RU2487353C1 - Method for describing indications for choosing conservative therapeutic approach to patients suffered recurrent myocardial infarction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method for describing indications for choosing a conservative therapeutic approach to the patients suffered recurrent myocardial infarction involves pre-therapeutic patient's blood examination to analyse blood serum for oxidation-resistant lipoproteids (ORLs), to analyse erythrocytes for the pyruvic acid concentration (PAC), and if the ORL value is equal to 1.89 nmole MDA/mg of protein of β-lipoprotein and lower, while the PAC value is equal to 1.81 mmole/l and higher, the conservative therapy is added with the preparations of lipoic acid.

EFFECT: method is simple, has a broad information value and allows a more objective assessment of the patient's state and identifying a group of the patients in need of the conservative treatment and suffered recurrent myocardial infarction by the preparations of lipoic acid.

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Description

The invention relates to medicine, namely to cardiology, and will find application for evaluating the effectiveness of prescribing drug therapy in the post-infarction period in patients after repeated myocardial infarction (MI).

Statistics show that morbidity and mortality from cardiovascular diseases among patients who have had MI are many times higher than among the general population (Belousov D.Yu., Mednikov OI, 2003; Chazov E.I. , Boytsov S.A., 2009). Despite the obvious successes in the treatment of patients with acute myocardial infarction and secondary prophylaxis, the percentage of recurrent myocardial infarction remains high. Repeated myocardial infarction occupy a special place due to the fact that they are more severe, determine a greater number of complications, increase the specific gravity of myocardial remodeling, and give the highest mortality rates in the structure of heart attacks. Patients who have undergone myocardial infarction have a high risk of developing complications of repeated myocardial infarction (rhythm disturbances, heart failure, sudden death) (Belousov D.Yu., Mednikov O.I., 2003; Malykhina O.P., 2006).

Improving the effectiveness of treatment of myocardial infarction largely depends on observing a pathogenetic integrated approach in assisting this group of patients, developing methods for myocardial revascularization, as well as advances in pharmacotherapy (Stupakov I.N., Gudkova R.G., 2007; Akchurin R.S. et al., 2010; Boqueria L.A. et al., 2010; Eefting F. et al., 2003; Naik MJ et al., 2003; Tavilla G. et al., 2004; Mussa S. et al., 2005). Cytoprotectors and antihypoxic drugs (Vinogradov V.M., Krivoruchko B.I., 2001; Vasiliev K.Yu., are the drugs that are able to alleviate energy deficiency, protect cells at the reversible stage of their damage and activate the formation of structure and function using various mechanisms) 2005; Mazina N.K., 2007; Astashkin E.I., 2008; Andreeva N.N., 2009; Zhukova E.M. et al., 2009; Tsaregorodtsev D.A. et al., 2010).

Currently, a large group of drugs, which are commonly called antioxidants, is extremely popular with a wide range of doctors. However, the lack of a methodological basis for the use of drugs with cytoprotective, antiradical and antihypoxic effects in the treatment of patients leads to the fact that the effectiveness of treatment suffers, which raises doubts about the principal effectiveness of the use of these drugs. All this dictates the need to create a rational concept for the use of drugs related to cytoprotectors.

Despite the well-studied pharmacodynamics of certain groups of drugs used to treat patients with various forms of coronary artery disease, the value of using laboratory biochemical markers to monitor the effectiveness of therapy in patients with myocardial infarction undoubtedly has broad prospects, since success in the treatment of primary myocardial infarction and a reduction in mortality raise the question of adequate PIX therapy.

For energotropic drugs that enhance metabolic rate at the cellular level, with antihypoxic and antioxidant effects, rational bases for their use are poorly developed, effective approaches are often insufficient or overestimated, drugs are applied randomly, without sufficient knowledge about their capabilities and features, without planning a strategy from the point of view of expediency.

A known method for predicting the effectiveness of the treatment of patients with coronary artery disease with preparations of essential phospholipids (RF patent No. 2088931, 1997.08.27). The result is achieved by the use of a new diagnostic criterion - the determination of diene conjugates on the 3rd day of therapy and with an increase in this indicator more than 10 μmol / ml, the prognosis is unfavorable, less than 10 μmol / ml - the prognosis is favorable.

The disadvantages of this method are not sufficiently high specificity, the complexity of the technical implementation in real clinical practice.

A known method for determining the sensitivity to inhibitors of angiotensin converting enzyme in patients with myocardial infarction (RF patent No. 2125447, 1999.01.27). To implement the method, the ratio of free and bound forms of water is determined in the patient’s venous blood and, with a value of this coefficient less than 1.2, the development of refractivity to drugs of this group is predicted, which makes them impractical in patients with acute myocardial infarction. With a ratio of more than 1.3, it is believed that the patient is sensitive to angiotensin converting enzyme inhibitors, and angiotensin converting enzyme inhibitors, for example, 25 mg captopril, are included in the patient's individual therapy regimen.

The disadvantage of these methods is the prediction of treatment failure for only one group of pharmaceuticals.

A known method for determining the differentiated purpose of heparins in patients with acute coronary syndrome without ST segment elevation (RF patent No. 2225617, 03/10/2004), which consists in the fact that the patient is determined by the concentration of antithrombin AT III in the blood serum and the functional class of heart failure, the patient is questioned, including the duration of coronary heart disease, age, the number of previous myocardial infarction; determine the risk of a fall in the concentration of AT III: first determine the values of the function F, then the obtained values of the function at point X1 and the values of the function at point X2 are compared, and if the value of the function at point X1 is greater than the value of the function at point X2, the risk of a decrease in the concentration of AT III is detected and assigned enoxaparin, and when the value of the function at point X1 is less than the value of the function at point X2, there is no risk of a drop in AT III concentration and unfractionated heparin is prescribed.

The disadvantage of this method is the difficulty of use in real clinical practice, which reduces its diagnostic reliability.

A known method of reducing the spontaneous aggregation of red blood cells with dyslipidemia (RF patent No. 2432936, 11/10/2011), including the use of a lipid-lowering diet, dosed static and dynamic physical activity, including morning hygienic gymnastics, therapeutic and preventive gymnastics, fractional physical exercises throughout the day , daily swimming for at least 30 minutes a day in the middle of the day and the introduction of simvastatin 10 mg 1 time in the evening after meals for 1.5 months.

The disadvantage of this method is that there are no specific indications indicating the effectiveness of the antilipidemic therapy, there is no systematic approach to assessing the effectiveness of therapy, which in our opinion should include an assessment of the effectiveness of the underlying disease according to blood pressure and lipoprotein spectrum of the blood.

A known method of reducing the spontaneous aggregation of red blood cells with arterial hypertension with dyslipidemia and impaired glucose tolerance (RF patent No. 2433813, 11/20/2011), including the use of a lipid-lowering diet, dosed static and dynamic physical activity, including morning hygienic gymnastics, therapeutic and preventive gymnastics , fractional physical exercises throughout the day, daily swimming for at least 30 minutes a day in the middle of the day, taking lisinopril at a dose of 10 mg once a day in the morning and met rmina 500 mg 2 times a day for 2 months. The disadvantage of this method is a fragmentary assessment of the studied system of primary hemostasis and disorders of carbohydrate metabolism.

A method of therapy with alpha-lipoic acid (espa-lipone) diabetic autonomic neuropathy of the heart is described (D.V. Kiriyenko, PN Bodnar. Therapy with alpha-lipoic acid (espa-lipon) diabetic autonomic neuropathy of the heart. - http: / /www.diabet.ru/Esparma/russian/doctors/cardio/cardio.htm). Diabetic autonomic neuropathy of the heart (DANS) was established by a comprehensive analysis of 5 tests of cardiovascular reflexes recommended by the conference in San Antonio, 1988. Espa-lipon was prescribed as monotherapy in combination with sugar-lowering drugs in 2 stages: intravenous drip at a dose of 600 mg per 100 ml of 0.9% saline (a total of 20, including weekends): immediately after this - oral administration of 1-2 tablets (600-1200 mg) for 4 weeks.

The disadvantage of this method is the lack of laboratory evidence, which complicates the reliability of the diagnosis.

Thus, the need for further development of clinical and laboratory algorithms, in particular using several informative markers that allow us to evaluate the systemic effect of these drugs at different levels of the organization of the circulatory system, is extremely urgent today.

The prototype of the claimed invention, we have chosen the method described in the patent of the Russian Federation No. 2088931, 1997.08.27.

The disadvantages of the prototype are eliminated in the claimed invention.

The objective of the invention is the development of a fairly simple way to determine the indications for choosing the tactics of conservative treatment of patients after repeated myocardial infarction.

The problem is solved in that before the start of treatment, a patient who has had a repeated myocardial infarction is examined for blood and the level of oxidation-resistant lipoproteins (RLP) is determined in the blood serum, and the concentration of pyruvic acid (PVA) is determined in red blood cells and, with an RLP value equal to 1.89 nmol MDA / mg protein and lower, and a PVA equal to 1.81 mmol / l and higher include lipoic acid (LA) preparations (synonyms: thioctic, lipoic acid, vitamin N), for example, thioctacid BV.

A positive technical result obtained as a result of the practical use of the proposed method is as follows:

- the method allows you to more objectively assess the patient’s condition and identify a group of patients who need conservative treatment after repeated repeated MI drugs LK;

- the method is simple, provides adequate treatment tactics for this group of patients in 99%, which reduces the number of complications in the post-infarction period, maximizes the quality of life of patients, reducing the symptoms of angina pectoris and heart failure;

- the method has wide information content by identifying the nature of changes in cellular adaptation and, at the same time, high sensitivity.

In the course of our study, it was found that patients who underwent repeated MI have a decrease in the concentration of total cholesterol by 14.6% (p> 0.05) relative to indicators of patients with coronary artery disease (comparison group), which may be associated with increased oxidative modification XC. In addition, changes in the metabolism of lipoproteins were revealed, characterized by the predominance of atherogenic fractions. So, in patients who underwent repeated MI, there was a significant decrease in HPSLP by 49.5% (p <0.001), which can be considered an unfavorable prognostic sign of the course of the underlying disease. At the same time, we recorded a marked increase in the concentration of HLDPLP by 45.5% (p <0.001) against the background of a decrease in the level of HLPLPP by 17.1% (p <0.001). Possibly, such changes are due to a violation of the transport systems and the reception of LP particles due to excessive oxidative destruction of their protein and lipid structures under conditions of oxidative stress. Such changes are a prerequisite for their prolonged circulation in the bloodstream, and also increase the risk of their oxidative modification.

In patients who underwent repeated MI, there was a significant decrease in the concentration of ALP by 42.6% (p <0.001) with a more significant decrease in the level of RLP from 1.92 ± 0.03 nmol MDA / mg of β-lipoprotein protein by 58.6% ( p <0.001) relative to the performance of the comparison group.

Apparently, such a pronounced decrease in the concentration of serum ALP indicates either their absorption by the macrophage system or the depletion of their pool due to the transition to resistant forms. This may reflect the features of the course of the post-infarction period and the development of cardiosclerosis, respectively. The revealed metabolic picture as a whole can be characterized as a decreased functioning of lipid metabolism, which corresponds to the concept of “hypoenergetic state”.

In patients who underwent repeated MI, there is a significant increase in the concentration of PVC by 439.3% to 1.51 ± 0.30 mmol / L (p <0.001), significantly exceeding the increase in lactate concentration by 138.8% (p <0.001) , which indicates the prevalence of the anaerobic phase of glycolysis in connection with a decrease in metabolism, which can provoke the development of complications, including arrhythmias.

It has been established that in chronic ischemia of the heart, first of all, the regulation of the activity of key enzymes involved in the metabolism of energy substrates is disrupted, and these changes occur against the background of prolonged preservation of the structure of the enzymes themselves (Essop M.F., Opie L.H., 2004). Therefore, the use of drugs that have a positive effect on the mechanisms of energy transport and utilization and on the morphofunctional state of the myocardium is pathogenetically justified (V. Makolkin et al., 2000; S.N. Tereshchenko et al., 2002; Pierre Coste, 2011). Drugs that affect the oxidative metabolism of energy substrates in cardiomyocytes are called antianginal metabolic drugs (Astashkin E.I., Glezer M.G., 2006; Lopaschuk GD, 2003; Marzilli M., 2003; Stanley WC, 2002; Rupp H et al., 2002; Grynberg A., 2005).

To stimulate adaptive reactions of the cardiovascular system, transition to the optimal level of functioning for the body in the conditions of formation of sclerotic processes, it is necessary to use drugs that have a complex corrective effect on all levels of the functioning of the cardiovascular system. We found that such a drug of choice may be LC. Lipoic acid (α-lipoic or thioctic acid) has an effect on those metabolic systems that can reduce the formation of reactive oxygen species, reduce the severity of systemic oxidative stress.

LC is a disulfide derivative of octanoic acid and is a coenzyme in the oxidative decarboxylation of PVC to acetyl-CoA - the starting compound in the Krebs cycle, and α-ketoglutaric to succinyl-CoA (in the Krebs cycle) (Berezov T.T., 1990; Amrus A. et al., 2009). As a coenzyme, it participates in carbohydrate and protein metabolism; α-lipoic acid (LK) is a natural prosthetic group in the α-keto-acid dehydrogenase complex of mitochondria and the glycine cleavage system (Dieter N.Z. et al., 2002; Miquel J., 2002). α-LC is classified as a vitaminoid, is a conditionally indispensable nutrient. In the body, it is synthesized in amounts that can prevent its deficiency (Bilska A.L. et al., 2002).

The main function of LA is direct participation in carbohydrate metabolism, namely in the aerobic metabolism of the glycolysis product - pyruvate. In the process of oxidation of LA, as a result, three ATP molecules are formed, which significantly increases the energy potential of the cell. Facilitates the conversion of lactic acid to pyruvic acid with subsequent decarboxylation of the latter, thereby contributing to the elimination of metabolic acidosis (Karlovich T.I., Ilchenko L.Yu., 2008). The antioxidant effect of LA is due to the presence of two thiol groups in the molecule (Sen C.K., Packer L., 2000). A deficiency of LA is expressed in the reservation of pyruvate in the cytosol and its conversion into lactic acid, as well as in a decrease in aerobic power, anaerobic threshold and available energy.

It was established that the hepatoprotective, hypolipidemic, hypocholesterolemic, hypoglycemic effect of α-lipoic acid, the ability to improve trophic neurons, unique antioxidant properties can influence not only the symptoms of a number of diseases, but also their pathogenesis (L.V. Stakhovskaya, A.V. Alekhin , OI Guseva. Clinical use of lipoic acid preparations. - Consilium Medicum. - Volume 05 / No.5 / 2007). Experimental and clinical studies of this substance for other pathological conditions are ongoing. This applies to the use of α-LC in cardiology.

We have not identified data on the use of drugs in the treatment of myocardial infarction and repeated myocardial infarction. Our studies have allowed us to establish the following: LC, being a powerful natural lipophilic antioxidant, captures free radicals: it effectively neutralizes peroxyl and hydroxyl radicals, as well as an oxygen radical, affecting the redox status of cells, reduces vascular dysfunction. The rationale for our use of α-lipoic acid in patients with repeated MI was:

- the ability to reduce lipid peroxidation [binds free radicals and free tissue iron];

- participation in the oxidation of fatty acids and acetate;

- participation in the decarboxylation of α-keto acids (cell energy supply);

- increased transmembrane transport of glucose into the cell.

Detailed description of the method and examples of its clinical use

Prior to treatment, a patient who undergoes MI undergoes a blood test and determines the level of oxidation-resistant lipoproteins (RLP) in blood serum, and the concentration of pyruvic acid (PVA) is determined in red blood cells and, with a RLP value of 1.89 nmol MDA / mg protein β-lipoproteins and below, and a PVC of 1.81 mmol / L and above, conservative therapy includes the preparation of lipoic acid: BV thioctacid from MEDA PHARMA GmbH & Co.KG, orally at a dose of 600 mg once a day 30 minutes before meals , within 30 days.

PVC is determined by Friedemann and Haugen in the modification of M.P. Babaskin (Babaskin M.P. Method for determination of pyruvic acid in the blood: A.S. No. 877436. USSR: Application of 13.02.80, No. 2877502 / 28-13, published on 30.10 .81. MKI G 33/52). A protein-free extract is obtained by the action of a 10% trichloroacetic acid solution on the erythrocyte hemolysate, followed by treatment with diphenylhydrosine (DNPH) and photometry of the mixture. To increase the accuracy of the method and accelerate it, an aqueous alkali solution (NaOH) is added to the reaction mixture containing DNPH. The results are expressed in μmol / ml dense erythrocyte sediment.

Oxidation-resistant lipoproteins are determined by the method of Ragino, Yu.I., Dushkin, M.I. (Resistance to oxidation of heparin-deposited serum β-lipoproteins in coronary heart disease. // Clinical Laboratory Diagnostics, 1998, No. 11, p.3-5). β-lipoproteins were obtained from 1 ml of blood serum by precipitation in the presence of heparin (200 PIECES per 1 ml of serum) and manganese chloride (50 mm per 1 ml of serum). To remove unbound heparin and manganese chloride, the precipitated β-lipoproteins are washed with a 0.9% sodium chloride solution with a 50 mM phosphate buffer pH 7.4 solution, after which the precipitated β-lipoproteins are dissolved in 1 ml of a 1M sodium chloride solution. Then, oxidative modification of β-lipoproteins is carried out in Dulbecco's medium containing 50 μmol of copper sulfate in the presence of 0.2 mg / ml β-lipoproteins. Samples are incubated for 2 hours at 37 ° C in a water bath.

Before incubation and after 2 hours of incubation, the degree of oxidative modification of β-lipoproteins is evaluated by determining the concentration of malondialdehyde (MDA) by the photometric method described by Steel I.D. (Steel I.D., Garishvili T.G. Modern methods in biochemistry. M: Medicine, 1977, p.66-68). To do this, 0.5 ml of the resulting solution is placed in a centrifuge tube, 2.5 ml of a 20% solution of trichloroacetic acid and 1 ml of a 0.67% solution of thiobarbituric acid (TBA) are added. Heated in a boiling water bath for 30 minutes. Then it is cooled and centrifuged for 10 minutes in a centrifuge of the TsLK-1 type at 3000 rpm. Then, the obtained centrifugate is photometered on a KFK-2 photoelectrocolorimeter at a wavelength of 540 nm in a 0.5 cm cuvette against a control sample. The calculation of the concentration of malondialdehyde is carried out using the molar extinction coefficient for the reaction product MDA / TAC equal to 1.56 × 10 ⁵ cm ^-1 M ^-1 . The result is expressed in nmol MDA / mg β-lipoprotein protein.

The performance of the proposed method is confirmed by the following clinical examples.

Example 1

Patient Z-cue, 48 years old, medical history No. 9453. In January 2011, he appealed to the polyclinic at the place of residence with complaints of weakness, fatigue, decreased performance. From the anamnesis it is known that in 2000 he underwent primary myocardial infarction, 6 months before treatment I suffered a repeated myocardial infarction. Constantly receives Plavix 75 mg 1 time per day; aspirin cardio 100 1 time per day; betalok ZOK 50 mg 1 time per day; cross 10 mg once a day. According to the clinical examination upon admission: heart sounds muffled, rhythm 82 beats / min, blood pressure 130/90 mm Hg In the lungs, vesicular breathing, no wheezing. No peripheral edema. On the ECG: sinus rhythm, heart rate 82 beats per minute. Q in V ₁ V ₂ V ₃ . Weakly positive T in V ₁ V ₂ V ₃ . Focal changes in the anterior septal region of the left ventricle indefinitely.

A preliminary diagnosis was established: coronary heart disease, post-infarction cardiosclerosis (2000; 2010). CHF I. FC II.

The results of biochemical blood tests

KFK 17 PIECES / l [norm 24-170 PIECES / l]; MV-KFK 0 U / l

Troponin T test negative quality

Test troponin T quantitative 0.1 ng / ml

According to the claimed methodology, the level of RLP was determined in blood serum, and the concentration of PVA in erythrocytes: RLP is 1.87 nmol MDA / mg β-lipoprotein protein, PVK is 1.81 mmol / L.

Blood glucose 4.8 mmol / L; creatinine 0.08 mmol / l; urea 7.0 mmol / l; bilirubin 17.4 μmol / l; AcAT 0.32 mmol / L; AlAT 0.32 mmol / L.

Echocardiography: Aorta abdominal 21 mm; Vmax 113 cm / s; arc 22 mm; Vmax in the downstream 102 cm / s. The ascending division is 27 mm. Aortic valve FC 25 mm, the valves are sealed; leaf divergence amplitude 16 mm; Vmax 132 cm / s no regurgitation. Left atrium 35 mm; left ventricle.

The final systolic size (DAC) is 33 mm; final diastolic size (MDC) 47 mm; interventricular septum (MJP) 10 mm; posterior wall of the left ventricle (VLJ) 11 mm; distance the anterior wall of the mitral valve (PSMK-MZHP) 5 mm; final systolic volume (CSR) 47 cm ³ ; final diastolic volume (BWW) of 102 cm ³ ; shock volume (UO) 55 ml; ejection fraction (EF) 53%; heart rate (HR) 76 beats / min. The global contractile function of the left ventricular myocardium is satisfactory. The zone of hypokinesia in the anterior septal region of the left ventricle. Doppler ultrasonography of a transmitral flow: E 43 cm / s; A 66 cm / sec. Right atrium 29 mm; right ventricle 32 mm; tricuspid valve not changed Vmax 251 cm / s; TR I Art. GP 25 mm Hg. Pulmonary artery 26 mm. Pulmonary Pressure 26 mm Hg. The inferior vena cava on inspiration drops by 50%; up to 17 mm. Diastolic dysfunction type I. Aortic sclerosis. Mitral valve insufficiency I step.

Conclusion

General contractile function of the left ventricular myocardium is slightly reduced. Focal changes in the anterior septal region of the left ventricle. Dilatation of the left atrium. Left ventricular myocardial hypertrophy.

Complete blood count: white blood cells (WBC) 4.7 × 10 ⁹ / L; erythrocytes (RBC) 4.25 × 10 ¹² / L; hemoglobin (HGB) 133 g / L; HCT 36.1 L; MCV 84.6 fL; MCH 29.6 Pg; MCHC 350 g / L; platelets (PLT) 280 × 10 ⁹ / L; neutrophils 57%; stab 3%; segmented 54%; lymphocytes 35%; monocytes 6%; eosinophils 2%.

In the complex ongoing therapy: Plavix 75 mg 1 time per day; aspirin cardio 100 1 tablet 1 time per day; betalok ZOK 50 mg 1 time per day; Crossor 10 mg 1 time per day additionally prescribed BV thioctacid 600 mg 1 time per day 30 minutes before meals for 30 days.

Re-examination of the patient after 32 days. No complaints. According to an objective examination: muffled heart sounds, heart rate of 76 beats / min, blood pressure 120/90 mm Hg In the lungs, vesicular breathing, no wheezing. No peripheral edema. On the ECG: sinus rhythm, heart rate of 76 beats per minute. Q in V ₁ V ₂ V ₃ . Weakly positive T in V ₁ V ₂ V ₃ . Focal changes in the anterior septal region of the left ventricle indefinitely.

Routine biochemical studies - without dynamics.

RLP 2.4 nmol MDA / mg β-lipoprotein protein; PVC 0.7 mmol / L.

Thus, the timely selection of this patient for the conservative treatment of repeated myocardial infarction with LA drugs significantly improved his health status, quality of life and reduced the number of complications.

Example 2

Patient L., 51 years old, medical history No. 14148. In October 2011, he went to a polyclinic at the place of residence with complaints of discomfort in the chest area on the left, he did not clearly communicate with physical exertion, weakness, fatigue. In the anamnesis: in 2005 suffered a primary myocardial infarction; 8 months before this treatment suffered a repeated MI. Constantly receiving cardiomagnyl 75 mg 1 time per day; egiloc 25 mg 2 times a day; Zocor 20 mg once a day. According to a clinical examination: muffled heart sounds, heart rate 86 beats / min, blood pressure 130/80 mm Hg In the lungs, vesicular breathing, no wheezing. No peripheral edema. On the ECG: sinus rhythm. Heart rate 86 beats per minute. Pathological Q in II, III, aVF leads, T wave weakly positive in III, aVF. Focal changes in the inferior diaphragmatic region of the left ventricle indefinitely.

Diagnosed with ischemic heart disease, postinfarction cardiosclerosis (2005; 2011). CHF I Art. FC I-II.

The results of biochemical blood tests

KFK 20 IU / L (norm 24-170 IU / L), MV-KFK 2 IU / L

Troponin T test negative quality

Troponin T quantitative 0.2 ng / ml

According to the claimed methodology, the level of RLP was determined in blood serum, and the concentration of PVC in erythrocytes: RLP was 1.82 nmol MDA / mg β-lipoprotein protein; PVC is 1.91 mmol / L.

Complete blood count: WBC 5.5 × 10 ⁹ / L; RBC 5.15 × 10 ¹² / L; HBV 146 g / L; HCT 40.4 L; MCV 78.4 fL; MCH 28.3 Pg; MCHC 361 g / L; PLT 228 × 109 / L; neutrophils 56%; stab 5%; segmented 51%; lymphocytes 39%; monocytes 5%.

Blood glucose 5.1 mmol / l; creatinine 0.09 mmol / l; urea 7.3 mmol / l; AcAT 0.32 mmol / L; AlAT 0.64 mmol / L; bilirubin 20.05 μmol / l.

Echocardiography data: Aorta abdominal 22 mm; Vmax 115 cm / s; arc 21 mm;

Vmax downstream 111 cm / s. The ascending division is 27 mm. Aortic valve FC 32 mm, the valves are sealed; the amplitude of the divergence of the valves 21 mm; Vmax 128 cm / s; no regurgitation. Left atrium 30 mm; left ventricle: DAC 31 mm; KDR 45 mm; MZHP 12 mm; ZSLZH 13 mm; distance PSMK-MZHP 7 mm; CSR 47 cm ³ ; BWW 98 cm ³ ; UO 60 ml; PV 50%; Heart rate 80 beats / min. The global contractile function of the left ventricular myocardium is satisfactory. Zones of hypokinesia were detected in the lower diaphragmatic region of the left ventricle. Doppler ultrasonography of the transmitral flow: E 42 cm / s; A 61 cm / sec. Right atrium 30 mm; right ventricle 31 mm; tricuspid valve not changed Vmax 240 cm / s; GP 26 mm Hg. Pulmonary artery 26 mm. Pulmonary Pressure 29 mm Hg.

Conclusion

The global contractile function of the left ventricular myocardium is reduced. Zones of hypokinesia in the lower diaphragmatic region of the left ventricle. Moderate dilatation of the left atrium. Left ventricular myocardial hypertrophy. Increased pulmonary artery pressure.

According to echocardiography, the results of standard biochemical studies cannot identify the cause of the deterioration in well-being and quality of life of the patient. However, the obtained RLP parameters of 1.82 nmol MDA / mg β-lipoprotein protein and PVC 1.91 mmol / L indicate a reduced cytogenetic status of the patient. The basic therapy (cardiomagnyl 75 mg 1 time per day; egilok 25 mg 2 times a day; zokor 20 mg 1 time per day) is additionally prescribed BV thioctacid 600 mg 1 time per day 30 minutes before meals for 30 days.

At the second examination, the patient appeared after 30 days. No complaints at the time of inspection. Echocardiography, general blood count, blood biochemistry - without dynamics. RLP 2.8 nmol MDA / mg β-lipoprotein protein; PVC 0.75 mmol / L.

Thus, the timely selection of this patient for the conservative treatment of repeated MI with LC drugs significantly improved his state of health and reduced the number of complications.

Example 3

Patient Xn, 51 years old, medical history No. 8661. Appeared for a scheduled inspection in September 2010. Complaints at the time of inspection does not show. Pressing pains behind the sternum associated with intense physical exertion are periodically noted. History: suffered a primary myocardial infarction in 2001; repeated - six months before treatment. In the last two months, no deterioration was noted. Constantly receiving aspirin cardio 100; egiloc retard 100 mg 1 time per day; Liprimar 10 mg 1 time per day. According to a clinical examination: muffled heart sounds, heart rate of 76 beats / min, blood pressure 120/80 mm Hg In the lungs, vesicular breathing, no wheezing. No peripheral edema. On the ECG: sinus rhythm, heart rate of 76 beats per minute.

Pathological Q in II, III, aVF leads, V ₇ V ₈ V ₉ , ST on the isoline, T wave weakly positive in III, aVF, V ₇ V ₈ V ₉ . Focal changes in the posterior (inferior diaphragmatic and posterior basal) wall of the left ventricle indefinitely.

Diagnosed with ischemic heart disease, postinfarction (2006; 2010) cardiosclerosis. CHF I Art. FC I-II.

The results of biochemical blood tests

KFK 18 PIECES / L (norm 24-170 PIECES / L); MV-KFK 0 U / l

Troponin T test negative quality

Troponin T quantification test not determined

Complete blood count: WBC 4.6 × 10 ⁹ / L; RBC 4.5 × 10 ¹² / L; HGB 142 g / L; HCT 35.8 L; MCV 82.1 fL; MCH 31.4 Pg; MCHC 346 g / L; PLT 263 × 10 ⁹ / L; neutrophils 61%; stab 5%; segmented 56%; lymphocytes 28%; monocytes 7%; basophils 1%; eosinophils 3%.

Blood glucose 5.3 mmol / L; creatinine 0.11 mmol / l; urea 6 mmol / l; AcAT 0.28 mmol / L; AlAT 0.56 mmol / L; bilirubin 20.05 μmol / l.

According to the claimed methodology, the level of RLP was determined in blood serum, and the concentration of pyruvic acid PVA was determined in red blood cells: RLP 2.9 nmol MDA / mg in drug, PVC 0.63 mmol / L.

Echocardiography: Aortic abdominal aorta 24 mm; Vmax 118 cm / s; arc 21 mm; Vmax in the downstream section 103 cm / s. The ascending division is 27 mm. Aortic valve FC 32 mm, sash calcified; leaf divergence amplitude 17 mm; Vmax 138 cm / s no regurgitation. Left atrium 40 mm; left ventricle: DAC 38 mm; KDR 54 mm; MZHP 11 mm; ZSLZH 12 mm; distance PSMK-MZHP 8 mm; CSR 62 cm ³ ; BWW 140 cm ³ ; UO 65 ml; PV 50%; Heart rate 78 beats / min. The global contractile function of the left ventricular myocardium is satisfactory. The zone of hypokinesia in the lower diaphragmatic region of the left ventricle. Doppler ultrasonography of the transmitral flow: E 58 cm / s; A 43 cm / sec. Right atrium 32 mm; right ventricle 33 mm; tricuspid valve not changed Vmax 250 cm / s; TR I Art. GP 24 mm Hg. Pulmonary artery 26 mm. Pulmonary Pressure 21 mm Hg.

Conclusion

The global contractile function of the left ventricular myocardium is slightly reduced. Zones of hypokinesia in the lower diaphragmatic region of the left ventricle. Dilatation of the left atrium. Left ventricular myocardial hypertrophy. Aortic valve calcification.

In the absence of complaints, according to echocardiography, the results of routine laboratory tests cannot be used to judge the patient’s cytoenergetic status and the need for the appointment of cytoprotectors. However, the results of RLP of 2.9 nmol MDA / mg of β-lipoprotein protein and PVC of 0.63 mmol / L make it possible to judge the satisfactory cytoenergetic state of this patient and the absence of the need to include LK in the treatment regimen. The patient is recommended to continue the previously conducted therapy: aspirin cardio 100 1 tablet 1 time per day; egiloc retard 100 mg 1 time per day; Liprimar 10 mg 1 time per day.

According to the claimed methodology, 93 patients were examined who had repeated MI and examined 5-8 months after the development of the repeated coronary incident, who included lipoic acid in the complex treatment regimen; the average age of patients in this group was 51 ± 7.9 years. The comparison group consisted of 22 patients with coronary heart disease, the average age of which was 51 ± 4.2 years.

All patients received basic therapy, which was as unified as possible and included β-blockers, disaggregants, statins, nitrates, angiotensin converting enzyme inhibitors (ACEs) or angiotensin II receptor blockers, if necessary.

Prior to treatment, the patient undergoes a blood test and determines the level of RLP in blood serum, and the concentration of pyruvic acid PVA is determined in erythrocytes and, with an RLP value of 1.89 nmol MDA / mg of β-lipoprotein protein and lower, and a PVC of 1 81 mmol / L and higher, lipoic acid preparations are additionally included in conservative therapy. In the treatment regimen for patients of this group, the basic therapy included BV thioctacid by MEDA PHARMA GmbH & Co.KG orally at a dose of 600 mg once a day 30 minutes before meals for 30 days. It is important to indicate that in the patients of the clinical group, our studies during the reasonable prescription of pathogenetic therapy (lipoic acid) revealed an increase in the concentration of RLP by 87.5% to 3.60 ± 0.20 nmol MDA / mg β-lipoprotein protein (p <0.001 ), which indicates a decrease in the involvement of lipoproteins in the reaction of peroxidation. The concentration of PVA in this group of patients decreased by 86.09% to 0.21 ± 0.025 mmol / L (p <0.05), which corresponded to indicators of practically healthy people. Such a dynamics of PVA is due to the influence of LA, characterized by a decrease in the inhibitory effect of acetyl-SKoA on pyruvate decarboxylase. Obviously, the simultaneous determination of the level of RLP and the concentration of PVC allows you to accurately evaluate the feasibility of conservative therapy, including drugs LK.

Analyzing the results of monitoring the clinical status of patients, it should be noted that in all patients after 30 days from the start of treatment, positive dynamics were observed in the form of an improvement in the general condition. All patients noted an increase in vitality, a decrease in fatigue, weakness, a decrease in irritability, a stabilization of sleep, an improvement in the emotional sphere, an increase in working capacity, and an increase in interest in life, which indicated the adequacy of treatment tactics.

In accordance with the tasks, along with the assessment of general clinical data, dynamic analysis of electrocardiograms and the main indicators of a traditional blood test, patients underwent bicycle ergometry, daily ECG monitoring, a study of the main indicators of global and regional systolic and diastolic functions of the left ventricle at rest and during stress-echocardiography with dobutamine.

The advantages of the proposed method over the known ones are that it is quite simple, specific and contributes to the selection of adequate therapeutic tactics and increase the effectiveness of treatment.

Thus, the use of the proposed method in clinical practice allows us to accurately assess the feasibility of conservative therapy, including lipoic acid preparations and the effectiveness / ineffectiveness of drug therapy in patients with a history of recurrent myocardial infarction, and an additional opportunity has been obtained to reduce the unreasonable drug load on the patient's body. The method allows a more objective assessment of the patient’s condition and the identification of a group of patients in need of conservative therapy, including lipoic acid preparations.

The inventive method is tested on sufficient clinical material and can be recommended for use in cardiological and therapeutic hospitals.

The implementation of the proposed method in practical medicine will provide rational management tactics for patients with coronary artery disease who have had repeated myocardial infarction, and prevention of heart failure, which will reduce the percentage of disability and mortality in patients who have had repeated myocardial infarction.

Claims (1)

A method for determining indications for choosing the tactics of conservative therapy for patients who have had repeated myocardial infarction by a blood test, characterized in that prior to treatment, the patient is tested for blood and the level of oxidation-resistant lipoproteins (RLP) is determined in blood serum, and the concentration of pyruvic acid is determined in red blood cells (PVC) and, with a RLP value of 1.89 nmol MDA / mg of β-lipoprotein protein and lower, and a PVC of 1.81 mmol / L and higher, lipoic acid preparations are included in conservative therapy.