RU2195872C2 - Method for predicting paroxysms of auricular fibrillation - Google Patents

Abstract

FIELD: medicine, cardiology. SUBSTANCE: a patient undergoes echocardiiographic testing at "M" and "B" modes. Simultaneously, electrocardiogram is registered. The value of intraauricular conductivity is estimated from the onset of electric auricular stimulation till the onset of mechanical contraction of either left or right auricle at "M" mode. In case of antegrade auricular stimulation one should carry out pharmacological cardiac denervation. At development of 1 or more parts of retrograde auricular stimulation before or after denervation it is possible to predict the paroxysms of auricular fibrillation. The method enables to predict the development for the paroxysms of auricular fibrillation during a year after testing, in patients with antegrade auricular stimulation, in particular. EFFECT: higher efficiency of prediction. 3 ex, 3 tbl

Description

 The invention relates to medicine, namely to cardiology, in particular to methods for predicting paroxysms of atrial fibrillation and atrial flutter.

 An analogue of the proposed solution is a method for determining the speed and direction of conduction of excitation (PV) from the atria myocardium, and in patients with paroxysms of atrial fibrillation and atrial flutter (MP and TP), sections of retrograde PV from the atria are determined outside the arrhythmia attack (at the sinus rhythm) (Olesin A. I., Andryushchenko OM The method of determining the speed of excitation on the myocardium - A positive decision on the application for invention N 93028215/14 (027381) from 02.14.1996, priority from 08.24.1993, A. Shabrov, A. Olesin A. I., Golub Y.V., Golub V.I. Clinical the price of using the non-invasive method for determining intra and atrial conduction in patients with coronary heart disease. // Ter. archive. -1999. - 1.-P. 34-39).

 According to the closest technical essence, the prototype is a method for predicting the development of the first occurring paroxysms of MP and TP, and with antegrade PV in the atria, transesophageal electrocardiostimulation (CPEX) is performed at a frequency of 50% more than the frequency of the basic sinus rhythm, and with the development of more than 4% retrograde PV as well as two or more sites of hypo- or akinesia of the walls of the atria before or after stimulation, the development of paroxysms of MP and TP (Olesin A.I., Shabrov A.V., Razumova T.V., Scheglova E.A., Kuharchik G A. Method of nozirovaniya of flicker and flutter paroxysms -. The patent application 2000121411 from 25.08.2000 city).

 The disadvantage of the analogue and the prototype is the lack of accuracy in predicting the paroxysms of MP and TP, as well as the sufficient invasiveness of the NPEX procedure used to predict the development of paroxysms of MP and TP.

 The objective of the invention is to improve the accuracy of predicting the development of paroxysms of MP and TP.

 The problem is solved by the fact that with antegrade PV in the atria, pharmacological denervation of the heart is carried out by intravenous sequential administration of 1.0 mg of atropine and 5 mg of anaprilin, and with the development of 1 or more sections of retrograde PV in the atria before or after denervation, the development of paroxysms of MP and TP is predicted.

 The method is as follows.

где V - скорость ПВ по миокарду в м/сек, А - расстояние между двумя соседними точками сердечной мышцы предсердия, определяемое по эхокардиограмме в "В" режиме в метрах, ИВПП_макс и ИВПП_мин - максимальные и минимальные значения ИВПП, определяемые по эхокардиограмме в "М" режиме в исследуемых точках в секундах. За антеградное ПВ принимают увеличение значений ИВПП от верхушки до основания, а за ретроградный характер распространения возбуждения - увеличение ИВПП от основания до верхушки. При наличии антеградного ПВ по предсердиям больному проводят фармакологическое денервирование сердца путем внутривенного последовательного введения 1,0 мг атропина и 5 мг анаприлина. При развитии 1 или более участков ретроградного ПВ по предсердиям до или после денервирования прогнозируют развитие пароксизмов МП и ТП.An echocardiography with simultaneous ECG examinations in the “M” and “B” modes according to the standard technique is performed for a patient at a sinus rhythm (Feigenbaum H. Echocardiography. - 5th Ed. Philadelphia, Lea and Fibiger, 1994. -695 p.). Then, the atrial conduction index (WFP) is determined (in seconds) from the beginning of the electrical excitation of the atria (wave "p" ECG) to the beginning of the mechanical contraction of the left or right atrium in the "M" mode, and the cursor is placed in these sections of the atria in the "B" perpendicular to the wall of the right and left atrium: one in the upper, two in the middle and the last in the lower third (from the apex to the base: in the region of the anterior wall of the right atrium, interatrial septum of the anterior, posterior and posterior-lateral wall of the lion of the atrium - at only 4 points of the walls of the atria) (Olesin AI, Andryushchenko OM The method for determining the speed of excitation on the myocardium. - A positive decision on the application for the invention N 93028215/14 (027381) from 02/14/1996, priority from 08.24.1993, Shabrov A.V., Olesin A.I., Golub Ya.V., Golub V.I. Clinical assessment of the use of the non-invasive method for determining intra and atrial conduction in patients with coronary heart disease. // Ter.archive. -1999. - 1. -C. 34-39). All indicators of the runway are averaged over the heart rate and calculated as the runway index (runway): runway / RR, where the runway is the atrial conduction time in seconds, RR is the interval of RR sinus rhythm of the ECG in seconds. The direction of the airflow is determined from the minimum to the maximum runway at neighboring points and according to the speed of the airflow between neighboring points. The calculation of the speed of PV in the myocardium is determined by the formula

where V is the myocardial PV velocity in m / s, A is the distance between two adjacent points of the atrial cardiac muscle, determined by the echocardiogram in "B" mode in meters, the runway _max and runway _min are the maximum and minimum runway values determined by the echocardiogram in "M" mode in the studied points in seconds. For antegrade PV, take an increase in runway values from apex to base, and for the retrograde nature of arousal propagation, an increase in runway from base to apex. In the presence of antegrade PV in the atria, the patient undergoes pharmacological denervation of the heart by consecutive intravenous administration of 1.0 mg of atropine and 5 mg of anaprilin. With the development of 1 or more sections of retrograde PV in the atria before or after denervation, the development of paroxysms of MP and TP is predicted.

 The essential distinguishing features of the proposed method are the following: in case of antegrade conduction of excitation (PV) in the atria, pharmacological denervation of the heart is carried out by intravenous sequential administration of 1.0 mg of atropine and 5 mg of anaprilin, and with the development of 1 or more sections of retrograde PV in the atria before or after denervation development of paroxysms of MP and TP.

 A causal relationship between the features in the formula and the result.

 At present, it is known that when registering excitations on the myocardium of the atria or ventricles, PV obeys the law of "drain" from one cardiomyocyte to another (Physiology and pathophysiology of the heart: T.1: transl. From English. - Ed. By N. Sperlaxis. -M : Medicine, 1990, Olshansky B., Okumura K., Hess PO, Waldo AL Demonstration of the area of slow conduction in human atrial flytter. // J. Amer. Coil. Cardiol. - 1991. - Vol. 16, N. 6. - P. 1639 - 1648, Shimisu A., Nosaki A., Rudy Y., Waldo AL Multiplexing studies of effects of rapid atrial pacing on the area of slow conduction during atrial flutter in canine pericarditis model. // Circulation. - 1991. - Vol. 83, N. 3. - P. 983 - 994). Therefore, by directly applying electrodes to the myocardium, the nature and direction of PV in the heart muscle is recorded. In addition, the atrial myocardium is a tissue with a quick response, i.e. the membrane potential of atrial contractile fibers is characterized by rapid depolarization (Physiology and pathophysiology of the heart: T.1: transl. from English. - Ed. by N. Sperlaksis. -M: Medicine, 1990). The onset of depolarization corresponds to electrical excitation of the myocardium, and the input of calcium current through the membrane of cardiomyocytes to the development of mechanical contraction of the myocardium (Physiology and pathophysiology of the heart: T.1: transl. From English. - Ed. N. Sperlaksisa. -M: Medicine, 1990). In our proposed method for determining PV using echocardiography, we used one reference point — the beginning of the atrial myocardial contractile excitation (the beginning of the EC wave “p”), and then we measured the interval from the beginning of the electric atrial excitation to the beginning of the mechanical contraction at different points of the atrial myocardium depolarization or the propagation time of sodium current in the heart muscle of the atria. It should be noted that the interval from the onset of electrical excitation of the myocardium to the beginning of its mechanical contraction in both clinical and experimental studies denotes the time of asynchronous contraction (Physiology and Pathophysiology of the Heart: T.1: transl. From English. - Ed. N. Sperlaxis. -M: Medicine, 1990).

 The results of our previous studies showed that the atrial PV determined using the proposed method for the accuracy of determining atrial conduction is highly correlated with the direct method of fixing the electrodes on the epicardial surface of the atrial myocardium (r = 0.85-0.93) (Olesin A.I. ., Andryushchenko OM The method for determining the speed of excitation on the myocardium - A positive decision on the application for the invention N 93028215/14 (027381) from 02.14.1996, priority from 08.24.1993, A. Shabrov, A. Olesin. , Golub Y.V., Golub V.I. Clinical evaluation mations non-invasive method for determining the inside and atrial conduction in patients with coronary heart disease .// Ter.arhiv -1999 -.. 1. -S.34-39). In addition, using the method described above, knowing the size of the myocardial sections in cm or meters, it is possible to determine the velocity and direction of the PV along the myocardium.

 The presence of supraventricular arrhythmias in patients with coronary artery disease, apparently, is due to the fact that there is a slowdown in PV in the upper and middle parts of the atria, which reflects the dispersion of excitability of the myocardium of the atria (Bokeria L.A. Tachyarrhythmias: Diagnosis and surgical treatment. - L .: Medicine, 1989, Olshansky B., Okumura K., Hess PG, Waldo AL Demonstration of the area of slow conduction in human atrial flytter. // J. Amer. Coil. Cardiol. - 1991. - Vol. 16, N. 6. - P. 1639 - 1648, Shimisu A., Nosaki A., Rudy Y., Waldo AL Multiplexing studies of effects of rapid atrial pacing on the area of slow conduction during atrial flutter in canine pericarditis model. // Circulation. - 1991.- Vol. 83, N. 3. - P. 983 - 994, Zipes DP Genesis of cardiac arrhythmias: electr ophysiological consideraton // Heart Disease / Ed. E. Braunwald, 1984.- P.605-647), and in these patients atrial conduction disturbance is noted long before the increase in atria and other predictors of the development of MP and TP (Shabrov A.V., Olesin A.I., Golub Y.V., Golub V.I. Clinical evaluation of the use of a non-invasive method for determining intra and atrial conduction in patients with coronary heart disease. // Ter. archive. -1999. - 1. -P.34-39). In most patients with supraventricular NDS, in particular, after stopping the first MP and TP paroxysms, when studying at a sinus rhythm, patches of retrograde PV in the atria with a slow (Vpv) and fast (Vapv) excitation propagation are observed, leading to heterogeneous atrial myocardial refractoriness , which is one of the conditions for the formation of re-entry, causing the recurrence of arrhythmias, and is an electropathophysitological substrate for the occurrence of supraventricular arrhythmias (Litvinenko V.A., Olesin A.I., Andryushchenko O.M., Borisov I.A., Shilov V.V.The state of sinus node function, sinoatrial conduction, atrial conduction and the nature of the course of supraventricular cardiac arrhythmias in patients with coronary heart disease before and after CABG. Ter. Archive. 1996. N2.-S. 34-37, Shabrov A.V., Olesin A.I., Golub Y.V., Golub V.I. Clinical evaluation of the use of the non-invasive method for determining intra and atrial conduction in patients coronary heart disease.// Ter.archive. -1999. - 1. -P.34-39) and is referred to by many authors as "electrical remodeling" of the atrial myocardium (Allessie MA, Rensma PL, Brugada J. et al. Pathophysiology of atrial fibrillation.// Cardiac electrophysiology. From cell to bedside. - Eds. Zipes DP, Jalife J. - Philadelphia: WB Saunders, 1990. - P. 548-559, Attuel P., Pellerin D., Gaston J. et al. Latent atrial vulner-abiliti: new means of electrophysiologic investigations in paroxysmal atrial arrhythmias.// The atrium and health disease. / Ed. Attuel P., Coumel P., Janse MJ et al. - NY, 1989 .-- P. 159-200, Rensma PL, Allessie MA, Lammers WJEP et al .Long of excitation wave and susceptibility to reentrant atrial arrhythmias in normal conscious dogs.//Circ. Res. -1990. -Vol. 92. - 4. -P.395-410, Wijffels MCEF, Kirchhof CJHJ, Dorland R., Allessie MA Atrial fibrillation begets atrial fibrillation. // Circulation. - 1995. - Vol. 92. - 6. - P. 1954-1968).

 Currently, pharmacological “denervation” by sequential intravenous administration of atropine at a dose of 1.0 mg and intravenous administration of anaprilin at a dose of 5 mg is used to assess the function of the sinus node during electrophysiological studies using pacemaker, including with CPEX, in particular elderly people and patients with excessive vagal influence (Smetnev A.S., Grosu A.A., Shevchenko N.M. Diagnosis and treatment of heart rhythm disturbances. - Chisinau: Shtinitsa, 1990, Litvinenko V.A., Olesin A. I., Andryushche k.O.M., Borisov I.A., Shilov V.V.The state of sinus node function, sinoatrial conduction, atrial conduction, and the nature of the course of supraventricular cardiac arrhythmias in patients with coronary heart disease before and after CABG. // Ther archive. 1996 .- N2. -S. 34-37, Kushakovsky M.S. Atrial fibrillation. -L.: Medicine, 1999). Our data from 225 patients showed that under conditions of pharmacological “denervation” (in the absence of sympathetic and vagal effects), the sinus node operates autonomously with a natural frequency of 45 to 70 beats per minute (an average of 55 ± 2 beats per minute), and in conditions of the basic rhythmic driving of the sinus node (after pharmacological "denervation") in patients with predicted supraventricular NDS, the development of 1 or more sections of retrograde PV in the atria is observed, which characterizes the presence of "electrical remodeling Ia "atrial myocardium.

 An example of a specific implementation.

 Example 1

 Patient S., 45 years old, was admitted to the day hospital on September 12, 1998. (IB 32847) in the direction of the district doctor about coronary heart disease: angina pectoris, periodic heart attacks. From the anamnesis it is known that the patient suffers from coronary heart disease: angina pectoris II functional class over the past 4-5 years. Constantly takes nitrong at a dose of 6.4 mg per day, aspirin at a dose of 300-400 mg per day, atenolol at a dose of 25-50 mg per day. In the last 3-4 months, I began to notice the appearance of interruptions in the work of the heart. With daily ECG monitoring performed on an outpatient basis on July 1, 1998, a single and paired atrial extrasystole (PE) was detected with a frequency of up to 1-2 per hour.

где V - скорость ПВ по миокарду в м/сек, А - расстояние между двумя соседними точками сердечной мышцы предсердия, определяемое по эхокардиограмме в "В" режиме в метрах, ИВПП_макс и ИВПП_мин - максимальные и минимальные значения ИВПП, определяемые по эхокардиограмме в "М" режиме в исследуемых точках в секундах.According to the clinical and instrumental examination, the patient’s condition was regarded as coronary heart disease in a hospital: stable angina pectoris of functional class II, data for the presence of “fresh” focal myocardial changes were not detected. The patient was continued therapy with 5.2 mg nitrong per day, aspirin, epalopril (ednit) at a dose of 5 mg per day. On the second day of the patient’s stay in the hospital, echocardiography with simultaneous ECG studies was performed. Then, the runway index (in seconds) was determined from the onset of electrical excitation of the atria (wave "p" ECG) to the onset of mechanical contraction of the left or right atrium in the "M" mode, and the cursor was placed in these "at" sections of the atrium perpendicular to the wall of each atria: one in the upper, two in the middle and the last in the lower third (from the apex to the base: in the region of the anterior wall of the right atrium, the atrial septum of the anterior, posterior and posterior-lateral walls of the left atrium - only 4 points of the walls of the inoculation) according to the previously described method (Olesin A. I., Andryushchenko OM. Method for determining the rate of excitation by the myocardium. - A positive decision on the application for the invention N 93028215/14 (027381) from 02.14.1996, priority from 08.24.1993 , Shabrov A.V., Olesin A.I., Golub Ya.V., Golub V.I. Clinical evaluation of the use of the non-invasive method for determining intra and atrial conduction in patients with coronary heart disease. // Ter. Archive. -1999. - 1. -C. 34-39). All indicators of the runway were averaged by heart rate and calculated as the runway: runway / RR, where the runway is the atrial conduction time in seconds, RR is the interval of RR sinus rhythm of the ECG in seconds. The direction of the PV was determined from the minimum to the maximum runway at neighboring points and by the speed of the PV between neighboring points of the atrial cardiac muscle. The calculation of the velocity of PV in the myocardium was determined by the formula

where V is the myocardial PV velocity in m / s, A is the distance between two adjacent points of the atrial cardiac muscle, determined by the echocardiogram in "B" mode in meters, the runway _max and runway _min are the maximum and minimum runway values determined by the echocardiogram in "M" mode in the studied points in seconds.

 The results of the runway in patient S., 45 years old, are presented in table 1. As can be seen from table 1, in patient S., aged 45, an increase in the value of the runway from the apex to the base of the atria, i.e. the antegrade nature of PV in the atria (see Table 1, baseline data). When assessing regional myocardial contractility, a normokinetic contraction of the walls of the atria was revealed. When analyzing echocardiographic parameters determined according to the generally accepted methodology (Feigenbaum H. Echocardiography. - 5th Ed. Philadelphia, Lea and Fibiger, 1994. -695 p.), Aortic fibrosis, interventricular septum, and diastolic left ventricular dysfunction (DLC) were detected: the velocity of the trasmitral blood flow in the phase of early (E) and late (A) filling was 55.2 m / s and 62.6 m / s, respectively, and their E / A ratio was 0.88, while the contractile function of the left the ventricle did not go beyond the limits of fluctuations of normal values. Atropine was administered intravenously to the patient at a dose of 1.0 mg, and then anaprilin was administered intravenously at a dose of 5 mg, and after 10 minutes the nature of PV in the atria was re-determined. After pharmacological denervation, 16% of myocardial sites with retrograde PV in the atria were observed. It should be noted that in addition to the runway values, with NPEX, indicators reflecting the function of the sinus node, such as the time of restoration of the function of the sinus node, the corrected time of restoration of the function of the sinus node, the time of sinoatrial conduction, determined according to the generally accepted method (Kushakovsky M.S. L .: Medicine, 1993), did not go beyond the limits of fluctuations of normal values. Then MP was induced by the method of volley super-frequent stimulation, and the threshold for arrhythmia induction (PIA) was 650 imp / min. Arrhythmia stopped on its own after 1 minute. Subsequently, the patient was treated with nitrates, aspirin, renitek (enalopril) at the doses indicated above. Antiarrhythmic drugs were not prescribed. Spontaneous seizures of MP and TP, lasting from several seconds to 1-3 minutes, were detected during 24-hour ECG monitoring 10 months after the above examination, and when performing PEEX in the same period (10 months after the first stimulation), the PIA was 420 imp / min

 This example showed that with the development of retrograde PV of the atria after the pharmacological denervation of atropine and anaprilin, with the initial antegrade PV, it is possible to predict MP and TP paroxysms within 10 months after the examination.

 Example 2

 Patient R., 67 years old, was admitted to the hospital on September 29, 1998, under the direction of an ambulance doctor (ИБ N 23357) regarding coronary heart disease: progressive angina pectoris. From the anamnesis it is known that the patient suffers from coronary heart disease: angina pectoris of functional class II over the past 3 years. Constantly takes Sustak, antiplatelet agents. Two days before hospitalization, the patient sore anginal pain in frequency, duration, intensity, and the nature of the pain syndrome changed. Hospitalization in a hospital.

 In a hospital, according to clinical and instrumental examination, the patient's condition was regarded as coronary heart disease: progressive angina pectoris, data for the presence of "fresh" focal myocardial changes were not detected. The patient was continued therapy with sustonitis at 19.2 mg per day, aspirin at a dose of 300 mg per day.

где V - скорость ПВ по миокарду в м/сек, А - расстояние между двумя соседними точками сердечной мышцы предсердия, определяемое по эхокардиограмме в "В" режиме в метрах, ИВПП_макс и ИВПП_мин - максимальные и минимальные значения ИВПП, определяемые по эхокардиограмме в "М" режиме в исследуемых точках в секундах.On the second day of the patient’s stay in the hospital, echocardiography with simultaneous ECG studies was performed. Then, the runway index (in seconds) was determined from the beginning of the electric excitation of the atria (wave “p” ECG) to the beginning of the mechanical contraction of the left or right atrium in the “M” mode, and the cursor was placed in these “sections” of the atrium perpendicular to the wall of each atria: one in the upper, two in the middle and the last in the lower third (from the apex to the base: in the anterior wall of the right atrium, atrial septum of the anterior, posterior and posterior-lateral walls of the left atrium - only 4 points of the walls of the inoculation) according to the previously described method (Olesin A.I., Andryushchenko O. M. The method for determining the rate of excitation by the myocardium. - Positive decision on the application for the invention N 93028215/14 (027381) from 02.14.1996, priority from 08.24.1993 , Shabrov A.V., Olesin A.I., Golub Ya.V., Golub V.I. Clinical evaluation of the use of the non-invasive method for determining intra and atrial conduction in patients with coronary heart disease. // Ter. Archive. -1999. - 1. -P.34-39). All indicators of the runway were averaged over the heart rate and calculated as the runway: runway / RR, where the runway is the atrial conduction time in sec, RR is the interval of the RR sinus rhythm of the ECG in sec. The direction of the PV was determined from minimum to maximum runway at neighboring points. The calculation of the velocity of PV in the myocardium was determined by the formula

where V is the myocardial PV velocity in m / s, A is the distance between two adjacent points of the atrial cardiac muscle, determined by the echocardiogram in "B" mode in meters, the runway _max and runway _min are the maximum and minimum runway values determined by the echocardiogram in "M" mode in the studied points in seconds.

 The results of the runway in patient R., 67 years old, are presented in table. 2. As can be seen from the table. 2, in patient R., 67 years old, an increase in the value of the runway from the apex to the base of the atria, i.e. the antegrade nature of PV in the atria (see table 2, baseline data). When assessing regional myocardial contractility, a normokinetic contraction of the walls of the atria was revealed. When analyzing echocardiographic parameters determined by the generally accepted methodology (Feigenbaum N. Echocardiography. - 5th Ed. Philadelphia, Lea and Fibiger, 1994. -695 p.), Aortic fibrosis was detected, interventricular hypokinesia, the E / A ratio was 1.12 , and the contractile function of the left ventricle, including the volume of the left atrium, did not go beyond the fluctuations of normal values. Atropine was administered intravenously to the patient at a dose of 1.0 mg, then anaprilin was administered intravenously at a dose of 5 mg, and after 10 minutes the nature of PV was determined from the atria according to the method described above (see Table 2, after PD). After pharmacological denervation, there was a development of 14% of the areas of retrograde PV in the atria. It should be noted that in addition to the runway values, with NPEX, indicators reflecting the function of the sinus node, such as the time to restore the function of the sinus node, the corrected time to restore the function of the sinus node, and the time of sinoatrial conduction, did not go beyond the limits of normal values.

 Then MP was induced by the method of volley super-frequent stimulation, and the PIA was 440 imp / min. Arrhythmia stopped on its own after 3 minutes. Subsequently, the patient was treated with nitrates, aspirin, renitek (enalopril) at the doses indicated above. Antiarrhythmic drugs were not prescribed. Spontaneous MP paroxysm developed on the 9th day of the patient’s hospital stay and was stopped by the intravenous administration of procainamide at a dose of 1000 mg. As an anti-relapse therapy of MP and TP paroxysms, the patient was prescribed sotalol at a dose of 80 mg per day. Arrhythmia did not recur for 3 years, moreover, when repeated (11 months after the appointment of sotalol), PIA with the help of NPEX values of this indicator amounted to 1020 imp / min.

 This example showed that in patients it is possible to predict the development of MP and TP paroxysms with the development of more than 9% of sites with retrograde PV in the atria after pharmacological denervation by the administration of atropine and anaprilin. It should be noted that the patient’s left atrium volume did not go beyond the normal range.

 Example 3

 Patient A., 49 years old, was admitted to the hospital on 05/11/1997 in the direction of a doctor at the polyclinic (IB No. 2878) for coronary artery disease: first-time angina. From the anamnesis it is known that the patient previously considered himself practically healthy.

 In the hospital, according to clinical and instrumental examination, the patient's condition was regarded as coronary heart disease: angina pectoris, data for the presence of "fresh" focal myocardial changes were not detected. The patient was initiated therapy with erinitis at 40 mg per day, aspirin at a dose of 300 mg per day, and zocor 20 mg per day.

где V - скорость ПВ по миокарду в м/сек, А - расстояние между двумя соседними точками сердечной мышцы предсердия, определяемое по эхокардиограмме в "В" режиме в метрах, ИВПП_макс и ИВПП_мин - максимальные и минимальные значения ИВПП, определяемые по эхокардиограмме в "М" режиме в исследуемых точках в секундах.On the fourth day of the patient’s stay in the hospital, echocardiography with simultaneous ECG studies was performed. Then, the runway index (in seconds) was determined from the beginning of the electric excitation of the atria (wave “p” ECG) to the beginning of the mechanical contraction of the left or right atrium in the “M” mode, and the cursor was placed in these “sections” of the atrium perpendicular to the wall of each atria: one in the upper, two in the middle and the last in the lower third (from the apex to the base: in the anterior wall of the right atrium, atrial septum of the anterior, posterior and posterior-lateral walls of the left atrium - only 4 points of the walls of the inoculation) according to the previously described method (Olesin A.I., Andryushchenko O. M. The method for determining the rate of excitation by the myocardium. - Positive decision on the application for the invention N 93028215/14 (027381) from 02.14.1996, priority from 08.24.1993 , Shabrov A.V., Olesin A.I., Golub Ya.V., Golub V.I. Clinical evaluation of the use of the non-invasive method for determining intra and atrial conduction in patients with coronary heart disease. // Ter. Archive. -1999. - 1. -C. 34-39). All indicators of the runway were averaged over the heart rate and calculated as the runway: runway / RR, where the runway is the atrial conduction time in sec, RR is the interval of the RR sinus rhythm of the ECG in sec. The direction of the PV was determined from minimum to maximum runway at neighboring points. The calculation of the velocity of PV in the myocardium was determined by the formula

where V is the myocardial PV velocity in m / s, A is the distance between two adjacent points of the atrial cardiac muscle, determined by the echocardiogram in "B" mode in meters, the runway _max and runway _min are the maximum and minimum runway values determined by the echocardiogram in "M" mode in the studied points in seconds.

 Patient A., 49 years old, showed an increase in the runway value from the apex to the base of the right atrium, i.e. the antegrade nature of PV in the atria. The patient was treated with nitrates, aspirin, renitek (enalopril) at the doses indicated above. Antiarrhythmic drugs were not prescribed. When analyzing echocardiographic parameters determined according to the generally accepted methodology (Feigenbaum H. Echocardiography. - 5th Ed. Philadelphia, Lea and Fibiger, 1994. -695 p.), Aortic calcification, interventricular hypokinesia were detected, the E / A ratio was 1.14 , and the contractile function of the left ventricle, including the volume of the left atrium, did not go beyond the fluctuations of normal values. Atropine was administered intravenously to the patient at a dose of 1.0 mg, then anaprilin was administered intravenously at a dose of 5 mg, and after 10 minutes the nature of PV was determined from the atria according to the method described above. After pharmacological denervation in patient A., 49 years old, antegrade PV in the atria remained. The patient was discharged from the hospital after stabilization of angina pectoris to functional class II.

 After discharge from the hospital, arrhythmia was not observed for 3 years.

 This example showed that in a patient while maintaining antegrade PV in the atria, before and after pharmacological denervation of atropine and anaprilin, the development of arrhythmia was not observed.

 There were 225 patients with coronary artery disease. All patients underwent echocardiography with simultaneous ECG examinations with the determination of the runway index (in seconds) from the beginning of the electric excitation of the atria (wave “p” ECG) to the beginning of the mechanical contraction of the left or right atrium in the “M” mode, and the cursor was placed in these sections of the atrium in the "In" mode, perpendicular to the wall of each atrium: one in the upper, two in the middle and the last in the lower third (from the apex to the base: in the region of the anterior wall of the right atrium, interatrial septum of it, of the posterior and posterior-lateral wall of the left atrium - at only 4 points of the walls of the atria) according to the previously described method (Olesin AI, Andryushchenko OM The method of determining the speed of excitation by the myocardium. - A positive decision on the application for invention N 93028215/14 (027381) from 02.14.1996, priority from 08.24.1993, Shabrov A.V., Olesin A.I., Golub Y.V., Golub V.I. Clinical evaluation of the use of the non-invasive method for determining intra and atrial conduction in patients with coronary heart disease. // Ter.archive. -1999. - 1. -C. 34-39). All indicators of the runway were averaged over the heart rate and calculated as the runway: runway / R-R, where the runway is the atrial conduction time in sec, R-R is the R-R interval of the ECG sinus rhythm in sec. The direction of the PV was determined from the minimum to the maximum runway at neighboring points.

 In all patients, the prognosis of MP and TP paroxysms was carried out according to the proposed method and according to the prototype, according to which the development of these arrhythmias was predicted by assessing PV in the atria before and after CPEKS (Olesin A.I., Shabrov A.V., Razumova T.V. , Scheglova EA, Kukharchik GA A method for predicting the development of paroxysms of atrial fibrillation and atrial flutter. - Patent Application 2000121411 of 08.25.2000).

 Statistical analysis of the results was carried out on a computer.

 In 83 (36.89%) of the 225 examined patients, antegrade PV was observed, while in the rest, an average of 23 ± 1% of the sections of retrograde PV of the atria was revealed. All patients underwent therapy with nitrates, antiplatelet agents, angiotensin-converting enzyme inhibitors (renitec, enalopril, enap). All patients with antegrade PV in the atria underwent CPEX, and then pharmacological denervation of the heart by sequential intravenous administration of 1.0 mg of atropine and 5 mg of anaprilin followed by determination of the state of PV in the atria according to the method described above (see above).

 The results of the study showed that in 10 (12.05%) and 44 (53.01%) of 83 patients, after pharmacological denervation and CPEX, antegrade PV remained, while the remaining patients showed an average development of 25 ± 1% and 21 ± 1% of the sections of the retrograde distribution of excitation in the atria after pharmacological denervation and CPEX, respectively. In all patients with preservation of antegrade PV in the atria after pharmacological denervation, supraventricular NDS, including MP and TP paroxysms, were not observed for 3 years of observation, while the remaining 65 (89.04%) of 73 patients for whom according to the proposed the development of these arrhythmias was predicted by the method, their development was noted within 1 year after the first examination. Only 32 (72.73%) of 44 patients in whom the development of supraventricular NDS using the prototype (CPEX) was predicted had the development of these arrhythmias (P <0.001).

 Thus, more accurately (on average by 47.92%), it is possible to predict the development of MP and TP paroxysms using the proposed method in comparison with the prototype (see table. 3).

 The proposed method allows to increase the accuracy of predicting the development of MP and TP paroxysms for 1 year or more after the first examination, and in particular in patients with antegrade PV in the atria, which will ensure the appointment of an adequate antirecurrent AAT of paroxysms of these rhythm disturbances.

Claims (1)

 A method for predicting paroxysms of atrial fibrillation and flutter by conducting echocardiography with simultaneous electrocardiography, characterized in that during antegrade excitation (PV) in the atria, pharmacological denervation of the heart is carried out by sequential intravenous administration of 1.0 mg of atropine and 5 mg of anaprilin and with development, 1 or more sections of retrograde PV in the atria before or after denervation predict atrial paroxysms and atrial flutter.

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