中西医结合治疗颈动脉粥样硬化斑块的研究现状

Current Research Status of Integrated Traditional Chinese and Western Medicine in the Treatment of Carotid Atherosclerotic Plaques

摘要: 颈动脉粥样硬化斑块是缺血性脑卒中的重要危险因素，其稳定性与进展速度直接关系脑血管事件的发生。当前以他汀类药物为基础的西医常规治疗在部分患者中存在斑块持续进展、血脂达标困难或药物不耐受等问题，而中医从痰浊、血瘀、毒损等角度认识本病，强调整体调节气血运行与脏腑功能，为斑块稳定与消退提供了补充思路。本文对近年发表于中西医结合及相关领域期刊的研究文献进行梳理，重点围绕三个问题展开：现有研究采用的主要干预模式、这些模式在稳定或消退颈动脉斑块方面的证据强度，以及研究设计与实施中存在的共性问题。文献显示中医病机认识已从早期的痰浊血瘀逐步发展为脉痹、脉内痈疡、血脉癥积以及郁结–肉腐–脓溃等多种动态理论框架，相应治法涵盖温阳通脉、解毒活血、祛瘀生新等方向，部分中药复方如脑心清片和丹蒌片在临床试验或动物实验中显示出缩小斑块长度、改善症状及调节脂质代谢的潜力，其机制涉及调控泛凋亡、巨噬细胞代谢重编程、miR-145介导的TGF-β1信号通路抑制等分子环节。西医方面阿托伐他汀的多效性和PCSK9抑制剂促进斑块稳定甚至逆转的证据也在不断充实。但现有临床研究多为小样本单中心设计，疗程偏短，缺乏对脑卒中或短暂性脑缺血发作等硬终点事件的观察，斑块评估指标多限于内中膜厚度和面积，难以充分反映斑块内部成分与力学稳定性的真实改变，中医证候分型不统一也限制了同类研究间的横向比较，证据等级整体偏低。后续研究需在多中心随机对照试验中延长随访时间，纳入斑块内出血、纤维帽厚度等影像学指标并关注脑血管事件发生率，同时深入验证中药对巨噬细胞脂质吞噬、胞葬功能及泛凋亡通路的调控作用，筛选可反映斑块稳定性的血清标志物，探索中医证型与分子表型的对应关系，逐步建立兼顾中医证候改善与现代影像和实验室证据的疗效评价体系，为中西医结合治疗提供更可靠的循证依据。

Abstract: Carotid atherosclerotic plaque is a major risk factor for ischemic stroke, and its stability and progression rate directly affect the occurrence of cerebrovascular events. Conventional western medical treatment based on statins still faces challenges in some patients, including persistent plaque progression, failure to reach lipid targets, or drug intolerance. Traditional Chinese medicine approaches this disease from the perspectives of phlegm turbidity, blood stasis, and toxic damage, emphasizing overall regulation of qi and blood circulation as well as visceral functions, which offers a supplementary rationale for plaque stabilization and regression. This review summarizes recent literature published in journals in the fields of integrated traditional Chinese and western medicine and related disciplines, focusing on three core questions: the main intervention models adopted in existing studies, the strength of evidence for these models in stabilizing or regressing carotid plaques, and common methodological issues in study design and implementation. The literature shows that the understanding of the pathogenesis in traditional Chinese medicine has gradually expanded from earlier concepts of phlegm turbidity and blood stasis to multiple dynamic frameworks such as vessel impediment, internal carbuncle of the vessel, blood-vessel mass accumulation, and the progression from stagnation to flesh putrefaction and suppurative ulceration. Corresponding therapeutic strategies include warming yang and unblocking vessels, detoxifying and activating blood, and removing stasis to promote regeneration. Several Chinese herbal compounds, such as Naoxinqing tablets and Danlou tablets, have demonstrated potential in reducing plaque length, alleviating symptoms, and regulating lipid metabolism in clinical trials or animal experiments, with mechanisms involving regulation of PANoptosis, macrophage metabolic reprogramming, and miR-145-mediated suppression of the TGF-β1 signaling pathway. In western medicine, evidence for the pleiotropic effects of atorvastatin and the stabilizing or even reversing effects of PCSK9 inhibitors on plaques is also accumulating. However, most existing clinical studies use small-sample, single-center designs and have short treatment durations and lack observation of hard endpoint events such as stroke or transient ischemic attack. Plaque assessment is often limited to intima-media thickness and plaque area, which cannot adequately reflect true changes in plaque composition and mechanical stability. Inconsistent traditional Chinese medicine syndrome classifications across studies further hamper comparisons across similar studies, and the overall level of evidence remains relatively low. Future research should extend follow-up periods in multicenter randomized controlled trials, incorporate imaging indicators such as intraplaque hemorrhage and fibrous cap thickness, and pay attention to cerebrovascular event rates. Mechanistic investigations should further validate the regulatory effects of Chinese herbs on macrophage lipid phagocytosis, efferocytosis, and PANoptosis pathways, screen for serum biomarkers that reflect plaque stability, and explore correspondences between traditional Chinese medicine syndrome types and molecular phenotypes. An evaluation system that integrates improvements in traditional Chinese medicine syndromes with modern imaging and laboratory evidence should be gradually established, so as to provide more reliable evidence for integrated traditional Chinese and western medicine treatment.