RU2326586C1 - Method of express diagnostics of ischemic heart disease - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: electrocardiographic monitoring is performed. At that patient is examined during 3-4 hours for ischemic variations against two maximal physical activities as walking up the stairs. The first activity is carried out against antianginal and anti-ischemic agent withdrawal. After that patient takes up prescribed medicines and 2-3 hours later the second activity is carried out. While physical activities are carried out duration of segment ST ischemic shift in minutes, depth of segment ST ischemic shift in mcv , total integral of segment ST shift in mcv/min, physical activity tolerance in Wt, max heart rate are detected and ischemic heart disease is diagnosed. Functional class of cardiac angina is detected by comparison of specified characteristics of the first and second physical activities.

EFFECT: reduced diagnostics time; more accurate diagnostics of IHD functional class for patients prescribed with Medical Social Expert Committee.

7 dwg, 3 tbl, 1 ex

Description

The invention relates to medicine, namely to cardiology and functional diagnostics, is intended for EXPRESS DIAGNOSTICS of the functional class of angina pectoris in patients with coronary heart disease: stable angina pectoris of functional class I-III, not suffering from rest angina pectoris and angina pectoris at night.

Due to the fact that CHD is one of the main reasons for the disability of the population in the last 2 years, after the introduction of the law on monetization of benefits No. 122 of the Federal Law of 08.22.04 “On Amendments ...”, the number of patients applying for a daily ECG sharply increased -monitoring for subsequent registration of a disability group, outpatient clinics have formed large queues for this study, which is not sufficiently reliable due to the lack of control over physical activity, which for MSEC should GSI amid mandatory medication.

From the practice of medicine, there is a known method for diagnosing ischemic conditions in patients with coronary heart disease according to patent No. 2170543 dated 2001.07.20, which consists in diagnosing the adaptive phenomenon of endogenous protection of the myocardium from ischemia using the method of daily monitoring of an electrocardiogram (ECG) in patients with coronary heart disease (CHD), having angina pectoris.

In this case, "episodes of ischemia" are recorded by the method of daily monitoring of ECG, which affect each other depending on the time interval between each other. Changes on the ECG, reaching diagnostically significant parameters and corresponding in time with angina attacks in the monitoring protocol, are referred to as an “ischemic episode”. We analyzed ischemic episodes following one after another, with a minimum time interval between the first and second episodes (no more than 60 minutes), recorded during the daily regimen, without additional provocation. Two main parameters of ischemia were evaluated - its duration in seconds and the integral of the ST segment displacement by more than 20% from the initial level. Based on this phenomenon, the authors diagnosed an ischemic background in patients.

Also known is a method for the diagnosis of coronary heart disease using Holter monitoring of the electrocardiogram according to patent No. 2279246 of 07/10/06. Bull. No. 19. The method is based on Holter monitoring of the electrocardiogram in combination with provocative effects against the background of exclusion of anti-ischemic and antianginal drugs, analysis of the patient’s sensations, heart rate, level and shape of the ST-segment of the electrocardiogram with the detection of signs of myocardial ischemia. A scoring of the patient’s sensations, changes in the ST-electrocardiogram segment during each provoking effect is performed for the first 5 minutes after it. At the same time, the above parameters are estimated from 0 to 2 points and for each provoking effect a comprehensive assessment of the signs of myocardial ischemia is calculated using a special formula and, based on the value of the maximum comprehensive assessment of the signs of myocardial ischemia, they conclude that the presence of coronary heart disease is likely.

However, the above methods have several disadvantages:

- a daily ECG is recommended against the background of the mandatory abolition of antianginal therapy,

- the procedure of daily ECG monitoring is very laborious for the cost of working time of medical workers;

- difficult for a patient who walks with a monitor of the device for a day;

- in an outpatient setting it is difficult to control all the physical activities performed by the subject;

- a point system for calculating sensations and changes on the ECG is problematic and difficult for a more accurate diagnosis;

- does not specify the diagnosis, but confirms the prerequisites for the development of the disease.

The closest prototype method is a method for diagnosing coronary heart disease using ECG monitoring during a stress test (D. D. Zotov, A. Grotova. Modern methods of functional diagnostics in cardiology. - St. Petersburg: "Foliant", 2002, p. 9-50).

However, this prototype has disadvantages:

- with age, patients lose physical activity and not everyone can perform stress tests in the idea of physical activity (for example, pedaling a bicycle or walking at a certain speed);

- many patients are contraindicated in carrying out exercise tests due to concomitant pathology (diseases of the joints of the legs, damage to the vessels of the lower extremities);

- in the majority of instructions for conducting stress tests there are age-related contraindications, mainly patients under 70 years of age.

Thus, the method cannot be used to diagnose coronary heart disease in untrained patients and patients who have contraindications for concomitant pathology in order to determine the functional class of angina pectoris.

The aim of the invention is a quick and reliable diagnosis of the disease, reducing the time of the study, increasing the number of patients who underwent research to clarify the diagnosis, using natural stresses, such as a stair test, as well as identifying signs of patient disability using a comparative analysis of ischemic changes in physical load on the background of withdrawal and administration of drugs.

The goal of the invention is achieved by the fact that the patient is tested for 3-4 hours with an analysis of ischemic changes against the background of two maximum physical activities in the form of climbing stairs: the first is against the background of withdrawal of antianginal and anti-ischemic drugs, after which the patient takes the prescribed medications to him as a doctor, and after 2-3 hours, repeated physical activity is performed, then, comparing the indicators during exercise: the duration of ischemic displacements of the ST segment in minutes, the depth of ischemic their ST segment displacements in μV, the total integral of the ST segment displacement in μV / min, exercise tolerance in W, maximum heart rate (max heart rate), ischemic heart disease is diagnosed, and the functional class of exertional angina is determined by comparing these indicators at the first and second loads.

In connection with the increase in the number of patients applying for daily ECG monitoring before registering a disability group in the Medical and Social Expert Commission (MSEC), it became necessary to find a way to diagnose coronary artery disease in less time, but with greater reliability of the study data. The Holter monitoring procedure, which is carried out in most cases of examining patients, is very time-consuming in terms of the time spent by medical workers and difficult for a patient who walks around the clock with a monitor. In an outpatient setting, it is difficult to control all the physical activities that the subject performs, and besides, to worsen the picture of the disease, the patient artificially causes a “drug withdrawal syndrome”, taking them off before the study. Thus, we see a worsened version of the study, which leads to overdiagnosis of IHD in the functional class and complicates the whole diagnosis. In addition, indicators of exercise tolerance worsen, patients on the background of a sudden withdrawal of drugs hardly perform normal physical exertion. Patients on the basis of a biased examination with worsened data, due to the removal of drugs and uncontrolled physical activity, require their provision at MSEC to obtain a disability group.

The proposed METHOD FOR EXPRESS DIAGNOSTICS OF ISCHEMIC HEART DISEASE, including ECG monitoring, is new and is not described in the literature.

The essence of the invention lies in the use of the METHOD FOR EXPRESS DIAGNOSTICS OF ISCHEMIC HEART DISEASE, includes ECG monitoring for 3-4 hours in order to quickly and accurately diagnose the functional class of IHD: Stable angina pectoris. The proposed EXPRESS DIAGNOSTICS is carried out within 3-4 hours using a portable wearable monitor, while the patient performs 2 physical activities in the form of climbing stairs until clinical or subjective changes (pain, shortness of breath, discomfort, etc.) occur accompanied by a nurse who records the start time of the climb, the number of steps completed and the time required to complete the load with a stopwatch, and the data is entered into the patient's diary, which determines the tolerance to physical activity in watts.

The choice of the method of dosed physical activity in the form of climbing stairs is associated with the availability, simplicity and relative reliability of the test, since bicycle ergometry and other functional tests are more aggressive research methods for the patient and are indicated for patients with no diseases of the musculoskeletal system, vascular system and not having contraindications by age criterion.

The first load is carried out against the background of the cancellation of antianginal and anti-ischemic therapy, after which the patient immediately takes the medicine, if the patient did not take the medicine, then after a preliminary examination according to the indications, a medicine (coronarolytic, B-blocker) is selected and given immediately after the load. After 2-3 hours, usually when the drugs begin to act, climbing the stairs, accompanied by a nurse, is repeated for the 2nd time. After 20-30 minutes, the sample stops. When conducting daily ECG monitoring in the express version, the time spent on the study is reduced. We can allow 3-4 patients to be examined on one wearable device in one working day and carry out an examination of the patient's ability to work with MSEC, and also allows us to analyze the effects of prescribed drugs or select drugs, evaluating their effectiveness in reducing time and depth of ischemia with computer processing. The results of the study are obtained, which are guaranteed to be carried out without medication and against the background of taking medications, which is mandatory for examination at MSEC and determining the disability group for the patient.

After the examination of the patient, the doctor using a computer program analyzes the ECG recording during the 1st and 2nd loads and compares them according to several parameters:

- the duration of ischemic displacements of the ST segment in minutes,

- the depth of ischemic displacements of the ST segment in μV,

- total integral of the ST segment offset in μV / min,

- exercise tolerance,

- max HR.

In 2006, 457 studies were conducted, of which:

1) daily ECG monitoring to detect ischemia during exercise and at rest - 276 people;

2) daily ECG monitoring to detect ischemia during exercise - 134 people;

3) rapid diagnosis of Holter ECG monitoring to detect ischemia under load - 47 people.

Within one month, 47 EXPRESS DIAGNOSTICS and 21 daily ECG monitoring were carried out on one wearable device (when working on one shift) (see the graph in figure 1).

Of the 47 people diagnosed with:

IHD: Stable angina. Functional class I - 3 people.

IHD: Stable angina. Functional class II - 29 people.

IHD: Stable angina pectoris Functional class III - 12 people.

The diagnosis of coronary heart disease in 3 people is doubtful (see table 1, 2).

Patients with rest angina pectoris, especially complaining of chest pains at night, were not included in express-diagnostic studies.

All patients with heart failure not higher than 2B F.K.

EXPRESS DIAGNOSTICS OF ISCHEMIC HEART DISEASE, including ECG monitoring was carried out on the Kardotehnika 4000 system (Russia) with registration of 3 modified ECG leads reflecting the potentials of the anterior-septal wall of the left ventricle (V4) and side wall (V, V5) .

The following indicators were determined:

- the duration of ischemic displacements of the ST segment in minutes,

- the depth of ischemic displacements of the ST segment in μV (100 μV = 1 mm),

- total integral of the ST segment offset in μV / min,

- max heart rate,

- exercise tolerance (W), which is automatically calculated by the computer, based on data entered by the doctor (start and end times for climbing stairs, number of steps taken).

Example:

Patient D., 65 years old, diagnosis with referral for examination: IHD: Stable angina pectoris III F.K. Aortic atherosclerosis, symptomatic hypertension, CHF-1.

The patient was examined by the METHOD OF EXPRESS DIAGNOSTICS OF ISCHEMIC HEART DISEASE, including ECG monitoring, and when the first load was performed against the background of drug withdrawal, ischemic changes and exercise tolerance of 95 W were revealed.

In a comparative analysis of ischemic changes in the 1st and 2nd loads, the patient's indicators improved significantly: the depth of ST decreased, exercise tolerance increased to 105 W (see table 3.).

11.20 - an episode of ischemic changes when climbing stairs to the 4th floor,

13.49 - an episode of ischemic changes when climbing the stairs to the 4th floor, while taking bisoprolol in a dose of 2.5 mg at 11.40, after 2 hours on the ECG extrasystoles disappeared during exercise, the depth of depression ST decreased.

Calculation of exercise tolerance showed an increase from 95 to 105, Max heart rate decreased from 134 to 113.

During the load on the ECG, it is clearly visible that the ventricular extrasystoles disappeared while taking the medications (see FIGS. 2 and 3).

In this example, it turned out that the patient satisfactorily tolerates physical activity while taking medications, and a comparative analysis of 1 and 2 loads determined the diagnosis of coronary artery disease: angina of exertion II F.K., which is not a disabling diagnosis. The patient was examined before being referred to MSEC.

Thus, the proposed method of EXPRESS DIAGNOSTICS of ISCHEMIC HEART DISEASE, including ECG monitoring, is economically advantageous in comparison with daily ECG monitoring, because reduces the time of examination of the patient from 24 hours to 3-4 hours, and also reduces the labor costs of medical personnel for the study, 3-4 patients can be examined in one working day instead of one. Also, this method allows you to analyze the adequacy of the treatment in a particular patient.

This method of EXPRESS DIAGNOSTICS of ISCHEMIC HEART DISEASE, including ECG monitoring, can be used for patients referred for examination before MSEC, as well as for all patients with coronary heart disease who do not have nocturnal attacks of angina and do not suffer from rest angina, i.e. . with a diagnosis of coronary heart disease: Stable angina pectoris F.K. (I-III), while the observations were carried out against the background of cancellation and after taking medications, which is reliable for conducting an examination of the patient's working ability.

The proposed METHOD FOR EXPRESS DIAGNOSTICS OF ISCHEMIC HEART DISEASE, including ECG monitoring, is convenient because it is much shorter than the daily study, allows up to 3-4 studies per day on one monitor, more physiological than other stress tests. It allows for more accurate diagnosis of the functional class of coronary heart disease in patients referred to the MSEC to determine the disability group, as the state of the cardiovascular system is analyzed against the background of cancellation of antianginal therapy and while taking drugs. The method is less time-consuming for medical workers conducting these studies, and is also not tedious for the patient.

In addition, this METHOD OF EXPRESS DIAGNOSTICS OF ISCHEMIC HEART DISEASE, including ECG monitoring, can be used to determine the effectiveness of drug treatment, to study the introduction into medical practice of new drugs and their doses to a specific patient.

Table 1
The analyzed indicators during the first physical activity Indicators during the first load №№ Duration Ischemic. Offset ST Seg (min) Depth ischemic. offset segment ST The total integral of the ST segment Tolerance to physical. load Max. Heart rate V4 V V5 one. four 320v 281c -93g 363 45 118 2. four 304c 281c -117g 296 36 110 3. 8 210v 140v -156g 794 43 106 four. 10 148c 117c -179n 1073 47 120 5. 9 265v 226v -109g 490 49 125 6. four 304c 226v -70g 316 38 98 7. 2 179g 281c -23g 194 75 130 8. 5 -70g -132g -195g 679 83 126 9. 9 -85 -148g -195g 949 65 112 10. 16 148c 125v -93g 1344 48 109 eleven. 8 156v 101c -54g 437 46 112 12. four 23g -101g -109g 91 82 132 13. 2 31c 39c -70g 139 104 135 fourteen. 9 218c 164c -16v 829 45 105 fifteen. 5 46 -117g -218g 415 76 120 16. four 62g -101g -132g 251 68 116 17. 6 -31g -93g -187 421 66 125 eighteen. 5 -15g -78g -156g 274 84 132 19. eighteen 39g -78g -179g 992 74 122 twenty. 9 31g -70g -109g 162 84 127 21. 5 46c 46c -62g 267 115 132 22. 9 -39v 23g -85g 795 105 140 23. 13 59g -120g -153g 1476 65 98 24. 6 110 -93g -76g 577 104 123 25. 2 -101g -109v -156g 245 105 134 26. 2 68g 137c 92g 91 110 140 27. 3 -34g 154g 50g 171 106 116 28. 2 43c 137c 76c 60 106 120 29. 2 25g 154g 42c 181 120 130 thirty. one 273c 242v 62g 58 64 98 31. 10 180g 102g -128g 640 26 74 32. 8 154g 120g -170g 1262 28 83 33. 8 188g 93g -144g 929 27 90 34. 10 -125g -140g -187g 2427 32 78 35. four 129g 86g 67g 298 55 106 36. 8 145g 137c 67g 637 78 124 37. 9 31g 39g -70g 961 62 110 38. 7 77g 43c -119g 300 52 115 39. 5 43g -68g 136g 207 62 120 40. 7 59g 34g -101g 168 62 118 41. 9 93g 43g -85g 540 72 126 42. eleven -25 -25g -144g 1140 95 130 43. 5 -31g -85g -156g 448 76 110 44. 21 179g 289g -46g 181 79 126 45. one -23 39 -7g 51 73 102 46. 8 -46 39 -46 834 90 140 47. one -39 -46 70g 73g 125 144

Table 2
The analyzed indicators during the second physical activity Indicators during the second load №№ Duration Ischemic. Offset ST Seg (min) Depth ischemic. ST segment offsets The total integral of the ST segment Exercise tolerance Heart rate max. Function class V4 V V5 one. 9 328v 312v -140g 1091 43 120 3 2. 7 406c 38c -101g 877 35 115 3 3 19 257c 203c -203g 2722 40 110 3 four. 12 179c 132c -125g 1101 45 122 3 5. 6 296v 242v -117g 656 fifty 130 3 6. 7 328v 226v -93g 610 37 102 3 7. 2 210g 289c -54g 136 72 135 2 8. 10 -132g -187g -296g 1476 78 130 2 9. 7 -140g -195g -273g 1604 59 115 2 10. 19 203c 195c -109g 3074 45 114 3 eleven. four 257c 265v -164g 425 42 120 3 12. 8 70g -109g -148n 441 79 135 2 13. 6 -101v -62g -128v 1189 97 140 2 fourteen. 7 296v 210v -125g 649 46 one hundred 2 fifteen. four 70g -62g -93n 271 79 112 2 16. 5 39g -93g -117g 131 72 110 2 17. 9 -15g -85g -156g 798 69 113 2 eighteen. 10 31g -70g -140g 323 84 110 2 19. 7 31g -85g -164g 377 75 112 2 twenty. 6 15g -39g -93g 171 75 120 2 21. one fifteen 31g -39g 56 118 130 2 22. 5 31g 31g -31g 167 115 120 2 23. 5 86 -59 -92g 540 72 90 2 24. 12 86g -68g -50g 755 107 113 2 25. one -39g -39g -78g 36 132 113 one 26. 2 43g 120g 67g 42 111 130 2 27. 3 -16v 120v 33c 118 108 110 2 28. four 16g 120g 50g 265 112 104 2 29. 2 7g 129c 33g 135 122 112 one thirty. 2 242g 242v 46g 47 66 90 2 31. 10 145g 59g -119g 849 thirty 70 3 32. 6 172v 68g -161g 694 32 75 3 33. fifteen 111g 59g -119g 1254 thirty 78 3 34. 8 -132g -101g -164g 1675 38 70 3 35. 8 120v 77c 33c 474 57 one hundred 2 36. four 120g 68g 50g 306 80 114 2 37. 6 39g 31c -54g 626 65 104 2 38. 6 50g 43g 110g 186 54 one hundred 2 39. 5 43 -16v -101g 118 66 110 2 40. 5 fifty 28g -101g 158 66 104 2 41. 6 50g 25c -85 223 75 114 2 42. four 86g 59g -85g 189 102 124 2 43. 5 -31g -101g -156g 457 77 108 2 44. one 187g 289c -46g 122 80 120 2 45. one -23v 39c -9g 53 73 one hundred with me 46. 8 -47v 39c -46v -836 91 105 with me 47. 10 -39v -46v 70g 735 125 143 with me

Claims (1)

A method for the rapid diagnosis of coronary heart disease, including ECG monitoring, characterized in that the patient is tested for 3-4 hours with an analysis of ischemic changes against the background of two maximum physical activities in the form of climbing stairs, while the first is carried out against the background of cancellation antianginal and anti-ischemic drugs, after which the patient takes the medications prescribed to him by the doctor, and after 2-3 hours they carry out a second physical activity, during the duration of the exercise, the duration and the ST segment displacements in minutes, the depth of the ST segment ischemic displacements in μV, the total integral of the ST segment displacement in μV / min, exercise tolerance in W, max HR and diagnose coronary heart disease, and the functional class of stress angina is determined by comparing the indicated indices for first and second loads.

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