RU2410021C2 - Method for prediction of acute coronary syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: Holter electrocardiographic and spirometry monitoring is carried out on the 15-20th days from the beginning of a disease. If spirometry values are as follows: supplemental air <1.78 l; vital capacity <3.71 l; functional vital capacity <3.80 l; flow rate <2.80 l/s, while Holter monitoring presents the following data: average 5-minute standard deviations of R-R-intervals calculated within 24 hours - SDNN index> 25 ms; a root mean square of successive R-R interval differences - RMSSD <24 ms; a number of cases wherein the difference between successive R-R interval duration exceeds 50 ms - NN50 <1333; a percentage of successive R-R intervals that differ by more than 50 ms - pNN50 <4.3 %, a circadian index> 1.2; a triangular index> 46, an unfavourable prognosis for the development of acute coronary syndrome is stated.

EFFECT: higher effectiveness of diagnosing vegetative reactions in predicting acute coronary syndrome.

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Description

The invention relates to medicine, in particular to cardiology, and can be used to improve the diagnosis of pathological autonomic reactions in predicting acute coronary syndrome.

A known method of assessing the functional state of the autonomic nervous system using a cold test (Vein A.M., Voznesenskaya T.G., Golubeva V.A. et al. // Ed. AMVane // Diseases of the autonomic nervous system. - M. : Medicine, 1991). The method registers changes in blood pressure and heart rate before and after lowering the hand in cold water (+ 4 ° C). Sample assessment: normal autonomic reactivity - an increase in systolic blood pressure by 20 mm Hg, and diastolic - by 10-20 mm Hg. after 0.5-1 minutes Return of blood pressure to the initial level after 2-3 minutes. Pathological deviations: 1) a more significant increase in systolic and diastolic blood pressure (increased autonomic reactivity); 2) a slight increase in blood pressure (decreased vegetative reactivity); 3) a decrease in systolic and diastolic pressure (perverse reaction).

The disadvantage of this method is a one-sided approach to the study of autonomic reactivity, not taking into account the dynamic interaction of the two departments of the autonomic nervous system of the sympathetic and parasympathetic.

A known method for assessing the functional state of the autonomic nervous system using Holter monitoring (Heart rate variability: measurement standards, physiological interpretation and clinical use / Working Group of the European Cardiology Society and the North American Society of Stimulation and Electrophysiology. - St. Petersburg: INCART, 2001. - 64 p. )

The disadvantages of this diagnostic method is an isolated assessment of the effect of the autonomic nervous system on the electrophysiological state of the myocardium, which does not make it possible to judge the prevailing effect of the parasympathetic or sympathetic departments on the cardiorespiratory system as a whole, while assessing the effect of the autonomic nervous system on the cardiovascular and the respiratory system is one of the determining factors in predicting the development of coronary disease in patients.

There is a method aimed at studying parasympathetic innervation - Valsalva test: breathing in the mouthpiece connected to a manometer, maintaining the pressure in the spirometer at 40 mm Hg within 10-15 s followed by the calculation of the Valsalva coefficient (the ratio of the elongated cardio interval in the first 20 s after the sample to the shortened cardio interval during the sample). To conduct this test, parallel ECG recording is required (Bannister R. Autonomic Failure: A Textbook of Clinical Disorders of the Autonomic Nervous System. - Oxford, 1983).

The disadvantage of this method is the one-sided study of the autonomic nervous system, which does not allow to give a complete assessment of the mutual influence on the body of its various departments.

The objective of the invention is to increase the reliability of information about the integrative effect of the autonomic nervous system on the cardiorespiratory system, which will more accurately predict the course of acute coronary syndrome.

The problem is solved by conducting Holter monitoring of ECG and spirometry on the 15-20th day of hospitalization and with spirometry indicators: reserve inspiratory volume less than 1.78 l; vital lung capacity less than 3.71 l; functional lung capacity less than 3.80 l; average volumetric velocity is less than 2.80 l / s and Holter monitoring indices: average value of 5-minute standard deviations of R-R intervals calculated over 24 hours - SDNN index is more than 25 ms; the square root of the average squared difference of the values of the successive intervals R-R - RMSSD is less than 24 ms; the number of cases in which the difference between the duration of consecutive R-R intervals exceeds 50 ms - the NN50 is less than 1333; the percentage of consecutive R-R intervals, the difference between which exceeds 50 ms - pNN50 is less than 4.3%, the circadian index is more than 1.2; a triangular index greater than 46 record a negative prognosis of the development of acute coronary syndrome.

The method includes daily Holter ECG monitoring and spirometry on the same day (on the 15-20th day of hospitalization). This set of functional studies will allow us to evaluate the effect of the autonomic nervous system both on the electrophysiological state of the myocardium and to reveal the prevailing effect of the autonomic nervous system on the respiratory system. Thanks to the use of Holter ECG monitoring and spirometry, the doctor of functional diagnostics has more than two dozen indicators for evaluating the functional state of the cardiorespiratory system. In the course of our research (Experience and organization of the functional diagnostics department of the emergency hospital / E.V. Vakhrameeva, A.V. Toropov // Materials of the scientific-practical conference "Clinical and fundamental aspects of critical conditions." Volume 2. - Omsk : Publishing House, 2007. - P.27-29) the greatest diagnostic value of the following indicators of Holter ECG monitoring was revealed: SDNN index - average value of 5-minute standard deviations of RR-intervals calculated over 24 hours, RMSSD - square root of average o the values of the squares of the differences in the values of consecutive RR intervals, NN50 is the number of cases in which the difference between the duration of consecutive RR intervals exceeds 50 ms, pNN50 is the percentage of consecutive RR intervals, the difference between them exceeds 50 ms, circadian and triangular indices, as well as spirometry: reserve inspiratory volume, vital lung capacity, functional vital lung capacity and volumetric velocity.

Description of the technique: on the 15-20th day of hospitalization of a cardiological patient, Holter ECG monitoring and spirometry are carried out in a standard way. When interpreting the results obtained, it is necessary to rely on the numerical characteristics of the following parameters: SDNN index (ms) is the average value of 5-minute standard deviations of RR-intervals calculated over 24 hours, RMSSD (ms) is the square root of the average squares of the differences in the values of consecutive RR intervals , NN50 - the number of cases in which the difference between the duration of consecutive RR intervals exceeds 50 ms, pNN50 (%) is the percentage of consecutive RR intervals, the difference between which exceeds 50 ms, circadian and triangular indices, inspiratory reserve volume, lung capacity, functional lung capacity, and volume velocities.

The prevailing effect of the sympathetic part of the autonomic nervous system on the cardiorespiratory, and therefore the negative prognosis of the development of acute coronary syndrome, is indicated by the following parameters: reserve inspiratory volume less than 1.78 l; vital lung capacity less than 3.71 l; functional lung capacity less than 3.80 l; average volumetric velocity is less than 2.80 l / s and Holter monitoring indices: SDNN index is more than 25 ms; RMSSD less than 24 ms; NN50 less than 1333; pNN50 less than 4.3%, circadian index greater than 1.2; a triangular index greater than 46 record a negative prognosis of the development of acute coronary syndrome. While the prevailing effect of the parasympathetic department on the functional state of the cardiorespiratory system, and, consequently, a positive prognosis can be judged with the following results: reserve inspiratory volume is more than 1.78 l; vital lung capacity is more than 3.71 l; functional lung capacity greater than 3.80 L; average space velocity greater than 2.80 l / s; SDNN index less than 25 ms; RMSSD more than 24 ms; NN50 greater than 1333; pNN50 greater than 4.3%, circadian index less than 1.2; the triangular index is less than 46.

Examples

Example 1. Patient T., 52 years old, was admitted to the cardiac reanimation department of the Omsk Emergency Hospital No. 1 in Omsk with a diagnosis of acute coronary syndrome, based on a typical clinical picture, the dynamics of electrocardiograms, and an increase in the level of troponin T. in the blood serum. met the standards adopted in the medical institution, based on the recommendations for the treatment of acute coronary syndrome adopted by the All-Russian Scientific Society of Cardiology. On the 17th day spirometry was performed: reserve inspiratory volume - 1.68 l; vital lung capacity - 3.11 l; functional lung capacity - 3.56 l; average space velocity is 2.60 l / s. Holter ECG monitoring was performed on the 18th day: average value of 5-minute standard deviations of R-R intervals calculated over 24 hours - SDNN index - 24 ms; the square root of the mean squares of the differences in the values of the successive intervals R-R - RMSSD - 22 ms; the number of cases in which the difference between the duration of consecutive R-R intervals exceeds 50 ms - NN50 - 1300; the percentage of consecutive R-R intervals, the difference between which exceeds 50 ms - pNN50 - 4.1%, circadian index -1.1; the triangular index is 44.

Based on the results of functional tests, a negative prognosis was made, the therapy of the underlying disease was intensified. However, on the 22nd day there was a repeated attack of angina pectoris, accompanied by an increase in markers of cardiac destruction.

Example 2. Patient A., 50 years old, was admitted to the cardiac reanimation department of the Omsk emergency hospital No. 1 in Omsk with a diagnosis of acute coronary syndrome based on a typical clinical picture, dynamics of electrocardiograms, and an increase in the level of troponin T. in serum. met the standards adopted in the medical institution, based on the recommendations for the treatment of acute coronary syndrome adopted by the All-Russian Scientific Society of Cardiology. Spirometry was performed on the 16th day: reserve inspiratory volume - 1.89 l; vital lung capacity - 3.72 l; functional vital capacity of the lungs - 3.88 l; the average space velocity is 2.90 l / s. Holter ECG monitoring was performed on the 17th day: average value of 5-minute standard deviations of R-R intervals calculated over 24 hours - SDNN index - 28 ms; the square root of the average squares of the differences in the values of the successive intervals R-R - RMSSD - 25 ms; the number of cases in which the difference between the duration of consecutive R-R intervals exceeds 50 ms - NN50 - 1420; the percentage of consecutive R-R intervals, the difference between which exceeds 50 ms - pNN50 - 4.4%, the circadian index - 1.3; the triangular index is 49.

Based on the results of functional tests, a positive forecast was made. The patient was discharged on time without any complications.

This forecasting method was used in 56 patients with acute coronary syndrome. Using the proposed method, due to a timely change in therapeutic tactics, allowed to reduce mortality in acute coronary syndrome, and also contributed in 96.8% of cases to reliable prediction of the early and long-term consequences of the development of acute coronary syndrome in patients.

In the proposed method for predicting acute coronary syndrome, the level of activity of both the sympathetic and parasympathetic divisions of the autonomic nervous system is determined, and, thanks to the parallel study of the bioelectric activity of the myocardium during the day and bronchial patency indicators (the most important indicator indicating the prevailing effect of the sympathetic or parasympathetic autonomic nervous divisions) systems on the respiratory system) with spirometry receive information about integrative the influence of the autonomic nervous system on the functioning of body systems, including cardiorespiratory in patients with a cardiological profile, which allows reliable prediction of the course of acute coronary syndrome.

Claims (1)

A method for predicting acute coronary syndrome, including Holter monitoring of ECG and spirometry on the 15-20th day from the onset of the disease, characterized in that when spirometry indicators: reserve inspiratory volume is less than 1.78 l; vital lung capacity less than 3.71 l; functional lung capacity less than 3.80 l; average volumetric velocity less than 2.80 l / s and Holter monitoring indices: average value of 5-minute standard deviations of R-R intervals calculated over 24 hours - SDNN index more than 25 ms; the square root of the average squared difference of the values of the successive intervals R-R - RMSSD is less than 24 ms; the number of cases in which the difference between the duration of consecutive R-R intervals exceeds 50 ms - the NN50 is less than 1333; the percentage of consecutive R-R intervals, the difference between which exceeds 50 ms - pNN50 is less than 4.3%, the circadian index is more than 1.2; a triangular index greater than 46 record a negative prognosis of the development of acute coronary syndrome.