是指自觉心中急剧跳动88课件

心悸概述是指自觉心中急剧跳动，惊惕不安，不能自主的一种病证。常伴有气短、胸闷、眩晕、失眠、脉律失常等症。或阵发性或持续性。因惊恐、劳累而发，时作时止，不发如常人，病情较轻者为惊悸；终日悸动，稍劳尤甚，病情较重者为怔忡。沿革1.《素问.至真要大论篇》：

《灵素.本神篇》：“心憺憺大动”“心怵惕”《素问.痹论篇》：“脉痹不已，复感于邪，内舍于心”“心痹者，脉不通，烦者心下鼓”2.张仲景〈金匮要略〉〈伤寒论〉提出：主要病因：惊扰、水饮、虚痨及汗后受邪等炙甘草汤3.隋代.巢元方〈诸病源候论.风惊悸候〉：”风惊悸者，由体虚，心气不足，心之府为风邪所乘，或恐惧忧迫，令人气虚，亦受于风邪，风邪迫于心，则惊不自安，惊不已，则悸动不定。“唐代孙思邈提出：因虚致悸4.金元时代，刘河间：水衰火旺朱丹溪：血虚、痰火5.清代，王清任：瘀血内阻，血府逐瘀汤范围各种心律失常以及心功能不全,心肌炎,心神经官能症等病机1.心阳虚衰,血脉瘀滞2.肾阳不足,阴寒凝滞3.肝失疏泄,气滞血瘀----邪扰心神,心神4.脾失健运,痰湿扰心不宁5.外邪犯肺,内舍于心病机1.心虚胆怯,心血不足2.肝肾阴虚,心肾不交---心失所养3.肾阳亏虚,心阳失于温煦4.脾胃虚弱,气血乏源5.肺气虚,不能助心以治节病位在心涉及肝脾肺肾病理因素：痰火、水饮、瘀血病理性质：虚实虚：脏腑虚损，气血阴阳衰少

实：痰火扰心，水饮凌心，心血瘀阻虚实之间或转化或兼夹并可互相影响脉象：快速型脉象：数脉1息6至疾脉1息7至极脉1息8至脱脉1息9至浮合脉1息10至以上阳盛则促，数为阳热2、详辨脉象变化过缓型脉象：迟脉1息3至损脉1息2至败脉1息1至夺精脉2息1至阴盛则结，迟而无力为虚寒凡久病体虚而脉象弦滑搏指者为逆，病情重笃而脉象散乱模糊者为病危之象。

病证鉴别1.惊悸与怔忡诱因,阵发或持续,轻重,实虚转化2.奔豚奔豚发作之时，亦觉心胸躁动不安。《难经·五十六难》曰：“发于小腹，上至心下，若豚状，或上或下无时”，称之为肾积。《金匮要略·奔豚气病脉证治》曰：“奔豚病从少腹起，上冲咽喉，发作欲死，复还止，皆从惊恐得之。”故本病与心悸的鉴别要点为：心悸为心中剧烈跳动，发自于心；奔豚乃上下冲逆，发自少腹。辨证要点1.分清虚实虚：心悸气短、神疲乏力、自汗者为气虚；心悸头晕，面色无华者属血虚；心悸盗汗，潮热口干者属阴虚；心悸肢冷，畏寒气喘者属阳虚；实：伴口苦便秘者为痰火；心悸面浮，尿少肢肿者为水饮；心悸心痛，唇暗舌紫者为瘀血2.详辩脉象变化脉缓，促脉，结脉，代脉3.辨证辨病相结合明确其原发疾病4.结合临床辅助检查24小时心电图，24小时动态血压胸片，心肌酶谱辨病3、结合辨病辨证功能性心律失常所引起的心悸，常表现为心率快速型心悸，多属心虚胆怯，心神动摇；冠心病心悸，多为气虚血瘀，或由痰瘀交阻而致；风心病引起的心悸，以心脉痹阻为主；病毒性心肌炎引起的心悸，多由邪毒外侵，内舍于心，常呈气阴两虚，瘀阻络脉证。2、酌情选用安神定悸之药：

养心安神：酸枣仁、柏子仁、五味子；重镇安神：龙骨、牡蛎、磁石、珍珠母、琥珀、朱砂。3、抗心律失常药：

加速心率：麻黄、麝香、鹿茸、洋金花、茶叶。减慢心率：柏子仁、玉竹、当归、灵芝、满山红、九里香、瞿麦、罗布麻根。抗心律不齐：炙甘草、人参、生地、麦冬、苦参、延胡索、赤芍、柴胡、仙鹤草、郁金。分型论治一.心虚胆怯组方：龙齿、琥珀、磁石：镇惊宁神：朱砂、茯神、菖蒲、远志安神定志加减心虚胆怯，神不自主而心悸者，加炙甘草、黄芪兼心阴不足，加柏子仁、酸枣仁、五味子、天冬或天王补心丹若心悸心烦，精神抑郁，胸胁时痛，加柴胡、合欢皮、郁金二.心血不足主症特点：心悸不安，怔忡、健忘、失眠（心主血脉，心血不足，不能养心）头晕目眩，面色无华（心主血脉，其华在面，心血不能上荣于面，不能上承于脑）神倦气短，或自汗（血虚及气，气血亏虚，卫表不固）舌淡红，脉细弱（心血不足）治则：补血养心，益气安神方药：归脾汤组方：当归、龙眼肉：补益心血；黄芪人参、白术、炙甘草益气健脾以生血；茯神、远志、枣仁，宁心安神；木香，行气，使补而不滞。加减：若乏力、气短、神疲明显，重用人参、黄芪、白术、甘草，少佐肉桂，取少火生气之意。兼心阴不足，见心烦口干舌红，加麦冬、玉竹、北沙参、五味子等。兼心气虚怯，善惊易怒，加生龙齿。其中，黄连、黄芩，清心火；阿胶、芍药、鸡子黄滋养阴血。加减：一般加酸枣仁、珍珠母、牡蛎等加强安神定惊阴虚而火不旺者，改用天王补心丹肾阴亏虚，虚火妄动，见遗精腰酸，酌加龟板、熟地、知母、黄柏，或加服知柏地黄丸。盗汗者，加煅龙骨、煅牡蛎、浮小麦收敛止汗；若阴虚夹有瘀热，可加丹参、赤勺、丹皮、知母等清热凉血，活血化瘀；兼有痰热，合用黄连温胆汤四心阳不振主症：心悸不安，动辄优甚，胸闷气短（久病体虚，损伤阳气，水气凌心，心失温养），形寒肢冷，面色苍白（心阳虚衰，血液运行迟缓，肢体失于温熏），舌淡，苔白，脉沉细无力或脉象虚弱。（心阳不足，鼓动无力）。治则：温补心阳，安神定志方药：桂枝甘草龙骨牡蛎汤加味参附汤桂枝，甘草，温补心阳；龙骨牡蛎，安神定悸加减：心阳不足明显，宜加人参、附子。兼有阴伤，加麦冬、玉竹、五味子。变证1.病重，汗出肢冷，面青唇紫，喘不得卧，重用人参、附子，加黑锡丹。2.肾阳不足者，或出现迟脉、结脉、代脉者，选麻黄附子细辛汤。七心血瘀阻主症特点：心悸，胸闷，（心主血脉，心脉瘀阻，心失所养，心阳被遏）心痛时作，痛如针刺（心络孪急）唇紫，舌紫舌暗紫，或有瘀斑，脉涩或结代（淤血阻滞）治法：活血化瘀，理气通络方药：桃仁红花煎合桂枝甘草龙骨牡蛎汤加减：阳虚致瘀：加附子，桂枝，干姜胸痛甚，加乳香，没药，三七病案分析李××，女，37岁职员1989年12月13日就诊20年前曾有膝、踝关节肿胀疼痛、发热病史，近二年来经常在疲劳后出现心慌，外院诊断为风湿性心脏病休息后能好转，故未予重视。平日畏寒怕冷，胃纳欠佳‘多食易腹胀，神疲乏力，耳鸣腰酸。近一周来，发现小便量少、下肢浮肿。今晨起床后突觉心慌、胸闷、气喘，艰于平卧，休息后不能缓解。刻诊：面色苍白，肌肤潮湿，口唇紫，舌紫暗，苔薄白，脉细弱，脉律不齐。查EKIT：HR94/分，房颤律。第一步：明确诊断第二步：寻找病因病机第三步：辨清虚实缓急第四步：辨别涉及脏腑第五步：应作哪些进一步检查第六步：治疗

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