RU2334468C1 - Method for optimising of diagnostics of pulmonary artery thromboembolia - Google Patents

Abstract

FIELD: medicine, cardiology.

SUBSTANCE: patient under examination undergoes echocardioscopic examination with measuring right and left atrium; these parameters are expressed in form of their ratio by formula K= RA/LA, where K is coefficient in units, RA is size of right atrium in cm, LA is size of left atrium in cm. If K index is 1.2 (units), diagnosis of thromboembolia of small and medium branches of pulmonary artery is predicted. If value of index K is more than 1.2 (units) diagnosis of thromboembolia of large branches of pulmonary artery is predicted. On the basis of obtained results conclusion about possibility of diagnosis of pulmonary artery thromboembolia of small, medium and large branches is made after performing standard echocardioscopy.

EFFECT: increase in diagnostic importance of method and simplification of result interpretation.

1 dwg, 4 ex, 1 tbl

Description

The invention relates to medicine, and more specifically to the diagnosis of thromboembolism of small and medium branches of the pulmonary artery based on the optimization of the method of echocardioscopic Doppler examination of the heart cavities, and can be used in clinical practice by doctors of the functional diagnostics departments, therapists, cardiologists, resuscitators with the aim of timely diagnosis of small thromboembolism and middle branches of the pulmonary artery.

At present, there is still no reliable and accessible method for the diagnosis of thromboembolism (PE) of small and medium branches of the pulmonary artery accessible to all medical institutions. The use of invasive diagnostic methods in the form of angiopulmonography, cavagraphy in practical medicine for the diagnosis of thromboembolism of small and medium branches of the pulmonary artery has not found widespread and widespread application in view of the high cost and inaccessibility.

A known method for the diagnosis of pulmonary embolism using the method of echocardioscopy (echocardiography) with pressure measurement in the pulmonary artery. However, the method has drawbacks, as some patients with thromboembolism of small and medium branches of the pulmonary artery do not have a significant increase in pressure in the pulmonary artery system by the time of echocardiography.

Closest to the proposed technical solution to the problem is a method for the diagnosis of pulmonary hypertension, based on the Echo method for acute pulmonary heart (see N. Schiller, MA Osipova. Clinical Echocardiography, second edition, Moscow, Practice, 2005, sections “Right ventricle”, “Atria and veins”), using some echo-signs. They are: a rise in pressure in the pulmonary artery, biphasic systolic blood flow in the pulmonary trunk; rapid increase in the right ventricle in volume; decreased contractility of the right ventricle and diastolic dysfunction of the left ventricle. However, the method has significant drawbacks in view of the fact that it cannot always objectively assess the degree of pulmonary hypertension; there is no statistical analysis of the reliability and correlation of each of the proposed signs. So, the average pressure in the pulmonary artery according to the echocardiography rarely exceeds 40 mm Hg. In addition, with a sharp increase after loading the right ventricle and its decompensation, the pressure in the pulmonary artery may be low. And, finally, the identification of the symptom — a decrease in contractility of the right ventricle — like the others listed above, is very subjective, depending on the experience of the doctor and the position of the sensor during the Doppler study during echocardiography.

All this ultimately does not allow to fully objectively and reliably assess the risk of developing pulmonary embolism of small and medium branches of the pulmonary artery.

The objective of the present invention is to eliminate the existing disadvantages - objectification of the analyzed sign, increasing the diagnostic significance of the method and simplifying the interpretation of the results, on the basis of which they make a judgment on the possibility of a diagnosis of pulmonary embolism of small and medium branches.

The problem is solved due to the fact that in patients with suspected pulmonary embolism of small and medium branches, echocardiography is performed with measurement of the size of the right and left atria. The results are expressed as a coefficient K - the ratio of the sizes of the right atrium in cm (PP) to the left atrium (LP) in cm.

In the literature available to us, we did not find information on the optimization and the possibility of diagnosing thromboembolism of small branches of the pulmonary artery using the indicator K = PP / LP.

The method is as follows. In patients with suspected pulmonary embolism of small and medium branches, a standard echocardiography is performed, the sizes of the right and left atria are determined. The preferred method for measuring the volume of the left atrium is a two-dimensional study in mutually perpendicular projections, since the left atrium has an irregular shape. The determination of its volume (LP), based on M-modal measurements, is not very accurate (N. Schiller, M.A. Osipov, 2005). The right atrium can be seen along the parasternal short axis of the aortic valve and along the long axis of the right ventricular delivery tract, from the apical four-chamber position and from the subcostal access. It is important that in healthy people, the right and left atria are the same size (N. Schiller, M.A. Osipov, 2005). Thus, the ratio of the volumes of the right atrium to the left at normal is always less than or equal to 1.0 (K = <1.0 in normal).

Diagnostically important in pulmonary embolism is an increase in the coefficient K above 1.0. Moreover, the probability of a diagnosis of pulmonary embolism of small and medium branches increases with an increase in this indicator (direct positive correlation). The coefficient K is calculated as the ratio of the size of the right atrium to the size of the left atrium in units according to the formula K = PP / LP. Normally, this coefficient K is less than or equal to 1.0 (units). Thus, an increase in the coefficient K reflects the degree of overload of the right heart, and therefore the degree of acute pulmonary hypertension that occurs with pulmonary embolism. In addition, dynamic monitoring of the coefficient K = PP / LP during treatment reflects the effectiveness of the treatment of pulmonary embolism of small and medium branches. Thus, a decrease in the initially elevated values of this coefficient K indicates a positive trend in the form of a decrease in the degree of pulmonary hypertension, and, conversely, with an increase in the coefficient K, the process progresses.

The basis for determining the value of K = PP / LP, in which it is possible to judge the optimization of the method for the diagnosis of thromboembolism of small and medium branches of the pulmonary artery, were the results of the analysis of the above parameters in patients with suspected pulmonary embolism of small and medium branches and who were being treated in the municipal unitary hospital The first city clinical hospital in Arkhangelsk. " Our prospective case-control study was conducted on a sample of patients with suspected pulmonary embolism of small and medium branches (n = 65, 28 men aged 51.1 ± 11.0 years and 37 women aged 49.9 ± 19.6 years). The comparison group was represented by 34 healthy volunteers (20 men aged 50.2 ± 13.1 years and 14 women aged 48.2 ± 15.3 years). The clinical part of the study was conducted on the basis of the 2nd therapeutic department of the Municipal Unitary Enterprise “First City Clinical Hospital” in Arkhangelsk.

In comparison with this coefficient K = PP / LP in healthy people (0.9 ± 0.2, M ± s, where M is the arithmetic mean, s is the standard deviation), the analyzed parameter in patients with pulmonary embolism of small and medium branches was 1.7 ± 0.2. Moreover, the difference of this indicator K in both groups had a high degree of reliability (p = 0.012).

Correlation analysis showed a statistically significant relationship between an increase in pressure in the pulmonary artery (DLA) and the coefficient K = PP / LP (see drawing).

We analyzed the relative risk of developing pulmonary embolism with standard echocardiography and coefficient K = PP / LP using one-dimensional analysis (statistical program SPSS 13.0) (table. Data are presented as absolute and% indicators, P - two-sided Fisher test).

Relative risk of pulmonary embolism according to echocardiography Echo sign Massive Tela Non-massive PE One dimensional analysis RR (95% CI) R The pressure in the aircraft above 35 mm Hg 15 (50.0) 7 (20.0) 3.43 (1.35-8.7) 0.008 K = PP / LP with a value above 1.2 15 (50) 4 (11.4) 4.0 (1.6-10.1) 0.003 Heart rate over 100 beats per min 23 (76.7) 18 (51.4) 3.1 (1.2-8.2) 0.015 Increase in software over 4.0 17 (56.7) 7 (22.6) 4.5 (1.8-11.4) 0.002 Increase in pancreas more than 2.3 21 (70.0) 9 (29.0) 5.7 (2.2-14.8) <0.001 The increase in the drug is more than 4.0 7 (23.3) 4 (12.9) 2.05 (0.67-6.3) 0.236

A retrospective analysis of the case histories of patients with pulmonary embolism allowed the proposed method to be tested on an array of K = PP / LP values separately in the pulmonary embolism group of small, medium and large LA branches. With pulmonary embolism of small LA branches, this ratio was 1.2, with pulmonary embolism of large branches K> 1.2. The sensitivity of this test, K = PP / LP, with confirmed pulmonary embolism was 64.4% (CI 50.8-76.1), and specificity 61.8% (CI 43.6-77.3).

Testing the method on a prospective sample of patients with pulmonary embolism showed that in 72.1% of cases it adequately optimizes the method for diagnosing pulmonary embolism.

We present several clinical examples that demonstrate the importance of this method in terms of optimizing the diagnosis of pulmonary embolism.

Clinical examples.

1. Patient K., 61 years old, medical history No. 3538. Received in 3 chir. Department of City Clinical Hospital №1 of Arkhangelsk with a diagnosis of Acute thrombophlebitis. On the 7th day of hospitalization after a toilet, shortness of breath suddenly occurred, lost consciousness. EchoX data: dimensions of pancreas 3.5 cm; PP 4.8 cm; PL 3.6 cm; K = 1.3; DLA 65 mm Hg Against the background of anticoagulant therapy after 11 days: pancreas 2.2 cm; PP 3.6 cm; PL 3.4 cm; K = 1.0; DLA 23 mm Hg The PP / LP ratio is initially 1.3, in dynamics - 1.0.

2. Patient B., 45 years old, medical history No. 14393. Was admitted to the cardiopulmonary resuscitation unit of City Clinical Hospital No 1 in Arkhangelsk with a diagnosis of Acute ileofemoral thrombosis. Tela? EchoC data: RV 2.9 cm; PP 4.2 cm; PL 2.8 cm; K = 1.5; DLA 40 mm Hg 28 days after systemic thrombolysis and anticoagulant therapy: RV 2.2 cm; PP 3.5 cm; PL 2.6 cm; K = 1.3; DLA 13 mm Hg

The ratio of PP / LP 1.5 and 1.3.

3. Patient K., 46 years old, medical history No. 9738. entered in 1 h.o. City Clinical Hospital №1 of the city of Arkhangelsk with a diagnosis of: Strangulated hernia of the white line of the abdomen. Toward the end of the first day after surgery, shortness of breath, dizziness suddenly occurred. EchoX data: RV 2.8 cm; PP 4.6 cm; PL 3.8 cm; K = 1.2; DLA 30 mm Hg Against the background of treatment with anticoagulants, after 20 days: PP 3.3 cm; Pancreas 2.1 cm; PL 3.7 cm; K = 0.9; DLA 28 mm Hg

The ratio of PP / LP 1.2 and 0.9.

4. Patient C., 75 years old, medical history No. 1230. Received in the gastroenterological department of the City Clinical Hospital №1 of Arkhangelsk with a diagnosis of chronic pancreatitis, exacerbation. Upon receipt of a complaint of pain in the left hypochondrium, lower chest, vomiting, nausea. Repeatedly loss of consciousness. Examined by a surgeon, data for pancreatitis were not identified. In connection with the presence of dyspnea, tachycardia, it has been suggested that there is a pulmonary embolism. EchoX data: RV 2.0 cm; PP 3.8 cm; LP 3.5 cm; K = 1.1; DLA 19 mm Hg The condition is regarded as a decompensation of chronic heart failure, therapy was carried out with preventive doses of heparin. The condition progressively worsened, after 3 days uncontrolled hypotension occurred. With echocardiography several hours before death: pancreas 3.0 cm; PP 5.5 cm; PL 4.1 cm; DLA 70 mm Hg At autopsy, the main branches of the pulmonary artery on both sides are completely obstructed by a thrombus, numerous blood clots in the small branches of the pulmonary artery. The PP / PL ratio at admission 1.1, in dynamics - 1.34.

The above material clinically confirms the simplicity and usefulness of the proposed method for optimizing the diagnosis of pulmonary embolism. In addition, the developed and tested method greatly simplifies the procedure for diagnosing pulmonary embolism, brings it closer to the technical capabilities of medical institutions at all levels, since it does not require complex and relatively dangerous invasive intervention, expensive equipment and a special service. It is important that the clinician in the finished form receives an objective indicator indicating the possibility of the presence of acute pulmonary hypertension. Ultimately, this method allows for the most effective therapy according to the results of the echo-cx using the K = PP / LP indicator.

Information about known analogues

1. Popova L.V. Importance of echocardiography in pulmonary embolism. / L.V. Popova // Thrombi, bleeding and vascular diseases. - 2004. - No. 4. S.19-22.

2. Naudjunas A. Chronic pulmonary hypertension after acute pulmonary thromboembolism. / A.Naujunas // Cardiology, 2005. - No. 2. - S. 54-55.

3. Schiller I, M.A. Osipov. Clinical ECHO cardiography. 2nd edition. Moscow. - Practice. 2005. S. 344.

4. Acute pulmonary embolism may result in right ventricular (RV) pressure overload with a dilated RV which can be diagnosed by two-dimensional echocardiography / R. Sukhija, W. S. Aronow, K. Yalamanchili et al. // Cardiology. - 2005 .-- 103 (3). - R.156-7.

5. Association of right ventricular dysfunction with in-hospital mortality in patients with acute pulmonary embolism and reduction in mortality in patients with right ventricular dysfunction by pulmonary embolectomy / R. Sukhija, W. S. Aronow, J. Lee et al. // Am J Cardiol. - 2005. - Mar 1; 95 (5). - R.695-6.

6. Association of right ventricular dilatation with bilateral pulmonary embolism. Pulmonary embolism in main pulmonary artery and lobar. Segmental pulmonary embolism in 190 patients with acute pulmonary embolism / R. Sukhija, W. S. Aronow, K. Yalamachili et al. // Cardiology. - 2005 .-- 103 (3). - P.156-7.

7. Davidson BL., Lensing AW. Should echocardiography of the right ventricle help determine who receives thrombolysis for pulmonary embolism. Chest 120 (1): 6-8, 2001.

Claims (1)

A method for optimizing the diagnosis of thromboembolism of small and medium branches of the pulmonary artery, which consists in examining a patient, characterized in that the subject undergoes an echocardioscopic examination with measurement of the sizes of the right and left atria, express these parameters in the form of their ratio according to the formula K = PP / LP, where K is the coefficient in units, PP is the size of the right atrium in cm, PL is the size of the left atrium in cm and with a value of K 1.2 (units), the diagnosis of thromboembolism of small and medium branches of the pulmonary artery is predicted, and with Achen records to more than 1.2 (units) - thromboembolism major branches of the pulmonary artery.