RU2525510C1 - Method of diagnosing ischemic heart disease by method of stress-echocardiography with combined isometric and psychoemotional stress - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: test is carried out by an application of a combined approach with simultaneous application of isometric and psychoemotional stress. Isometric stress is performed by means of two ring expanders, which a patient compresses in each hand with the maximal effort for the maximally possible time interval - usually for 2-3 minutes. In the process of performing an isometric test additional psychoemotional stress in the form of constant psychological setting of the patient to the maximal pressure of the hand expanders for the entire test is carried out. Simultaneously a registration of echocardiographic scans is performed from the apical access in a projection of a four-chamber and two-chamber section with an application of 16-segmented model in a combination with ECG AND AP registration.

EFFECT: method makes it possible to increase an accuracy and self-descriptiveness of non-invasive ultrasonic diagnostics of ischemic heart disease in clinical practice due to the creation of the powerful synergic effect from two stressing factors.

Description

The invention relates to medicine, namely to ultrasound diagnostics in clinical cardiology.

Coronary heart disease (CHD) for many years is the main cause of mortality in many economically developed countries, including Russia. The mortality rate from diseases of the circulatory system in the Russian Federation is about 56% of the total mortality structure, of which about half are due to IHD mortality (Oganov R.G., Shalnova S.A., Kalinina AM Prevention of cardiovascular disease: a guide. M .: GEOTAR-Media, 2009. - 216 p.).

At present, along with attempts to reduce the value of coronary heart disease using primary prophylaxis in a number of cardiac pathologies, the task of early diagnosis and timely secondary prevention of this disease is being advanced.

Functional stress tests play an important role in the diagnosis of coronary heart disease, in particular, a test with dosed physical activity, a test with electrical stimulation of the heart, and pharmacological tests (Aronov D.M., Lupanov V.P. Functional tests in cardiology. MEDpress-inform, 2007. - 328 p.).

The most widely used in clinical practice are samples with dosed physical activity and registration of electrocardiography (ECG): bicycle ergometry test and treadmill test. However, there are factors that significantly limit the performance of these samples. So, the test is not informative in the case of blockade of the left leg of the bundle of His, severe left ventricular myocardial hypertrophy, WPW syndrome. Non-cardiac reasons that limit the performance of tests with dosed physical activity on the treadmill and bicycle ergometer include arthritis of large joints, lower limb injuries, obesity, old age, etc. (Aronov D.M., Lupanov V.P. Functional tests in cardiology. MEDpress-inform, 2007. - 328 p.). According to British authors, only 40% of patients with suspected coronary heart disease may perform a stress test using dosed physical activity and ECG recording (Senior R., Monaghan M., Becher H. et al. Stress echocardiography for the diagnosis and risk stratification of patients with suspected or known coronary artery disease: a critical appraisal. Supported by the British Society of Echocardiography // Heart. - 2005. - No. 91 (4). - P.427-36). In this regard, at present, echocardiographic control is widely used when performing various functional tests (“stress echocardiography”). Stress echocardiography (stress echocardiography) is a method of non-invasive ultrasound diagnosis of induced myocardial ischemia and / or changes in intracardiac hemodynamics in combination with basic functional tests. Diagnosis of induced myocardial ischemia is based on the detection of transient disorders of local left ventricular contractility (LV) using two-dimensional echocardiography (EchoCG) (Rybakova MK, Alekhin MN, Mitkov VV Practical guide to ultrasound diagnostics. Echocardiography. - M .: Vidar-M., 2008 .-- 544 p.).

Stress Echocardiography has a number of advantages compared to traditional non-invasive instrumental methods for detecting myocardial ischemia: with ECG and radionuclide load tests. Stress Echocardiography is distinguished by high sensitivity and specificity, the availability of research for both inpatient and outpatient stages of diagnosis, the possibility of repeated repetition, the absence of ionizing radiation, the possibility of use in the initial modified ECG (signs of left ventricular myocardial hypertrophy, intraventricular conduction disturbances, electrolyte disturbances, actions medicines, etc.).

Almost all known types of dosed loads used in modern cardiology are used to conduct stress echocardiography. The most common are medicinal tests, tests with transesophageal electrical stimulation (NPES) and tests with physical activity.

Of the pharmacological samples, dobutamine and dipyridamole tests are most often used. The main disadvantages of pharmacological tests are the high incidence of side effects, up to the development of severe cardiac arrhythmias (dobutamine test) and low diagnostic significance in the initial stages of coronary heart disease (dipyridamole test) (Aronov D.M., Lupanov V.P. Functional tests in cardiology . MEDpress-inform, 2007. - 328 p.).

In some cases, conducting NPV in combination with echocardiography is an alternative to pharmacological stress tests (Atar S., Nagai T., Cercek B. et al. Pacing stress echocardiography: an alternative to pharmacologic stress testing // JACC. - 2000. - 36 ( 6) .- P.1935-41). The main limitations and disadvantages of this method are associated with the difficulty of introducing the probe into the esophagus and unpleasant sensations for the patient.

Samples with dosed physical activity are quite widespread in clinical practice. However, it should be noted that in samples with dynamic physical activity, a post-load version of stress echocardiography is usually used, in which the main echocardiographic positions are recorded after the load is terminated, which is a significant drawback of this technique.

Combined methods of stress echocardiography in the diagnosis of coronary heart disease are also known, for example, a combination of a pharmacological test with dosed physical activity or with NPES (Vasiliev A.Yu., Mikheev N.N. Combined methods of stress echocardiography with dipyridamole in combination with paired bicycle ergometric test and transesophageal stimulation atria in the diagnosis of coronary heart disease // Russian Journal of Cardiology. - 2005. - 5. - P.83-86). Such a combination of samples leads to a significant complication of the stress echocardiography technique, it is demanding for the technical equipment of an ultrasound cabinet. When using dipyridamole test, a prerequisite is the presence of a prepared antidote of aminophylline. All this leads to an increase in the duration of the procedure and its cost. At the same time, combining these samples increases the risk of possible serious complications (Sicaril R., Nihoyannopoulos P., Evangelista A. et al. Stress Echocardiography Expert Consensus Statement - Executive Summary. European Heart Journal. - 2009. - 30. - P.278- 289).

A sample with isometric (static) physical activity has several advantages, namely: simplicity and accessibility of the method, high safety, the possibility of use in patients for whom stress testing with dynamic physical activity is impossible or difficult (obesity, diseases of the musculoskeletal system, damage vessels of the lower extremities, general detraining, etc.).

A known method for the diagnosis of coronary heart disease using stress echocardiography using a dosed isometric load, based on two-dimensional echocardiography and assessing local contractility of the LV myocardium during a patient's dosed isometric load. The interpretation of stress echocardiography is based on changes in the local systolic function of the myocardium and, above all, the local thickening of the myocardium in response to an isometric load. Initially, systolic thickening of each of the segments of the myocardium and global systolic function in the initial state are evaluated. Next, an analysis of the contractility of the myocardial segments at the height of the load. (Mitamura H., Ogawa S., Hori S., et al. Two dimensional echocardiographic analysis of wall motion abnormalities during handgrip exercise in patients with coronary artery disease // Am J Cardiol. - 1981. - 48 (4). - P .711-719).

In patients with hemodynamically significant stenosing lesions of the coronary arteries, the segmental thickening of the myocardium decreases due to an imbalance between the increasing needs of the working myocardium for oxygen and its delivery capabilities. The myocardial zone supplied by the stenotic coronary artery will be detected by reducing systolic thickening and / or reducing the amplitude of wall movement in systole (the zone of violation of local contractility of the left ventricle), thereby allowing not only to identify transient myocardial ischemia, but also to assess the localization and prevalence of coronary lesions beds (Sicari R., Nihoyannopoulos R., Evangelista A., et al. Stress Echocardiography Expert Consensus Statement - Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC) // Eur Heart J. - 2009. - 30 (3) .- P.278-89).

According to this technique, an isometric test is carried out with a manual dynamometer, which allows the subject to be given a metered load on the upper limbs. In this case, the maximum compression force that the patient can create is initially determined. Then he continues to squeeze the dynamometer with both hands for 5 minutes with a force equal to 50% of the maximum. The test is considered positive in detecting violations of local LV myocardial contractility at rest or at the height of an isometric load. (Mitamura H., Ogawa S., Hori S., et al. Two dimensional echocardiographic analysis of wall motion abnormalities during handgrip exercise in patients with coronary artery disease // Am J Cardiol. - 1981. - 48 (4). - P .711-719).

However, the method has several disadvantages. The relatively low increase in heart rate (HR) and systolic blood pressure (BP) at the height of the load leads to a slight increase in the double product reflecting myocardial oxygen consumption (Peter S.A., Jones RH Effects of isometric handgrip and dynamic exercise on left-ventricular function // J Nucl Med. - 1980.- 21 (12) .- P.1131-1138). This, in turn, does not allow diagnosing coronary blood flow disorders in some patients, since the level of the generated load during the test is insufficient for the coronary blood flow to not meet myocardial oxygen requirements, which leads to a low sensitivity of the technique - about 40% (Mitamura H., Ogawa S ., Hori S., et al. Two dimensional echocardiographic analysis of wall motion abnormalities during handgrip exercise in patients with coronary artery disease // Am J Cardiol. - 1981. - 48 (4) .- P.711-719). According to other data, the sensitivity of this method is 30%, and the diagnostic value is only 47% (Loimaala A., Groundstroem K., Pasanen M., et al. Comparison of bicycle, heavy isometric, dipyridamole-atropine and dobutamine stress echocardiography for diagnosis of myocardial ischemia // Am J Cardiol. - 1999.- 84 (12) .- P.1396-1400). Low indicators of sensitivity and diagnostic value make this test inapplicable in clinical practice.

A known method for the diagnosis of coronary heart disease using stress echocardiography using a sample with mental stress. According to this test, the method of mathematical counting in the mind is used as psychoemotional stress. During the test, registration of standard echocardiography positions is performed. The sample is considered positive in detecting violations of local myocardial contractility of the left ventricle. (Modena M.G., Corghi F., Fantini G. et al. Echocardiographic monitoring of mental stress test in ischemic heart disease // Clin Cardiol. - 1989. - 12. - P.21-24).

However, this modification has a number of significant limitations. Firstly, the methodology for modeling psychoemotional stress is difficult to standardize, which makes it difficult to quantify the result. Secondly, this technique is more suitable for patients with a special psychological profile, in the personality characteristics of which aggressiveness, bitterness, irritability are expressed. Thirdly, this is the low sensitivity of the method 73.5% (Modena MG, Corghi F., Fantini G. et al. Echocardiographic monitoring of mental stress test in ischemic heart disease // Clin Cardiol. - 1989. - 12. - P. 21-24). According to a study by Burg M. et al. only in 45% of patients with coronary atherosclerosis, LV myocardial dysfunction is detected according to EchoCG during mental stress (Burg MM, Jain D., Soufer R., et al. Role of behavioral and psychological factors in mental stress-induced silent left ventricular dysfunction in coronary artery disease // J Am Coll Cardiol. - 1993. - 22 (2). - P.440-448). All this significantly limits the use of samples with mental stress.

It is also known that the psychoemotional test “mathematical count” and manual dosed isometric load are informative methods for detecting hemodynamic disturbances in patients with arterial hypertension (AH) (Shabalin AV et al. Informativeness of the psychoemotional stress test “mathematical count” and manual dosed isometric load in the diagnosis of stress dependence in patients with essential arterial hypertension. Arterial hypertension. 2003. - N 3. - P.98-101). However, these tests were used to detect stress dependence in patients with hypertension, the diagnostic effectiveness of these methods in detecting myocardial ischemia was not demonstrated.

The objective of the invention is to increase the accuracy and information content of non-invasive ultrasound diagnostics of coronary heart disease, using a combined test with isometric and psycho-emotional load.

To solve the problem in the diagnosis of coronary heart disease, including stress echocardiography, followed by an assessment of local LV contractility, a combined test is performed with isometric and psychoemotional stress.

The essence of our proposed method for the diagnosis of coronary heart disease using stress echocardiography is to use a combined approach with the simultaneous use of isometric and psycho-emotional stress. This combination of samples, on the one hand, allows you to achieve the highest possible level of intensity of the isometric load for the patient, on the other hand, causes additional activation of the sympathoadrenal system during the psychoemotional load.

Stress echocardiography with a combined isometric and psychoemotional load was performed on an IE 33 ultrasound machine (Philips, Germany, USA) with a 4-2 MHz phased sensor. The test was carried out according to the method of underdosed loading using two carpal ring expanders, which the patient squeezed with maximum effort in each hand for the maximum possible period of time (usually within 2-3 minutes). This method of isometric loading differs from the standard dosage methods of isometric loading described above, in which the patient compresses the dynamometer at a certain level from the maximum volitional force. This modification allows you to achieve a higher increase in blood pressure and heart rate during the test. In addition, during an isometric load, the doctor constantly psychologically adjusts the patient to the maximum pressure of the expanders to the maximum compression in the hands throughout the test. Emotional encouragement of the patient increases the compression force and lengthens the load time, thereby creating a synergistic effect. A similar technique for increasing effectiveness through psychological adjustment (self-hypnosis) to achieve maximum results is used by professional athletes (Management of the athlete's psyche, 02/20/2011, On line http://www.swiming.kiev.ua/index.php/articles/500-swimming -artikles.html). But the application of this approach in patients is extremely difficult, since it requires the involvement of a psychiatrist and additional time for conducting a psycho-regulatory training. In our case, the emotional encouragement of the patient is carried out by the doctor of ultrasound diagnostics, and this encouragement in itself is an additional stress factor. In this modification, the patient is affected by two kinds of load - physical and psycho-emotional. During a psycho-emotional load, an additional increase in heart rate and blood pressure occurs due to increased secretion of catecholamines, increased vascular resistance with vasoconstriction of the coronary vessels, impaired microcirculation in the myocardium, which leads to a significant increase in myocardial oxygen demand. Simultaneously, the registration of echocardiographic scans from apical access in the projection of a four-chamber and two-chamber section occurs using a 16-segment model in combination with registration of ECG and blood pressure. The progress of the study was recorded in the form of clips on the hard disk of the device.

Regional contractility of the walls of the left ventricle was evaluated from apical access in the projection of a four-chamber and two-chamber section using a 16-segment model. We calculated the index of violation of local contractility of the left ventricle at rest and at the peak of the isometric load using a four-point scale: 1 - normokinesia, 2 - hypokinesia, 3 - akinesia, 4 - dyskinesia (Rybakova MK, Alekhin MN, Mitkov V. B. A practical guide to ultrasound diagnostics. Echocardiography. - M.: Vidar-M., 2008. - 544 p.). Visual analysis of regional LV contractility was carried out by two independent operators in a blind mode, with a difference in diagnosis, the study was evaluated by a third independent operator. The sample was regarded as positive and terminated when detecting violations of local contractility in at least two segments of the left ventricle.

Coronary angiography as a reference method for the diagnosis of coronary artery disease was performed in all patients within three days after stress echocardiography with a combined isometric and psychoemotional load.

The study included 87 people aged 37 to 70, the average age of 53.8 ± 7.3 years with a probable or typical angina pectoris, sent by a cardiologist to conduct stress echocardiography to verify latent myocardial ischemia.

The study included individuals with a regular sinus rhythm, ejection fraction of the left ventricle of more than 55% and preserved global systolic function of the left ventricle, without violations of local myocardial contractility according to standard transthoracic echocardiography. Exclusion criteria were: age older than 70 years, unstable angina pectoris, a history of myocardial infarction, diabetes mellitus or impaired carbohydrate tolerance, valvular heart defects, atrioventricular and intraventricular conduction disorders, organic diseases of the pharynx and esophagus. 2-3 days before the study, all drugs were canceled for patients.

Disorders of local left ventricular myocardial contractility were detected in 53 patients, of which hemodynamically significant coronary lesions were detected in 92.5% of cases (in 49 patients) according to selective coronary angiography. During an isometric test, a violation of local left ventricular myocardial contractility was detected in 84.5% of patients with diagnosed coronary artery disease according to angiography. Thus, the specificity of the method was 85.7%, the sensitivity was 84.5%, which is 40% -45% higher than that of a conventional sample with an isometric load. The positive predictive value of the test was 91.9%. It should be noted that according to the literature, the sensitivity and specificity of stress-echocardiography with dobutamine breakdown in the diagnosis of coronary heart disease is on average 86.3% and 84.1%, respectively, and sterss-echocardiography with dynamic physical activity - 79% and 82%, respectively (Sicari R., Nihoyannopoulos P., Evangelista A. et al. Stress Echocardiography Expert Consensus Statement - Executive Summary: European Association of Echocardiography (EAE) (a registered branch of the ESC) // Eur Heart J. - 2009 .-- No. 30 (3). - S.278-289).

Thus, stress echocardiography with a combined isometric and psychoemotional load can increase the sensitivity of echocardiography in the recognition of coronary artery disease, increase the prognostic value of the technique. The method is affordable, cost-effective and quick to use in the diagnosis of coronary heart disease in an outpatient setting. The test is safe, we did not observe any complications. The resulting myocardial asinergy is completely reversible after the cessation of the sample.

The essential features characterizing the invention, showed in the claimed combination of new properties that are not explicitly derived from the prior art and are not obvious to a specialist.

An identical set of features was not found in the patent and medical literature.

The proposed method can be used in practical health care, does not require special conditions for carrying out, economical in time, easy to operate.

Based on the foregoing, the present invention should be considered relevant to the conditions of patentability "novelty", "inventive step", "industrial applicability".

Claims (1)

A method for the diagnosis of coronary heart disease by stress echocardiography with combined isometric and psycho-emotional load, characterized in that the test is carried out using a combined approach with the simultaneous use of isometric and psycho-emotional load, the isometric load is performed using two ring expanders, which the patient compresses with maximum effort into each arm for the maximum possible period of time - usually within 2-3 minutes, as well as the fact that during execution of an isometric test, an additional psychoemotional load is performed in the form of a constant psychological adjustment of the patient to the maximum pressure of the hand expanders throughout the entire test.