RU2768575C1 - Method for determining the degree of risk of developing cardiovascular complications in covid-19 - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to infectology and cardiology, and can be used to determine the risk of developing cardiovascular complications in COVID-19. In the blood serum of a patient with confirmed COVID-19, a laboratory determination of the content of endothelin-1 is carried out using a quantitative enzyme immunoassay. Depending on the value obtained, the degree of risk of developing cardiovascular complications is established in accordance with the following division: less than 0.16 pmol/l - low risk; from 0.16 to 0.5 pmol/l - medium risk; from 0.5 to 2.0 pmol/l - high risk; more than 2.0 pmol/l - a very high risk.

EFFECT: method provides the possibility of establishing the risk levels of developing cardiovascular complications in COVID-19: low, medium, high, very high, regardless of the presence or absence of a history of chronic somatic pathology of the circulatory system, by determining endothelin-1 in blood serum, which is a marker of endothelial dysfunction.

1 cl, 5 tbl, 4 ex

Description

The invention relates to medicine, namely to infectious diseases and circulatory diseases of the adult population, can be used as an objective prognostic criterion for the risk of developing cardiovascular complications and, therefore, the associated severity of the course of the disease in patients with COVID-19 who are on outpatient or inpatient treatment. The method can also be used in patients who have had a disease and are at the stage of recovery in order to assess the effectiveness of the therapy and the need to continue treatment or adjust the treatment regimen.

Despite the wide coverage of the population by vaccination against COVID-19, the problem of the spread of SARS-CoV-2 does not lose its relevance [1]. From February 2020 to the present, the number of sick and dead people has been continuously growing in the world. The highest incidence with the maximum number of deaths was registered in India and the USA. In Russia, the overall incidence of coronavirus infection caused by SARS-CoV-2 also remains at a high level [2].

Currently, a large number of severe forms of COVID-19 are being recorded due to the adult population with a protracted course, cardiovascular complications are often recorded, which is one of the features of a new coronavirus infection. In this regard, the problem of predicting the course of the disease and the possibility of determining the degree of cardiovascular risk in patients at an early stage in order to timely prevent adverse outcomes is highly relevant [3]. It is important for an outpatient and inpatient practitioner to identify a group of patients who need a more rapid additional examination and the appointment of active preventive therapy.

To date, it is known that SARS-CoV-2 enters the cell through interaction with angiotensin-converting enzyme type 2 (ACE-2) receptors. At the same time, ACE-2 receptors are present in most organs and systems of the body, especially in the vascular bed, which allows the virus to cause systemic damage. A significant progression of endothelial dysfunction is promoted by activation of inflammation, leading to an increase in the activity of ACE-2 receptors on the surface of the endothelium, which in turn leads to the release of endothelin-1, the main vasoconstrictor substance. Due to the pronounced vasoconstriction, tissue perfusion is disturbed, which leads to focal necrosis with damage to the intima of the vessels and hypercoagulation. This stimulates increased release of pro-inflammatory cytokines. Thus, uncontrolled production of endothelin-1 leads to the progression of systemic inflammation and thrombosis, its high values can be a marker of an unfavorable prognosis, and a decrease can correlate with positive dynamics.

Currently, there are no reliable indicators characterizing the degree of vascular damage in COVID-19. The widely used definition of the level of D-dimer as a marker of thrombosis cannot be used in practice for timely prediction of the outcome and revision of therapy tactics, since it is a product of the destruction of an already formed thrombus and characterizes late processes occurring in the vessels in patients with coronavirus infection [4-7] .

The closest analogue of the claimed invention can be considered "Method for assessing the effectiveness of vascular therapy by the severity of endothelial dysfunction" (patent RU No. 2455641, author - Inzhutova A.I.) [8]. According to the proposed method, to determine the degree of endothelial dysfunction, the number of endotheliocytes labeled with annexin-V is determined. The disadvantage of this method lies in its complexity. In addition, it is focused on patients with somatic pathology.

Also a close analogue is the "Method for determining the risk of developing cardiovascular complications in women with hypertension (RU patent No. 2530621 authors Radaeva O.A. and Novikova L.V.), according to which the risk of developing cardiovascular complications is estimated based on interleukin levels -1, interleukin-1α, leukemic cell inhibitory factor and CD34 count [9]. The main disadvantages of the method is the need to determine 4 indicators and applicability only for cases with essential arterial hypertension.

From the patent literature it is known to determine the state of the vascular wall in patients with arterial hypertension using a mathematical model based on the results of determination of total cholesterol, high density lipoproteins, endothelin-1, homocysteine and C-reactive protein in the blood serum. in patients with arterial hypertension with abdominal obesity (patent RU No. 2567606 by Petelina T.I., Gapon L.I., Avdeeva K.S., Musikhina N.A. and Dyachkova S.M.) [10]. As with the previous methods, its disadvantage is the complexity and limited use for patients with somatic pathology.

A similar result can be achieved by other methods. Known "Method for detecting dysfunction of the endothelium of the coronary arteries" (patent RU No. 2199266, authors Parnes E.Ya., Parnes M.E., Parnes M.E., Krasnoselsky M.Ya.). According to this method, the conclusion about the presence or absence of dysfunction of the endothelium of the coronary arteries is given on the basis of the results of the analysis of the power of the spectral components of heart rate variability on the recorded rhythmocardiogram [11]. The disadvantage of this method is, first of all, the assessment of only a certain part of the vascular bed - the coronary arteries, as well as the possibility of influencing the rhythm variability of electrolyte, biochemical and hereditary disorders.

Another close to the inventions under consideration is the “Method for predicting the variant of arterial hypertension in elderly and senile patients” (patent RU No. 2266702 of the authors Katelnitskaya L.I., Khaisheva L.A., Ivanchenko D.N., Jagessar R.K., Kitsiev A.A., Luzhetskoy I.V.). According to this method, in patients at risk of elderly and senile age, the value of endothelium-dependent vasodilation - EDVD is determined as the difference between the diameters of the brachial artery in reactive hyperemia and at rest, correlated to its diameter at rest, and endothelium-independent vasodilation - ENVD, calculated in a similar way while taking nitroglycerin. In addition, the level of endothelin-1 is determined, and the development of systole-diastolic or isolated arterial hypertension is predicted by all these values [12]. The disadvantage of this method is that the prediction of arterial hypertension is associated with the intake of nitroglycerin, which may exhibit undesirable effects: first of all, significantly reduce blood pressure with the likelihood of fainting. In addition, the evaluation can only be carried out in the specified age category.

Another close to the invention presented by us is the result of the work of Senchikhin V.N. and Lyamina S.V. "Vasomotor and secretory functions of the endothelium in young patients with arterial hypertension" (Proceedings of the Congress "Perspectives of Russian Cardiology", Moscow, 2005). To assess the vasomotor and secretory function of the endothelium, the authors determined the level of nitric oxide, the concentration of endothelin-1, and the magnitude of endothelium-dependent vasodilation. In this work, it is indicated that in healthy young people, the level of nitric oxide production is 19.1 ± 4.5 µmol/dL, the content of endothelin-1 in blood plasma is 8.8 fmol/mL [13]. However, this method is focused on use in persons with a certain pathology - arterial hypertension, and not in infectious pathology.

Thus, none of the available methods is focused on assessing the state of the vessels in patients with COVID-19.

The technical problem to be solved by the present invention is the development of a method for determining the degree of risk of developing cardiovascular complications in patients with COVID-19, which is widely used in everyday clinical practice in primary care and in inpatient treatment.

This problem is solved by determining the level of endothelin-1 in the blood serum of patients with COVID-19, including in the early period and during the convalescence period, followed by evaluation of the results obtained to determine the degree of risk of developing cardiovascular complications.

The proposed method is based on the fact that in patients with COVID-19, due to the peculiarities of the action of the virus, there is damage to the vessels with damage to the vascular wall and the release of endothelin-1 into the bloodstream. In this case, the degree of vascular damage may depend on the number of receptors with which the virus interacts. Endothelin-1 causes vasoconstriction with subsequent thrombus formation and increased inflammatory response, which affects the function of the heart muscle and other organs. These manifestations are directly dependent on the amount of released endothelin-1. The release of this substance occurs at the earliest stages of endothelial damage, when other markers (MB-creatine kinase, transaminases, natriuretic peptide, D-dimer) are still not involved. Thus, the determination of the level of endothelin-1 is essential for determining the prognosis of cardiovascular risk during various periods of COVID-19. Obviously, this indicator can increase in response to damage to the vascular wall of another etiology, which can be studied in the future and does not contradict the technical task.

The essence of the invention lies in the fact that when implementing the proposed method, a laboratory determination of the concentration of endothelin-1 by enzyme immunoassay in the blood serum of patients with COVID-19 is carried out, followed by an assessment of the risk of developing cardiovascular complications depending on the values obtained.

The advantages of the proposed method are the ability to quickly assess the risk of cardiovascular complications in the early stages of vascular damage, the objectivity and accuracy of the result, the ability to determine the level of endothelin-1 by a known method of enzyme immunoassay in the presence of a set of reagents, both on an outpatient basis and at the inpatient stage.

The technical result of the method is to establish the degree of risk of developing cardiovascular complications: low, medium, high, very high, regardless of the presence or absence of a history of chronic somatic pathology of the circulatory system. The method allows to significantly reduce the adverse outcomes of the disease, both at the stage of primary care and at the inpatient stage due to the timely correction of the therapy regimen. In addition, a timely forecast of cardiovascular risk will reduce the number of hospitalizations and optimize the work of the primary care. Assessment of the degree of cardiovascular risk allows you to select a group of patients who need urgent hospitalization (at high and very high risk) and active therapy; a group of people who need additional examination, but with possible outpatient monitoring and treatment (at an average degree of risk), as well as a group with a low cardiovascular risk, in which a minimum amount of control and therapy is needed.

Method for determining endothelin-1 in blood serum:

1st stage. From a patient with COVID-19 on an empty stomach, venous blood is taken in a volume of at least 1 ml into a serological test tube.

2nd stage. The taken whole blood is centrifuged in the standard mode, the serum is pipetted into a tube for aliquoting.

3rd stage. Using a set of reagents for the determination of endothelin-1 by a quantitative method and an analyzer by the enzyme immunoassay method, the concentration of endothelin-1 is determined. If it is impossible to determine within a day after taking the biomaterial, the blood serum can be frozen at a temperature of -20°C.

After receiving the result, the compliance of the established value with the degree of risk is determined:

- less than 0.16 pmol/l - low risk;

- from 0.16 to 0.5 pmol / l - medium risk;

- from 0.5 to 2.0 pmol/l - high risk;

- more than 2.0 pmol / l - a very high risk of developing cardiovascular complications.

The degrees of risk were established by comparing the obtained values of endothelin-1 in the blood serum of patients and the results of subsequent observation (complaints, general condition, ECG data, results of a biochemical study with additional analysis for the levels of D-dimer and cardiospecific markers in dynamics, MRI of the brain) with assessment of developed complications and outcomes.

The invention is illustrated by the following materials.

Table 1 presents laboratory data from a study of 63 patients, where the main group consisted of 32 patients in the acute phase of COVID-19, before the start of therapy, and 31 patients with recovery or minimal changes that did not limit daily habitual activity (0 or 1 point on a scale WHO Clinical Improvement). after the course of therapy, on the 28th day from the start of complex (antiviral, anticoagulant and other, if necessary) treatment. Additionally, the most common cardiospecific markers of damage to the cardiovascular system, traditionally used in routine clinical practice, were evaluated, and their significance was assessed in comparison with enothelin-1 in the compared groups. Patients of both groups are comparable in age, gender composition and comorbidity. Verification of the diagnosis of COVID-19 was carried out by polymerase chain reaction (PCR, Amplisens test system, RF). All patients gave informed consent to participate in the study and to use anonymized data from their medical records for scientific purposes and in publications. The study was approved by the local ethics committee. Inclusion criteria for the study: men and women aged 18 to 85 years, laboratory-confirmed diagnosis of coronavirus infection caused by the SARS-CoV-2 virus.

The non-inclusion criteria included conditions that, independently of others, indicate a severe course and a high risk of an adverse outcome: hospitalization of the patient in the intensive care unit at the time of inclusion in the study, the need for mechanical ventilation, a decrease in the level of consciousness, agitation, established unstable hemodynamics, subtotal diffuse compaction of the lung ground glass tissue and consolidation in combination with reticular changes; involvement of the lung parenchyma ≥75% (CT picture corresponding to CT-4), hydrothorax. The study did not include patients with concomitant diseases that significantly worsen the prognosis of the disease (oncological pathology, acute myocardial infarction, HIV, tuberculosis, and others).

Statistical analysis of the obtained data was carried out using a standard set of statistical software package IBM SPSS Statistics Version 23 using one-way analysis of variance to estimate the difference in the means taking into account the standard deviation (M±SD) for two or more samples. Statistical significance of differences when calculated by the method of one-way ANOVA for two or more samples was considered achieved at a p value of less than 0.05.

Tables 2, 3, 4 present data on the results of the study of cardiospecific markers traditionally used in practice.

Thus, the results obtained by assessing the level of endothelin-1 demonstrate significant differences between groups before treatment and after a course of effective therapy, which led to recovery or a significant improvement in the condition. There were no differences in the level of other markers used in routine practice, although they were elevated in some patients in the acute phase.

When identifying groups of patients with different prognosis, we obtained the results presented in Table 5. As can be seen from it, the highest risk of complications was in patients with high values of endothelin-1: from 2.1 to 3.0 (upper limit of determination for the used set of reagents), and the smallest corresponded to values from 0.02 (- the lower limit of sensitivity of the used set of reagents) to 0.15, which confirms the selected values. At the same time, the significance of differences between groups is high. Certain maximum and minimum indicators made it possible to distinguish the boundaries of values between groups with the corresponding degrees of risk.

Among these patients, the following examples most clearly confirm the need to use the proposed method. To study the level of endothelin-1, in addition to the indicators routinely determined by the laboratory, due to the lack of an appropriate set of reagents at that time, blood serum was aliquoted and frozen. The level of endothelin-1 was determined later, simultaneously for all blood samples taken, after the completion of the acute period in the patients presented in the examples.

Example 1

A 79-year-old man applied for outpatient care in connection with a diagnosed coronavirus infection caused by SARS-CoV-2.

Complaints of weakness, fatigue, lack of appetite. Sick for 2 days, a week ago there was contact with a patient infected with the SARS-CoV-2 virus. In history: prostate adenoma, chronic gastritis, denies other pathology. Objectively: at the time of examination, the state of moderate severity, body temperature - 37.5°C, oxygen saturation - 95-96%, blood pressure - 110/70 mm Hg. Art., HR=68 beats per minute, NPV=18. Hard breathing was determined on auscultation, heart sounds were muffled. According to the computed tomography of the chest organs, there is no lung injury, CT-0. Laboratory control was carried out: a complete blood count, D-dimer, coagulograms, a blood sample was taken for the level of endothelin-1. According to the results of the examination: the level of endothelin-1 is 3 pmol/l, which is determined in accordance with the developed method as a very high risk. Changes in other indicators were generally consistent with the acute phase of COVID-19. The patient was prescribed treatment in accordance with the current recommendations of the Ministry of Health of the Russian Federation. Over the next day, the patient's condition worsened, in connection with which he was hospitalized in the intensive care unit. Against the background of hypercoagulability, confirmed by laboratory, the ineffectiveness of the therapy, the patient died.

Thus, at the time of the first examination of the patient, no data, with the exception of the level of endothelin-1, did not indicate the likelihood of a critical deterioration in the condition. A timely risk assessment could justify early prescribing of the most effective anticoagulant therapy with intensive monitoring of hemostasis and cardiovascular activity, which was not done due to the lack of data on the significance of endothelin-1 levels at that time.

Example 2

An 83-year-old man asked for help with complaints of a feeling of interruptions in the work of the heart, an increase in body temperature up to 37.5°C. According to the results of PCR diagnostics, infection with a coronavirus infection caused by SARS-CoV-2 was established. Sick for 3 days. Objectively: temperature is 37.5°C, D-dimer level is 594 ng/l. The level of endothelin-1 is 0.8 pmol/l, which corresponds to a high risk of developing cardiovascular complications. According to computed tomography of the chest, there is no lung injury, the picture corresponds to the age norm, CT-0. According to the ECG, conduction disturbance, repolarization disturbance, single ventricular extrasystoles, ischemic type changes in the myocardium in the anterolateral region. Among the drugs recommended by the Ministry of Health of the Russian Federation for the treatment of COVID-19, the most active combination was chosen. Antiviral (favipiravir with a loading dose of 1800 mg 2 times on the first day, then 800 mg 2 times a day) and anticoagulant (rivaroxaban 20 mg - the maximum dose recommended for the prevention of thromboembolic complications) therapy was prescribed. Additionally, an antibiotic (levofloxacin 500 mg 2 times a day) and an anti-inflammatory Janus kinase inhibitor (baricitinib 4 mg a day) are recommended. The patient was followed up on an outpatient basis with daily remote control and, if necessary, examination on the 5th, 10th and 14th days. Against the background of therapy for 2 weeks, a gradual positive trend was noted, hospitalization was not required.

Thus, early detection of a high risk could provide a compelling rationale for an active, frequently monitored therapy option. In this case, in the absence of results from an endothelium-1 study, this was done based on assumptions about age and high levels of D-dimer, which rises with pre-existing thrombus formation. The treatment was carried out on an outpatient basis, the patient recovered without complications. At the same time, ECG changes, along with the absence of lung damage, could not be the rationale for prescribing the maximum prophylactic dose of rivaroxaban and a Janus kinase inhibitor.

Example 3

A 39-year-old man applied for outpatient care in connection with a diagnosed coronavirus infection caused by SARS-CoV-2 and complained of severe weakness, fever, shortness of breath. From the anamnesis: sick for 7 days. During this time, he was treated independently by folk and generally accepted means for the treatment of acute respiratory viral infections, without effect. By the end of the week, I felt suffocation: increasing weakness, aches all over my body, a persistent increase in body temperature to 38.5 ° C, a decrease in oxygen saturation to 93-92%. According to computed tomography of the chest organs, lung damage was noted - 25% on each side, CT-2, there is a pericardial effusion. According to laboratory data, an increase in D-dimer up to 1000 ng/l, C-reactive protein up to 80 ng/l, the level of endothelin-1 - 0.38 mmol/l, which corresponds to an average risk of developing cardiovascular complications. The patient was prescribed antiviral (favipiravir), anticoagulant (rivaroxaban at an average dose used for prevention - 10 mg per day), antibacterial (levofloxacin), and anti-inflammatory therapy (Janus kinase inhibitors). While taking the drugs, there was a steady improvement, the total course of treatment was 14 days, no hospitalization was required.

Thus, the example confirms the presence of an average degree of risk, according to the analysis of the level of endothelin-1, despite the long period from the onset of the disease and the presence of lung damage, it could objectively confirm the choice of the average dose of rivaroxaban and outpatient treatment. In the absence of an endothelial-1 test result, the choice of average therapy doses and outpatient therapy options was made based on the age of the patient, which is not a reliable criterion.

Example 4

A 62-year-old woman complained of an increase in body temperature up to 37.8°C, aching joints and muscles, loss of smell for 3 days. Based on the results of PCR diagnostics, infection with a coronavirus infection caused by the SARS-CoV-2 virus was established. The laboratory parameters of the clinical blood test, D-dimer, coagulogram were evaluated, a blood test was made for the level of endothelin-1. The level of endothelin-1 is 0.10 pmol/l, which corresponds to a low risk of developing cardiovascular complications. Changes in other indicators were generally consistent with the acute phase of COVID-19. According to computed tomography of the chest, the picture corresponds to the age norm, there is no lung damage, CT-0. Among the drugs recommended by the Ministry of Health of the Russian Federation for the treatment of COVID-19, the easiest therapy regimen was chosen. The antiviral drug umifenovir 200 mg 4 times a day and the anticoagulant rivaroxaban at the minimum dose of 2.5 mg were prescribed. Due to recovery, the course of treatment was completed after 7 days.

Thus, the determination of the level of endothelin-1 could objectively confirm the low risk of cardiovascular complications and the possibility of using minimal therapy with a low risk of developing side effects from the drugs used. In the absence of data on the level of endothelin-1, this was done on the basis of a short time from the onset of symptoms and a low body temperature, which are not reliable criteria.

Output. The developed method for determining the risk of developing cardiovascular complications makes it possible to objectively determine the likelihood of an unfavorable outcome of COVID-19, prescribe more effective therapy in a timely manner and provide active monitoring of the patient's condition when a high risk is detected, both at the outpatient and inpatient stages. At the same time, in some cases, risk assessment makes it possible to avoid large doses of drugs and the use of active regimens, which makes it possible to avoid side effects and reduce the cost of treatment.

Bibliography

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Claims (5)

A method for determining the risk of developing cardiovascular complications in COVID-19, characterized in that in the blood serum of a patient with confirmed COVID-19, a laboratory determination of the content of endothelin-1 is carried out using a quantitative enzyme immunoassay method and, depending on the value obtained, the degree of risk of developing cardiovascular disease is determined. - vascular complications according to the following division: - less than 0.16 pmol/l - low risk; - from 0.16 to 0.5 pmol / l - medium risk; - from 0.5 to 2.0 pmol/l - high risk; - more than 2.0 pmol/l - very high risk.