of blood stasis, qi deficiency and yang deficiency were lower significantly in the NQABC intervention group than that of control group at the 3rd,6th month, the difference had statistical significance (P<0.05, P<0.01), but the turbid phlegm between two groups had not different significantly. At the 12th month, the proportions of blood stasis and yang deficiency were lower significantly in the NQABC intervention group than that of control group, the difference had statistical significance (P<0.01), but qi deficiency between two groups had not different significantly, which related to the intervention time of NQABC Chinese herbs. In addition,16 cases in 241 ACS patients had cardiovascular events, and there were 12 cases in the control group and 4 cases in the NQABC intervention group, the result of chi square test showed that the difference between two groups has statistical significance (χ2=4.137, P<0.05).3.2 Animal experiment research3.2.1 The effects of Chinese herbs of NQABC combined with IPoC protecting rat myocardium with reperfusion injury.Compared with IPoC group, NQABC plus IPoC further reduced infarction size and release of myocardial enzyme CK-MB (P<0.01), the content of serum cTNT was also lower in the NQABC+IPoC group than that of IPoC group, but the difference between two groups had not statistical significance. The results of macropathology and transmission electron microscope observations in the NQABC+IPoC group showed that there were not significant intracellular edema, myocardial fiber arrangement was still regular, mitochondrial structure was integrity, no swelling and vacuolation, nucleus and nucleolus were normal, no obvious nucleus cavity-like degeneration and nuclear pycnosis phenomenon.3.2.2 The effects Chinese herbs of NQABC combined with IPoC on TLR2.4 and downstream pro-inflammatory cytokines of rat myocardium with reperfusion injury.Compared with IPoC group, NQABC plus IPoC further decreased the expression of TLR2,4 (P<0.01). At the same time, Chinese herbs of NQABC on the basis of IPoC could further decrease the contents of IL-1β, IL-6, TNF-αand MCP-1 in rat myocardium with IPoC (P<0.05,P<0.01).4 Conclusions4.1 Blood stasis and qi deficiency were main syndrome elements of ACS patients, qi deficiency and blood stasis was main syndrome performance, the feature of TCM syndrome elements combinations in ACS high-risk patients mainly manifested yang deficiency+blood stasis+turbid phlegm tending toward cold.4.2 Blood stasis and qi deficiency run through the whole course of disease of ACS during one year after PCI, the evolutional features of TCM syndrome elements of ACS after PCI were from excess to deficiency and from complex to simple.4.3 This study further validated that NQABC might be the main therapy method of ACS after PCI. 4.4 The pretreatment with Chinese herbs of NQABC enhanced the protective effect of IPoC on rat myocardial I/R injury, and its mechanism might be related to the inhibition of TLRs expression and the expression of the downstream proinflammatory cytokines.