RU2276574C1 - Method for evaluating treatment effectiveness in myocardial ischemia patients of various vegetative trend types - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out cardiointervalographic examination with histographic analysis, calculating skewness and excess coefficient before and after three months of treatment. Skewness infarction risk factors are evaluated from anamnesis. Gradations and excess coefficient drop being observed, the treatment is evaluated as effective. The values remaining unchanged or growing high, the treatment is evaluated as ineffective and the patients are advised to receive cardiosurgical treatment.

EFFECT: high accuracy of prognosis.

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Description

The invention relates to medicine, namely to cardiology and disease prevention.

The analysis of heart rate variability (HRV) is a methodology for studying the processes of regulation of physiological functions, where the circulatory system is considered as an indicator of adaptive reactions of the whole organism. HRV reflects the state of the sympathetic and parasympathetic parts of the autonomic nervous system. Existing methods of analysis (mathematical, temporal, spectral) allow you to determine the direction of the etiological search, and histographic - to visually assess the value of the dominant influence of the sympathetic or parasympathetic division of the ANS in each individual clinical case.

As a prototype for predicting the effectiveness of treatment, the author proposes to use dynamic Holter monitoring. Moreover, the effectiveness of therapy is evaluated by reducing the total duration of myocardial ischemia, reducing the average duration of one episode and the depth of ST segment depression (V.A. Orlov, D.M. Urusbieva "Asymptomatic myocardial ischemia: the ratio between proven, unproven," Russian Journal of Cardiology No. 5, 2003, pp. 89-98). The prognostic value of daily monitoring of ECG increases with various forms of painless ischemia only with the simultaneous study of indicators of heart rate variability, a stress test with an assessment of myocardial perfusion.

The disadvantages of this method are:

- the parameters of Holter monitoring do not allow to predict the effectiveness of treatment in patients with painless myocardial ischemia (BBIM);

- given the data of Holter monitoring, it is impossible to differentially prescribe therapy with various vegetative provision;

- heterogeneity of BBIM, comorbid mechanisms of occurrence, multidirectional vegetative support level significant differences between the indicators before and after treatment;

- the lack of standardized criteria does not make it possible to predict the effectiveness of therapy.

The author offers his own method for predicting the effectiveness of treatment in patients with painless myocardial ischemia with various types of vegetative support. Histologically, the averaged normotonic (mode - 0.7-0.9 s), sympathetic (mode - 0.5-0.7 s) and vagotonic (mode - from 1.0 to 1.2 s) types (Fig. one). Moreover, the author proposes to use the value of the asymmetry coefficient (K _a ) and excess (E _x ) for averaged sympathetic, vago, and normotonic histogram types in the dynamics before and after treatment. The calculation of the latter was carried out according to the formulas

M is the average value;

n is the number of elements in the sample;

σ is the standard deviation;

x _j is the value of an individual sample element.

To confirm the results of the study, the applicant examined 128 patients with coronary heart disease with BBIM. Sympatotonic histograms were recorded in 65 (50.9%) patients, normotonic - in 34 (26.5%), vagotonic - in 29 (22.6%). All patients underwent cardiointervalography with a 5-minute ECG recording according to a standard technique. The analysis of the obtained HRV data was carried out in the following ways: mathematical, temporal, frequency, and histographic. Moreover, a comparison of the average values of the results obtained when evaluating them in different ways in the whole group made it difficult to establish a vegetative orientation. The heterogeneity of the group of patients with BBIM makes it difficult to use each of the three methods to assess the effectiveness of treatment due to the multidirectional vegetative changes. All patients underwent drug treatment according to the standard scheme for BBIM (beta-blockers and / or calcium antagonists, aspirin, prolonged nitrates, antiarrhythmic drugs, angiotensin-converting enzyme inhibitors), its effectiveness was confirmed after 3 months to reduce K _a and E _x (p <0 , 05-0.001). In order to control the results of the study, all patients underwent Holter monitoring in accordance with generally accepted criteria for ischemia.

It should be noted that for the first time an analysis of HRV by species and types with an estimate of the values of asymmetry coefficients (K _a ), excess (E _x ) was used by S.Z. Kletskin (in the collection "Instrumental methods for studying the cardiovascular system" under the editorship of T .S. Vinogradova, Moscow, "Medicine", 1986, pp. 156-163.

After treatment in patients with BBIM, the decrease in K _a and E _x occurred mainly in patients with sympathetic and normotonic types of histograms (p <0.001), and with the vagotonic type they did not significantly change or tended to increase (p> 0.05), which points to various mechanisms of the formation of painless myocardial ischemia, including the effect of extracardiac factors and the absence of a clear effect of drug therapy. Holter monitoring confirmed a decrease in the number of episodes, the total integral of the ST segment shift, the amplitude of maximum depression while maintaining a threshold heart rate at the level of tachycardia with sympathetic and normotonia. When vagotonia after treatment, K _a and E _x did not change, while in 9% they increased slightly (p <0.05). Control Holter monitoring of the dynamics of the above indicators in these patients did not reveal. Thus, the use of K _a and E _x in the analysis of averaged types of histograms opens up the possibility of determining the effectiveness of treatment and allows to identify patients with reduced coronary reserve who need cardiac surgery.

The advantages of the proposed method are:

- the ability to identify patients with ineffective drug therapy and determine their worsening myocardial insufficiency for timely planning of cardiac surgery;

- An integrated approach to assessing the vegetative orientation;

- definition of criteria for the effectiveness of treatment;

- a simple, economical method that does not require additional costs and time, allowing more widely use the diagnostic capabilities of the equipment;

- the use of the results by cardiologists on an outpatient basis;

- allows you to monitor the effectiveness of therapy during dynamic observation.

Clinical examples.

The medical history No. 123589. Patient A., 49 years old, an engineer, turned up about recurring unmotivated weakness in the morning, and the deterioration of exercise tolerance. Cardiointervalography revealed an asymmetric sympatotonic type of histogram (figure 2). K _a = 0.9 and E _x = 1.6. Treatment was prescribed, the effectiveness of which after 3 months was assessed by repeated cardiointervalography. An asymmetric sympathotonic histogram was recorded (FIG. 3). It was found that there was a decrease in K _a to 0.3 and E _x to 1.1. Information content was confirmed using Holter monitoring. Holter monitoring confirmed the effectiveness of the prescribed therapy (3 episodes of painless myocardial ischemia were recorded instead of 9, the duration of ischemia decreased from 42 to 11 minutes per day with maintaining the circadian rhythm, the average threshold heart rate practically did not change, making 105-108 beats / min, respectively, while reducing the maximum the amplitude of the ST segment depression from 1.9 to 1.5 mm and the total displacement integral from 4462 to 2989 μV * min). Therefore, the recommended treatment is effective, and the long-term administration of drugs is justified.

The medical history No. 1467823. Patient E., 45 years old, first contacted a cardiologist with complaints of periodic heartbeats, weakness, sleep disturbances, and increased irritability. Based on complaints, medical history, objective examination, clinical examination, echocardiography and Holter monitoring, IHD was diagnosed with painless myocardial ischemia, post-infarction cardiosclerosis (no known myocardial infarction). Identified polymodal vagotonic type of histogram (figure 4). To _a = 0.6, E _x = 2.1, recommended additional examination and treatment with control after 3 months. The dynamics of the patient's condition did not improve, the number of episodes of ischemia during Holter monitoring increased from 6 to 8 per day, the total duration increased from 22 to 29 minutes per day, the threshold heart rate did not change, remaining at the level of 69-88 beats / min, the amplitude maximum depression of the ST segment increased slightly from 2.1 to 2.3 mm, the total displacement integral - from 3112 to 3375 μV * min. Cardiointervalography revealed a significant increase in K _a to 0.9 and E _x to 3.5. The patient was hospitalized in the Department of IHD RAMS and Transplantology. An operation of coronary artery bypass grafting was performed, and medication was prescribed. 4 months after surgical treatment, control cardiointervalography was performed, a symmetric sympatotonic type of histogram was recorded (Fig. 5), there was a clear dynamics of a sharp decrease in K _a to 1.3 and E _x to 1.6.

Claims (1)

A method for evaluating the effectiveness of treatment in patients with painless myocardial ischemia with various types of autonomic provision, characterized in that they perform cardiointervalography with histographic analysis, calculate the asymmetry coefficient and kurtosis before and three months after treatment, and if the asymmetry coefficient and kurtosis are decreased, the treatment is evaluated as effective, and in if the indicators of the coefficient of asymmetry and excess after treatment have not changed or increased, treatment is assessed as ineffective and these patients are defined as Oujda to conduct cardiac surgery treatment.

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