RU2078539C1 - Method for differential diagnostics of painful and painless myocardium ischemia in patients affected with unstable stenocardia - Google Patents

Abstract

FIELD: medicine, cardiology. SUBSTANCE: sensitivity to pain is determined in patient affected with ischemic heart disease to pulsed voltage of 14-16 V at cardiac rhythm frequency. Next patient is subjected to transoesophageal electrocardiostimulation and, in absence of painful sensation followed by deviation of ST segment from isoline at threshold stimulation frequency, painless myocardium ischemia case is considered as confirmed. EFFECT: proposed method makes it possible to carry out differential diagnostics of painful and painless forms of myocardium ischemia.

Description

 The invention relates to medicine, in particular to cardiology, and can be used for the differential diagnosis of myocardial ischemia.

 The development of ischemic reaction to ECG for a long time was considered until recently the equivalent of angina pectoris / 1 /. However, when using stress tests in patients with IVS, it was found that often the reason for their cessation is the development of ECG changes in the absence of anginal pain. Continuous long-term ECG recording showed that the frequency of ST segment deviation from the contour during the day significantly exceeds the total number of angina attacks, since then there is an idea of painless myocardial ischemia / 2 /. A study of the mechanisms of its development, electrocardiographic and hemodynamic characteristics in patients with coronary artery disease, and then long-term monitoring of this category of patients showed that, compared with patients mainly with painful myocardial ischemia, the risk of developing acute myocardial infarction and sudden coronary death sharply increases / 1.2 /, which dictates the need for the earliest possible diagnosis of patients with painless myocardial ischemia.

 However, the methods of differential diagnosis of pain and painless forms used so far have been conceived of a subjective nature and have not noted sufficient reproducibility, which made the diagnosis difficult.

 A method for differential diagnosis of pain and painless myocardial ischemia is proposed. For its implementation in a patient prior to transesophageal pacing, pain sensitivity to an impulse voltage of 14-16 V at a heart rate is determined. In the absence of such and the subsequent deviation of the ST segment from isolation at the threshold stimulation frequency, the painless myocardial ischemia is considered confirmed.

 The aim of the invention is to ensure the reproducibility of the method.

 This goal is achieved by the fact that before the transesophageal electrocardiostimulation, the patient is determined to be sensitive to a voltage pulse of 14-16 V at the heart rate supplied to the probe electrode, and if there is no such and subsequent deviation of the ST segment from isolation at the threshold stimulation frequency, the painless confirmed myocardial ischemia.

 The method is carried out in the following way. Prior to transesophageal electrocardiostimulation, the patient is intranasally injected with a bipolar probe electrode (manufactured by Kamenetz-Podolsky SLE), which is connected to an electrocardiostimulator ("SP-3" company "Temed", Poland). A voltage of 15 V is set on the pacemaker, and after determining the heart rate, the corresponding pulse frequency of the rectangular pulses is set. After 1 min, the subjective sensations of the patient are assessed, characterized as the presence or absence of pain sensitivity. In the future, a stimulation rhythm of 30 impulses / min is imposed on the patient, followed by an increase in the stimulation stage by 20 pulses and a stimulation duration of 2 minutes at each stage. With the development of a typical anginal attack or myocardial ischemia on an ECG, further stimulation is stopped. Subjective pain syndrome is assessed at the incidence of ST segment variance.

 Based on the studied array of patients (n = 300), a randomized sample was made, which is presented in the table according to the significant parameters of the proposed method.

 Clinical example No. 1. Patient K-ko, 56 years old, was admitted to the department at 10 h 20 min in connection with intense sternal compressive pain arising from walking. They first appeared 3 days before hospitalization with accelerated walking and stopped after stopping. On admission objectively: the patient’s condition is moderate, the pain syndrome persists. Hemodynamic parameters are stable: pulse 74 beats per 1 min, blood pressure 145/80 mm Hg Heart sounds are muffled, rhythmic activity. In the lungs, vesicular breathing. The abdomen is soft, painless. No peripheral edema. On the ECG, a depression of the ST segment of the horizontal type of 1.5 mm in leads 1, AVL, V2-4 is recorded. The diagnosis of coronary heart disease: the first arising angina pectoris. To stabilize the patient, analgesics were introduced, intravenous infusion of nitroglycerin was established. At 11 hours 40 minutes on the same day the pain was stopped, signs of myocardial ischemia on the ECG were not recorded. It was decided to differential diagnosis of myocardial ischemia. For this purpose, the patient was intranasally injected with a bipolar probe electrode (manufactured by Kamenetz-Podolsky SKB) and connected to a pacemaker (for example, "SP-3" from the company "Temed", Poland). A voltage of 15 V was set on the pacemaker, and after determining the heart rate, the corresponding frequency of the rectangular pulses was set. After 1 min, the subjective sensations of the patient were evaluated, characterized as the absence of pain sensitivity. A stimulation rhythm was imposed on the patient, which amounted to 80 imp / min, followed by an increase in the stimulation stage by 20 pulses and a stimulation duration of 2 minutes at each stage. At a stimulation frequency of 120 pulses / min, in the 2nd minute of stimulation with monitor control, a horizontal ST segment depression of 1.5 mm was recorded in leads 1, AVL, V5-6, and 2.5 mm in V2-4. Further stimulation discontinued. Subjectively, there was no pain at the incidence of ST segment depression. Registration occurred after 25 cardiocycles. Since there was no pain sensitivity before transesophageal electrocardiostimulation and pain at the height of stimulation also did not occur, painless myocardial ischemia was established with the first occurrence of angina pectoris. The patient was prescribed the following treatment and recommendations in accordance with the specifics of the course of the disease. Due to the fact that the patient is not able to control his sensations, a cardioselective beta-adrenoblocker sectral (400 mg / day, divided into 2 doses) and ticlide (1 tablet twice a day) are constantly prescribed before the repeated outpatient examination during the follow-up.

 Clinical example N 2. A patient B-uk, 52 years old, was admitted to the department with pressing pains in the heart area that intensified over the last 2 weeks, noted a decrease in exercise tolerance, a sharp decrease in the effectiveness of nitroglycerin. Sick about 3 years, when the diagnosis of coronary heart disease, angina pectoris was first established. Upon receipt, the patient’s condition of moderate severity is objectively, relapse of the pain syndrome is noted. Pulse 68 beats in 1 min, blood pressure 125/80 mm Hg Heart sounds are muffled, rhythmic activity. In the lungs, vesicular breathing. The abdomen is soft, painless. No peripheral edema. On the ECG, a depression of the ST segment of the horizontal type of 1.0 mm in leads 1, AVL, V3-6 is recorded. The diagnosis of coronary heart disease: progressive angina pectoris. To stabilize the patient, analgin 50% 2.0 ml and diphenhydramine 1% - 1.0 ml were injected intravenously. The pain was stopped, the ECG returned to normal. For the differential diagnosis of myocardial ischemia, the patient was intranasally injected with a bipolar probe electrode (manufactured by Kamenetz-Podolsky SLE) and connected to a pacemaker apparatus (for example, "SP-3" from the company "Temed", Poland). A voltage of 16 V was set on the pacemaker, and after determining the heart rate, the corresponding frequency of the rectangular pulses was established. After 1 min, the subjective sensations of the patient were evaluated, characterized as a sensation of pain tremors. A stimulation rhythm was imposed on the patient, which amounted to 80 imp / min, followed by an increase in the stimulation levels by 20 pulses and a stimulation duration of 2 mm. At a stimulation frequency of 140 cpm / min, in the 2nd minute of stimulation on the monitor control, a horizontal segment depression of 1.5 mm was recorded in leads 1, AVL, V3-6. Further stimulation discontinued. Subjectively, in addition to changes in the ST segment, pain is noted at the threshold frequency. Restitution came through 35 cardiocycles. Since pain sensitivity arose before transesophageal electrocardiostimulation and pain at the height of stimulation accompanied ECG changes, pain myocardial ischemia was established in a patient with progressive angina pectoris. The patient was prescribed nitrates of prolonged action (nitrosorbide 80 mg / day, divided into 4 doses, aspirin 325 mg / day). If anginal pain occurs, sublingual nitroglycerin is recommended. The duration of treatment until a second outpatient study during the follow-up.

 The inventive method can be widely used in cardiology departments for the diagnosis of pain and painless myocardial ischemia, preceding a load transesophageal electrocardiostimulation. The simplicity of implementation and its safety make it possible to use it for timely diagnosis of various types of myocardial ischemia and the appointment of adequate therapy.

Claims (1)

 A method for differential diagnosis of pain and painless myocardial ischemia in patients with unstable angina pectoris, including transesophageal pacemaking under the control of an electrocardiogram, characterized in that the patient determines pain sensitivity to an impulse voltage of 14 16 V at the heart rate electrode voltage, before applying transesophageal pacing, and in the absence of such and the subsequent deviation of the ST segment from the contour at the threshold stimulation frequency, painless ish is considered myocardialemia confirmed.

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