RU2750716C1 - Method for predicting cardiovascular complications in patients with low or moderate cardiovascular risk by assessing their psychological status - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to predicting cardiovascular complications. Initially, a clinical examination is carried out to assess the risk of cardiovascular complications on the SCORE scale, patients with a risk on the SCORE scale of 0-4% are additionally questioned using the hospital scale of anxiety and depression HADS. If the result is D>6 points on the "Depression" scale (D) and/or A>7 points on the "Anxiety" scale (A), the risk of cardiovascular complications is predicted. If a patient has dyslipidemia with the identification of two or more indicators according to the results of a clinical examination, different from the norm and SBP>130 mm Hg. Art., the risk of cardiovascular complications is considered to be high.

EFFECT: invention provides an increase in the efficiency and information content of the diagnosis of cardiovascular complications.

1 cl, 1 tbl, 3 ex

Description

The invention relates to medicine, in particular, to predicting cardiovascular complications.

Often, cardiovascular complications (CVC) first occur in people with a seemingly low risk of their development. This determines the need to search for additional criteria for predicting the incidence of coronary heart disease (IHD) and other cardiovascular diseases (CVD) and to determine indications for active primary prevention. Depression, anxiety and other psychosocial factors are currently considered as independent factors in the development of atherosclerosis and its complications [Yusuf S., Hawken S., Ounpu S., et al. on behalf of the INTERHEART Study Investigators, 2004], however, their role in risk stratification in patients with SCORE <5%, i.e. persons of low / moderate risk of CVC, insufficiently studied.

A known method for assessing the level of depression and psychological exhaustion using the DEEX scale (Depressed mood / exhaustion was assessed by the DEpression and Exhaustion subscale). This scale combines eight subscales: irritability, fatigue, fatigue, internal tension, loss of energy, difficulty concentrating, nervousness, anxiety), which are rated from 0 to 3 points. In a population study that took place in Germany from 1984 to 1995, 3428 men aged 45-74 years were examined (mean age 57.5 years). Male subjects who entered the top tertile of the DEX score distribution were considered the high DEX group (n = 1 1164) compared to 2264 subjects in the low DEX group (control group). During 10 years of follow-up, 269 cardiovascular events (CVD) and 557 deaths from all causes were recorded. For patients with depression, the absolute risk was 11.2 for CVS and 23.1 deaths for all causes per 1000 person-years. The relative risk increased by 52% for both all-cause mortality and CVD (p <0.01). The contribution of depression was higher than that of dyslipidemia and obesity.

(Ladwig K.-H., Baumert J., Marten-Mittag B., Lukaschek K., Johar H., Fang X., Ronel J Meisinger, Ch., Peters A., for the KORA Investigators. Room for depressed and exhausted mood as a risk predictor for allcause and cardiovascular mortality beyond the contribution of the classical somatic risk factors in men.Atherosclerosis 2017, 257: 224-231; http://dx.doi.org/10.1016/j.atherosclerosis.2016.12.003 )

A known method for predicting the risk of developing acute myocardial infarction (AMI). A retrospective cohort study included 96,612 patients from 25 to 80 years old without CVS. At baseline, depression was diagnosed by a psychiatrist based on interviews with 2,000 patients. According to 7-year follow-up, the risk of developing AMI was higher in patients not only with depression (odds ratio (OR) 1.39), but also with "unspecified anxiety disorders" (OR 1.34), panic attacks (OR 1, 43) and post-traumatic stress disorder without clinical symptoms of depression (OR 1.25). The models were adjusted for various risk factors for AMI and socio-demographic factors.

(Scherrer JF, Chrusciel T., Angelique Zeringue A. et al. Anxiety Disorders Increase Risk for Incident Myocardial Infarction in Depressed and Nondepressed Veterans Administration Patients. Am Heart J 2010; 159: 772-779 doi: 10.1016 / j.ahj.2010.02 .033).

In both presented methods, patients with only clinically significant depression were distinguished, while the presence of subclinical depression was not taken into account. In addition, the participation of a psychiatrist was required, therefore, the risk stratification of CVC, taking into account psychological status, could not be carried out by a general practitioner or therapist, which reduces the effectiveness and availability of these methods in therapeutic practice.

There is also known a method for assessing the risk of cardiovascular complications, including conducting a clinical examination, assessing the risk of cardiovascular complications on the SCORE scale, determining the individual age norm aoPVR using the regression equation and attributed to a high risk group with a total risk of more than 5% on the SCORE scale and aoPVR above the calculated age norm or the total risk less than 5% on the SCORE scale (moderate and low risk group) and aoPVV above the calculated age norm.

(RF patent No. 2527356, IPC А61В 5/021, publ. 27.08.2014.)

However, being an effective tool for practical work, the currently used risk stratification systems (including the SCORE scale - the main tool for determining the magnitude of risk in Europe and Russia) are not without such a significant drawback as underestimating the true likelihood of developing cardiovascular complications in patients with low and moderate risk, determined by the criteria of this system. In addition, the SCORE scale recommended by EOK and PHOK experts for screening assessment of the risk of fatal cardiovascular complications in patients has a limited set of variables and does not take into account the patient's psychological status.

The objective of the present invention is to create an effective and informative method for predicting cardiovascular complications in patients with low or moderate cardiovascular risk, allowing for a more individual approach, taking into account the psychological status of the patient, which allows the timely use of a set of therapeutic and prophylactic measures, including inpatient stage.

The technical result of the invention is to improve the efficiency and information content of the method.

This is achieved by the fact that in the inventive method for predicting cardiovascular complications in patients with low or moderate cardiovascular risk by conducting a clinical examination, assessing the risk of cardiovascular complications on the SCORE scale, according to the invention, patients with a risk on the SCORE scale of 0-4% additionally, a questionnaire is conducted using the hospital scale of anxiety and depression HADS, and if the result is D> 6 points on the "Depression" scale (D) and / or A> 7 points on the "Anxiety" scale (A), the risk of cardiovascular complications is predicted, in addition , if a patient has dyslipidemia with the identification of two or more indicators according to the results of a clinical examination, different from the norm and SBP> 130 mm Hg. Art, the risk of cardiovascular complications is considered high.

Increasing the efficiency and information content of the method when using the data of the patient's clinical examination and the SCORE scale is achieved taking into account the psychological status of the patient using the HADS (Hospital Anxiety and Depression Scale) scale of anxiety and depression. The hospital scale HADS is designed for the primary detection of depression and anxiety in general medical practice, does not cause difficulties for the patient and does not require a long time to complete and interpret the results.

The method is carried out as follows.

During a visit to a doctor (general practitioner, general practitioner), a patient undergoes a standard clinical examination, including taking anamnesis, measuring blood pressure (BP) and evaluating the lipid profile - total cholesterol (TC), triglycerides, low-density lipoprotein cholesterol (LDL-C) and high density (HS-HDL). Next, the risk of CVC is assessed using the SCORE scale. At a risk of 0-4% (low / moderate), the patient is additionally surveyed using the HADS anxiety and depression scale. Patients with results above 6 points on the D scale - depression (D> 6) and / or above 7 points on the A scale - anxiety (A> 7) predict the risk of CVO or CVS, as the probability increases 4.9 times. With a combination of dyslipidemia (2 or more indicators different from the norm), SBP> 130 mm Hg. Art. and D> 6 and / or A> 7 - the risk of CVC increases by 7.3 times and is considered high.

Example 1.

Patient S. 53 years old, Dz. Hypertension II Art. Grade 2, risk of CVC 1% on the SCORE scale

At the first visit (2009), the patient has been suffering from arterial hypertension for 3 years, the maximum BP is 170/100 mm Hg. Art., was treated irregularly. At the time of inclusion, she was taking bisoprolol 2.5 mg, lisinopril 5 mg / day in "courses". Family history is not burdened. I do not smoke. Menopause at 48

Objectively: the patient's height is 164 cm, weight 100 kg (BMI 37), waist circumference 130 cm. BP 150/100 mm Hg. Art. Heart rate 76 / min. Biochemical analysis revealed: total cholesterol - 5.04 mmol / l, TG - 2.24 mmol / l, cholesterol - LDL - 2.94 mmol / l, HDL-cholesterol 1.08 mmol / l.

On the HADS scale: A (anxiety) - 9 points, D (depression) - 8 points

Thus, the patient has a SCORE risk of 1% (moderate), but the presence of subclinical anxiety and depression increases her real risk by 2.9 times.

According to a telephone survey, she had an acute cerebrovascular accident (ischemic stroke with disability) in 2011

Example 2.

Patient Ch, 46 years old. At the first visit (2009) there is no history of cardiovascular disease, he denies arterial hypertension. He does not receive drug therapy. Smokes since 18 years old, 2-5 cigarettes a day. The menstrual function is preserved. Complicated family history (father suffered acute myocardial infarction at age 49)

Objectively: the patient's height is 170 cm, weight 74 kg (BMI 22.1), waist circumference 79 cm. BP 125/80 mm Hg. Art. Heart rate 80 / min. Biochemical analysis revealed: total cholesterol - 5.88 mmol / l, TG - 3.18 mmol / l, cholesterol - LDL - 2.54 mmol / l, cholesterol - HDL 1.87 mmol / l.

On the HADS scale: A (anxiety) - 6 points, D (depression) - 12 points (clinical depression)

Thus, the patient has a SCORE risk of 0% (low), but the presence of subclinical anxiety and depression increases her real risk by 2.9 times.

According to a telephone survey of relatives - fatal myocardial infarction in 2014.

Example 3.

Patient K., 49 years old, Dz. Hypertension 1 tbsp. Grade 1, risk of CVC 1% on the SCORE scale

At the first visit (2009) The patient has transient increases in blood pressure for 2 years, max numbers 150/90 mm Hg. Art., does not receive therapy. I do not smoke. Family history is not burdened.

Objectively: the patient's height is 158 cm, weight 64 kg (BMI 25.6), waist circumference 85 cm. BP 130/90 mm Hg. Art. Heart rate 68 / min. Biochemical analysis revealed: total cholesterol - 6.52 mmol / l, TG - 0.97 mmol / l, cholesterol - LDL - 4.62 mmol / l, cholesterol - HDL 1.34 mmol / l.

On the HADS scale: A (anxiety) - 4 points, D (depression) - 3 points

Thus, the patient has a SCORE risk of 0% (low)

According to the telephone survey, there was no SSO for the period 2009-2020.

The method was tested on 164 patients with a SCORE risk of <5%, whose data were entered into the database "Programs for the development of new methods and technologies for the prevention, diagnosis and treatment of cardiovascular diseases associated with atherosclerosis in medical institutions of the Western Administrative District of Moscow" ... The patients were examined at the A.L. Myasnikov Research Institute of Clinical Cardiology. in 2009 - 2010, in addition to the standard clinical examination, patients were questioned using the HADS questionnaire to assess the level of anxiety and depression (Hospital Anxiety and Depression Scale - HADS). In 2019, a telephone call was made to patients, with the completion of a telephone contact questionnaire reflecting CVD over the past time: death from CVD (CVD), fatal and non-fatal myocardial infarction (AMI), unstable angina pectoris, acute cerebrovascular accident (CVA), cases of revascularization myocardium, as well as a combined endpoint (CVC = CVS + AMI + unstable angina + stroke + myocardial revascularization).

Results.

Over a period of 10 years in the study group, CVCs occurred in 15 patients (9.1%). In the study group, there were 3 CVS, 6 AMI, 4 cases of unstable angina pectoris, 12 tranluminal balloon angioplasty of the coronary arteries (TBAP), 5 stroke.

When comparing the initial data, it was found that the groups of patients who underwent CVC (CVC +) and did not undergo CVC (CVC -) differed only in the level of depression D. Levels of lipid profile, glucose, blood pressure (DBP), heart rate (HR) , smoking status, and level of anxiety did not differ. Table 1 shows the baseline clinical characteristics of patients with low / moderate risk who underwent and did not undergo CVS according to 10-year follow-up data.

The level of depression was shown to be an independent predictor of the development of CVC in the model including age, sex, blood pressure and cholesterol levels. A depression level of more than 6 points increased the likelihood of CVC by 2.9 times (OR 2.9,% CI 1.1-7.7). In individuals with depression above 6 and / or anxiety above 7, the chance of CVD or CVD is already 4.9 times higher than in persons without anxiety and / or depression.

The likelihood of developing CVC (including CVS) increases by 7.28 (95% CI 2.48-21.36) times in patients with impairment of two or more parameters of the lipid spectrum (cholesterol-LDL> 3.0 mmol / l and cholesterol-HDL > 0.9 mmol / L, TG> 1.5 mmol / L), SBP more than 130 mm Hg. Art. (high rate) and the presence of depression and / or anxiety, even subclinical.

Thus, this method increases the prognostic accuracy and helps to implement a more individual approach in predicting cardiovascular complications in patients with low or moderate cardiovascular risk, taking into account the psychological status of the patient, which allows the timely use of a set of therapeutic and prophylactic measures to prevent the development of serious complications. The proposed method can be widely used to monitor patients with low or moderate cardiovascular risk at the stationary stage. The method is highly informative, and its implementation takes little time and does not involve the use of expensive consumables.

Claims (1)

A method for predicting cardiovascular complications in patients with low or moderate cardiovascular risk by conducting a clinical examination, assessing the risk of cardiovascular complications on the SCORE scale, characterized in that patients with a risk on the SCORE scale of 0-4% are additionally surveyed using a hospital scales of anxiety (A) and depression (D) HADS, measure blood pressure (BP), determine blood lipid profile: total cholesterol (TC), triglycerides, low density lipoprotein cholesterol (LDL-C) and high density (HDL-C) and if the result is D more than 6 points and / or A more than 7 points, SBP is more than 130 mm Hg. Art., identifying two or more lipid profile indicators, different from the norm, predict the risk of cardiovascular complications.