Epidemiological Investigation Of TCM Syndromes On Essential Hypertension In KwangTung And Hong Kong Region

BackgroundEssential hypertension(EH) is one of the frequent cardiovascular diseases,and its morbidity rate was rising for the past few years all over the world.Epidemiological investigation showed that hypertension morbidity rate of Kwang Tung had gone up to nationwide secondary level from the lowest.Facing the state of gradually rising morbidity rate,low ratio of knowledge,treatment and control,it ask us to solve that how to undertake the prevention and treatment of hypertension better.Bian Zheng Lun Zhi(determination of treatment based on pathogenesis obtained through differentiation of synptoms and signs,BZLZ) is the peculiarity and quintessence of Traditional Chinese Medicine(TCM).Zheng Hou(Syndrome) is the premise and foundation of BZLZ.Also it is the bridge and juncture correlating TCM theory with clinical diagnosis and treatment.Syndrome is constantly one of the hot research spot in TCM.At eighty age last century,it had proposed that normalization of Syndrome was the premise and foundation of syndrome essence research,and the prerequisite for TCM striding forward to modernization and scientific.For the past few years,people have observed that Syndrome is one kind of scientific methods to konw vital movement.Getting hold of Syndrome research means getting hold of the bottleneck of TCM research.Although Syndrome have been the hot research spot for twenty years and it got some progress,but there was still no breakthrough.In recent years,mass explorations have been done in the prevention and treatment of TCM intemal.Researches on normalization of BZLZ have become a hot spot.From combining modern medical test facilities to study the essence of Syndrome to draw assistance from different mathematic models to undertake normalized Syndrome typing research of EH,it had got some achievement.In 1993,the Ministry of Public Health promulgated Clinical Research Guide Principle of Chinese Medicinal Materials on Treating Hypertension.It definited the diagnostic criteria and curative effect of syndromes of EH.And it had momentous guide effect on standarding TCM reseaches of EH.It also enhanced the scientific nature of clinical studies.But clinical workers found that the Guide can not satisfy the actual need in clinic.Some new syndromes appeared and its ratio raised up.So it hinted that the syndromes of EH produced by the Guide needed to be consummated.Summarizing the researches on EH over the years,we found that the syndrome standardization of EH was disunit and the manipuility was poor.Why? We think it is because some problems existing researching thinking and methods.So the study result can not reveal the genuine diagnostic criteria.It also hinted the difficulty of syndrome standardization.So the thinking and method of syndrome standardization need to be improved and bringed new ideas.It is said that Clinical Epidemiology and Evidence-based Medicine are the most receiced scientific methodology in nowadays medical world to do clinical research. The principle and methods of Epidemiology provide helpful inspiration for us to do the normalized study of TCM syndromes.And it also has important meaning for us to master the morbidity rules and TCM syndrome features exactly.So based on literature research,expert consultant and case review,following clinical epidemiological principle,combining Disease with Syndrome,we can undertake large sample clinical study and analyze and evaluat the clinical data to observe different clinical manifestation of syndrome of EH.Through that,we can find the appearanced frequency difference of Syndrome,and can master syndrome's rule steply.We also can formulate the standard of syndrome type,get the diagnostic criteria which is better fit clinical actuality.At the same time to make up the current situation that there was still no report on syndrome reseach of EH in Kwang Tung and Hong Kong region.ObjectiveGet the message of distribution status of TCM syndromes on EH in Kwang Tung and Hong Kong region.Identify primary,minor and complex syndromes,frequency of different syndromes,and turnover of syndromes.Then accoding to the frequency and degree of symptoms,get the main syndromes and make clear the transmission rule of EH syndrome.Also investigate epidemiological rule and main influential factors of EH syndromes.Provide objective evidence to formulate clinical standard of Bian Zheng(differentiation of symptoms and signs) of frequent syndromes on EH in Kwang Tung and Hong Kong region.Redeem the situation that there was still no report of TCM syndromes in KwangTung and Hong Kong region and provide theoretical evidence for better clinical treatment through BZLZ.Method1.Investigative bojects were EH patients who were residents in KwangTung and Hong Kong region.2.Diagnosis criteria:Diagnostic criteria of EH and the ranking criteria were based on Prevention and Treatment Guide of Hypertension of China 2005.TCM syndromes were confered on Clinical Research Guide Principle of Chinese Medicinal Materials on Treating Hypertension and literature analysis.Then finish out the five main syndromes which were Gan Yang Shang Kang(hyperactivity of liver-YANG, GYSK),Gan Shen kin Xu(hepatic and renal yin deficieney,GSYX),Yin Xu Yang Kang(asthenic yin causing predominant yang,YXYK),Tan Shi Yong Sheng (phlegmatic hygrosis obstruct and excessive,TSYS)and Yin Yang Liang Xu (deficiency of both yin and yang,YYLX).Use body mass index(BMI) to diseriminat obesity.Obesity diagnostic criteria reference over weight and obesity diagnostic criteria of Asian adult.3.Sampling methode:Divided Kwang Tung into four districts which were northern part,eastern part,western part and Pearl river delta using group sampling. And Hong Kong was a district.According to the hypertension management network record of community public health service station spots of each city of each districts, investigated the definite EH patients using random sampling.4.Quality eontrol:Including investigator training,investigate process and analytic process.5.Epidemiological investigation:Correct TCM syndrome questionnaire according to the result of pre-investigation.And use the way of direct inquisition to carry out the investigation.The questionnaire includes basic information,EH history, family medical history,lifestyle,donec treatment,TCM symptoms,et al.6.Medical examination:Blood pressure was measured by the way recommended from prevention and treatment of hypertension guide.Body height,body weight and abdomen circumference were measured using the international unified methods.7.Statistical method:Used Epidata 2.1 software to set up database.Two person used two computers to input the data,then converted to the SPSS database after check. Used SPSS 13.0 software to do the statistical analysis.Applied descriptive statistics to analyze basic information.Used chi-square test to do the comparision of constituent ratio and single factor analysis.Used Binary Lolgistie Regression to do multiplicity.Result1.General epidemiologie feature727 EH patients were investigated.The eases of each region were Kwang Tung northern part 35(4.81%),eastern part 128(17.61%),western part 111(15.27%),Pearl river delta 305(41.95%) and Hong Kong 148(20.36%).406 eases were male,321 eases were female.The age of onset mainly concentrated on 50 to 79 years old,which was about 79.5%.After 50 years old,the patient increased obviously,and the male female ratio was at equal pace each age segment.There were no difference(x~2=8.443, P=0.207).The number of obesity patients was 177,about 24.3%.Disease course from 1 to 5 years has the maximal ratio(36.3%).Among the patients,the percentages of 1,2,3 grade of blood pressure were 53.8%,34.1%and 12.1%respectively.The most frequent complications were diabetes(37.2%),cornoary heart disease(22.7%), cerebral infarction(22.1%),hypertensive heart disease(7.3%)and apolexy(6.3%).In the family medical diseases inquiry,the family clan members who had hypertension were parents(14.6%)and children(3.9%).In the lifestyle inquiry,23.4 percent patients often had high salt diet,9.6 percent patients often drunk wine excessively,21.7 percent patients had been or have being smoking and 19.8 percent had never done exercise.The patients who often ate chinese double-stewed soup were 23.1%,who often drunk herb tea were 12%.In the treatment aspect,the treat rates of 1,2,3 grade of blood pressure were 67.8%,75.4%and 86.4%respectively.And the difference between different grade of blood pressure was significant(x~2=13.944,P=0.001).2.Epidemiologic feature of TCM syndromeIn this investigation,according to the frequency,the sequence of main syndromes were YXYK(29.6%),GYSK(18.6%),GSYX(12.7%),YYLX(12.5%), TSYS(11.4%).Other syndromes which its ratio was less than ten percent were Wu Zheng Ke Bian(3.3%),Tan Re Nei Yun(3%),Qi Xu(1.9%),Qi Yin Liang Xu(1.9%), Yang Xu(1.5%),Xue Yu(1.5%).The statistical results primitively accorded with Clinical Research Guide Principle of Chinese Medicinal Materials on Treating Hypertension and literature analysis.And YYLX was more obvious in Kwang Tung and Hong Kong region.In addition,the difference of TCM syndromes between the five distrcts was significant(x~2=151.016,P=0.000).The main syndromes of Pearl river delta and Kwang Tung eastern part were YXYK and GYSK.The main syndromes of KwangTung western part were YXYK and TSYS.The main syndromes of KwangTung northern part were GYSK and YXYK.The main syndromes of Hong Kong region were YYLX and YXYK.3.Syndrome distribution were influenced by age,disease course,constitution, blood pressure grade,high salt diet,excessive wine drink,Chinese double-stewed soup and herb tea.Analyzing the relationship between age,disease course and syndrome,we found that different age layer and disease course manifested different main syndromes(x~2= 60.077,P=0.001;x~2=70.528,P=0.000).Before 40 years old,it mainly displayed as GYSK(46.7%),the next syndromes were TSYS(13.3%)and YXYK(13.3%).GSYX and YYLX were the least in this age segment.From 40 to 49 years old,GYSK was decreased obviously,and YXYK was increased.After 50 years old,YXYK became the main syndrome,and GYSK still fall-off.Then after 60 years old,YYLX increased obviously and became the main syndrome.It mainly displayed as GYSK(26.98%) when the disease course was less than 1 year,the next syndrome was YXYK(19.05%).When the disease course was from 1 to 5 years,YXYK was the main syndrome(32.58%),and GYSK had the tendency to decrease,when the disease course extend to 6 to 9 years,the main syndrome was still YXYK(35.71%),but GYSK deeended significantly(12.14%),YYLX increased obviously(11.43%).YXYK was still the main syndrome when the disease course extended to 10 to 14 years,but droped to 29.08%,and YYLX sequentially increased.When the disease course was more than 15 years,the main sydrome was YYLX.So,we can see that the changes of TCM syndrome of EH were along with aetatis increasing and the development of disease course.It is a process that sthenia syndrome changes to deficient syndrome. At the begining,GYSK and TSYS are the main syndomes.Then Be along with aetatis increasing and development of disease course,it change to YXYK which is a Xu Shi Jia Jia syndrome(excess and deficiency mixed syndrome).At last,it develope to YYLX,the deficient syndrome.Male and female also have difference in syndromes(x~2=13.116,P=0.022). GYSK and TSYS were more obvious on male than female,syndromes with yin asthenia were more significant on female.There were diference between different blood peressure grade(x~2=38.992,P=0.000).No matter whether complicating with other cordis-eerebral vessels diseases or metabolic diseases or not,the distribution of each syndrome was basic conformity.The difference had no statistically significant(x~2 =8.112,P=0.150;x~2=4.268,P=0.512).The distribution of each syndrome in different salt intake was different(x~2= 19.303,P=0.037).GSYX among the patients who often had high salt diet was obviously less than those who never.GYSK among the patients who often drunk wine was mostly obvious(42.9%).The patients who never drunk had the least ratio of TSYS.The investigation also showed that smoking and exercise had no influence on the distribution of syndrome.There was difference on different intake Chinese double-stewed soup and herb tea(x~2=31.124,P=0.001;x~2=29.457,P=0.001).The ratios of YXYK,GSYX and GYSK of those who often ate Chinese double-stewed soup were less than those who never.The ratio of GYSK was the least in those who often drunk herb tea.4.Binary Logistic Regression of correlation factors of each syndromeLead in each factors to analyze and get the equations of GYSK.And through chi-square test the equations was significant(x~2=61.337,P=0.000).The goodness of fittest of the equations is ideal(Cox & Snell R Square=0.081 and Nagelkerke R Square=0.131).Among the influential factors,age segment 4(50～59 year),age egment 5(60～69year),age segment 6(70～79year),sex,BP grade 2 and 3,disease course 1(＜1year) had statistical significance(P＜0.05).Then using Wald to test the function of partial regression coefficient of each influential factors,we found that along with the grew of age,the negative value of partial regression coefficient was more great, which means its norientation function to GYSK was more little.It also shows that along with the rising of BP grade,its norientation effect become more great The function of vrile partial regression coefficient of male was greater than female.It mean male easily predispose to GYSK than female.The equations of YXYK was also significant(x~2=15.035,P=0.002).But the goodness of fittest of the equations was not ideal(Cox & Snell R Square=0.010 and Nagelkerke R Square=0.020).BP grade and overdose had statistical significance(P＜0.05).The equations of TSYS was also significant(x~2=7.256,P=0.007).And the goodness of fittest of the equations was also not ideal(Cox & Snell R Square=0.010 and Nagelkerke R Square=0.020). Chinese double-stewed soup had statistical significance(P＜0.05).The equations of GSYX was significant(x~2=44.857,P=0.009).The goodness of fittest of the equations was common(Cox & Snell R Square=0.060 and Nagelkerke R Square=0.112).Body type and complicating with angiocardiopathy had statistical significance(P＜0.05).The equations of YYLX was significant(x~2=91.017,P=0.000). And the goodness of fittest of the equations was good(Cox & Snell R Square =0.0.118 and Nagelkerke R Square=0.220).Among the influential factors,BP grade 1 and 3,disease course 1(＜1year) and 5(15～19years),excessive wine drink,exercise and overdose had statistical significance(P＜0.05).According to the partial regression coefficient,along with the rising of BP grade,the probability of YYLX was more little.Along with the extension of disease course,the probability of YYLX was more great.The patient who often had high salt diet easily got YYLX.The one who often drunk wine excessively didn't easily get YYLX.Analyzing the whole Logistic Regression,the equations goodness of fittest of GYSK and YYLX were ideal.And according to the partial regression coefficient,the influential factors consistented with clinic.But the equations goodness of fittest of TSYS,GSYX and YXYK was not ideal, and the influential factors were not typical.Maybe it related with the narrow scope value resulting in no statistical significance.Conclusion1.Ying Xu Yang Kang(YXYK),Gan Yang Shang Kang(GYSK),Gan Shen Yin Xu(GSYX),Yin Yang Liang Xu(YYLX),Tan Shi Yong Sheng(TSYS) are the main TCM syndromes of essential hypertension in Kwang Tung and Hong Kong region. This result primitively accorded with Clinical Research Guide Principle of Chinese Medicinal Materials on Treating Hypertension and literature analysis.But YYLX was more obvious in Kwang Tung and Hong Kong region.Maybe it is concerned with geography characteristic of southern China which in TCM it means "the South is prevalent for heat evil,so the diseases display as damaged yin."2.The difference of TCM syndromes between the five distrcts was significant. Pearl river delta and Kwang Tung eastern part were mainly for YXYK and GYSK, KwangTung western part was mainly for YXYK and TSYS,KwangTung northern part was mainly for GYSK and YXYK.Hong Kong region was mainly for YYLX and YXYK.3.Different age layer and disease course had different main syndromes.Before 40 years old,it mainly displayed as GYSK,GSYX and YYLX were the least in this age segment.From 40 to 49 years old,GYSX decreased obviously,and YXYK increased.After 50 years old,YXYK had become the main syndrome,and GYSK still fall-off.Then after 60 years old,YYLX increased obviously and became the main syndrome.GYSK was the main syndrome in the disease course which less than 1 year, the next syndrome was YXYK.YXYK was the main syndrome in the course of 1 to 5 years,and GYSK had the tendency to decrease,when the disease course extend to 6 to 9 years,the main syndrome was still YXYK,but GYSK decended significantly, YYLX increased obviously.YXYK was still the main syndrome when the disease course extended to 10～14 years,but droped severely,and YYLX sequentially increased.YYLX became the main sydrome in the course of more than 15 years.The changes of TCM syndrome of EH were along with aetatis increasing and development of disease course.It is a process from sthenia syndrome changing to deficient syndrome.4.The distribution of syndromes was also influenced by constitution,high salt diet,excessive wine drink,and Chinese double-stewed soup,herb tea.5.Among the influential factors,age segment 4(50～59 year),age egment 5 (60～69year),age segment 6(70～79year),sex,BP grade 2 and 3,and disease course 1(＜1year) had statistical significance to GYSK.Along with the increacing of age,the negative value of partial regression coefficient was more great,which mean its norientation function to GYSK was more little.Along with the heighten of BP grade, it norientation effect become more great.And male easily predisposed to GYSK than female.BP grade and overdose had statistical significance to YXYK.Chinese double-stewed soup had statistical significance to TSYS.Body type and complicating with angioeardiopathy had statistical significance to GSYX.Among the influential factors,BP grade 1 and 3,disease course 1(＜1year) and 5(15～19years),excessive wine drink,exercise and overdose had statistical significance to YYLX.According to the partial regression coefficient,along with the rising of BP grade,the probability of YYLX was more little.Along with the extension of disease course,the probability of YYLX was more great.The patient who often had high salt diet easily got YYLX. The one who often drunk wine excessively didn't easily get YYLX.Seeing from the whole Logistic Regression,the equations goodness of fittest of GYSK and YYLX was ideal.And according to the partial regression coefficient,the influential factors eonsistented with clinic.But the equations goodness of fittest of TSYS,GSYX and YXYK was not ideal,and the influential factors was not typical.Maybe it related with the narrow scope value result in no statistical significance.