RU2703517C1 - Method of treating paroxysmal form of atrial fibrillation in patients with chronic heart failure in arterial hypertension - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to cardiology, and can be used for treating a paroxysmal form of atrial fibrillation in patients with chronic heart failure in arterial hypertension. That is ensured by prescribing drug-induced therapy with angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists, selective beta-adrenoreceptor blocking agent, mineralocorticoid receptor antagonists and additionally: a loop diuretic – torasemide in dose of 15–30 mg a day in two steps to normalize the maximum and minimum diameter of pulmonary veins and left atrial volume, magnesium orotate 1,500 mg, 3-unsaturated fatty acids in dose of 1,000 mg, vitamin C in dose of 200 mg and vitamin E in dose of 400 mg a day.

EFFECT: method allows to stop atrial fibrillation paroxysms.

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Description

The invention relates to medicine, namely to cardiology, and can be used to treat a paroxysmal form of atrial fibrillation (AF) in patients with chronic heart failure with arterial hypertension.

Numerous clinical and epidemiological data indicate that patients with AF have a mortality rate of two times higher, and the likelihood of acute cerebrovascular accident is 5-6 times higher than patients without AF (Stewart S, Hart CL, Hole DJ , McMurray JJ. A population-based study of the longterm risks associated with atrial fibrillation: 20-year follow-up of the Renfrew / Paisley study. Am J Med 2002; 113: 359-364. Wolf PA, Abbott RD, Kannel WB Atrial fibrillation as an independent risk factor for stroke: the Framingham Study. Stroke 1991; 22: 983-988.).

One of the main causes of the paroxysmal form of atrial fibrillation in patients with chronic heart failure is arterial hypertension. It was shown that patients with chronic heart failure with atrial fibrillation compared with patients without it have significantly more pronounced structural changes in the heart: against the background of more pronounced dilatation of the left atrium, dilatation and right atrium, dilatation of the end-diastolic and end-systolic volume of the left ventricle, increased systolic pressure in the pulmonary artery. Microscopic examination of the myocardium of the ears of the right atrium of patients with chronic heart failure with atrial fibrillation revealed interstitial edema compared with patients without rhythm disturbances, which, according to the author, is one of the mechanisms for the development and / or maintenance of atrial fibrillation, since in the heart there is a mechanical-electrical feedback: mechanical changes in the myocardium lead to a change in its electrical processes and vice versa (Kirillova V.V. Remodeled e infarction in patients with atrial fibrillation and chronic heart failure J. Translational Medicine 2018; 5 (2):.. 15-21).

Interventional treatment of paroxysmal AF can maintain sinus rhythm in 70% of patients (Ganesan AN, Shipp NJ, Brooks AG, Kuklik P, Lau DH, Lim HS, Sullivan T, Roberts-Thomson KS, Sanders P. Long-term outcomes of catheter ablation of atrial fibrillation: a systematic review and metaanalysis. J Am Heart Assoc 2013; 2: e004549).

There is a method of interventional treatment of a paroxysmal form of atrial fibrillation by applying radiofrequency ablation (RFA) to the ganglionic vegetative plexus of the heart from the right atrium at the back of the atrial septum from the mouth of the superior vena cava to the upper edge of the oval fossa and from the mouth of the inferior vena cava to the mouth of the coronary and also around the mouth of the coronary sinus (RF, patent No. 2364370, IPC АВВ 18/18, publ. 08/20/2009). The disadvantage of RFA is the deterioration of the reservoir function of the left atrium and the contractile function of the pulmonary vein couplings, hemopericardium, perforation with cardiac tamponade, strokes, atrioesophageal fistulas, hematomas at the puncture site. In addition, RFA is an expensive method, which requires qualified specialists, expensive consumables.

Closest to the invention is a method of drug antiarrhythmic treatment of paroxysmal AF using amiodarone, as the most effective drug for pharmacological cardioversion in patients with heart failure, allowing to restore the sinus rhythm in 49% -70% of patients [Hohnloser SH, Kuck K.N., Lilienthal J . // Lancet. 2000. No.356. P. 1789-1794.]. The disadvantage of this method is the possible proarrhythmic effect of amiodarone, lack of effectiveness and possible recurrence of atrial fibrillation.

The objective of the invention is to improve the treatment of paroxysmal forms of atrial fibrillation that occurs in patients with chronic heart failure.

The technical result that will be achieved from the use of this invention is to stop paroxysms of atrial fibrillation.

The technical result is solved by the fact that in the method of treating the paroxysmal form of atrial fibrillation in patients with chronic heart failure with arterial hypertension, angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists, selective beta adrenoblockers, mineralocorticoid receptor antagonists 10 and 10 additional -30 mg to normalize the maximum and minimum diameter of the pulmonary veins, the volume of the left atrium with additional taking magnesium orotate at a dose of 1500 mg, 3-unsaturated fatty acids at a dose of 1000 mg, vitamin C at a dose of 200 mg and vitamin E at a dose of 400 mg per day. According to indications, an oral anticoagulant can be additionally prescribed. From the analysis of scientific, technical and patent literature of the claimed combination of features, ensuring the achievement of the technical result, we have not identified, which allows us to draw conclusions about the conformity of the claimed technical solution to the criteria of "novelty" and "inventive step".

The essence of the invention lies in the use of drug therapy of chronic heart failure in the form of angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists, selective beta-blockers, mineralocorticoid receptor antagonists and the additional use of loop diuretic - torasemide at a dose of 10-30 mg, allowing normal diameter of the veins to allow normal venous diameter 30-30 mg volume of left atrium and additionally prescribed magnesium orotate at a dose of 1500 mg, 3-unsaturated fatty acids at a dose of 1 000 mg, vitamin C at a dose of 200 mg and vitamin E at a dose of 400 mg per day.

The invention is as follows. Patients with paroxysmal atrial fibrillation, developed against the background of chronic heart failure with arterial hypertension, with dilatation of the left atrium, dilatation of the maximum and minimum pulmonary vein diameters, are prescribed medication for chronic heart failure: angiotensin converting enzyme inhibitors, antagonists of receptor II antagonists, antagonists of receptor antagonists, or antagonists of receptor antagonists of antagonists of mineralocorticoid receptors, a loop torus diuretic is additionally prescribed emid at a dose of 10-30 mg to normalize the maximum and minimum diameters of the pulmonary veins and the volume of the left atrium with the additional use of magnesium orotate at a dose of 1500 mg per day as a preventive measure for the elimination of magnesium when taking torasemide, 3-unsaturated fatty acids at a dose of 1000 mg restoration of the bilipid layer of the plasma membrane of cardiomyocytes, vitamin C at a dose of 200 mg and vitamin E 400 mg per day as classic antioxidants that have a membrane-stabilizing effect. According to the indications, an oral anticoagulant can additionally be prescribed to prevent thrombosis.

In this way, 23 patients (19 women, 4 men) aged 73.25 ± 1.59 years with a symptomatic paroxysmal form of atrial fibrillation in patients with chronic heart failure 2A and 2B stage II and III FC according to NYHA against the background of hypertension were treated.

Over the course of the year, while taking the above-described therapy, patients did not have rhythm disruptions. During Holter monitoring of electrocardiography, a sinus rhythm was recorded.

In addition, this method in two cases led to the restoration of sinus rhythm in patients with a constant form of atrial fibrillation, lasting for 2 years.

Examples of the method.

Example 1. Patient E., born in 1939, went to an outpatient appointment with a cardiologist complaining of an increase in blood pressure to a maximum of 170-180 / 110 mm Hg, accompanied by severity in the precardial region, most often blood pressure - 160/100 mm Hg, the background of regular intake of Lozap N 50 / 12.5 mg 1 time per day, concor 2.5 mg 1 time per day; increased and prolonged attacks of irregular heartbeat up to 3-4 times a month for up to several hours.

From the history of this disease: an increase in blood pressure from 47 years over the past 32 years, the last three years have been marked by irregular heartbeats - a “bird in a cage” lasting up to 30 minutes with self-control (with a fixed paroxysm of atrial fibrillation on the ECG at the time of these complaints) 1 every 2-3 months. Deterioration over the past three months. No history of respiratory diseases.

From an objective examination, the condition is satisfactory. Skin integument of physiological color, high humidity. BMI - 34. In the lungs, breathing is weakened in the lower sections on both sides, there are no wheezing. The respiratory rate is 16 per minute, the respiratory rate when dressing is 24 per minute. Heart sounds are rhythmic, frequent, muffled, no noise. HELL - 170/100 mm Hg Heart rate - 94 beats / min. The abdomen is soft, painless, the liver is not palpable. Slight symmetrical swelling of the feet, lower third of the legs. Urination: nocturia - 2 times.

On the ECG, the sinus rhythm with heart rate is 66 beats / min. Deviation of the electrical axis of the heart to the left. Signs of a slowdown in atrial conduction (duration z. P - 0.12 mm). Signs of left ventricular myocardial hypertrophy. A six-minute walk test is 280 meters, which corresponds to NYHA functional class III. An echocardiographic study was performed on the patient, dilatation of the left atrium was revealed: anteroposterior size - 4.6 cm, volume - 170 ml, indexed volume of the left atrium - 87.7 ml / m ² . Eccentric left ventricular hypertrophy: Devereaux index - 0.36. The indexed mass of the left ventricular myocardium is 112 g / m ² . Left ventricular dilatation: final diastolic volume - 186 ml, final systolic volume - 69 ml, ejection fraction according to Simpson - 63%. Dilation of pulmonary vein diameters: the maximum diameter of the upper right pulmonary vein is 21 mm, the minimum diameter of the upper right pulmonary vein is 11 mm, indicating the presence of venous pulmonary hypertension. Systolic pressure in the pulmonary artery - 40 mm RT. Dilation of the right atrium: S - 20.8 cm ² with increased pressure in it: diameter of the inferior vena cava - 18 mm, collapses on inspiration more than 50%. Based on the indicators of transmitral blood flow in a pulsed-wave Doppler mode (E - 70 cm / s, A - 80 cm / s), tissue dopplerography of the movement of the mitral valve fibrous ring from the interventricular septum (e '- 6 cm / s, a' - 9 cm / s), from the side of the free wall of the left ventricle (e - 8 cm / s, and '- 18 cm / s), diastolic dysfunction of the left ventricle of type 1 is determined. Based on the indicators of transtricuspid blood flow in a pulse-wave Doppler mode (E - 60 cm / s, A - 40 cm / s), tissue Doppler ultrasound of the movement of the fibrous ring of the tricuspid valve (e '- 12 cm / s, a' - 16 cm / c) diastolic dysfunction of the right ventricle of the psedonormal type is determined.

Based on complaints, the history of the present disease, an anamnesis of life, an objective examination, the results of an instrumental examination, the diagnosis is made: Stage III hypertension. Eccentric left ventricular hypertrophy. Dyslipidemia. Obesity of 1 degree. Risk 3. Violation of the rhythm: paroxysmal atrial fibrillation, tachyform. CHF 2B stage FC III. Moderate mixed pulmonary hypertension.

According to the proposed method, treatment is prescribed:

1. Selective beta-blocker (metoprolol succinate) 100 mg in the morning

2. Antagonist of receptors for angiotensin II (candesartan) at 32 mg in the evening

3. Antagonist of mineralocorticoid receptors (eplerenone) 50 mg in the morning and in the afternoon, after 1 month 50 mg in the morning

4. Loop diuretic (torasemide) 10 mg in the morning and 10 mg in the afternoon

5. New oral anticoagulant (apixaban) 5 mg 2 times a day Additionally: 3-EFA (omacor) 1000 mg, magnesium orotate (magnerot) 500 mg 3 times a day, vitamin C 200 mg, vitamin E 400 mg.

After 1 month at the second consultation, the patient notes an improvement: from the moment of the first consultation, attacks of rapid irregular heartbeat did not occur, decreased sweating, nocturia to 1, decreased blood pressure to 130-140 / 80-90 mm Hg. The titration of lercanidipine was carried out to achieve the target numbers of blood pressure.

After 3, 6 and 9 months of observation, the sinus rhythm, paroxysms of atrial fibrillation did not occur, noted the absence of sweating, nocturia, blood pressure 110-130 / 70-80 mm RT.

Example 2. Patient S., born in 1948, was consulted by a cardiologist dated 09/12/2016 with complaints of shortness of breath of an inspiratory character when walking after 100 m, an increase in blood pressure more often to 150-170 / 80-98 mm Hg, up to a maximum of 220/100 mmHg.

Hypertension for 16 years. I took antihypertensive drugs irregularly. A history of short episodes of frequent irregular heartbeat for the past 8 years. The last 3 years, the increase in heart attacks with heart rate - 140-160 beats per min. Inpatient treatment in the cardiology department from 08/29/2016 to 09/10/2016 with a diagnosis of coronary artery disease: arrhythmic variant, a constant form of atrial fibrillation. Hypertension stage III. Risk 4. CHF 2B FC III. Right-sided hydrothorax. Recommended treatment: digoxin 0.125 mg once a day, concor 2.5 mg in the morning, losartan 50 mg 2 times a day, indapamide 2.5 mg, spironolactone 50 mg at lunch, clexane 15 mg.

Echocardiography from 08/30/2016: dilatation of both atria, diffuse decrease in contractile function of the left ventricle, left ventricular ejection fraction according to Simpson - 47%. Moderate pulmonary arterial hypertension (systolic pressure in the pulmonary artery - 47 mm Hg). ECDF from 2016 - atherosclerosis with stenosis of the brachiocephalic arteries.

Objectively, the condition is satisfactory. Skin integument of physiological color, normal humidity. In the lungs, breathing is weakened, no wheezing. Respiratory rate - 16 per minute, when undressing / dressing - 20 per minute. Heart sounds are arrhythmic, muffled, no noise. HELL - 170/90 mm Hg ZhZhS - 75 beats / min. Pulse - 70 beats per min. The abdomen is soft, painless, the liver protrudes from under the edge of the right costal arch along the midclavicular line +1 cm. Moderate dense symmetrical swelling of the feet, up to the middle third of the legs.

Clinical diagnosis exhibited: Stage III hypertension. IHD: Rhythm disturbance: constant atrial fibrillation, normosystolic form. Risk 4. CHF 2B stage FC III. Moderate pulmonary arterial hypertension.

According to the proposed method, treatment is prescribed:

1. Selective beta-blocker (bisoprolol) 2.5 mg in the morning

2. Angiotensin II receptor antagonist (valsartan) 80 mg 2 times a day

3. Antagonist of mineralocorticoid receptors (eplerenone) 50 mg in the morning and 50 mg in the afternoon

4. Loop diuretic (torasemide) 10 mg in the morning and 5 mg in the afternoon

5. Anticoagulant (warfarin) 1.5 tablets under the control of MHO

Additionally: 3-EFA (omacor) 1000 mg each, magnesium orotate (magnerot) 500 mg 3 times a day, vitamin C 200 mg, vitamin E 400 mg.

At the second consultation after 4 months, the patient notes the restoration of a rhythmic heartbeat for the last 2 weeks.

Objectively, the condition is satisfactory. Skin integument of physiological color, normal humidity. In the lungs, vesicular breathing, no wheezing. Respiratory rate - 16 per min. Heart sounds are rhythmic, muffled, no noise. HELL - 130/80 mm Hg ZhZhS - 55 beats / min. The abdomen is soft, painless, the liver does not protrude from under the edge of the right costal arch. No peripheral edema. Urination: nocturia - 0.

ECG: sinus rhythm with heart rate - 55 beats / min.

Echocardiography in dynamics after 3 months: normalization of the volume of the atria: the size of the left atrium is 3.1 cm, the volume of the left atrium is 45 ml, the area of the right atrium is 12 cm ² . Left ventricular hypertrophy. Diastolic dysfunction of the right ventricle type 2, diastolic function of the left ventricle is not impaired. The systolic function of the left ventricle is not impaired, the ejection fraction of the left ventricle according to Simpson is 60%.

An XMT ECG in dynamics after 3 months: during monitoring, a sinus rhythm was recorded with an average heart rate of 75 beats / min during the day and 60 beats / min at night. Infrequent single polytopic atrial extrasystoles (301 per day), 11 verses, 8 unstable paroxysms of supraventricular tachycardia were registered. Achieved 76% of max heart rate by age without ischemic changes in the ST segment.

After 6 and 12 months of observation, rhythm disruptions were not repeated.

Thus, the proposed method made it possible to reduce the size (volume) of both atria with the restoration of sinus rhythm.

3 example. Patient M., born in 1942, complained of weakness, a breakdown in the rhythm of the last 4 days, severe sweating at night. She regularly takes cordarone 200 mg once a day, corenitec 5 / 12.5 mg, xarelto 15 mg, bisoprolol 2.5 mg, rosuvastatin 20 mg. Yesterday I called an ambulance, in the emergency room of the city hospital the atrial fibrillation attack did not stop on the intravenous infusion of amiodarone. Hospitalization is recommended, which the patient refused.

From the anamnesis of life: since 1995, an EX has been implanted due to sinus node weakness syndrome with reimplantation from 2004, 2014. From the anamnesis of the disease, paroxysm of AF during the last year. During the year, twice inpatient treatment in a city hospital for rhythm failure.

Objectively: BMI - 26. Skin integument of physiological color, moist. HELL - 125/86 mm Hg, heart sounds are arrhythmic, muffled. In the lungs, breathing is weakened, no wheezing. BH - 16 per min. The liver protrudes 2 cm from under the edge of the right costal arch along the right midclavicular line. Nocturia - 2.

Clinical diagnosis was made: Rhythm disturbance: paroxysmal AF, paroxysm from 01.02.2018, SSU. EKS from 1995 (reimplanted from 2004, 2014). Hypertension stage III. Risk 4. CHF 2A stage FC III. Moderate mixed pulmonary hypertension. CKD C3a (GFR 50 ml / min / 1.73 m ² )

According to the proposed method, therapy is prescribed:

1. Selective beta-blocker (bisoprolol) 2.5 mg in the morning

2. Inhibitor of angiotensin-converting enzyme (ramipril) 2.5 mg in the evening

3. Antagonist of mineralocorticoid receptors (eplerenone) 50 mg in the morning and afternoon

4. Loop diuretic (torasemide) 20 mg in the morning and 10 mg for lunch for 7 days, then 10 mg in the morning and 10 mg for lunch

5. New oral anticoagulant (rivaroxoban) 14 mg once a day

Additionally: magnesium orotate (magnerot) 500 mg 3 times a day, 3-EFA (omacor) 1000 mg, vitamin C 200 mg, vitamin E 400 mg.

The next day, on a phone call, the patient noted an improvement in the condition, did not observe an irregular heartbeat. I additionally donated blood to NT-proBNP - 268.2 pg / ml. Two days later, Echocardiography: sinus rhythm with heart rate - 66 beats per minute. Dilatation of the left atrium: anteroposterior size 4.69 cm, the volume of the left atrium - 196 ml, the indexed volume of the left atrium - 112.6 ml. Concentric hypertrophy of the left ventricle: Devereaux index - 0.65, indexed mass of the left ventricular myocardium - 101 g / m ² . Simpson left ventricular ejection fraction - 64%. Dilation of the diameter of the pulmonary veins: the maximum diameter of the upper right pulmonary vein is 25 mm, the minimum diameter of the upper right pulmonary vein is 22 mm, E / e 'average is 15.9, indicating the presence of venous pulmonary hypertension. Systolic pressure in the pulmonary artery - 15 mm RT. Dilation of the right atrium: the area of the right atrium is 19 cm ² . The pressure in the right atrium is not increased: the diameter of the inferior vena cava is 16 mm, it collapses on inspiration more than 50%. Diastolic dysfunction of the left ventricle of the restrictive type: E / A - 2.6; e 'septal - 3.8. Diastolic dysfunction of the right ventricle of the pseudo-normal type: E / A - 1.15; e '/ a' - 0.83 with normal systolic function of the right ventricle: TAPSE - 20 mm.

At the second appointment, the patient noted the absence of rhythm failure within 16 days from the moment of the first consultation. After 3, 6 and 12 months of observation, rhythm disruptions were not repeated.

Thus, the proposed method for the treatment of the paroxysmal form of atrial fibrillation in patients with chronic heart failure, aimed at reducing / normalizing the diameter of the pulmonary veins and atrial volumes, allows stopping irregular heartbeats without the use of antiarrhythmics and radiofrequency ablation.

The advantages of the claimed method in comparison with the prototype are shown in the table.

Claims (2)

1. A method of treating a paroxysmal form of atrial fibrillation in patients with chronic heart failure with arterial hypertension, including drug therapy, characterized in that angiotensin converting enzyme inhibitors or angiotensin II receptor antagonists, selective beta-adrenocortin receptor antagonists are prescribed as drug therapy optional: loop diuretic - torasemide at a dose of 15-30 mg per day in two doses until the maximum and minimum normalize ceiling elements pulmonary vein diameter and volume of the left atrium, magnesium orotate at a dose of 1500 mg 3-unsaturated fatty acids 1000 mg, vitamin C 200 mg vitamin E 400 mg per day. 2. The method according to p. 1, characterized in that it further prescribe an oral anticoagulant.