RU2760854C1 - Method for predicting risk of ischemic stroke in patients with myocardial infarction - Google Patents

Abstract

FIELD: medicine; cardiology; neurology.

SUBSTANCE: in patients with myocardial infarction, prognostic criteria are identified, namely: a type of mitral valve lesion, a form of atrial fibrillation, the presence of other arrhythmias, the presence of sinoatrial and atrioventricular conduction disorders, heart failure according to the classification of the New York Heart Association, the presence of a stroke in the anamnesis, a type of a stroke in the anamnesis, the duration of hypertension, the maximum diastolic blood pressure, a type of aortic valve lesion, and the prognostic coefficient (Z) is calculated according to the original formula. At Z>0.5545, a high risk of ischemic stroke is predicted in a patient with myocardial infarction. At Z<0.5545, it is predicted that there is no risk of ischemic stroke in a patient with myocardial infarction. At Z=0.5545, the average risk of ischemic stroke is predicted in patients with myocardial infarction.

EFFECT: method makes it possible to identify the risk group for ischemic stroke in patients with myocardial infarction at an early stage, as well as to reduce the number of complications, the number of days of disability and the duration of the patient’s stay in the hospital, in addition, the method has high sensitivity and informativeness.

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Description

The invention relates to the field of medicine, namely cardiology, neurology and can be used to predict the combined development of myocardial infarction and acute cerebrovascular accident by ischemic type.

According to epidemiological studies from 2006 to 2017. in Russia, a moderate decrease in mortality from coronary heart disease (CHD) was recorded at a rate of -2.9%. At the same time, in 2017, there is an increase in the proportion of myocardial infarction among other causes of mortality from coronary artery disease to 12.6%. [Gerasimov, A.A. Epidemiological aspects of myocardial infarction in the Russian Federation: abstract of the thesis. ... Cand. honey. sciences. / A.A. Gerasimov. - Moscow, 2019 - 24 p.]. In the first two weeks of the disease, myocardial infarction can be complicated by the development of ischemic stroke, according to various sources from 1.3% to 12.8% of cases [Simonenko, V. B. Preventive cardioneurology / V. B. Simonenko, E. A. Shirokov. - SPb: FOLIANT, 2008. - 224 p.].

In clinical medicine, there are currently no known methods for early predicting the development of ischemic stroke in patients with myocardial infarction using discriminate analysis.

However, there are various ways to predict stroke in patients with coronary artery disease and cerebral atherosclerosis. The author has developed a regression equation that includes 12 signs: clinical manifestations of cerebral atherosclerosis (paresis of convergence of pupils with accommodation, Babinsky's symptom, anisoreflexia, cognitive impairment); signs characterizing ischemic heart disease (position of the ST segment in standard lead III, left ventricular hypertrophy); laboratory data: prothrombin time and lipid profile; indicators of cerebral hemodynamics (linear blood flow velocity in the right subclavian and right orbital arteries); cervical osteochondrosis and respiratory rate [Chetkarev, Yu.E. Prediction of ischemic stroke in patients with cerebrovascular pathology / Yu.E. Chetkarev // Military Medical Journal. - 2004. - No. 11. - S. 51.]. However, despite the obtained high prediction accuracy, this method has disadvantages, since the selected criteria, according to the authors, related to IHD, are not specific and do not reflect the presence of myocardial ischemia. The development of ischemic stroke, especially in young patients, in 36% of cases is caused by cardiogenic embolism, which occurs against the background of cardiac arrhythmias and conduction disturbances. In the presented method, the author does not take into account the electrical instability of the myocardium and signs of heart failure, which play an important role in the development of cerebral stroke.

The literature describes a method for predicting stroke for the next 3 years in elderly patients with essential hypertension in combination with coronary artery disease. The decisive rule included 11 criteria: the presence of coronary artery disease, obesity, diabetes mellitus, smoking, atrial fibrillation, cognitive impairment, functional class of heart failure, degree of arterial hypertension, age, prothrombin time, constant. The quantitative addition of the obtained parameters gives an integral index of the likelihood of developing a stroke [Kalenov, I.E., Predicting the occurrence of ischemic stroke / I.E. Kalenov, V.I. Shmyrev, V.V. Boyarintsev, Yu.E. Chetkarev, V.N. Ardashev // Clinical Medicine. - 2013. - No. 9. S. 48-52.]. However, the proposed method for predicting the development of ischemic stroke is designed for a limited category of elderly patients, since there are other predictors of the development of the disease at a younger age. Also, not all patients included in the study were diagnosed with coronary heart disease.

Of interest is a method for predicting the development of recurrent ischemic stroke, in which the risk of a vascular event is calculated using an original mathematical formula, including: age, sex, educational level, arrhythmia, cervical osteochondrosis, overweight, the total number of cerebral blood supply basins with multiple stenoses [Sprah, V.V. Pat. 2332170 Rus. Federation, IPC A61B 8/06 A method for predicting the development of repeated ischemic stroke / V.V. Shprakh, V.V. Tushemilov, I.M. Mikhalevich; applicant and patentee of GOU DPO "Irkutsk State Institute for Advanced Training of Doctors of the Federal Agency for Healthcare and Social Development". - No. 2007109592/14; declared 03/15/2007; publ. August 27, 2008. Bul. No. 24]. However, in the proposed criteria, the authors do not take into account the presence of arterial hypertension as one of the main factors in the development of stroke. The disadvantages of this method is also predicting only recurrent stroke, without taking into account the presence of coronary heart disease.

The closest, taken as a prototype, is the work of Yu.A. Gerasimova, which describes a method for the development of prognostic criteria for the combination of ischemic stroke and acute myocardial infarction [Gerasimova, Yu. A. Clinical and functional characteristics of ischemic stroke in combination with myocardial infarction: author. dis. ... Cand. honey. sciences. / Yu.A. Gerasimov. - Ivanovo, 2015. - 16 p.]. The author has created prognostic tables for assessing the total risk of developing vascular catastrophes depending on gender. The main clinical criteria were: the duration of arterial hypertension, the presence of postinfarction cardiosclerosis, atrial fibrillation, heart failure, ventricular extrasystole, tortuosity of the carotid and vertebral arteries, hypoplasia and small diameter of the vertebral arteries.

The disadvantage of this method is the lack of assessment of the structural state of the heart, in patients with myocardial infarction and ischemic stroke as an important factor in the development of cerebral hemodynamic disorders and initially low hemodynamic reserves. The author takes into account the presence of only atrial fibrillation and ventricular extrasystole, however, according to the literature, threatened rhythm disturbances include atrial focal (focal paroxysmal and chronic) tachycardia, including those with antegrade blockade of the II degree, atrial multifocal ("chaotic") atrioventricular reciprocal paroxysmal and chronic tachycardia. It has been proven that frequent supraventricular extrasystole causes a reduction in cerebral blood flow by 7%, ventricular paroxysmal tachycardia - 40-75% [Starodubtseva, OS Analysis of the incidence of stroke using information technologies / O.S. Starodubtseva, S. V. Begicheva // Fundamental research. - 2012. - No. 8-2. - S. 424-427]. The proposed tables are cumbersome and hard to read. To predict the development of the disease, it is more preferable, from the point of view of efficiency, to use discriminant analysis.

The presented invention is aimed at early detection of the risk of ischemic stroke in patients with myocardial infarction, for the development of active preventive measures and correction of treatment tactics for this category of patients.

The specified technical result is achieved by the fact that in patients with myocardial infarction, prognostic criteria are identified, namely: the type of mitral valve lesion, the form of atrial fibrillation, the presence of other arrhythmias, the presence of disorders of sinoatrial and atrioventricular conduction, heart failure according to the classification of the New York Heart Association, the presence of history of stroke, history of stroke type, duration of hypertension, maximum diastolic blood pressure, type of aortic valve lesion and calculate the prognostic coefficient using the formula:

Z = -0.4 * X ₁ + 0.093 * X ₂ + 0.897 * X ₃ -2.04 * X ₄ + 0.404 * X ₅ -3.128 * X ₆ + 8.102 * X ₇ - 0.013 * X ₈ + 0.012 * X ₉ + 2.264 * X ₁₀ -6.252, where:

Z is the prognostic coefficient;

X ₁ - type of mitral valve lesion: 0 - no pathology, 1 - mitral valve insufficiency, 2 - mitral valve stenosis, 3 - combination of stenosis and mitral valve insufficiency;

X ₂ - form of atrial fibrillation: 0 - no arrhythmia, 1 - paroxysmal form, 2 - permanent form, 3 - persistent form;

X ₃ - presence of other arrhythmias: 0 - no, 1 - present;

X ₄ - the presence of violations of SA and AV conduction: 0 - no; 1 - yes;

X ₅ - heart failure according to the classification of the New York Heart Association: 0 - no signs of heart failure; 1 - I class NYHA, 2 - II class NYHA, 3 - III class NYHA, 4 - IV class NYHA;

X ₆ - history of stroke: 0 - no, 1 - yes;

X ₇ - history of stroke type: 0 - no, 1 - ischemic type; 2 - hemorrhagic type, 3 - transient ischemic attack;

X ₈ - duration of hypertension in absolute numbers, years;

X ₉ - maximum diastolic blood pressure, in absolute numbers, mm Hg;

X ₁₀ - type of aortic valve lesion: 0 - no pathology, 1 - aortic valve insufficiency, 2 - aortic valve stenosis, 3 - a combination of stenosis and aortic valve insufficiency;

and at Z> 0.5545, a high risk of ischemic stroke is predicted in a patient with myocardial infarction; at Z <0.5545, the impossibility of the risk of ischemic stroke in a patient with myocardial infarction is predicted; at Z = 0.5545, the average risk of ischemic stroke in a patient with myocardial infarction is predicted.

The proposed method is carried out as follows:

A patient admitted with acute myocardial infarction undergoes an initial examination with anamnesis and identification of the duration of hypertension, the presence and type of stroke in history, the maximum level of diastolic blood pressure, the class of heart failure according to the classification of the New York Heart Association, the presence of atrial fibrillation with its assessment forms, violations of sinoatrial and atrioventricular conduction and other arrhythmias, using echocardiography to assess the type of damage to the aortic and mitral valves. The established prognostic factors are assigned numerical gradations, where

X ₁ - type of mitral valve lesion: 0 - no pathology, 1 - mitral valve insufficiency, 2 - mitral valve stenosis, 3 - combination of stenosis and mitral valve insufficiency;

X ₂ - form of atrial fibrillation: 0 - no arrhythmia, 1 - paroxysmal form, 2 - permanent form, 3 - persistent form;

X ₃ - presence of other arrhythmias: 0 - no, 1 - present;

X ₄ - the presence of violations of SA and AV conduction: 0 - no; 1 - yes;

X ₅ - heart failure according to the classification of the New York Heart Association: 0 - no signs of heart failure; 1 - I class NYHA, 2 - II class NYHA, 3 - III class NYHA, 4 - IV class NYHA;

X ₆ - history of stroke: 0 - no, 1 - yes;

X ₇ - history of stroke type: 0 - no, 1 - ischemic type; 2 - hemorrhagic type, 3 - transient ischemic attack;

X ₈ - duration of hypertension in absolute numbers, years

X ₉ - maximum diastolic blood pressure, in absolute numbers, mm Hg.

X ₁₀ - type of aortic valve lesion: 0 - no pathology, 1 - aortic valve insufficiency, 2 - aortic valve stenosis, 3 - a combination of stenosis and aortic valve insufficiency;

The decision rule works according to the formula:

Z ₁ = -0.739 * X ₁ -2.418 * X ₂ + 1.524 * X ₃ -2.348 * X ₄ -1.242 * X ₅ + 1.516 * X ₆ -2.206 * X ₇ -0.608 * X ₈ + 1.469 * X ₉ -1.844 * X ₁₀ -70.45

Z ₂ = -1.139 * X ₁ -2.325 * X ₂ + 2.421 * X ₃ -4.388 * X ₄ -0.838 * X ₅ -1.612 * X ₆ + 5.896 * X ₇ -0.621 * X ₈ + 1.481 * X ₉ +0 .42 * X _{10 -76.702}

If Z ₁ > Z ₂ , then the patient has only myocardial infarction, if Z ₂ > Z ₁ , then the patient should be referred to the group of high risk of a combination of ischemic stroke against the background of myocardial infarction.

The group of patients with myocardial infarction and ischemic stroke is more severe, so the inequality Z ₂ > Z _{1 can} be replaced by the inequality Z ₂ - Z ₁ > 0. A new variable has been introduced Z = Z ₂ -Z ₁ . If Z> 0, then we predict the development of a combination of two vascular catastrophes.

Generalized linear discriminant function Z:

Z = -0.4 * X ₁ + 0.093 * X ₂ + 0.897 * X ₃ -2.04 * X ₄ + 0.404 * X ₅ -3.128 * X ₆ + 8.102 * X ₇ -0.013 * X ₈ + 0.012 * X ₉ + 2.264 * X ₁₀ -6.252

The quality of the discriminant function was checked on the training set and the rolling exam method. The accuracy of prediction of belonging to the group of patients with a combination of myocardial infarction and ischemic stroke was 100%.

_{New variables Z 1} , Z ₂ and Z were created in MS Office Excel 2007. Their values were calculated for each patient. The value of the Z variable was used to plot the ROC curve and select the cut-off value. The ROC curve gives an estimate of the quality of the model by dividing the 2 groups. The graph shows the dependence of correctly classified positive examples on the number of incorrectly classified negative examples. Sensitivity (Se) is plotted on the ordinate, and 1-specificity (Sp) is plotted on the abscissa.

To select the cut-off point, the requirement for the maximum total sensitivity and specificity of the model was used.

Cut off = max (Se + Sp).

A cut-off point of 0.5545 was obtained with a sensitivity of 1 and a specificity of 0.958. The quality of the model was assessed using the area under the ROC-curve - the AUC indicator. AUC = 0.98. This corresponds to the very good quality of the resulting model (0.8-0.9).

How to use the decision rule:

In the Z function, the values of the patient's indicators from X ₁ to X _{10 are} substituted. If Z> 0.5545, then the patient should expect the combined development of myocardial infarction and ischemic stroke. If Z <0.5545, then the patient is not at risk of ischemic stroke. If Z = 0.5545, then the patient is at high risk of developing myocardial infarction and ischemic stroke, as a more severe category of patients.

The proposed method of the invention was tested on 286 patients admitted with acute myocardial infarction to the City Clinical Hospital No. 3 (Astrakhan). The average age of the examined patients was 63.15 ± 0.73 years. All patients included in the study were treated for myocardial infarction according to the recommended standards of medical care.

Below are the results of testing.

Example No. 1. Patient M, 49 years old, was admitted to the cardiology department with complaints of pressing pain behind the breastbone, at rest, shortness of breath, numbness and weakness in the left arm, dizziness.

From the anamnesis of the disease: the patient considers himself to be about 10 years old, when the blood pressure began to rise to a maximum of 220/120 mm Hg. Adapted to 150/80 mm Hg Regularly takes: perindopril 8mg / day, bisoprolol 5mg / day, atorvastatin 10mg / day, aspirin 100mg / day. Since 2011, he has been diagnosed with coronary heart disease, exertional angina with a tendency to progression of the disease. In May 2012, coronary angiography was performed, multivessel coronary lesion was diagnosed. Performed mammary-coronary bypass grafting of the anterior interventricular artery, coronary artery bypass grafting of the blunt-edge branch, the diagonal artery on the beating heart. About 1 week marks the return of angina pectoris. In connection with the appearance of an intense pain syndrome, he sought medical help.

The general condition is serious, the consciousness is clear. The patient is of the correct physique, the development of subcutaneous adipose tissue is excessive. Height - 176 cm, weight - 99 kg, BMI = 32 kg / m². The skin is pale pink in color, clean, of normal moisture. Peripheral lymph nodes are not enlarged. Percussion over the lungs pulmonary sound. Auscultation in the lungs, vesicular breathing, is carried out in all departments, no wheezing. Respiratory rate 17 in 1 minute. The boundaries of relative cardiac dullness are shifted to the left by 1.5 cm. Heart sounds are muffled, the rhythm is correct. The heart rate is equal to the pulse rate - 87 beats per minute. BP - 180/100 mm Hg. The abdomen is painless on palpation. Liver along the edge of the right costal arch. The spleen is not palpable. No peripheral edema. Rigidity of the occipital muscles was not revealed. No nystagmus. The tongue is in the midline, there is no smoothness of the nasolabial fold. Muscle tone is moderately reduced in the left hand with impaired sensitivity.

Examination: - complete blood count - hemoglobin 169 g / l, erythrocytes 5.5x10 ¹² / l, leukocytes 6.7x10 ⁹ / l, leukocyte formula is not changed, platelets 305x10 ⁹ / l. ESR 20 mm / h. In a biochemical blood test: glucose 5.5 mmol / l, uric acid 10.5 mmol / l, creatinine - 64 μmol / l, potassium - 4.5 mmol / l, sodium - 140 mmol / l, AST - 36 units / L, ALT - 35 U / L, total cholesterol - 6.25 mmol / L, triglycerides 1.55 mmol / L, LDL cholesterol - 4.09 mmol / L, HDL cholesterol - 0.72 mmol / L, creatine phosphokinase MB- fraction - 37 U / l, the maximum troponin level - 127 pg / ml.

- general urine analysis: no pathology.

- ECG: sinus rhythm, correct. Heart rate 76 beats / min. EOS is tilted to the left. Negative T waves in leads III, AVF. Signs of left ventricular hypertrophy.

- ECHO-KS - Concentric hypertrophy of the left ventricular myocardium. Dilation of the left atrium, left ventricle. Global myocardial contractility is normal. EF - 54%. Insufficiency of the mitral valve of a minor degree. Insignificant tricuspid valve insufficiency.

Diagnosed with ischemic heart disease. Acute myocardial infarction without ST segment elevation of the LV inferior wall. Background: Hypertension stage III, III degree. Risk of CVC - 4. Complications: Acute heart failure I class according to Killip. CHS I (Strazhesko-Vasilenko), FC II NYHA.

To predict the development of ischemic stroke, we calculate using the generalized linear discriminant function Z:

Z = -0.4 * 0 + 0.093 * 0 + 0.897 * 0-2.04 * 0 + 0.404 * 2-3.128 * 1 + 8.102 * 1-0.013 * 10 + 0.012 * 120 + 2.264 * 0-6.252 = 0 , 84

Thus, Z> 0.5545, the patient has a high risk of ischemic stroke in combination with myocardial infarction.

The patient was examined by a neurologist, during the initial CT scan of the brain: data for acute cerebrovascular accident were not obtained. According to the results of CT of the brain on the second day of observation, it was revealed: signs of stroke by ischemic type in the basin of the right middle cerebral artery. Atrophic cystic-gliosis changes in the left hemisphere of the brain, due to a previous violation of cerebral circulation in the basin of the left posterior cerebral artery. Diagnosed with Recurrent ischemic stroke in the PSMA pool. Left-sided monoparesis.

Thus, in the given clinical example, it is shown that the proposed method for predicting ischemic stroke in patients with myocardial infarction has a high diagnostic sensitivity in the early follow-up period of the patient, when there is a latent clinical picture of the disease and a CT scan of the brain is not informative on the first day of acute cerebrovascular accident.

Example No. 2. Patient P, 62 years old, was admitted to the cardiology department with complaints of pressing pains behind the sternum, radiating to the shoulders, feeling of lack of air.

From the anamnesis of the disease: the patient considers himself to be about 16 years old, when the blood pressure began to rise to a maximum of 200/110 mm Hg. Adapted to 130/80 mm Hg She regularly takes enalapril 20 mg / day, aspirin 100 mg / day. Diabetes mellitus type 2, on hypoglycemic drugs. Since 2013, atrial fibrillation, a paroxysmal form with rare rhythm disruptions. Does not take anticoagulants. In connection with the appearance of an intense pain syndrome, wheezing in the chest, he called an ambulance.

The general condition is serious, the consciousness is clear. The patient is of the correct physique, the development of subcutaneous adipose tissue is excessive. Height - 165 cm, weight - 90 kg, BMI = 33.1 kg / m². The skin is pale pink in color, clean, moist. Peripheral lymph nodes are not enlarged. Percussion over the lungs pulmonary sound. Auscultation in the lungs vesicular breathing, weakened in the lower-lateral parts, a large number of moist rales. Respiratory rate 22 in 1 minute. The boundaries of relative cardiac dullness are shifted to the left by 1.5 cm. Heart sounds are muffled, the rhythm is correct. The heart rate is equal to the pulse rate - 80 beats per minute. BP - 140/80 mm Hg. The abdomen is painless on palpation. Liver along the edge of the right costal arch. The spleen is not palpable. No peripheral edema. Rigidity of the occipital muscles was not revealed. No nystagmus. The tongue is in the midline, there is no smoothness of the nasolabial fold. Muscle tone is normal. No sensitivity disorders.

Examination: - general blood test - hemoglobin 111 g / l, erythrocytes 3.88x10 ¹² / l, leukocytes 13x10 ⁹ / l, leukocyte formula is not changed, platelets 259x10 ⁹ / l. ESR 21 mm / h. In a biochemical blood test: glucose 8.9 mmol / l, uric acid 9.4 mmol / l, creatinine - 94 μmol / l, potassium - 3.5 mmol / l, sodium - 132 mmol / l, AST - 43 units / L, ALT - 37 U / L, total cholesterol - 5.84 mmol / L, triglycerides 1.87 mmol / L, LDL cholesterol - 3.0 mmol / L, HDL cholesterol - 0.84 mmol / L, creatine phosphokinase MB- fraction - 40 U / L, maximum troponin level - 2352 pg / ml.

- general urine analysis: no pathology.

- ECG: sinus rhythm, correct. Heart rate 60 beats / min. The horizontal position of the EOS. There is a rise in the ST segment in leads II, III, aVF. A prehospital ECG recorded an episode of AV block of stage 2, type 2.

- ECHO-KS - Dilation of the left atrium, left ventricle. The global contractility of the myocardium is reduced. EF - 50%. Insufficiency of the mitral valve of a minor degree. Insignificant tricuspid valve insufficiency.

Diagnosed with ischemic heart disease. Acute myocardial infarction with ST segment elevation of the LV inferior wall. Background: Hypertension stage III, III degree. Risk of CVC - 4 type 2 diabetes mellitus, subcompensated.

Complications: Acute heart failure III class according to Killip. CHS I (Strazhesko-Vasilenko), FC II NYHA. AV block 2 tbsp., 2 types

To predict the development of ischemic stroke, we calculate using the generalized linear discriminant function Z:

Z = -0.4 * 0 + 0.093 * 1 + 0.897 * 0-2.04 * 1 + 0.404 * 3-3.128 * 0 + 8.102 * 0-0.013 * 16 + 0.012 * 110 + 2.264 * 0-6.252 = - 5.88

Thus, Z <0.5545, the patient has no risk of ischemic stroke in combination with myocardial infarction. The patient was discharged from the hospital in satisfactory condition. During outpatient follow-up for 1 year, no acute cerebrovascular accident was recorded.

In the given clinical example No. 2, the high efficiency of predicting the proposed method in patients with acute myocardial infarction has been proved.

Example No. 3. Patient L., 82 years old. Was admitted to the cardiology department with complaints of intense pressing pain behind the sternum with irradiation, in the interscapular region, a feeling of lack of air.

The patient considers himself to be within 25 years, when blood pressure began to rise, up to a maximum of 180/100 mm Hg. Adapted to 140/80 mm Hg Takes enalapril 10 mg / day and metoprolol 50 mg / day, aspirin 100 mg / day. For about 10 years, angina attacks have been troubling. She suffered an acute cerebrovascular accident 5 years ago with good recovery. Notes a gradual decrease in exercise tolerance, increased shortness of breath. About 8 hours ago, there were intense pressing pains behind the sternum, a feeling of lack of air, she took nitroglycerin on her own, without effect, due to the increase in the intensity of the pain syndrome and shortness of breath, she sought medical help. Anamnesis was collected from the words of the patient and relatives.

On examination: the general condition is severe. Consciousness is clear. Body temperature 36.7 ° C. The skin is pale pink in color, clean, moist. Acrocyanosis. The patient is of the correct physique, the development of subcutaneous adipose tissue is normal. Height - 162 cm, weight - 70 kg, BMI (body mass index) = 26.7 kg / m ² . Peripheral lymph nodes are not enlarged. Percussion over the lungs pulmonary sound. Auscultation in the lungs, vesicular breathing, is carried out in all sections, a small amount of wet rales in the lower-lateral sections. Respiratory rate 20 in 1 minute. The boundaries of the relative cardiac dullness are shifted to the left by 1.5 cm. The heart sounds are muffled, the rhythm is correct, the systolic murmur at the points of aortic valve auscultation is carried out on the vessels of the neck. The heart rate is 96 beats per minute, the pulse rate is 96 beats per minute, the blood pressure is 80/60 mm Hg. The abdomen is soft and painless on palpation. Liver along the edge of the right costal arch. The spleen is not palpable. Swollen legs. There are no dysuric disorders.

Examination: - complete blood count - hemoglobin 127 g / l, erythrocytes 4.39x10 ¹² / l, leukocytes 8.8x10 ⁹ / l, leukocyte formula is not changed, platelets 237x10 ⁹ / l. ESR 17 mm / h. In a biochemical blood test: glucose 5.6 mmol / l, uric acid 8.2 mmol / l, creatinine - 72 μmol / l, potassium - 4.2 mmol / l, sodium - 144 mmol / l, AST - 28 U / L, ALT - 30 U / L, total cholesterol - 5.42 mmol / L, triglycerides 1.45 mmol / L, LDL cholesterol - 3.61 mmol / L, HDL cholesterol - 0.73 mmol / L, creatine phosphokinase MB- fraction - 56 U / L, maximum troponin level - 1741 pg / ml.

- general urine analysis: no pathology.

- ECG: sinus rhythm, irregular. Single ventricular premature beats. Heart rate 98 beats / min. EOS is tilted to the left. Reduction of the ST segment to 2 mm below the isoelectric line in leads V1-V5, negative T waves in leads V1-V5.

- ECHO-CS - Degenerative calcification of the aorta, aortic valve leaflets, significant aortic stenosis, moderate mitral valve insufficiency, asymmetric left ventricular myocardial hypertrophy, decreased global myocardial contractility: EF - 33%. Dilation of the left atrium, left ventricle.

Diagnosed with ischemic heart disease. Acute myocardial infarction without ST segment elevation of the antero-septal, lateral wall of the left ventricle. Background: Hypertension stage III, III degree. Risk of CVC - 4. Complications: Acute heart failure IV class according to Killip. HSN II B (Strazhesko-Vasilenko), FC IV NYHA.

Find Z from the generalized linear discriminant function:

Z = -0.4 * 0 + 0.093 * 0 + 0.897 * X ₃ -2.04 * 1 + 0.404 * 4-3.128 * 1 + 8.102 * 1-0.013 * 25 + 0.012 * 100 + 2.264 * 2-6.252 = 6.64

Thus, Z> 0.5545, therefore, the patient has a high probability of developing ischemic stroke in the early period of myocardial infarction.

On the second day of observation, the patient had a sharp deterioration in her condition: she did not actively present complaints, speech disorders were noted. Consciousness level stunning. Rigidity of the occipital muscles was not revealed. No nystagmus. The movements of the eyeballs are limited outward. Tongue in the midline, smoothness of the nasolabial fold on the left. Deviation of the tongue to the left. Left hemiplegia, strength 0 points. Left hemigipesthesia. Controls the function of the pelvic organs.

On an emergency basis, computed tomography of the brain was performed, according to the conclusion: CT-picture of discirculatory encephalopathy, internal non-occlusive and external hydrocephalus. Taking into account the clinical picture of the disease, a competing diagnosis was made: Recurrent ischemic stroke in the basin of the right middle cerebral artery. Left-sided hemiplegia. Dysarthria.

Despite the ongoing therapeutic measures for the combined treatment of acute myocardial infarction and ischemic stroke, on the third day of observation, the death of the patient was stated. A postmortem examination was carried out, which diagnosed a combination of acute myocardial infarction and repeated ischemic stroke.

Analyzing the data obtained, we see that the indicators included in the discriminant analysis make it possible to classify patients with a high degree of reliability into the group of a combination of myocardial infarction and ischemic stroke.

Example No. 4. Patient A., 77 years old, was admitted to the neurological department in an extremely serious condition. According to relatives, arterial hypertension for 18 years, with a maximum increase in blood pressure up to 200/100 mm Hg. Adapted to 140/80 mm Hg Takes losartan 100 mg / day, metoprolol 100 mg / day, aspirin 100 mg / day. Diabetes mellitus type 2. For about 8 years, angina attacks have been troubling. She suffered 2 myocardial infarctions, and underwent stenting of the coronary arteries. History of acute ischemic cerebrovascular accident. About 2 hours ago she suddenly lost consciousness; cramps, tongue biting was not.

On examination: the general condition is extremely serious. Consciousness is stunning. Body temperature 36.4 ° C. The skin is pale, there is a "marbling" of the anterior surface of the chest, abdomen. Cyanosis of the lips. The patient is of the correct physique, the development of subcutaneous adipose tissue is normal. Height - 160 cm, weight - 65 kg, BMI = 25.4 kg / m ² . Peripheral lymph nodes are not enlarged. Percussion over the lungs pulmonary sound. Auscultation in the lungs, vesicular breathing, is carried out in all departments, a small amount of moist fine bubbling rales in the lower-lateral parts of the lungs on both sides. Respiratory rate 21 in 1 minute. The boundaries of relative cardiac dullness are displaced to the left by 2 cm. Heart sounds are muffled, the rhythm is correct, pathological murmurs are not heard. Heart rate is 100 beats per minute, pulse rate is 100 beats per minute, blood pressure is 90/60 mm Hg. (on vasopressors). The abdomen is soft and painless on palpation. Liver along the edge of the right costal arch. The spleen is not palpable. No edema. Rigidity of the occipital muscles was not revealed. No nystagmus. The tongue is in the midline, there is no smoothness of the nasolabial fold. Muscle tone is normal. No sensitivity disorders.

Examination: - complete blood count - hemoglobin 134 g / l, erythrocytes 4.8x10 ¹² / l, leukocytes 12.4x10 ⁹ / l, platelets 291x10 ⁹ / l. ESR 10 mm / h. In a biochemical blood test: glucose 16.2 mmol / L, uric acid 7.8 mmol / L, creatinine - 95 μmol / L, potassium - 3.8 mmol / L, sodium -140 mmol / L, AST - 43 U / L , ALT - 40 U / L, total cholesterol - 5.9 mmol / L, triglycerides - 2.45 mmol / L, LDL cholesterol - 4.6 mmol / L, HDL cholesterol - 0.93 mmol / L, creatine phosphokinase MB-fraction - 47 U / L, the maximum troponin level is 1496 pg / ml.

- general urine analysis: no pathology.

- ECG: sinus rhythm, correct. Heart rate 100 beats / min. EOS is tilted to the left. Reduction of the ST segment to 1 mm below the isoelectric line in leads V3-V6, negative T waves in leads V3-V6.

- ECHO-KS - Degenerative calcification of the aorta, aortic valve leaflets, insignificant mitral valve insufficiency, left ventricular myocardial hypertrophy, decreased global myocardial contractility: EF - 48%. Dilation of the left and right atrium, left ventricle.

- CT scan of the brain - data for stroke were not obtained.

Diagnosed with ischemic heart disease. Acute myocardial infarction without ST segment elevation of the anterolateral wall of the left ventricle. Background: Hypertension stage III, III degree. Risk of CVC - 4. Diabetes mellitus type 2.

Complications: Acute heart failure IV class according to Killip.

Find Z from the generalized linear discriminant function:

Z = -0.4 * 0 + 0.093 * 0 + 0.897 * 0-2.04 * 0 + 0.404 * 2-3.128 * 1 + 8.102 * 1-0.013 * 18 + 0.012 * 100 + 2.264 * 0-6.252 = 0 , 49

Thus, Z <0.5545, therefore, the patient has a low probability of developing ischemic stroke. The patient was discharged from the hospital in a satisfactory condition. No acute cerebrovascular accident was observed during 1 year follow-up.

The presented clinical example No. 4 shows that the proposed method makes it possible to objectively assess the likelihood of ischemic stroke in a patient with acute myocardial infarction occurring with an atypical clinical picture of the disease.

The algorithm for individual preclinical prediction allows using publicly available methods to diagnose a combination of two vascular catastrophes, which contributes to the timely adoption of active preventive measures to reduce the mortality of patients with a combination of myocardial infarction and ischemic stroke.

Thus, the proposed method for predicting ischemic stroke in patients with myocardial infarction provides:

1. Therapeutic efficacy of the method of the invention is associated with early identification of the risk group for ischemic stroke in patients with myocardial infarction using prognostic criteria that require more active treatment and control tactics.

2. High information content. The proposed algorithm for predicting the combined development of myocardial infarction and ischemic stroke is highly sensitive and informative.

3. The availability of using the method of the present invention is determined by the simplicity of the technical implementation and the quick obtaining of the result.

4. The economic efficiency of the method of the presented invention is due to the individual calculation of the risk of ischemic stroke in patients with acute myocardial infarction, which makes it possible to reduce the number of complications, days of disability and hospital stay.

Claims (13)

A method for predicting the risk of ischemic stroke in patients with myocardial infarction is achieved by the fact that prognostic criteria are identified in patients with myocardial infarction, namely: the type of mitral valve lesion, the form of atrial fibrillation, the presence of other arrhythmias, the presence of sinoatrial (SA) and atrioventricular conduction disorders ( AB), heart failure according to the classification of the New York Heart Association, history of stroke, type of stroke in history, duration of hypertension, maximum diastolic blood pressure, type of aortic valve lesion and calculate the predictive coefficient using the formula Z = -0.4 * X ₁ + 0.093 * X ₂ + 0.897 * X ₃ -2.04 * X ₄ + 0.404 * X ₅ -3.128 * X ₆ + 8.102 * X ₇ -0.013 * X ₈ + 0.012 * X ₉ + 2.264 * X ₁₀ -6.252, where Z is the prognostic coefficient; X ₁ - type of mitral valve lesion: 0 - no pathology, 1 - mitral valve insufficiency, 2 - mitral valve stenosis, 3 - combination of stenosis and mitral valve insufficiency; X ₂ - form of atrial fibrillation: 0 - no arrhythmia, 1 - paroxysmal form, 2 - permanent form, 3 - persistent form; X ₃ - presence of other arrhythmias: 0 - no, 1 - present; X ₄ - the presence of violations of SA and AV conduction: 0 - no; 1 - yes; X ₅ - heart failure according to the classification of the New York Heart Association: 0 - no signs of heart failure; 1 - 1 class NYHA, 2 - II class NYHA, 3 - III class NYHA, 4 - IV class NYHA; X ₆ - history of stroke: 0 - no, 1 - yes; X ₇ - history of stroke type: 0 - no, 1 - ischemic type; 2 - hemorrhagic type, 3 - transient ischemic attack; X ₈ - duration of hypertension in absolute numbers, years; X ₉ - maximum diastolic blood pressure, in absolute numbers, mm Hg; X ₁₀ - type of aortic valve lesion: 0 - no pathology, 1 - aortic valve insufficiency, 2 - aortic valve stenosis, 3 - a combination of stenosis and aortic valve insufficiency; and at Z> 0.5545, then the patient should expect the combined development of myocardial infarction and ischemic stroke, and at Z <0.5545, then the patient has no risk of developing ischemic stroke, and if Z = 0.5545, then the patient belongs to a high-risk group for developing myocardial infarction and ischemic stroke, as a more severe category of patients.