RU2429785C2 - Diagnostic technique for left ventricular hypertrophy in patients with rheumatoid arthritis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: left ventricular mass index (LVMI) is determined. That is ensured by calculating a regression equation containing with the variables presented by pulse wave velocity in elastic vessels (Ev), total cholesterol (TC) level and DAS 28 index by formula: LVMI=47.25+8.26×TC+2.96×Ev+0.85×DAS28, where 47.25 is a free term, a constant, 8.26 is a nonstandardised regression coefficient b, TC is the total cholesterol level, mmol/l, 2.96 a nonstandardised regression coefficient b, Ev is pulse wave velocity in elastic vessels, km/s, 0.85 a nonstandardised regression coefficient b, DAS 28 is an activity index of rheumatoid arthritis. If the LVMI is equal to or more than "ON" for women, and the LVMI is equal to or more than 125 for men, left ventricular hypertrophy is diagnosed.

EFFECT: technique can be used as a screening method for preliminary evaluation of the LVMI and selection of patients for targeted studies.

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Description

The invention relates to medicine, namely to clinical diagnosis in rheumatology, cardiology, therapy. An increase in left ventricular mass is associated with an increased risk of developing cardiovascular disease. According to the Framingham study, in people from 35 to 64 years old with electrocardiographic signs of left ventricular hypertrophy (LVH), the risk of developing cardiovascular disease is 3-6 times higher than in people without LVH. After the appearance of ECG signs of LVH, 35% of men and 20% of women 35-64 years old die within 5 years; in older age groups, 5-year mortality among men and women reaches 50 and 35%, respectively [Kannel W.B. In: Left ventricular hypertrophy and its regression. Eds. J. M. Cruickshenk, F. H. Messerli. London, 1992; 1-11].

In patients with rheumatoid arthritis (RA), the risk of cardiovascular disease and mortality from them is significantly higher than the general population [Gabriel SE. Cardiovascular morbidity and mortality in rheumatoid arthritis. Am J Med 2008; 121 (10 Suppl 1): S9-14; Bergsrem U.G.B., Jacobsson L., Turesson C. / Cardiovascular morbidity and mortality remains increased in patients with rheumatoid arthritis. // Ann. Rheum. Dis. 2006; 65 (suppl II): 95.]. PA revealed early occurrence (in 86.7% of examined patients already within 1 year of RA disease), significant LVH, and in 68.5% of patients with RA and normal blood pressure, the left ventricular myocardial mass index (LVMI) met the criteria LVH [Myasoedova E.E., Myasoedova S.E., Omelyanenko MG, Obzherina S.V. / Structural and functional features of the left ventricular myocardium and endothelial dysfunction in rheumatoid arthritis depending on the presence of arterial hypertension // Scientific and Practical Rheumatology. - 2007 - No. 3. - S.15-19].

Due to the important prognostic value of LVH in relation to the unfavorable cardiovascular prognosis and the high prevalence of LVH in RA, clear criteria are needed to diagnose LVH as soon as possible and to conduct dynamic monitoring of the process of heart remodeling. The pathophysiological basis of LVH, on the one hand, is primary cardiac damage due to RA activity, and on the other, the early development and progression of atherosclerosis, which is currently regarded as a systemic manifestation of this disease [Van Doornum S, McColl G, Wicks IP. Accelerated atherosclerosis. An extraarticular feature of rheumatoid arthritis. Arthritis Rheum 2002; 46: 862-873]. To determine the activity of PA, the DAS 28 index is used, including an account of painful and swollen joints, ESR and a general assessment of his condition by the patient on a visual analogue scale. Of the several combined indices, the DAS correlated best with the overall assessment of disease activity by the doctor and patient and with 12 other methods for assessing disease activity [Clinical Recommendations. Rheumatology / Ed. E.L. Nasonova. - M.: GEOTAR-Media. - 2008. - 264 s]. The recommendations of the Russian Medical Society for Arterial Hypertension (AH) and the All-Russian Scientific Society of Cardiology 2008 include, among other criteria for risk stratification, the level of total cholesterol> 5.0 mmol / l and the pulse wave propagation velocity from the carotid to the femoral artery> 12 m / s as predictors of heart damage and cardiovascular complications [Diagnosis and treatment of hypertension. Recommendations of the Russian Medical Society for AH and the All-Russian Scientific Society of Cardiology. - M., 2008].

Currently, there are several methods for diagnosing left ventricular myocardial hypertrophy. The simplest and most affordable method is electrocardiography. Despite the high specificity of the electrocardiographic method (96-100%), it has little sensitivity (22-42%), which does not allow it to be effectively used to solve the tasks.

The diagnosis of LVH can also be established as a result of a pathological study (normal myocardial mass is 1/215 of body weight in men and 1/250 of body weight in women [Human Anatomy. Weight M.G., N.K. Lysenkov, V . I. Bushkovich. St. Petersburg, “Hippocrates”, 1997], but it can only be performed posthumously, which significantly limits the possibility of its use.

Currently, one of the most reliable methods for non-invasive diagnosis of LVH is echocardiographic (echo-KG) research, which has a higher sensitivity compared to ECG. According to echocardiography, it is possible to calculate the mass of the left ventricular myocardium (LVM), the value of which is a reliable prognostic risk factor for cardiovascular morbidity and mortality.

In clinical diagnosis, the left ventricular myocardial mass index (LVMI) is taken into account. This is a calculated indicator, which is calculated by the following formula:

LVMI (g / m ² ) = LVM (g): body surface area (m ² ).

LVH is established with LVMI ≥125 g / m ² for men and ≥110 g / m ² for women [Diagnosis and treatment of hypertension In Sat: National clinical guidelines. - M., 2008. - p.19-56].

The value of LVM is calculated on the basis of echocardiography data; there are several formulas for this.

Often used the formula R.B.Devereux (1986) [Devereux R.B., Reichek N. Echocardiographic determination of left ventricular mass in man: anatomic validation of the method // Circulation. - 1977. - Vol. 55. - P.613-618]:

MMLZH (g) = 1.04 × ((TZSLZH + TMZhP + KDR) ³ -KDR ³ ) -13.6, where:

CML - the mass of the left ventricular myocardium, TLCM - the thickness of the posterior wall of the left ventricle, TMC - the thickness of the interventricular septum, CRC - end-diastolic size of the left ventricle.

This formula was obtained on the basis of mathematical transformations of echocardiography data with subsequent comparison with CML, measured by autopsy in 55 patients [Devereux R.B., Alonso D.R., Lutas EM et al. Echocardiographic assessment of left ventricular hypertrophy: comparison to necropsy findings. // Amer. J. Cardiology. - 1986. - Vol. 57. - P.450-458.]. The study found a strong positive correlation between the LVMI values obtained by the Penn Convention formula and the data obtained by autopsy (r = 0.92, P <0.001). The criterion for hypertrophy is the autopsy value of MMVD that exceeds 215 g. The sensitivity of the calculations according to echocardiography in patients with LVH was 100%, and the specificity was 86%. Subsequently, good reproducibility of results was demonstrated in series of studies in 183 patients with hypertension [Palmieri V., Dahlof B., De Quattro V. et al. Reliability of echocardiographic assessment of left ventricular structure and function: The Preserve Study // J. Amer. Coll. Cardiology. - 1999. - Vol. 34. - P.1625-1632].

The cubic formula recommended by the American Society of Echocardiography (ASE) is also widely used; it was originally proposed by B.L. Troy et al. And modified by R.B. Devereux et al. [Troy B.L., Pombo J., Rackley C.E. Measurement of left ventricular wall thickness and mass by echocardiography // Circulation. - 1972. - Vol. 45. - P.602-611]):

MMLJ (g) = 0.8 × (1.04 × ((TZSLZH + TMZHP + KDR) ³ -KDR ³ )) + 0.6, where:

CML - the mass of the left ventricular myocardium, TLCM - the thickness of the posterior wall of the left ventricle, TMC - the thickness of the interventricular septum, CRC - end-diastolic size of the left ventricle.

Thus, the currently used methods for non-invasive diagnosis of LVH are limited by ECG criteria, which are insensitive, and echocardiographic evaluation of LVMI. The latter technique can be considered as a reference, but it has certain limitations and cannot be applied to all patients with RA due to the high cost of the study. The indications for echo-CG in RA according to clinical recommendations are the diagnosis of rheumatoid pericarditis, myocarditis and coronary heart disease (CHD) associated with heart damage [clinical recommendations. Rheumatology / Ed. E.L. Nasonova. - M .: GEOTAR. - Media. - 2008. - p.288]. In this regard, there is a need to develop a method for preliminary diagnosis of LVH in patients with RA, which is accessible to widespread clinical practice, which has a higher sensitivity compared to existing ECG criteria and is comparable with the evaluation of LVMI according to ECHO-CG data. The technical result of the proposed method lies in the fact that the diagnosis of left ventricular hypertrophy in patients with rheumatoid arthritis, including the calculation of the left ventricular myocardial mass index, differs in that for its determination, the regression equation is used as a screening method, including the pulse wave propagation speed as vessels of the elastic type, the level of total cholesterol and the index DAS 28, according to the formula:

LVMI = 47.25 + 8.26 × OX + 2.96 × Ce + 0.85 × DAS28,

where 47.25 is a free term, constant a

8.26 - non-standardized regression coefficient b

OH - the level of total cholesterol, mmol / l

2.96 - non-standardized regression coefficient b

Се - pulse wave propagation speed through the vessels of elastic type, m / s

0.85 - non-standardized regression coefficient b

DAS 28 is an index for calculating the activity of rheumatoid arthritis, and for LVMI for women ≥110 g / m ² , and for men ≥125 g / m ^2, left ventricular hypertrophy is diagnosed.

The essence of the method lies in the fact that on the basis of data from a clinical and laboratory examination of a patient with RA, the activity of this disease is evaluated in a standard way according to the DAS 28 index [Clinical recommendations. Rheumatology / Ed. E.L. Nasonova. - M .: GEOTAR-Media, 2008. - P.47-48], the level of total cholesterol (OH) in blood serum, expressed in mmol / l, and also determine the propagation velocity of the pulse wave in m / s (Se) through the vessels elastic type with the help of the sphygmographic attachment of the agro-industrial complex “Polispectr-12” (LLC “Neurosoft”, Ivanovo). 43 patients were examined (of which 41 were women and 2 men) with a reliably established diagnosis of rheumatoid arthritis of the I-III degree of activity with articular and systemic manifestations of the disease. The average age of the patients was 49.6 ± 11.2 years.

During statistical processing, namely regression analysis, the regression equation was derived, based on which LVMI is calculated. The proposed method allows you to pre-evaluate LVMI in RA and carry out targeted selection of patients for additional echocardiographic studies.

Clinical example No. 1. Patient N., 56 years old, was treated in the rheumatology department of the city clinical hospital No. 4 from 03/06/08 to 03/20/08.

Diagnosis: Rheumatoid arthritis seropositive, polyarthritis, articular form, A 3, advanced stage, IV radiological stage, functional class (FC) III.

Complaints: For non-intense pain and swelling of small joints of the hands and feet, wrist, elbow and knee joints, limitation of movements in the wrist joints, morning stiffness up to 2 hours.

Anamnesis: For the first time, articular syndrome appeared 3.5 years ago, when pain and swelling in the knee and wrist joints occurred acutely for no apparent reason. It was not treated for anything for 2.5 years and joint pain stopped on its own. During the year, methotrexate was prescribed at a dose of 10 mg per week, which was independently canceled. In connection with the exacerbation of the disease, it is aimed at hospitalization in the rheumatology department.

Inspection data: Condition is satisfactory. Height 152 cm, weight 52 kg. The skin is clean, pale pink, moderately moist. Peripheral lymph nodes are not enlarged. In the study of the musculoskeletal system, attention is drawn to ulnar deviation and restriction of movements in the wrist joints, deformation of the II-III metacarpophalangeal joints, swelling in the metacarpophalangeal joints of the fourth finger and proximal interphalangeal joints of the I-IV fingers of both hands, wrist elbow, knee and ankle joints. There is no increase in skin temperature, hyperemia in these areas. On palpation, all joints are painless. Reduced strength in the hands. Pain with active abduction in the shoulder joints. The number of swollen joints - 24, painful - 0.

Assessment on a visual analogue scale is 100. Activity (A) according to the DAS 28 index is 4.83 (corresponds to high activity, A3).

In the lungs, vesicular breathing, no wheezing. HELL 125/75 mm RT. Art.

Heart sounds are muffled, rhythmic, soft systolic murmur at the apex without irradiation. The abdomen on palpation is soft, painless. Dysuria, no edema. The chair is decorated.

Laboratory and instrumental examinations: General blood test: (07.03.08) ESR = 19 mm / h.

Biochemical blood test (03/07/08.): Total protein - 73 g / l, rheumatoid factor - 1:32, cholesterol - 4.0 mmol / l, glucose - 5.2 mmol / l, uric acid - 171 mmol / l , C - reactive protein - positive.

Chest x-ray (03/11/08): Diffuse osteoporosis. The joint cracks are sharply narrowed down to the ankylosis of the carpal, wrist, wrist and carpal joints. Roughly deformed II-III metacarpophalangeal joints.

The treatment was carried out: nimesulide 1 t. 2 p. per day, prednisone 5 mg per day, methotrexate 10 mg / week., Pentoxifylline in / drip.

ECG (03/07/08): Sinus rhythm, heart rate 87 per minute. Normal position of the electrical axis of the heart. Increased activity of the left ventricle.

Special research methods: Pulse wave propagation velocity (SRWP): SRWW in the vessels of muscle type 8.13 m / s, SRWW in the vessels of elastic type 14.6 m / s.

The expected LVMI calculated by the formula of the regression equation:

LVMI = 47,25 + 8,26 × 4,0 mmol / l + 2,96 × 14,6 m / s ² + 0,85 × 4,83 = 127,61 g / m ² (LVMI ≥110 g / m ² , which indicates LVH).

The patient is directed to echocardiography to verify the diagnosis of LVH.

Echocardiogram (07.03.08): LVMI = 123.28 g / m ^2, calculated by the formula RBDevereux, 1986 Georgia (end-diastolic left ventricular size 4.6 cm, IVST - 1.1 cm, PWLV - 1, 1 cm).

Conclusion: moderate LV hypertrophy, a moderate decrease in global myocardial contractile function. Mitral valve insufficiency I tbsp.

Clinical example No. 2. Patient Ch., 54 years old, was undergoing treatment in the rheumatology department of the city clinical hospital No. 4 from 11/13/08. on 11/27/08 with a diagnosis of Rheumatoid arthritis, seronegative polyarthritis, articular form, A 2, very early stage, X-ray stage II, FC II.

Complaints: For moderate pain and swelling of the small joints of the hands, wrist and knee joints, limitation of movements in the wrist joints, morning stiffness for about an hour.

Anamnesis: For the first time, articular syndrome appeared 2 months ago, when pain and swelling gradually appeared in the knee and wrist joints. Treated with non-steroidal anti-inflammatory drugs. To establish a diagnosis, he is sent to a rheumatologist for hospitalization.

Inspection data: Condition is satisfactory. Height 172 cm, weight 87 kg. The skin is clean, pale pink, moderately moist. Peripheral lymph nodes are not enlarged. When examining the musculoskeletal system, swelling in the area of the metacarpophalangeal joints of the I-III fingers of the right and wrist joints, as well as pain when walking in the knee joints is noteworthy. On palpation, painful left wrist and knee joints. Reduced strength in the hands.

The number of swollen joints - 5, painful - 4. Assessment on a visual analogue scale - 80. Activity according to the DAS 28 index - 3.64 (corresponds to moderate activity, A 2).

In the lungs, vesicular breathing, no wheezing. HELL 125/80 mm RT. Art. Heart sounds are muffled, rhythmic, no noise. The abdomen on palpation is soft, painless. Dysuria, no edema. The chair is decorated.

Laboratory and instrumental examinations: General blood test: (07.03.08) ESR = 3 mm / h.

Blood biochemical analysis (07.03.08.) Total protein - 78 g / l, rheumatoid factor - negative, cholesterol - 4.6 mmol / l, glucose - 4.8 mmol / l, uric acid - 281 μmol / l, C - reactive protein is positive.

X-ray of the hands (11. 03. 08): Diffuse osteoporosis. Joint spaces in the wrist joints are narrowed. There is no utilization.

The treatment was carried out: nimesulide 1 t. 2 p. per day, sulfasalazine.

ECG (03/07/08): Sinus rhythm, heart rate 56 per minute. The normal position of the EOS. Partial blockade of the right bundle branch block.

Special research methods: Pulse wave propagation velocity (SRPV): SRPV for muscle vessels of 7.45 m / s, SRV for vessels of elastic type 8.33 m / s.

Expected LVMI = 47,25 + 8,26 × 4,6 mmol / l + 2,96 × 8,33 m / s ² + 0,85 × 3,64 = 113,0 g / m ² (g IMMLZH≤125 / m ² , which indicates the absence of LVH).

The patient was sent for echocardiography to verify the diagnosis of LVH.

Echo-KG (03/07/08): LVMI = 103.1 g / m ² calculated according to the RBDevereux formula, 1986 (end-diastolic size of the left ventricle is 5.0 cm, TML - 1.1 cm, VLH - 1.1 cm).

Conclusion: the size of the heart chambers and the contractile function of the myocardium are not impaired. VSK is not changed.

From clinical examples, it follows that the formula presented by us is used for a preliminary assessment of LVMI in RA and targeted selection of patients for additional echocardiographic studies.

Claims (1)

A method for diagnosing left ventricular hypertrophy in patients with rheumatoid arthritis, including calculating the left ventricular myocardial mass index, characterized in that for determining the left ventricular myocardial mass index (LVMI) as a screening method, the regression equation is used that includes the speed of the pulse wave propagation through the vessels of the elastic type (Ce), total cholesterol (OH) and DAS 28 index, according to the formula
LVMI = 47.25 + 8.26 × OH + 2.96 × Ce + 0.85 × DAS28,
where 47.25 is a free term, a constant;
8.26 - non-standardized regression coefficient b;
OH - the level of total cholesterol, mmol / l;
2.96 - non-standardized regression coefficient b;
Се - pulse wave propagation speed through the vessels of elastic type, m / s;
0.85 - non-standardized regression coefficient b;
DAS 28 is an index for calculating the activity of rheumatoid arthritis,
and with LVMI equal to or greater than 110, for women and LVMI equal to or greater than 125, for men, left ventricular hypertrophy is diagnosed.