RU2462186C1 - Method of predicting risk of progressing stenocardia in smoking patients with chronic obstructive lung disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to cardiology and pulmonology, and can be used for predicting risk of progressing stenocardia in smoking patients with chronic obstructive lung disease (COLD). Volume of forced exhalation during first second (VFE1) is determined for patient at the time of the first observation and after twelve months. After that, coefficient of risk of progressing stenocardia is calculated by formula: coefficient of risk=4.9945*X-0.4589, where X is drop of VFE1, calculated as difference of VFE1 during the first observation and after twelve months. Coefficient of risk is expressed in percent. If coefficient value is lower than 10%, risk of stenocardia development is considered to be low. If coefficient value equals or is higher than 10%, it is considered to be high.

EFFECT: method makes it possible to identify patients with high risk of progressing stenocardia among smoking patients with COLD and perform treatment with statins with prophylactic aim in due time.

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Description

The invention relates to medicine, in particular to cardiology and pulmonology, and can be used to predict the risk of progressive angina pectoris in smoking patients with chronic obstructive pulmonary disease.

A known method for the diagnosis of coronary heart disease in patients with chronic obstructive pulmonary disease by conducting a provocative pharmacological test [US Pat. RU No. 2187240, publ. 08/20/2002, Krasnova Yu.N., Dzizinsky A.A., Chernyak B.A.]. The test consists in inhalation of salbutamol in a dose of 5 mg or phenoterol 1 mg through a nebulizer and monitoring of the ECG for an hour after inhalation. If there is a clinic of angina pectoris and / or registration of electrocardiographic signs of myocardial ischemia, lasting more than 1 minute, the test is considered positive. The method allows to identify concomitant coronary heart disease in patients with COPD. The disadvantage of this method is that it can detect coronary heart disease in the early stages in patients with chronic obstructive pulmonary disease, but cannot determine the risk of progressive angina pectoris in patients with COPD, which is the reason for hospitalization and an increase in the time of disability in workers.

Close to the proposed is a method for assessing the individual cardiovascular total risk for the population of Russia [patent application RU, priority of 04/28/2007, reg. No. 2007116057, Oganov R.G., Shalnova S.A., Kalinina A.M.]. This model is calculated using computer programs using the following characteristics: gender, age, level of education, the presence of angina pectoris, a history of myocardial infarction, smoking, alcohol consumption, ECG changes at rest, systolic blood pressure, total cholesterol, LDL cholesterol, frequency heart rate, body mass index. After introducing these parameters, the program calculates the relative risk as a percentage of the excess or decrease in risk relative to the average indicator of the same age-gender group of population and level of education.

The disadvantage of this method is that it does not take into account background diseases, in particular COPD, which increases the risk of cardiovascular events. The method we offer is quite relevant, because at the present time a combination of COPD with cardiovascular diseases is quite common.

Also known is a method of early diagnosis of angina pectoris of typical and atypical course in chronic obstructive pulmonary disease [US Pat. RU 2414847 dated 5.10.2009, Pavlenko V.I.], which is carried out by examining the blood of patients with COPD. The cytoleukogram of granulocyte-binding lymphocytes is evaluated. The rosette formation index is calculated as the ratio between LSH-1 (lymphocyte + one granulocyte), LSH-2 (lymphocyte + 2 granulocytes), LSH-3 (lymphocyte + 3 granulocytes) and free-lying lymphocytes. With an increase in the RTI of LSH-3 more than 0.03, a decrease in the RTI of LSH-2 less than 0.11, patients with COPD are diagnosed with stable angina pectoris. This method is quite difficult to perform. While our proposed method is simple and minimally invasive.

The disadvantage of this method is its ability to be used only for the diagnosis of stable angina, not taking into account the appearance of progressive angina pectoris in the future.

The well-known SCORE scale (Systemic Coronary Risk Evaluation), developed in 2003 by a group of experts from European and other cardiological communities to assess the risk of death from cardiovascular causes for 10 years [publ. on the website http://medi.ru/doc/a0280610.htm.]. The SCORE scale is a table thanks to which, based on known parameters such as gender, age, smoking, total cholesterol and systolic blood pressure, you can calculate the percentage of risk of death from cardiovascular disease. At a risk level of 5% or more, a high probability of death from cardiovascular causes within 10 years is considered.

However, this scale is used for all patients and does not take into account the specifics of bronchopulmonary pathology, namely COPD. In addition, an anamnestic data set was used, the collection of which requires time and effort.

The aim of the invention is to develop a method for predicting the risk of progressive angina pectoris in smokers with chronic obstructive pulmonary disease, based on the annual decrease in forced expiratory volume (FEV1) by 10% or more from that measured at the beginning of observation for the timely appointment of preventive measures, since often progressive angina pectoris precedes myocardial infarction.

The proposed method is as follows.

The fall in FEV1 per year is defined as the difference between the volume of forced expiration in the first second in the first measurement in a patient with COPD and the same indicator, measured after 12 months of observation of this patient. FEV1 is determined by spirometry, for example, on the installation "Diamond", Russia. The study is carried out in a sitting position. First, the patient is closed the nose with a special clamp, they are offered to tightly grasp the mouthpiece with the lips and breathe through the mouth calmly and evenly for a minute. After this, a maneuver of the study of vital capacity of the lungs (VC) is performed, while the patient must take a deep breath and then exhale as much as possible. Then, forced spirometry is performed, in which the VC and speed indicators (FEV1) are determined. The patient should breathe evenly, calmly, then take a deep breath, quickly inhale as deeply as possible and immediately exhale as much as possible. The test is repeated three times. Evaluation of the results relative to the proper values takes into account age, gender and is carried out automatically and is expressed as a percentage of what is due.

After dynamic observation of the decrease in FEV1 in smokers with COPD, the likely risk of unstable angina is assessed. With an annual fall in FEV1 to 10%, the risk of progressive angina pectoris is considered low. When the level of FEV1 is reduced by 10% or more, the proposed formula is used to identify individuals with a very high and moderately high risk of progressive angina pectoris. The formula determines the risk factor (risk coefficient) of progressive angina in smokers with COPD and an annual decrease in FEV1 by 10% or more, a decrease in FEV1 for a year of less than 10% is associated with a low risk.

Coeff. risk = 4.9945 * X-0.4589

where X is the FEV1 drop calculated as the difference in the FEV at the first observation and at observation after twelve months.

Then express the risk factor in percent:

Coeff. risk% = Coeff. risk * 100.

The regression analysis procedure was performed using the STATISTICA 6.1 application package in the Multiple Regression module with a preliminary check of the applicability of the method.

Primary quantitative data were prepared in the form of tables in the MS Excel package version 7.0, then analyzed by means of the "Descriptive Statistics" module of the STATISTICA package. The threshold level of statistical significance was 0.05. For the accuracy of the calculations, the primary quantitative data of FEV1, presented as a percentage of the norm, are converted to decimal fractions.

To obtain a reliable assessment of the correspondence of the studied characteristics to the normal law, the method of testing statistical hypotheses on the type of distribution was used.

The statistical null hypothesis about the compliance of the data with the normal law was checked using the Shapiro-Wilk test, which is used for an initially unknown mean value and standard deviation.

Empirically determined threshold values of the risk coefficient of progressive angina pectoris for each of the patient groups. Also, all patients were calculated the risk according to the SCORE table and the obtained threshold coefficient values were comparable with those obtained by us according to the proposed formula. With Y from 5% inclusive and up to 10%, the risk of progressive angina was considered moderately high, with Y 10% inclusive or more, the risk was considered very high.

To build the formula, we used a sample of 115 patients with stage II-III COPD aged 38 to 76 years. All patients were divided into 2 groups. Patients of the 1st group (main, in the amount of 58 people) had a clinically confirmed severe course of COPD, a large number of exacerbations per year, a decrease in FEV1 per year of observation of more than 10%, in each patient from 2 to 4 cases of progressive angina pectoris per year. Patients of the 2 groups (control, in the amount of 57 people) had a not severe course of COPD, the FEV1 drop for the follow-up year was less than 10%, cases of unstable angina in patients were single - one attack in 7 people (12% of the group size).

As a result of applying our formula in patients with COPD and an annual decrease in FEV1 by 10% or more (main group), 2 subgroups were distinguished: patients with a moderately high risk of progressive angina pectoris and with a very high risk. Persons of the subgroup with a very high risk (in the amount of 26 people) had 3-4 cases of progressive angina pectoris and, accordingly, hospitalizations per year. In the subgroup with a moderately high risk (in the amount of 32 people), progressive angina was observed 1-2 times a year. Thus, in the subgroup with a very high risk compared with a moderately high risk, there was a more frequent occurrence (1.5-2 times) of progressive angina pectoris per year. Therefore, the selection of this subgroup using the proposed formula is very important, since it allows you to maximize the number of preventive measures in relation to this category of patients.

Preventive measures based on the results of using the method we proposed were taken in 20 smokers with COPD with a very high risk of progressive angina pectoris. Patients were prescribed a drug from the group of statins - Torvacard at a dose of 20 mg, after a year of monitoring patients, when the risk was determined by the rate of decline in FEV1. Torvacard is prescribed to slow the progression of atherosclerosis, the underlying pathogenesis of cardiovascular disease. Since statins possess not only a lipid-lowering property, but also a large number of pleiotropic effects: anti-ischemic, antiarrhythmic, vasodilating, antioxidant, anti-inflammatory, etc., their use helped to reduce cases of progressive angina compared to a subgroup of patients with a very high risk who did not take statins. The control group included very high-risk patients who did not take statins, despite recommendations on discharge, considering their use unnecessary and expensive. In the group of patients who took torvacard for 12 months, a decrease in FEV1 drop was observed by about 2 times compared with the same time period of observation of these patients before prescribing the drug. Accordingly, the risk of progressive angina has decreased. The results are presented in the table.

Comparative results of reducing FEV1 and the number of cases of progressive angina in patients without using the proposed method (control group) and according to the results of using the proposed method (main group) Group FEV1 reduction The number of cases of progressive angina pectoris for the first year of observation for the second year of observation for the first year of observation for the second year of observation Control (no statins) 12.7% ± 0.01 11.47% ± 0.01 3.23 ± 0.12 3.26 ± 0.1 Primary (statins prescribed) 12.0% ± 0.01 5.26% ± 0.01 3.1 ± 0.12 1.45 ± 0.1

We give examples of the use of the claimed method:

Example 1

A man P., 73 years old, suffering from stage II COPD for 25 years, was admitted on September 4, 2009 to the pulmonology department of the BSMP group of patients No. 1 with complaints of cough with difficult to separate yellow-green sputum, shortness of breath at rest, chest congestion, general weakness. From the history of the patient it is known that COPD suffers for 25 years. Smokes 40 years per pack per day. Periodically undergoes inpatient treatment (2-3 times a year), is often treated on an outpatient basis. It is used by berodual on demand, it does not use other drugs because of their high cost. Deterioration of well-being within 2 weeks with the appearance of a strong dry cough, fever up to 38 degrees, chest congestion. It was treated on an outpatient basis: antipyretic, lazolvan, antibiotics. Against the background of the treatment, the state of health did not improve; he was sent by the clinic to the pulmonology department.

From the anamnesis it is known: for many years he suffers from hypertension, max blood pressure = 220/100 mm Hg, adapted to blood pressure = 150-160 / 90 mm Hg Constantly taking enalapril 5 mg 2 times a day. For 5 years, stable angina pectoris.

Objective research data: The skin is clean, normal color, cyanosis of the lips. Pulse = 86 beats per minute, 1-2 extrasystoles per minute.

Heart sounds are rhythmic, muffled, systolic murmur at the apex and above the aorta, the emphasis of the second tone on the aorta. In the lungs, harsh breathing, scattered dry rales in all fields. NPV = 28 per minute. The abdomen is soft, painless. Liver, spleen not palpable. Pastosity of the legs and feet.

Complete blood count: HB = 122 g / l, red blood cells = 4.2, col. indicator = 0.9, white blood cells = 8.6, ESR = 18 mm / h, n = 3%, s = 57%, e = 1%, l = 32%, m = 7%.

B / x blood: glucose = 5.3, urea = 6.7, creatinine = 0.112, ALAT = 97, ACAT = 62, bilirubin = 11, total cholesterol = 6.8.

General analysis of urine: transparent, color s / f, rel. density = 1014, acid reaction, epithelium flat unit, white blood cells unit.

ECG: sinus tachycardia, EOS is not rejected, single ventricular extrasystoles.

X-ray analysis of OGK: on a radiograph in a direct projection of focal and infiltrative shadows it was not revealed, the pulmonary pattern is strengthened, the roots are densified, expanded, cor not expanded. Conclusion: pulmonosclerosis

According to spirometry, FEV1 = 69.73%.

The diagnosis was made: stage II COPD, exacerbation. NAM II. CHD: stable angina of exertion II FC. Coronarosclerosis Atherosclerotic cardiosclerosis. Violation of the rhythm by the type of extrasystole. Hypertension of the III century, the risk of CCO IV. CHF II A, FC III.

After 10 days, the patient was discharged from the hospital.

Throughout the year, the patient underwent monthly spirometry. The decrease in FEV1 for the year was 14.9%, which is a high risk, as this is more than 10%. When calculating the proposed formula, the risk was:

Coef. risk = 4.9945 * 0.149-0.4589 = 0.2852

Coef. risk,% = 0.2852 * 100 = 28.52% - this corresponds to a very high risk of progressive angina pectoris.

Conclusion: During the 2 years of follow-up, the patient had an average of 3 cases of progressive angina pectoris annually.

Example 2

A man P., 74 years old, suffering from COPD for 22 years, was admitted to the pulmonology department on 01/13/2010 with complaints of cough with a yellow sputum, shortness of breath, chest tightness, general weakness.

From the anamnesis it is known that COPD suffers for 22 years. Inpatient treatment periodically, at least 2 times a year. Over the past 2 years, exacerbations have become more frequent, up to 4-5 times per year. Constantly uses berodual as needed. Deterioration within a week after hypothermia, when the cough intensified, sputum appeared yellow, shortness of breath, chest tightness, increased need for berodual up to 6 times per day. Ambulance was hospitalized in the pulmonary department of the hospital.

From the anamnesis it is known that the patient suffers from stable angina pectoris of FC II for 5 years. Periodically takes Sydnopharm. He suffers from hypertension for many years, max blood pressure = 200/100 mm Hg. Art., adapted to blood pressure = 140/80 mm Hg Constantly takes monopril 10 mg per day.

An objective examination: the skin of normal color, clean, acrocyanosis. NPV = 26 per minute. In the lungs, harsh breathing, scattered dry rales in all fields. Percussion box sound. Pulse 80 beats per minute, rhythmic, satisfactory qualities. Heart sounds are rhythmic, muffled, accent of the 2nd tone over the aorta. HELL = 140/80 mm Hg The abdomen is soft, painless. Liver, spleen not palpable. No peripheral edema.

Complete blood count: Hb = 126, red blood cells = 3.5, color indicator = 0.9, white blood cells = 8.2, ESR = 19, n = 5%, s = 56, e = 1, l = 32, m = 6.

B / x blood: glucose = 5.6, urea = 6.1, creatinine = 0.111, ALAT = 85, ACAT = 78, total cholesterol = 6.1.

General analysis of urine: transparent, color s / f, rel. density = 1023, epithelium flat unit, white blood cells unit.

ECG: sinus rhythm, sinus tachycardia, EOS to the left.

X-ray analysis of OGK: on a radiograph in a direct projection of focal and infiltrative shadows it was not revealed, the pulmonary pattern is strengthened, the roots are tightened, deformed, cor is not expanded. Conclusion: pulmonosclerosis.

With spirometry in the first month of observation, FEV1 = 65.18%.

Based on complaints, medical history, objective examination data, laboratory and instrumental studies, the diagnosis was made: stage II COPD, exacerbation. NAM II. CHD: stable angina pectoris FC II. Coronarosclerosis Atherosclerotic cardiosclerosis. Hypertension III Art. CCO IV. CHF I, FC II:

After 10 days of treatment, the patient was discharged from the hospital. When observing a patient (1.5 years), the FEV1 drop for the year was 11.5%, which corresponds to a high risk of progressive angina pectoris.

Calculation of risk by the formula:

Coeff. risk = 4.9945 * 0.115-0.4589 = 0.1154675

Coeff. risk% = 0.1154675 * 100 = 11.54% - this corresponds to a high risk of progressive angina pectoris.

After a year of observation, observing the dynamics of the FEV1 drop and determining the risk using the formula, we used statins (torvacard) at a dose of 20 mg in order to prevent progressive angina pectoris. The patient used Torvacard for six months.

Conclusion: Since the patient was diagnosed with a very high risk of progressive angina pectoris during the follow-up year, torvacard was prescribed for prophylactic purposes. During the year before receiving statins, the patient had 4 cases of progressive angina pectoris, and in the following year, only 2 cases of progressive angina were recorded from the use of torvacard. This is due to the inhibition of the progression of atherosclerosis, which underlies many cardiovascular diseases and additional pleiotropic effects of statins: anti-ischemic, antiarrhythmic, vasodilator, antioxidant. In addition, while taking torvacardium, a decrease in FEV1 was observed, and as a consequence, a decrease in the risk of progressive angina pectoris.

Claims (1)

A method for predicting the risk of progressive angina pectoris in smoking patients with chronic obstructive pulmonary disease with an assessment of the dynamics of FEV1, namely, that the risk factor for progressive angina pectoris is calculated by the formula: coefficient. risk = 4.9945 * X-0.4589, where X is the drop in FEV1, calculated as the difference in FEV at the first observation and at observation after twelve months, express the risk factor in percent, Coeff. risk% = Coeff. risk * 100; if the fall coefficient. a risk of less than 10%, then the risk is considered low, if equal to or more than 10%, the risk of progressive angina pectoris is considered high, the appointment of drugs of the statin group is recommended.