RU2408256C1 - Method of diagnosing painless myocardial ischemia in women - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to cardiology. Increase of systolic arterial pressure (AP) higher than 139 mm Hg and/or diastolic AP higher than 89 mm HG and presence of abdominal type of obesity, characterised by waist circumference greater or equal 80 cm are detected, also determined are interleukin level -18 and ratio of apolipoproteins B to apolipoproteins A 1. If interleukin -18 value is 87.4 pg/ml and higher and ratio of apolipoproteins B to apolipoproteins A 1 equal or higher than 0.8 painless myocardial ischemia is diagnosed. ^ EFFECT: method increases reliability of painless myocardial ischemia diagnostics, which is achieved due to complex of used parametres. ^ 3 ex

Description

The invention relates to medicine, namely to cardiology, and is intended for the diagnosis of painless myocardial ischemia in women.

Diagnosis of myocardial ischemia in women presents certain difficulties. Examination of women to detect coronary atherosclerosis can be more complex than in men. Currently, there is not a single non-invasive test that can reliably identify women with coronary heart disease when screening large numbers of women who do not have symptoms. (Aronov D.M. Stress tests in the diagnosis of coronary heart disease in women / 07/12/2007/ card-cgb.narod.ru).

A known method for the diagnosis of painless myocardial ischemia, based on the implementation of a dosed stepwise increasing physical activity with simultaneous recording of an electrocardiogram and correlation of the volume of work performed with myocardial oxygen consumption, which allows you to indirectly assess the degree of metabolic processes in the myocardium, and the appearance of signs of myocardial ischemia indicates the presence of painless ischemia myocardium [Aronov D.M., Lupanov V.P. Functional tests in cardiology. - M .: MEDpress-inform, 2002 - 296 p.]. However, this method does not allow to directly judge the functional state of myocytes, especially in the case of metabolic disturbances at the microcirculatory level, which leads to a decrease in the reliability of diagnosis.

A known method for the diagnosis of coronary heart disease according to A.I. Koryakov (patent RU 2004127635, 10.06.05), which involves the definition of painless ischemia. A method for diagnosing painless myocardial ischemia, including two stress tests under the control of an electrocardiogram, the first test being carried out on a non-drug background, and the second after administering a therapeutic dose of a nitrovasodilator; they make a modified score for the signs of myocardial ischemia for each load test, and with a modified comprehensive assessment of the paired test of more than 4 points, they make a conclusion about undoubted hemodynamically significant coronary atherosclerosis and with a 100% probability diagnose coronary heart disease in the form of isolated painless myocardial ischemia. The disadvantages of this method are the large number of analyzed signs and the risk of cardiovascular complications associated with stress breakdown and the introduction of nitrovasodilator.

The closest analogue is the "Method for the diagnosis of coronary heart disease in patients with arterial hypertension", which involves the definition of painless ischemia (patent RU 2316995, 02.20.2008). The known method involves conducting daily monitoring of blood pressure (BPM) with measuring heart rate (HR) and double product (DP) in the daytime and at night, the magnitude of the morning rise in systolic blood pressure (V UP GARDEN), daily index of systolic blood pressure (SI) GARDEN). Perform venous blood sampling. The content of total cholesterol (OHL) in blood plasma is determined. Receive platelet membranes and determine the content of diene conjugate (DC) in them. Next, calculate the probability coefficient of the event P = e ^y (1 + e ^y ), where c = 2.72 (mathematical constant), and y is the logistic regression equation: y = 3.77 + heart rate (day) × 0.342 + heart rate (night .) × (-0.592) + SI GARDEN × 0.446 + IN UP GARDEN × (-0.043)-DP (day) × 0.508 + DP (night) × 0.653 + OHL × 0.016-DC tr. × 0.003. At P> 0.5, the presence of IHD is determined in patients with hypertension with metabolic disorders (MN).

The main disadvantage of this method is the lack of accuracy and sensitivity, since an increase in the level of total cholesterol is also observed in other diseases, and the levels of blood pressure are affected by both external conditions and errors in nutrition, in addition, daily monitoring of blood pressure creates some discomfort during this samples.

We set the task of increasing the accuracy of diagnosis of painless myocardial ischemia in women by taking into account the pathogenetic parameters of the development of painless myocardial ischemia in women.

The technical result of the claimed invention consists in the safety of its use, including in patients with arterial hypertension and obesity, in expanding the diagnosis of complex cases when it is impossible to perform stress tests or if there are contraindications for their implementation, in improving the accuracy and objectivity of diagnosing painless myocardial ischemia in women, due to the assessment of the functional state of cardiomyocytes and the severity of atherosclerotic lesions of the vascular wall of the coronary arteries.

It is known in the literature that apo-protein concentrations are involved in the pathogenesis of atherosclerotic lesions of the coronary arteries (Yusuf S, Hawken S, Ounpuu S et al. Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART study): case-control study. Lancet 2004, 364: 937-52), and the level of the pro-inflammatory cytokine, interleukin-18, will affect the functional state of cardiomyocytes (Prep Biochcm Biotechnol. 2008; 38 (2): 201-12. Links. Mechanical stretch induced interleukin-18 ( IL-18) expression through Angiotensin subtype 1 receptor (AT1R) and endothelin-1 in cardiomyocytes. Naka T, Sakoda T, Doi T, Akagami T, Tsujino T, Masuyama T, Ohyanagi M. Department of Internal Medicine, Division of Coronary Heart Disease, Hyogo College of Medicine, Nishinomiy a, Hyogo, Japan). We found that the ratio of indicators in combination with other diagnostic criteria established by us turned out to be informative for the detection of painless myocardial ischemia. We determined the level of these indicators that is significant for the diagnosis of painless myocardial ischemia.

The essence of the claimed invention lies in the fact that after detecting arterial hypertension and abdominal obesity, this risk group additionally examines blood for interleukin-18, apolipoproteins B and apolipoproteins A1, calculates the ratio of apolipoproteins B to apolipoproteins A1, with an interleukin-18 of 87, 4 pg / ml or more and the level of the ratio of apolipoproteins B to apolipoproteins A1 0.8 and higher judge the presence of painless myocardial ischemia.

The method is as follows.

In women, to determine painless myocardial ischemia, a study is carried out by identifying arterial hypertension, characterized by an increase in systolic blood pressure of more than 139 mmHg. and / or an increase in diastolic blood pressure over 89 mmHg or receiving antihypertensive treatment, the detection of blood pressure involves the study of anamnestic fluctuations in blood pressure and / or an increase in blood pressure at home and / or during routine examinations, and / or during daily blood pressure monitoring (Recommendations of the Russian Medical Society for Arterial Hypertension and the All-Russian Scientific Society of Cardiology. Appendix 2 to the journal "Kar diovascular therapy and prevention "2008; 7 (6)). Also, abdominal obesity is detected by measuring the waist volume (OT), OT is measured in a standing position, only underwear should be on patients. The measurement point is the middle of the distance between the apex of the iliac crest and the lower lateral edge of the ribs. It does not have to be at the navel level. The measuring tape should be held horizontally. At a waist of 80 cm or more, obesity is diagnosed. After this, a blood test is prescribed to determine interleukin-18 (IL-18), apolipoproteins B (APOV) and apolipoproteins A1 (APOA1). For this, we used a biochemical analyzer-automaton, for example, Hitachi 912. The determination of APO A1, APOV is carried out by immunological turbedimetry (for example, Rosh reagents). For the determination of IL-18, an enzyme immunoassay is used to quantify the human IL-18 Human IL-18 ELISA (for example, Bender MedSystems). Monoclonal antibodies to IL-18 are adsorbed in the cells of the tablet. IL-18, present in samples or standards introduced into the cell of the tablet, binds to antibodies adsorbed in the cells. Then, a conjugate of monoclonal anti-IL-18 antibodies with biotin, which binds to IL-18 molecules, is added to the wells, and streptavidi HRP conjugate, which binds to biotin conjugated to IL-18, is added to the wells. After incubation and washing, unbound HRP streptavidi conjugate is removed from the cells and a substrate solution is added to the cells, which interacts with HRP to form a colored solution. The reaction is stopped by the addition of acid. The color intensity measured at a wavelength of 450 nm is directly proportional to the concentration of IL-18 present in the samples. The concentration of IL-18 in the samples is determined by seven prepared dilutions of the standard. The calculation of the index APOV / APOA1. The level of APOV / APOA1 is 0.8 or more and IL-18 is 87.4 pg / ml or more and the presence of a central (abdominal) type of obesity is the waist circumference (OT) of more than 80 cm, as well as arterial hypertension (BP> 140/90 mm Hg), are the basis for the diagnosis of painless myocardial ischemia.

The proposed method is implemented in the presented examples.

Examples 1

The patient K-na, 55 years old, 08/12/1954, underwent medical examination at the clinic Clinical Hospital № 13. She did not actively complain. From the anamnesis revealed: smokes from 25 years to 1 pack per day. Marks an increase in blood pressure to 180/110, does not receive permanent antihypertensive therapy, periodically takes amlodipine and atenolol.

Objectively: waist 110 cm, blood pressure 140/90 mm Hg, pulse 95 beats. in minutes, heart sounds are rhythmic, no noise. Vesicular breathing is heard over the lungs. Complete blood count is normal. ECG at rest: no features. TG 1.08 (N TG <1.7 mmol / L), CS 5.54 (N up to 5.2 mmol / L), HDL 2.35 (N> 1.38), LDL 3.27 (N < 4.32), VLDL 0.49 (N <0.49) Ind. At 1.6. When analyzing the studied parameters, it was revealed: APOLP A1 = 1.66, APOLP B = 0.86, APOV / APOA1 = 0.52, IL-18 = 85.4.

Based on our proposed method, there is no data for painless myocardial ischemia, despite the presence of numerous risk factors for a coronary event.

When conducting VEM: the test is negative, exercise tolerance is average. It is recommended to control blood pressure, continuous use of antihypertensive drugs: ACE inhibitors 10 mg - 2 times a day, indapamine 1.5 mg - in the morning.

After 6 months, a second VEM study was performed: the sample was negative without dynamics. Thus, the diagnosis of painless myocardial ischemia is confirmed by VEM.

Diagnosis: GB 2 tbsp., 3 steps., Medium risk. Obesity 2 tbsp.

Example 2

Patient F, 63 years old, born on 08/08/1946, underwent medical examination at the polyclinic GKB No. 13. She did not actively complain. From the anamnesis revealed: smokes from 30 years to 1 pack per day. Marks an increase in blood pressure to 150/90, does not receive permanent antihypertensive therapy.

Objectively: waist 82 cm, blood pressure 150/100 mm Hg, pulse 90 beats. in minutes, heart sounds are rhythmic, no noise. Vesicular breathing is heard over the lungs. Complete blood count is normal. ECG at rest: no features. TG 2.35 (N TG <1.7 mmol / L), cholesterol 9.07 (N up to 5.2 mmol / L), HDL 2.01 (N> 1.38), LDL 5.99 (N < 4.32) VLDL 1.07 (N <0.49) Ind. At 3.51. When analyzing the studied parameters, it was revealed that: APOLP A1 = 1.47, APOLP B = 1.64, APOV / APOA1 = 1.11, IL-18 = 87.4. During VEM: a positive test, horizontal depression STII, III, Avf 1.0-1.5 mm, duration 80 ms from point J, exercise tolerance is reduced. There were no complaints.

Diagnosis: coronary heart disease: painless myocardial ischemia, type I. GB 2 tbsp. 2 tbsp., High risk of CCO. Dyslipidemia II type. It is recommended to control blood pressure, continuous use of antihypertensive drugs: ACE inhibitors 5 mg - 2 times a day, lipid-lowering drugs and antiplatelet agents 100 mg at night.

Example 3

Patient Sh-na, 41 years old, born on 02/06/1968, underwent medical examination at the polyclinic GKB No. 13. She did not actively complain. From the anamnesis revealed: no smoking, mom mom type 2 diabetes. Marks an increase in blood pressure to 160/100, does not receive permanent antihypertensive therapy.

Objectively: waist 85 cm, blood pressure 140/90 mm Hg, pulse 80 beats. in minutes, heart sounds are rhythmic, no noise. Vesicular breathing is heard over the lungs. Complete blood count is normal. ECG at rest: no features. TG 1.85 (N TG <1.7 mmol / L), CS 5.75 (N up to 5.2 mmol / L). When analyzing the studied parameters, it was revealed: APOLP A1 = 1.28, APOLP B = 1.03, APOV / APOA1 = 0.8, IL-18 = 125.4. During VEM: a positive test, horizontal depression of ST in v 4-v5 1.0 mm for a duration of 80 ms from point J, exercise tolerance is reduced. There were no complaints.

Diagnosis: CHD: painless ischemia type II. GB 2 tbsp., 2 tbsp., High risk of MTR. It is recommended to control blood pressure, continuous use of antihypertensive drugs: ACE inhibitors 5 mg - 2 times a day, lipid-lowering drugs and antiplatelet agents 100 mg at night.

The presented method was tested on 58 patients, in all cases a painless form of coronary heart disease was detected by the presented method, it was confirmed by the Bicycle ergometry method.

According to the literature, one of the methods for assessing painless myocardial ischemia is the Bicycle Energy. According to numerous studies and meta-analyzes, the sensitivity and specificity of ST segment depression as a criterion for a positive test in the diagnosis of coronary heart disease are: 23-100% (average 68%) and 17-100% (average 77%), respectively. (Draft recommendations for the diagnosis and treatment of stable angina. Russian recommendations Draft (II revision.) GFCF-2008).

Criteria for positive bicycle ergometry (Bernard Attal, Alain Ducardonnet, Olivier Hoffman, and al. Exercise Testing in Cardiology. Springer-Verlag France, Paris 2009. 38-39):

- horizontally or obliquely descending ST segment or its rise by 1 mm or more;

- in 2 concordant leads;

- the extent of depression ST is not less than 80 ms after point J.

Claims (1)

A method for the diagnosis of painless myocardial ischemia in women, including the detection of arterial hypertension in the form of an increase in systolic blood pressure (BP) of more than 139 mm Hg and / or diastolic blood pressure greater than 89 mmHg, characterized in that the patient further determines the presence of an abdominal type of obesity characterized by a waist circumference of more than or equal to 80 cm, as well as the level of interleukin-18 and the ratio of apolipoproteins B to apolipoproteins A1, and when the value of interleukin-18 is 87.4 pg / ml or more and the ratio of apolipoproteins B to apolipoproteins A1 equal to or more than 0.8, painless myocardial ischemia is diagnosed.