RU2197173C2 - Method for predicting complications in case of myocardial infarction - Google Patents

Abstract

FIELD: medicine, cardiology. SUBSTANCE: during the first day of myocardial infarction after applying a thrombolytic therapy one should detect the signs-predictors of uncomplicated disease flow. Both diagnostic and curative tactics should be determined. Beginning since the second day one should detect interrelated complexes of symptoms, quantitative values, parameters individually for every patient. They'll help to evaluate the risk of lethality and possibility for the development of cardiac rhythm lesions and conductivity, acute heart failure relapsing disorders of coronary circulation in acute period. Ventricular tachyarrhythmias and acute cardiac aneurysm are detected. Lethal result in acute and remote periods of infarction are predicted due to clinical, instrumental, laboratory data and medicinal computerized technologies, statistic calculating programs, discriminant and regression analysis. EFFECT: higher efficiency of prediction. 2 dwg, 3 tbl

Description

 The invention relates to the field of clinical cardiology, in particular to the treatment of patients with myocardial infarction (MI), and can be used in cardiology centers, hospitals, hospitals, resorts, clinics, as well as in the departments of cardiology of medical universities.

 The problem of treating large focal myocardial infarction is one of the leading problems in modern cardiology, which is caused, on the one hand, by the persistent high mortality and disability of patients, and, on the other, by the high frequency of the spread of this disease (Chazov E.I. et al., 1987; Oganov R.G. ., 1990; Ronald V.F. Campbell et al., 1997; Barbagelata A. et al., 1997).

 Predicting the development of MI complications is necessary to identify patients in whom certain medical interventions can improve clinical outcomes. Therefore, assessing the risk of complications in a particular patient is an essential component of clinical tactics (Makarov I.M. et al., 1997; Gelfand I.M. et al., 1997; Vinogradov A.V. et al., 1999; Bisi et al ., 1996; Peterson ED et al., 1997). The doctor’s first impression of the likelihood of developing MI complications is formed on the basis of the medical history collected at admission, the results of the examination of the patient and the ECG. Data from various diagnostic studies supplement this information. The prognosis of many patients can be judged fairly accurately no earlier than the fifth day from the onset of the disease. And only a comprehensive assessment of clinical, laboratory and instrumental data using modern methods of medical statistics can make it possible to predict with high reliability the development of MI complications in the first day of the disease (Ardashev V.N., 1990; Murakami T. et al., 1996; vom-Dahl J. et al., 1996; Peterson ED et al., 1997). Differentiated therapy of groups of patients selected at the beginning of the disease with a favorable clinical outcome on the one hand and a high risk of developing various complications on the other allows increasing the effectiveness of treatment and maximizing the economic feasibility of using medical devices and resources (Ruda M. Ya., 1993; Braunwald E., 1989; Harrison, T.R. et al., 1995).

 The closest medical-technical solution, selected as a prototype method for the treatment of MI, is a known method for the treatment of large focal MI, described in / 3 /. This method for predicting the complications of a patient with myocardial infarction includes assessing the immediate outcome of a heart attack according to the clinical data of the patient admitted to the hospital, the onset of an acute attack, with pathological Q or QS teeth formed on the electrocardiogram no later than the first three days after hospitalization, assessment of heart failure and the nature of anginal pain with using the construction of structural units of heart failure in the acute period of heart attack, the choice of the prognostic rule for predicting complications and using the course of a heart attack based on the structural units of heart failure and anginal pain in the acute period. It also includes the compilation of algorithms for an unfavorable, relatively favorable and favorable prognosis of the immediate outcome of a heart attack, an assessment of the results of a patient’s prognosis at the first level of formalization of the disease, and quantitative indicators and signs at the second, computer level with the influence of drugs received by the patient on his physiological parameters - heart rate , respiratory rate, blood pressure and others.

The prototype method has the following disadvantages:
1). It has not developed enough rules to predict the outcome of myocardial infarction and the likelihood of developing certain complications at the inpatient stage of treatment already on the first day of the disease.

 2). The previously proposed prognostic rules, as well as the known prototype method, are outdated, since they do not take into account the introduction into clinical practice of new medical devices, including thrombolytic therapy (TLT) (A. Syrkin et al., 1993; Herlitz J. et al. , 1996; Khattar RS et al., 1996; Poldermans D. et al., 1997). Therefore, even now, studies on predicting the complications of myocardial infarction have not lost their relevance, and the real conditions under which most cardiologists in our country work, force us to use traditional clinical and laboratory-instrumental signs in developing prognostic rules (Syrkin AL et al., 1997 ; Shevchenko Yu.L. et al., 1998).

 3). The use of TLT in the prototype in the treatment of patients with myocardial infarction significantly reduced the frequency of complications and hospital mortality in this disease (Kaji Y. et al., 1996; Yusuf S. et al., 1996; William R. Nathway et al., 1998). However, in the long-term MI period, the survival of patients did not depend on the results of thrombolysis (A. Golikov et al., 1992; L. T. Malaya et al., 1995; A. Gospodarenko, 1998). In patients who received TLT, there was an increase in the incidence of recurrent coronary circulatory disorders (RRCC) compared with patients who did not receive this treatment (I. Kharash et al., 1998, Basu S. et al., 1996).

 4). To reduce the incidence of acute heart failure (AHF) and hospital mortality in the prototype, in the acute period of MI, angiotensin converting enzyme (ACE) inhibitors are used. However, there are different opinions regarding the selection criteria for patients who need to prescribe these drugs in the acute period of myocardial infarction, and there are conflicting views on the advisability of prescribing ACE inhibitors from the first day of the disease (I. Lazarev et al., 1996; Preffer MA et al., 1992 ; Galcera-Tomas J. et al., 1993; Erhardt L., 1996; Ferrari R. et al., 1996; van-Gilst et al., 1996; Kober L., et al., 1997).

 5). When predicting the complications of myocardial infarction, the prototype method does not use group medical computer videoconferences between cardiologists of the functional diagnostics center of the hospital and other leading medical institutions and the treating physicians of the resuscitation and intensive care units of the cardiology center of the hospital.

 6). The prototype did not solve the urgent problem of cardiology for early prediction of the development of complications of large focal myocardial infarction, which would allow for preventive therapy and reduce hospital mortality. In the domestic literature, we did not find works devoted to the identification of clinical predictors and the prognosis of complications of large focal myocardial infarction after the use of TLT.

 7). The known method does not record the features of the treatment of myocardial infarction and surgical operations on the heart, aorta and coronary vessels in cardiopulmonary bypass, and they do not provide for the entry and storage in cardiology databases of information about the passport and anthropometric parameters of each patient, under the number of his medical history they do not register a diagnosis, data on complications, the nature of coronary artery disease, the duration of cardiopulmonary bypass, time of aortic compression, blood tests, details of the operation and the postoperative period.

 8). The prototype method does not provide simultaneous transmission of audio, video and digital data on a single channel using the integration of network technologies and local area networks, while it does not have a forecast using a neural network computer package of a dangerous increase in blood pressure and deviations of other parameters from norms in each patient.

 9). The development of recurrent coronary circulation disorders lengthens the inpatient treatment of patients, increases in-hospital mortality. Reducing the volume of myocardial necrosis in the area of a myocardial coronary artery, TLT does not eliminate either its residual stenosis or stenotic changes in other heart arteries, which leads to a high risk of repeated coronary catastrophes in this group of patients. However, the prototype method does not predict the development of RRKK.

 10). The main disadvantage of the prototype method is that the prediction of the outcome of MI is provided for patients who have already survived the acute period of the disease after the first 3-4 days, and not on the first or second day after MI, i.e. the outcome is predicted within 4-6 weeks after an acute MI attack. This prediction is only useful for patients who are discharged home or sent to a rehabilitation hospital (sanatorium).

 The objective of the invention is to increase the effectiveness of the treatment of patients with myocardial infarction by identifying groups of patients with suspected uncomplicated and complicated myocardial infarction, predicting the development of its individual complications and outcomes by signs of the first day of the disease due to a comprehensive assessment of clinical, laboratory, instrumental data and the use of computer technology.

 The problem is solved in such a way that on the first day of myocardial infarction after applying thrombolytic therapy, signs-predictors of the uncomplicated course of the disease are identified, diagnostic and therapeutic tactics are determined, and starting from the second day, interconnected sets of symptoms, quantitative values of indicators, parameters are individually determined for each patient and with their help, they assess the risk of death and the likelihood of developing in the acute period of cardiac arrhythmias and conduction disturbances, acute heart failure accuracy, recurrent disorders of coronary circulation. In this case, acute aneurysm of the heart is determined, a fatal outcome is predicted in the acute and long-term periods of heart attack with the help of clinical, instrumental, laboratory data and the use of medical computer technologies, statistical computing programs, discriminant and regression analysis.

 The course of large-focal myocardial infarction currently has clinical features that require new approaches to the diagnosis and prediction of complications of the disease. Therefore, the use of the proposed predictors for the development of uncomplicated myocardial infarction after the use of thrombolytic therapy makes it possible to identify patients with a low risk of complications.

 Based on the mathematical models developed in the claimed method, the development of complications and the outcome of the disease in patients with myocardial infarction after thrombolytic therapy are predicted and preventive treatment is carried out.

 Figure 1 shows the algorithm of diagnostic tactics in the allocation of patients with uncomplicated MI. Figure 2 shows the algorithm of therapeutic and diagnostic tactics in patients with myocardial infarction in assessing the likelihood of developing recurrent coronary circulation disorders.

 The inventive method is as follows. The restoration of the cardiovascular system of each MI patient includes interconnected integrated technologies of medical, physical and psychological rehabilitation. Medical rehabilitation includes the diagnosis, prognosis, prevention and treatment of coronary and heart failure, cardiac arrhythmias and conduction disorders, concomitant diseases, as well as the prevention of the progression of atherosclerosis. First of all, they evaluate the general functional state of the patient and the long-term consequences of her treatment, stabilize hemodynamic disorders, external respiration functions, monitor the first stages of physical rehabilitation, and ensure psychological readaptation. With the help of physical and psychological rehabilitation, they improve the functional state of the circulatory system by stimulating extracorporeal mechanisms while training the heart and coronary circulation, restore and develop full breathing, contribute to the elimination and prevention of complications, increase overall motor activity, affect the general and emotional tone, and contribute to improvement functional state of the nervous system and cerebral circulation, vaccinate self-ki with the purpose of conscious participation of the patient in the recovery of his health.

 First, the first group of patients with an uncomplicated heart attack or a low risk of developing its complications is distinguished, and an algorithm of diagnostic tactics is chosen to determine preventive therapy, based on comparison with the norm of the following predictors of uncomplicated heart attack on the first day of the disease - age less than 58 years, absence of pre-infarction, a month before heart attack, unstable angina, heart rate before thrombolytic therapy is less than and equal to 78 beats / min, the average elevation of the ST segment before thrombolytic erapiey less than or equal to 6.0 mm and then TLB less than or equal to 4.0 mm, the quantity of the electrocardiogram QT interval teeth before TLB less than or equal to 38 ms, the presence of myocardial reperfusion, the value of the total ejection fraction in the first day of myocardial than or equal to 41%. Moreover, with a probability of uncomplicated heart attack equal to at least 95%, each patient who has all eight signs below predetermined thresholds is included in the first group of low risk of complications. Then, in patients of the first group, the probability of developing complications and the risk of death in the acute period of the disease are assessed, and the second group includes patients with complicated heart attack, in whom the predictors of heart attack on the first day are in contrast to the above norm. If coronary insufficiency of the cardiovascular system is detected, an intermittent intake of nitrates of medium duration is prescribed - Sustac-forte and / or Sustonit-forte in single doses of 6.4 mg, nitrong-forte 6.5 mg, nitrosorbide (isodinite) 10, 20 mg, and in cases of development of tolerance to nitrates, the drug is canceled for 3-5 days and replaced with corinfar (kordafen), molsidomin (corvaton). With prolonged-action nitrate inefficiency and concomitant hypertension, especially with the hyperkinetic type of hemodynamics, beta-blockers are prescribed - obzidan or anaprine at a dose of 40-120 mg / day or more, predicted - 40-60 mg / day, and with concomitant chronic respiratory diseases system, diabetes mellitus, disorders of atrioventricular conduction, receive cardioselective beta-blockers - cordanum 200-400 mg / day, betalok - 100-300 mg / day. When detecting cardiac arrhythmias and patient conduction, antiarrhythmic drugs cordarone - 600 mg / day (saturation dose) are used to treat ventricular extrasystoles until a clinical effect is obtained with a further dose reduction to a maintenance of 100-200 mg / day or sotalol 40-80 mg / cyt combined with sedatives - valerian, motherwort, valocardine, tazepam. Moreover, 1-2 reserve drugs are selected that are effective for this patient, due to the possible development of tolerance to drugs with their long-term use.

 The treatment of acute cardiac circulatory failure is carried out in the intensive care unit using adrenomimetics, peripheral vasodilators - drugs of nitroglycerin and isosorbide dinitrate prolonged action, ACF inhibitors. In case of circulatory failure of the second stage, captopril, acupro, prestarium blockers are used, as well as isosorbide dinitrate preparations - nitrosorbide, isoket, etc., and if they are ineffective, cardiac glycosides are prescribed in maintenance doses, which reduce, when pronounced sinus bradycardia occurs, less than 50 strokes in 1 min, in combination with thiazide diuretics - hypothiazide at a dose of 50-150 mg / day in two divided doses or non-thiazide sulfonamides - brinaldins 20-60 mg / day in one dose, in combination with potassium-sparing diuretic mi - veroshpiron - 12-150 mg / day, triampur - 100-120 mg / day, and if this therapy is ineffective, more powerful diuretics are prescribed - furosemide - 40-200 mg / day or uregitis - 50-200 mg / day, taking the whole doses once, in the morning on an empty stomach, with the addition of aminophylline or theophylline, which improve renal blood flow. In a patient with IM with arterial hypertension, the main risk factor for acute and chronic forms of cerebrovascular accident, cerebral hemodynamics are assessed using rheoencephalography, and the most positive hemodynamic and clinical effects are observed in patients with angiospastic type of cerebral hemodynamics, differentially prescribing physiotherapeutic procedures depending on them on the type of cerebral hemodynamics disorders. Moreover, with the angiospastic type, the pulse blood supply to the brain is increased, the excessive increase in the tone of the cerebral arteries is removed by the combined effect of the strength of an alternating magnetic field, acupuncture, softwood pearl baths, physiotherapy exercises and individual medications for homeopathic therapy, and with a mixed type of cerebral hemodynamic disorders, when venous outflow is difficult to reduce arterial inflow, electrophoresis with aminophylline on the collar zone is prescribed, collar massage kovoy zone information-wave therapy, exercise therapy and gomeoterapiyu in combination with conventional cardiac drugs such as auxiliary agent series.

 In this case, the selection of homeopathic remedies is carried out both according to the classical Hahnemann technique, and using the diagnosis according to Fole.

 Statistical processing of the results of experimental studies when analyzing the clinical picture of large-focal myocardial infarction in patients who received thrombolytic therapy is carried out using more than 140 signs, indicators and measured parameters, the information content of which is evaluated by the effectiveness or percentage of the relative total value of the differences of each indicator in the comparison groups and the predicted severity heart attack complications. The latter are determined using a package of computing programs such as Statistica 5.1 for Windows-98 and mathematical models for predicting complications and the outcome of a heart attack, constructed in the form of decision rules using discriminant and regression analysis.

 In this case, a non-parametric correlation analysis of independent signs is carried out and the predicted severity of recurrent coronary circulation disorders is determined on a ten-point scale for each patient with myocardial infarction (IM) using a computer-resolved rule in the form of a discriminant regression equation. Moreover, a nonparametric correlation analysis of clinical predictors of RRCC development is carried out in patients with MI of three comparison groups. In these patients, a direct relationship between recurrent coronary circulation disorders and pre-infarction angina (a correlation coefficient r = 0.74, p <0.001), also with a score of pain before TLT (r = 0.58, p <0.001), non-transmural necrosis is revealed myocardium (r = 0.40, p <0.03), with diabetes mellitus (r = 0.36, p <0.03), hypertension (r = 0.33, p <0.05), which is significantly 3 patients with relapse of MI are more often noted in patients. In this case, 7 selected independent signs are determined and the predicted complication severity is calculated in points with a probability of 80%, as a result, for the 1 group of patients without RRCC, the predicted complication severity is obtained in (2.4 - 5.4) points, for 2 groups of patients in whom MI was complicated by the development of post-infarction angina pectoris, they received severity of RRCC in (5.8-6.8) points, and for the 3rd group - in (9.0-9.8) points with an efficiency of explained variance of predicted severity of RRCC of at least 54%, exceeding the information content of all individual signs in 2 times and worth fidelity of the mathematical model according to coinciding forecasts of complications of RRCC in 78%.

 Then assess the likelihood of complications and the risk of death in the acute period of the disease in patients with probable, but not obligatory development of complications, in which at least one of the signs predicting the uncomplicated course of MI is absent. Why are patients divided into groups with a favorable and unfavorable course of the disease and additional diagnostic and treatment procedures are determined for them. In this case, a mathematical forecasting model is used according to the first day of myocardial infarction taking into account the most unfavorable symptom - arterial hypotension before TLT, as well as a history of stroke, shortness of breath on the 1st day with a respiratory rate of up to 2 per minute, less than or more than 26 breaths in min, taking into account the development of complete atrioventricular and intraventricular blockade on the 1st day of myocardial infarction, the average elevation of the ST segment after TLT and the magnitude of the constant member of the regression equation. Moreover, if when solving the obtained discriminant equations, the reliability or overall percentage of correctness of which was 95.6%, the value of the first equation for surviving patients will be greater, then with a probability of 96.8% it is determined that this patient will survive an acute period of the disease, and if If the value of the second equation is greater, then with a probability of 78.6% they predict that a lethal outcome will occur in the acute period of myocardial infarction. For this, a step-by-step discriminant analysis of all the studied signs is carried out and the decisive rule for predicting the lethal outcome of the acute MI period is applied according to the first day of MI (Fig. 2). Arterial hypotension before TLT is the most unfavorable prognostic sign in determining the likelihood of death in the acute period of the disease. If, when solving the obtained discriminant equations, the value of the first equation is greater, then with a probability of 96.8% the patient will survive an acute period of the disease, if the second - then with a probability of 78.6%, a fatal outcome in the acute period of myocardial infarction will occur. The total percentage of correctness of the discriminant equations was 95.6%.

 The main predictors of the development of OSA in myocardial infarction patients after TLT use are: the absence of myocardial reperfusion, the average elevation of the ST segment 24 hours after the onset of the disease, more than 3.9 mm, the identification of akinesia zones in the area of myocardial infarction with echocardiography. When determining a high risk of developing OSA, ACE inhibitors are prescribed from the first day of myocardial infarction.

 After that, there are six significant signs of predicting a fatal outcome in the long term, within 3 years after the first heart attack - the presence or absence of pulmonary edema, repeated myocardial infarction, ventricular fibrillation, beta-blockers and cardiac glycosides, age. Then, a discriminant analysis is carried out, which is determined during the acute period of inpatient treatment of signs of a prospective prognosis of a fatal outcome in a long period of MI. Why solve the obtained regression equations and with a larger value of the 1st equation with a probability of 94.7% determine that the long-term prognosis will be favorable, and with a larger value of the 2nd equation with a probability of 78.6% determine that there will be a fatal outcome in the long-term period of the disease. Moreover, they get the reliability of the mathematical model according to coinciding forecasts equal to at least 93.4%, while upon discharge of patients from the hospital, a group of patients is determined who need careful outpatient monitoring, examination and treatment in the clinic.

 Throughout the entire diagnostic process, audio, video and digital data are simultaneously transmitted over a single channel using the integration of APP network technologies - networks (asynchronous information transfer mode) and Gigabit Ethernet local area networks with a bandwidth of 1000 Mbps. At the same time, a dangerous increase in the blood pressure of each patient with a reliability of at least 98% and an increase in the insufficiency of blood supply to the heart of each patient with a reliability of at least 90% are predicted using a neural network computer package.

 As an integration of information resources for the treatment and diagnostic process when predicting the complications of myocardial infarction, group medical computer videoconferences are conducted between cardiologists of the functional diagnostics center of the hospital and other leading medical institutions and treating physicians of the resuscitation and intensive care units of the cardiology center of the hospital using telecommunication equipment, devices removal of primary information, digital interface, tools for connections to the ISDN network, ARP network and wireless broadband Internet access with compatibility of video formats and operating systems. At the same time, during video conferencing, data of echocardiograms, diagrams of operations and defects of the heart muscle, fragments of conclusions, diagnostic data, static and dynamic video materials of data on catheterization of heart cavities and heart operations proper are transmitted and discussed, and ECG, EEG, computer data are also transmitted through communication channels tomography and magnetic resonance imaging.

 To take into account the features of the treatment of myocardial infarction and surgical operations on the heart, aorta and coronary vessels in cardiopulmonary bypass, it is necessary to enter and store information on the passport and anthropometric parameters of each patient in cardiological databases, the diagnosis, data on complications, and the nature of the disease are recorded coronary vascular lesions, duration of cardiopulmonary bypass, aortic clamping time, blood tests, features of the operation and postoperative ne iodine. At the same time, the parameters of mechanical ventilation, the doses of inotropic support used during the treatment of drugs are recorded, and they use a comprehensive assessment of hemodynamics and gas exchange, objectify medical monitoring and timely correct preventive therapy using hardware and software.

 To solve the tasks we analyzed the results of treatment of 271 patients (all men) with large focal MI, which were received in 1992-1997. in the GVKG them. N.N. Burdenko. The diagnosis of myocardial infarction was confirmed on the basis of the clinical picture, ECG data, and an increase in cardiospecific serum enzymes. All patients received TLT.

 The clinical features of the course of large-focal IM after TLT are considered, mathematical models are constructed that predict the development of complications and the outcome of the disease, based on a retrospective assessment of the clinical data array of 215 patients (main group) aged 41 to 84 years (mean age 63.0 ± 2, 8 years), admitted to the hospital after 4.1 ± 0.8 hours from the onset of the disease. The developed models of the clinical course of large-focal myocardial infarction were verified on an independent sample of 56 patients (control group), examined by a similar diagnostic scheme and clinical condition, not different from the main group. The average age of patients in the control group was 63.7 ± 3.9 years, the time of admission from the onset of MI was 3.9 ± 1.4 hours.

 The clinical characteristics of patients with MI are presented in Table 1. TLT efficacy was evaluated taking into account a complex of clinical, electrocardiographic and laboratory data. Signs of myocardial reperfusion after TLT were observed in 133 (61.9%) patients of the main group.

 For the diagnosis of heart failure, Killip's classification was used.

 We considered the criterion of PS to be the appearance of repeated attacks of anginal pain that occurred no earlier than 24 hours after the onset of the disease at the inpatient stage of treatment and accompanied by ECG dynamics, and we regarded the increase in cardiospecific serum enzymes after an anginal attack as a relapse of MI.

 When registering ventricular extrasystole, the Bigger classification was used; the complication was diagnosed only when the number of extrasystoles exceeded 10 per hour. Ventricular tachycardia was diagnosed when paroxysm was observed with a duration of at least 5 complexes. The development of ventricular arrhythmias was determined 2 hours after the end of TLT. The occurrence of heart rhythm disturbances until this time was regarded as reperfusion arrhythmias.

 The development of OSA was confirmed on the basis of an electrocardiographic picture - a “frozen” ST segment elevation in 2 or more leads when discharged from the hospital, preservation of dyskinesia and akinesia zones with repeated echocardiography.

 In the main group, 38 (17.7%) people. Received Actylysis (Boehringer Ingelheim, Germany): 34 (15.8%) patients - 100 mg in 3 hours with systemic and 4 (1.9%) patients - 50 mg with a speed of 0.83 mg / hour with intracoronary administration. 177 (82.3%) people streptokinase (Avelizia, Arzneimittelwerk Dresden GmbH, Germany) was used. In systemic TLT, various doses of the drug were administered over an hour: in 33 (15.3%) people. - 1.0 million units, 70 (32.6%) people. - 1.5 million units and 51 (23.7%) people. - 2.0 million units. With intracoronary TLT in 23 (10.7%) people. - 250.000 PIECES of avelizine at a speed of 4 thousand units / hour.

  After the completion of TLT in 212 (98.6%) people. heparin was intravenously infused at a rate of 1000 U / h for 2-5 days, then the drug was administered subcutaneously at 5 thousand units 3 times a day for 10-14 days. In 212 (98.6%) patients, from the first day of the disease, 250 mg / day aspirin was prescribed orally until discharge from the hospital. All patients underwent intravenous infusion of 20% gamma-oxybutyric acid at a rate of 0.33 g / h for 2-5 days, in 199 (92.6%) people. - intravenous infusion of nitroglycerin at a rate of 2-4 mg / h for 2-5 days, after completion of parenteral administration of the drug, 20 mg nitrosorbide was prescribed after 4 hours. 92 (42.8%) people on the first day of myocardial infusion, propranolol was intravenously infused at a rate of 1 mg / h, followed by oral administration of 10-20 mg • 3 times a day. 68 (31.6%) people from the first day, MI was prescribed kapoten inside by 6.5 mg 3 times a day, in 9 (4.2%) people. (from 14 to 20 days IM) - digoxin inside 0.125 mg 2 times a day.

 The pain syndrome was evaluated according to a scale developed by us that takes into account the duration of a sore throat, its recurrent nature, and the effectiveness of the use of narcotic analgesics.

 All patients underwent ECG recording in 12 standard leads. The dynamics of the average elevation of the ST segment before TLT was evaluated, immediately after treatment, 1 day, 3 days and 5 days after TLT (the ST segment elevation in millimeters was summed in all leads where it was, and the obtained value was divided by this number of leads).

 Monitoring of cardiac arrhythmias was carried out using the computer system "Sirecust" -121 C (Siemens, Germany). Analysis and registration of arrhythmias was carried out automatically throughout the entire period of treatment of the patient in the intensive care unit and intensive care. In 99 patients on 22.3 ± 3.4 days of MI, exercise tolerance was studied according to the generally accepted method of multistage exercise bike ergometry. Daily ECG monitoring was performed in 48 patients after being transferred to the bed unit using the Oxford Medilog EXCEL apparatus. All patients received a chest x-ray upon admission. Echocardiography was performed on an Acuson Sequoia 512 device twice during the patient’s stay in the hospital - on the first day and on the 15-30th day of the disease (on average, 22.5 ± 1.8 days). On 3-5 days after TLT, in 65 patients, radioisotope ventriculography was performed on a GMS-5500 apparatus with an IMAG computer system (France). To assess the condition of the coronary bed in 53 people. on 6.1 ± 1.1 days, coronary angiography (CAG) was performed according to the M.Judkins method, including the left and right polypositional CAG.

 The dynamics of necrotic processes in the heart muscle was studied in all patients, conducting a study of the activity of creatine phosphokinase (CPK) and its MV fraction, alanine aminotransferase (ALT), aspartate aminotransferase (ACT) before TLT, after 6 and 12 hours, on the 1st, 3rd and 5th day after treatment, as well as with the occurrence of anginal attacks. The total CPK and its MV fraction, ALT, ACT were determined on a SPECTRUM apparatus (Abbot, USA).

 Using the stratified sampling method, we analyzed the effect of capoten and propranolol on the incidence of certain MI complications and in-hospital mortality (patients with cardiogenic shock were excluded).

 Statistical processing of the material (141 signs) was carried out using the software package Statistica 5.1 for Windows-95. The information content of the indicators was estimated by the percentage of the variance explained (the relative total value of the parameter differences in the comparison groups), which reflects the information content of the indicator in identifying the differences of the groups. Decisive rules for predicting complications and the outcome of MI (mathematical models) were developed using regression and discriminant analysis.

 Linear regression equations were solved by substituting the numerical values of the attributes included in the equation, which were multiplied by the coefficients developed for each of them. Then all the results obtained and constanta were added. When solving regression equations, a number from 1 to 10 (ten-point scale) can be obtained. Depending on the result, the patient belonged to a particular group of predicted conditions.

 The linear discriminant equations were presented in the form of a table, where one column is the features included in this rule, the other two are the coefficients (weight score of the characteristic) calculated for two states (is there a complication or not a complication). The equations were solved by substituting the numerical values of the attributes included in the decisive forecasting rule, and multiplying them by the coefficients presented in this table. Then all the results obtained and constanta were added separately in each column. Thus, solutions of two discriminant equations were obtained, where one predicts the development of complications, and the second - its absence. In this case, the highest numerical value corresponded to the predicted state (there will be a complication or not).

 An analysis of the clinical picture of large-focal MI in patients who received TLT revealed that some patients did not develop complications during the inpatient treatment period (the results were evaluated when patients were discharged from the hospital). To identify the features inherent in this most favorable variant of the course of the disease, we divided the patients into two groups: group 1 - 67 (31.2%) people. with uncomplicated MI, group 2 - 148 (68.8%) people. with a complicated course of the disease.

 When evaluating the effectiveness of TLT, it was noted that in patients with uncomplicated MI, signs of myocardial reperfusion were recorded significantly more often - in 82.1% of cases, while in group 2 - in 55.9% (p <0.001).

 In 47.8% of patients with uncomplicated MI, transmural damage to the heart muscle was diagnosed, while in the group of patients with complicated MI, 68.9% were diagnosed. (p <0.01). In patients with uncomplicated MI, there was a significantly lower average ST segment elevation before TLT, immediately after TLT and 24 hours after the onset of MI: 6.0 ± 0.5 mm, 3.3 ± 0.6 mm and 1.7 ± 0 5 mm compared with 6.7 ± 0.1 mm, 4.3 ± 0.2 mm and 2.9 ± 0.1 mm, respectively, in group 2 (p <0.05).

 In patients with uncomplicated MI on the first day of the disease, FEV was significantly greater - 42.7 ± 1.2%, while in patients of the 2nd group - 38.5 ± 0.6% (p <0.01). At discharge, patients with uncomplicated MI showed an increase in FEV to 46.1 ± 1.5%, while in patients of group 2, the increase in FEV was less than 1% to 39.4 ± 0.9% (p <0.001).

 Predictors of the development of uncomplicated MI were: reperfusion (r = 0.46, p <0.001), age less than 58 years (r = 0.41, p <0.001), lack of PrS (PrS is an unstable angina that appeared no earlier than in a month before the development of MI) (r = 0.40, p <0.03), heart rate before TLT is less than 78 per minute (r = 0.40, p <0.001), the FEV value on the first day of myocardial infarction is more than 41% (r = 0 , 40, p <0.001), the average elevation of the ST segment before TLT less than 6.0 mm (r = 0.40, p <0.001) and after TLT less than 4.0 mm (r = 0.40, p <0.001), the QT interval before TLT is less than 38 ms (r = 0.39, p <0.001).

 The developed complex of predictors of uncomplicated MI course was verified in the control group. In the case when the patient determined all eight of the above symptoms, the probability of uncomplicated MI was 95% and this patient was included in the low-risk group of complications.

 Thus, based on the results of the study, signs of the first day of myocardial infarction were identified, which served as predictors of the uncomplicated course of the disease in patients who received TLT. The algorithm of diagnostic tactics is presented in figure 1. Early identification of patients with a low risk of developing MI complications allows them to reduce additional research, patients can be quickly transferred from the intensive care unit and discharged from the hospital earlier without deteriorating treatment results, which leads to significant material savings.

 Using the diagnostic tactics algorithm to identify patients with uncomplicated MI (Fig. 1) at the same time allows distinguishing patients with the probable (but not obligatory) development of complications - these are patients who have at least one of the above signs predicting the uncomplicated course of MI. In such patients, it is necessary to assess the likelihood of complications and the risk of death in the acute period of the disease. A complicated course of MI after the use of TLT was observed in 68.8% of patients.

 The most common complication in the acute period of the disease was heart rhythm and conduction disturbances: a variety of ventricular arrhythmias. The second most common complication of myocardial infarction was AHF, which arose in total in 87 (40.6%) patients (Killip Class 2 AHL was in 73 (34.0%) people, pulmonary edema developed in 10 (4.7 %) people, and cardiogenic shock - in 4 (1.9%) people).

 RRCC, which was noted in 63 (29.3%) people, took the third place in the frequency of development among MI complications. Moreover, PS attacks complicated the course of the disease in 49 (22.8%) people, recurrence of MI in 14 (6.5%) people. (of these, 78.6% before this had PS, 21.4% of patients immediately developed a relapse of MI).

 OSA was diagnosed in 41 (19.1%) patients, external myocardial rupture in 7 (3.3%) people, thromboembolic complications were noted in 2 (0.9%) people.

 Intrahospital mortality was 9-8%. Of the 21 patients who died in the acute period of the disease, the cause of death in 12 (57.1%) patients was AHF, in 7 (33.3%) patients - rupture of the heart muscle, in 2 (9.6%) patients - recurrence of MI. To solve this problem, we divided the patients into three groups: 1 group - 152 (70.7%) people. (without RRKK), group 2 - 49 (22.8%) people. (MI course was complicated by the development of PS), group 3 - 14 (6.5%) people. (recurrence of myocardial infarction developed).

 Analysis of the effectiveness of TLT showed that the frequency of myocardial reperfusion did not statistically differ in the comparison groups. When conducting a nonparametric correlation analysis of clinical parameters with the development of RRCC, a direct reliable relationship was found with: PrS (r = 0.74, p <0.001), the level of scoring for pain before TLT (r = 0.58, p <0.001), non-transmural necrosis myocardium (r = 0.40, p <0.03), diabetes mellitus (r = 0.36, p <0.03), hypertension (r = 0.33, p <0.05). Hypertension was significantly more often observed in patients with recurrence of MI in 85.7% of patients, while in patients with PS, in 66.7% of people, and in patients without RBCK, in 52.2% of people. (p <0.05). 42.9% of patients in group 3 had diabetes mellitus, compared with 9.5% and 7.5% of people in groups 2 and 1, respectively (p <0.03). CR attacks were detected in 78.6% of patients in the 2nd and 3rd comparison groups, while in the 1st group - in 18.2% of patients (p <0.01). The proportion of explained variance in PrS as a clinical sign associated with the development of RRCC was 30.0%. In patients with PS, the pain score was, on average, 2.52 ± 0.3 points, in patients with recurrence of MI - 2.57 ± 0.3 points, while in patients without RBCK - 1.83 ± 0, 1 point (p <0.01). The share of the explained variance in the scoring of pain, as a clinical sign associated with the development of RRCC - 11.8%. The development of PS attacks was more often observed in patients with non-transmural MI in 32.8% of cases, while in patients with transmural MI in 14.7% (p <0.03).

 On the 1st day of myocardial infarction, the total ejection fraction (FEV), determined with echocardiography, was less in patients of the 3rd group - 38.9 + 2.7%, compared with 41.7 + 1.3% and 42.8 ± 0 , 7% in groups 1 and 2. ACT activity 12 hours after TLT in group 2 was 211.2 ± 16.3 IU / L, compared with 152.4 ± 15.5 IU / L in group 1 (p <0.05) and 133.9 ± 19.0 ME / L in group 3 (p <0.01).

As the initial variables for the regression analysis, all indicators of the clinical and instrumental examination were set. As a result, 7 independent features were identified and a decisive forecasting rule for RRCC was developed:
Y = 1.424xX1-0.017xX2 + 0.829xX3 + 0.03xX4-0.646xX5 + 0.058xX6 + 0.683xX7 -0.875,
where Y is the predicted severity of the complication in points, X1 is the presence of PrS *, X2 is the heart rate before TLT, X3 is the depth of MI **, X4 is the activity of ACT 12 hours after TLT, X5 is the localization of MI ***, X6 is the FEV in the first day of MI, X7 - scoring of pain before TLT ****. * yes - 1, no - 0, ** transmural IM - 1, non-transmural IM - 2, *** anterior IM - 1, posterior IM - 2, **** recurrent nature of pain (no - 0, yes - 1) + duration of anginal attack (up to 2 hours - 0, more than 2 hours - 1) + relief of pain after administration of narcotic analgesics (full - 0, residual pain - 1).

 For each patient from the main group, the values of the regression equation were calculated, which made it possible to develop a ten-point severity scale predicting the development of RRCC with an 80% probability. In group 1, the average score was 3.9 ± 1.5 points, in group 2 - 6.3 ± 0.5 points, in group 3 - 9.4 ± 0.4 points. The percentage of the explained variance of the developed parameter (predicted severity of RRCC) was 54.5%, which is 2 times higher than the information content of all individual signs. The constructed mathematical model is verified on the control group. The results of the assessment of the diagnostic properties of the model showed that the level of its information content amounted to 78% of the matching forecasts.

 The condition of the coronary bed was studied in 53 people, of which 36 patients had seizures of RRCC, in 17 patients they were absent. It was noted that in patients with RBCK, residual stenosis of heart attack-associated CA was noted significantly more often - in 33 of 36 (91.7%) people, while in the absence of RBCK only in 9 of 17 (52.9%) people. (p <0.01). The frequency of other CA lesions did not significantly differ in the comparison groups. In patients with RRCC, the number of CAs changed by the stenotic process was significantly higher - 2.78 ± 0.22, compared with 1.53 ± 0.37 in patients without RRCC (p <0.05). When analyzing the effect of drugs on the incidence of RRCC, it was found that there was no significant decrease in the incidence of complications in patients receiving capoten. In patients taking propranolol, PS attacks were significantly less likely to develop - in 7.5% of people, compared with 45.9% of people. in patients for whom the drug was not prescribed (p <0.05).

 In patients with RRCC, modern treatment methods were used, including surgical myocardial revascularization in 19 (8.8%) people. in the acute period of MI. CABG at the inpatient stage of treatment of MI was performed in 17 (7.9%) patients. Moreover, in patients with RRCC surgery was performed significantly more often - in 16 (28.6%) people. , compared with 1 (0.6%) people. in the group of patients without RRCC (p <0.01). AKS was carried out, on average, on a 27.5 ± 3.5 day MI. At the inpatient stage of treatment, out of 17 patients who underwent surgical treatment, not one died. Percutaneous transluminal coronary angioplasty was performed in 2 (0.9%) patients, of which one patient had myocardial infarction on the first day due to cardiogenic shock, and on the fifth day myocardial infarction was performed on myocardial infarction. Over a three-year period of prospective observation, it was revealed that after discharge from the hospital, CABG was performed in 8.0% of all patients surveyed. In patients with RRSC at the hospital stage of myocardial infarction treatment, CABG was significantly more frequent during the three-year follow-up period - in 22.2% of people, while in patients without RBC in the acute period of the disease - in 4.6% of people . (p <0.05).

 Thus, the incidence of RRCC in patients receiving TLT reaches almost 30%. Residual stenosis of infarction-associated CA is observed in more than 90% of patients with RRCC, which is the main mechanism for the development of PS and relapse of MI after the use of TLT. The developed mathematical model, which included the signs of the first day of myocardial infarction, allows you to select patients with a high risk of RRCC. The recommended algorithm for diagnostic tactics in patients with myocardial infarction in assessing the likelihood of developing RBCK is presented in figure 2. In patients with a predicted severity of RRCC greater than or equal to 5.8 points, it is necessary to perform CAG in the acute period of MI to assess the condition of the coronary bed and determine the indications for surgery.

 To determine the clinical features of the course of myocardial infarction complicated by acute aneurysm, patients were divided into two groups: group 1 - 41 (19.1%) people. (patients with OSA), group 2 - 174 (80.9%) people. (patients who did not have OSA).

 When studying the effectiveness of TLT in comparison groups, it was found that in the group of patients with OSA, reperfusion was significantly less frequent - in 39.4% of patients, compared with 70.2% in patients without OSA (p <0.001).

 When conducting a nonparametric correlation analysis of clinical parameters with the development of OSA, a reliable relationship was revealed with: reperfusion (r = -0.51, p <0.001), average elevation of the ST segment 24 hours after the onset of the disease (r = 0.39, p <0.001) , stenosis of the permanent pancreatic ulcer (r = 0.38, p <0.05), detection of echocardiography in the area of heart attack zones of akinesia (r = 0.35, p <0.01), FEV on the first day of myocardial infarction (r = -0, 30, p <0.001), anterior MI (r = 0.28, p <0.001).

 The average age of patients with OSA was greater - 66.5 ± 1.3 years, compared with 62.2 ± 0.8 years in group 1 (p <0.02). In patients with OSA, there was a more pronounced average elevation of the ST segment before TLT, immediately after thrombolysis, 24 hours after the onset of MI - 7.6 ± 0.4 mm, 5.1 ± 0.3 mm and 4.2 ± 0.3 mm, compared with 6.3 ± 0.2 mm, 3.7 ± 0.1 mm and 2.1 ± 0.1 mm, respectively, in group 1 (p <0.001). More often, OSA was formed in patients with anterior MI in 26.8% of people, while in posterior MI it was formed in 10.8% (p <0.001).

 In patients with AHF who received capoten, the incidence of OSA was significantly lower - 9.8%, while in patients for whom ACE inhibitors were not prescribed - 59.5% (p <0.05). There was no significant decrease in the incidence of OSA in patients receiving propranolol.

 To predict the outcome of MI, on the first day of its development, patients are divided into groups with a favorable and unfavorable course of the disease to identify patients who need additional diagnostic and treatment procedures. For this, patients were divided into two groups - 1 group (194 people) - survivors in the acute period, 2 group (21 people) - who died in the acute period of MI.

 When studying the effectiveness of TLT in the comparison groups, it was found that in the group of deceased patients, myocardial reperfusion was significantly less likely - in 33% of patients, compared with 65% in group 1 (p <0.004).

 When conducting nonparametric correlation analysis, it was noted that with the development of a fatal outcome in the acute MI period, transmural myocardial damage (r = 0.68, p <0.001), arterial hypotension before TLT (r = 0.62, p <0.001) are most closely correlated. the development of complete AV blockade on the first day of myocardial infarction (r = 0.41, p <0.001), the value of FEV on the first day of the disease (g = -0.38, p <0.001), the development on the first day of myocardial infarction (r = 0.36, p <0.002).

 Arterial hypotension before TLT was in 48% of patients of group 2, while in group 1 - only in 11% (p <0.001). Clinical signs of circulatory failure before MI were significantly less frequently observed in patients of group 1 — in 82 (42.3%) people compared to 19 (90.5%) in group 2 (p <0.048). Prior to myocardial infarction, 5 (23.8%) patients of group 2 suffered an ischemic stroke, while in 1 - 3 (1.5%) people. (r = 0.30, p <0.001). Significantly more often in patients of group 2, anterior MI was diagnosed - in 80.0% of people, while in group 1 in 50% of people. (p <0.05). In patients of group 2, the average Killip score of OSF was 2.2 ± 0.4, compared with 1.4 ± 0.2 in group 1 (p <0.01). On the first day, MI was short of breath in 42.9% of people. in group 2, while in group 1 - 17.0% (r = 0.28, p <0.03). In group 2, ventricular fibrillation was observed in 52% of patients, while in group 1 - in 5% of people. (p <0.001).

 In patients of group 2, a more pronounced average elevation of the ST segment after TLT was 6.0 ± 0.5 mm, compared with 3.8 ± 0.1 mm in group 1 (r = 0.34, p <0.001). In patients of group 2, on the 1st day, MI of FEV was 34.0 ± 1.4%, while in group 1 - 40.2 ± 0.4% (p <0.001).

 The developed mathematical model is verified on the control group. The results of the assessment of the diagnostic properties of the model showed that the level of its information content ranges from 75 to 92% of matching forecasts.

 To identify signs of an acute period of myocardial infarction, which can affect the lethal outcome in the long-term period of the disease, we conducted a prospective study. 194 patients out of 215 were discharged from the hospital. According to the developed protocol, 187 patients or their relatives were interviewed. The follow-up period after discharge ranged from 2 to 6 years, an average of 3.2 ± 0.9 years.

 During the observation period, recurrent MI developed in 31 (16.6%) people. 14 (7.5%) patients died after discharge from the hospital, 65% of them from repeated MI, 20% from malignant tumors, and 15% did not know the cause of death.

 Patients were divided into two groups: group 1 (173 people) - surviving patients, group 2 (14 people) - deceased patients.

 When analyzing the effectiveness of TLT, it was noted that the frequency of myocardial reperfusion did not statistically differ in the comparison groups.

 When conducting a nonparametric correlation analysis, it was found that MI in the long-term period is most closely correlated: pulmonary edema (r = 0.41, p <0.001) and ventricular tachyarrhythmias (r = 0.39, p <0.002), observed in acute period of the disease, repeated MI (r = 0.38, p <0.002) and age (r = 0.38, p <0.001).

 When analyzing the comparison groups, it was found that in the 2nd group the average age of the patients was significantly higher - 71.1 ± 4.2 years, but compared with 61.4 ± 2.1 years in the 1st group (p <0.05). In patients of group 2, when admitted to the hospital with echocardiography, a lower FEV was determined, which amounted to 37.1 ± 2.1%, compared with 40.8 ± 0.7% in group 1 (p <0.024). During inpatient treatment in patients of group 2, a complicated course of MI was observed in 93% of people, while among patients of group 1 - in 60% of people. (p <0.015). In patients of group 2, the average Killip score of OOS was higher - 1.86 ± 0.3, compared with 1.35 ± 0.1 in group 1 (p <0.001). Ventricular tachycardia was observed in 50% of patients of group 2 and only in 8% of people. - in 1 (p <0.002). In group 2, β-blockers received 14% of people, in 1 - 50% of people. (p <0.01), cardiac glycosides - 14% of patients in group 2 and 3% of patients in group 1 (p <0.04). We performed a step-by-step discriminant analysis of all the studied signs and developed a decisive rule for predicting a fatal outcome in the long-term MI period according to the signs determined during the hospital treatment of the disease (Table 2). From table 3 it is seen that the development of pulmonary edema in the acute period of myocardial infarction most increases the likelihood of a fatal outcome of the disease in the long term. Features of the therapy at the inpatient stage of treatment are important: if the patient received β-blockers in the hospital, this is a favorable sign, but if the patient has been prescribed cardiac glycosides (due to the development of severe congestive heart failure), the risk of death in the long term increases. When solving the obtained discriminant equations with a larger value of the first equation with a probability of 94.7%, a distant prognosis will be favorable, and with a larger value of the second equation with a probability of 78.6%, a fatal outcome will occur in the long-term period of the disease (within three years after MI). The overall percentage of model correctness is 93.4%. The resulting model was verified in the control group. The results of the assessment of the diagnostic properties of the model showed that the level of its information content ranges from 78 to 95% of matching forecasts.

 So, “hidden” interconnected sets of signs have been identified that make it possible to predict the course of large-focal myocardial infarction after thrombolytic therapy on the first day of the disease. Original mathematical models have been proposed to determine the risk of developing complications of large focal myocardial infarction after thrombolytic therapy.

 A clinical diagnostic system has been developed, including: analysis of a complex of symptoms, identification of stable interrelated signs, assessment of the information received, determination of the severity of complications, followed by the choice of treatment tactics. The prognostic signs of the acute period of myocardial infarction after thrombolytic therapy have been identified, which determine the long-term prognosis of the disease. The developed mathematical model makes it possible to isolate patients with a high risk of death in the acute period of the disease on the first day of myocardial infarction, in whom it is necessary to increase the length of stay in the intensive care unit, expand the scope of the examination and conduct intensive dynamic monitoring of the main hemodynamic parameters. Based on the results of the study, a mathematical model is developed that predicts a fatal outcome in a remote MI period based on signs of an acute period of the disease. The most unfavorable factors that increase the risk of death in the long term are the development of pulmonary and ventricular tachyarrhythmias during treatment in a hospital. The proposed prognostic rule allows already at discharge of patients from the hospital to determine the group of patients who need more careful outpatient monitoring, examination and treatment. The data on the effect of capoten and propranolol on the course of large-focal myocardial infarction complicated by acute heart failure after thrombolytic therapy have been clarified.

 Thus, the use of the results of the study in clinical practice allows us to identify patients with uncomplicated disease on the first day of myocardial infarction, to predict the development of complications and the outcome of myocardial infarction in the acute period, to implement a differentiated approach to diagnostic measures and conduct preventive treatment aimed at reducing the frequency the development of complications of myocardial infarction and hospital mortality after thrombolytic therapy. The results of scientific work have been introduced into the practical activities of the cardiology center of the Main Military Clinical Hospital named after Acad. N. N. Burdenko, 7th Central Military Clinical Aviation Hospital, 2nd Central Military Clinical Hospital, in the educational process at the departments of therapy and cardiology of the State Institute of Advanced Medical Doctors of the Ministry of Defense of the Russian Federation.

Sources of information
1. A. L. Gospodarenko, V. M. Klyuzhev, A. M. Litvinov, V.A. Chernetsov. - A method for the treatment of large focal myocardial infarction // Priority certificate for the grant of a patent for an invention / state. Registration 98119265 dated 10.10.1998, M., FIPS, Rospatent.

 2. V.A. Chernetsov, A.M. Litvinov, A.A. Meshcheryakov et al. - Method for the rehabilitation of patients with myocardial infarction // Priority certificate for the grant of a patent for an invention / state. Registration No. 2000101789 dated January 21, 2000, M., FIPS, Rospatent.

 3. I. M. Gelfand. M.L. Izvekov, E.I. Kasparov, A.L. Syrkin. - Structural units in the task of predicting the outcome of transmural myocardial infarction // Informatics and Medicine. - M .: Science. - 1997. -208 p. (prototype).

Claims (1)

A method for predicting the complications of a patient with myocardial infarction, including assessing heart failure and the nature of anginal pain, characterized in that on the first day of a heart attack, the first group of low development of complications includes patients with an age of less than 58 years, lack of pre-infarction, a month before a heart attack, unstable angina, s heart rate before thrombolytic therapy less than or equal to 78 beats / min, average elevation of the ST segment before thrombolytic therapy (TLT) less than or equal to 6 mm and after TLT men e or equal to 4 mm, the size of the interval of QT teeth of the electrocardiogram before TLT is less than or equal to 38 ms, the presence of myocardial reperfusion, the value of the total ejection fraction on the first day of the heart attack is more than or equal to 41%, and all other patients - in the second group with complicated heart attack, all patients determine the prognostic severity of recurrent coronary circulatory disorders (RRCC) Y on a ten-point scale according to 7 independent signs according to the equation
Y = 1.424 • X1-0.017 • X2 + 0.829 • X3 + 0.03 • X4-0.64 • X5 + 0.058 • X6 + 0.683 • X7-0.875, where Y is the prognostic severity of complications in points;
X1 - the presence of attacks of preinfarction unstable angina *;
X2 - heart rate before TLT;
X3 - depth of myocardial infarction **;
X4 - AST activity 12 hours after TLT;
X5 - localization of myocardial infarction ***;
X6 - total ejection fraction on the first day of myocardial infarction;
X7 - point score pain before TLT ****,
to solve the regression equations, the value of each of these characteristics is determined as *: yes - 1 point, no - 0, ** transmural myocardial infarction - 1, non-transmural heart attack - 2, *** anterior heart attack - 1, posterior heart attack - 2, * *** recurrent nature of pain (no - 0, 1 -) + duration of an anginal attack (up to 2 hours - 0, more than 2 hours - 1) + relief of pain after the administration of narcotic analgesics (full - 0, residual pain - 1), if severity of RRCC is less than 5.8 points, then stress echocardiography or scintigraphy is performed, then signs of viability are evaluated myocardium and, if available, prescribe coronarography, perform a step-by-step discriminant analysis of all the studied symptoms, assess the risk of death in the acute period of the disease in patients with probable, but not obligatory development of complications, which lack at least one of the signs predicting the uncomplicated course of myocardial infarction, moreover, the forecast is carried out by comparing the values of the results of the regression equations for groups of survivors and deceased, while analyzing the following characteristics for each patient : arterial hypotension before TLT * (1), a history of stroke * (2), shortness of breath on the 1st day of myocardial infarction (OD) (3), development of complete atrioventricular blockade on the 1st day of MI * (4), development of intraventricular blockade on the 1st day IM * (5), the absolute value of the average elevation of the ST segment after TLT (6), to solve the regression equations, the value of each of these characteristics is determined as *: yes - 1 point, no - 0, and for OD with a respiratory rate of up to 20 per minute - 1 point, with a respiratory rate of 21 to 26 per minute - 2 points, more than 26 per minute - 3 points, multiply this value by the coefficients for the percentage of survivors and deceased, respectively, 1.2 and 5.1 for (1), 5.1 and 15.6 for (2), 11.3 and 18.8 for (3), 1.0 and 4.2 for (4), 3.9 and 7.0 for (5), 1.2 and 1.9 for (6), taking into account the constant term of the regression equation, equal to minus 11.518 for the 1st group (survivors ) and minus 32.114 for the second (deceased), and if for this patient the result of the regression equation for the group of survivors is greater than for the group of deceased, then survival is predicted, and if this value is exceeded in the group of deceased over the group of survivors, acute myocardial infarction, prognosis h fatal outcome in the long term is carried out in the acute period of the disease by comparing the values of the results of the regression equations for the groups of survivors and deceased, while analyzing the following characteristics for each patient: lung compartment (7), repeated myocardial infarction (8), ventricular fibrillation (9), taking beta-blockers (10), an age less than or equal to 61.4 + 2.1 (11), the appointment of cardiac glycosides due to the development of severe congestive heart failure (12), each of these characteristics is rated at 1 point if available and at 0 points when their In fact, if the age is more than 61.4 + 2.1, then characteristic (11) is not taken into account, the obtained value is multiplied by the coefficients for the groups of survivors and deceased, respectively, by 8.2 and 20.8 for (7), by minus 4, 6 and plus 2.5 for (8), minus 5.7 and plus 2.6 for (9), 4.3 and 1.9 for (10), 0.6 and 0.8 for (11 ), by minus 6.1 and minus 1.5 for (12), taking into account the constant term of the regression equation, equal to minus 46.123 for the 1st group and minus 61.731 for the second, and if for this patient the result of the regression equation for the group of survivors more than for the group of deceased, they predict survival, and in the case of e exceeded this value in the group died over the group of survivors predict death in the remote myocardial infarction within 3 years after the initial myocardial infarction.

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