RU2420228C2 - Method of predicting outcome of myocardium infarction in patients with diabetes mellitus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely, to cardiology and pathological anatomy. Severity of the state of a patient with myocardium infarction, which developed at the background of diabetes mellitus, is calculated by summing up the points by the map for predicting myocardium infarction outcome in patients with diabetes mellitus, if the sum is 58 points and higher, high probability of lethal outcome is predicted.

EFFECT: method makes it possible to estimate severity of patient's state with higher degree of objectivity, basing on the analysis of the most aspects of pathological process, which will facilitate the choice of optimal therapeutic tactics.

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Description

The invention relates to medicine, namely to cardiology and pathological anatomy.

Predicting the outcome of myocardial infarction (MI) is the most important task of medicine, because it is one of the most common causes of death and disability in a population.

The results of numerous studies show that mortality in the acute period of myocardial infarction reaches 40% (Kupriyanova A.V. Predicting outcomes of the hospital period and clinical and morphological parallels in acute myocardial infarction: abstract of dissertation, candidate of medical sciences. - Irkutsk, 2006. - 22 p .; Zyablov, Yu.I., Okrugin, S.A., Orlova, S.D., Occurrence, course, and immediate outcome of acute myocardial infarction in men and women. / Clinical Medicine. - 2001. - No. 11. - P.26- 28; Kudenchuk PJ, Maynard C., Martin JS et al. Comparsion of presentation, treatment, and outcome of acute myocardial infarction in men versus women. // Am. J. Cardiol. - 1996. - No. 1. - P.9 -fourteen; Vans AG, Opaleva-Stegantseva VA Lethal outcomes in acute myocardial infarction in men and women / Cardiology -.. 1988. - №4 -. S.5-9). The risk of developing MI in patients with diabetes mellitus (DM) increases by a factor of 2–3 (Kupriyanova A.V. Prediction of hospital outcomes and clinical and morphological parallels in acute myocardial infarction: abstract of dissertation of Candidate of Medical Sciences. - Irkuts, 2006. - 22 p.; Zyablov Yu.I., Okrugin S.A., Orlova S.D. Occurrence, course and immediate outcome of acute myocardial infarction in men and women./ Clinical medicine. - 2001. - No. 11. - S. 26-28; 2001; Rechkova E.V., Belova E.O. Myocardial infarction in women with diabetes mellitus / In the book: Organizational, diagnostic and therapeutic problems emergency conditions. - Moscow - Omsk. - 2000. - S.118-120).

According to the patent information search, the quantitative methods found to assess the severity of the condition of patients with advanced MI on the background of diabetes do not have a complete set of prognostic criteria for the outcome of this pathology.

The difficulty of risk stratification in this pathology is associated with a huge number of factors affecting its development, course, and outcome. In addition, the same factor / clinical sign has a different coefficient of significance for predicting the outcome at different periods after MI (Belsky N.Ye., Yurova T.A. Questions of predicting the outcome of myocardial infarction. / Clinical medicine. - 1983. - T. LXI. - No. 1. - 64-69).

The first attempts to predict the outcome of MI were made taking into account the clinical picture (Marx H., Paul N. In the book: Myocardial infarction. -M .: Medicine. - 1977.- P.142-152), then they began to use the data of laboratory and instrumental methods studies (Glezer M.G., Syrkin A.L. et al. Acute coronary syndrome without ST segment elevation: prognostic value of determining the level of troponin I and KFK-MV _mass . / Therapeutic archive. - 2002. - No. 9. - P. 26-30; Rechkova E.V., Belova E.O. Myocardial infarction in women with diabetes mellitus./In the book: Organizational, diagnostic and therapeutic problems of emergency conditions. - Moscow - Omsk. - 2000. - P.118-120; Telkova I.L., Teplyakov A.T. et al. Hyperinsulinemia and its contribution to the clinical course and outcomes of myocardial infarction. 5-year prospective observations / Therapeutic archive. - 2002. - No. 9. - P.20-25; Lupanov VP, Chotchaev Kh.Kh. et al. Clinical course of the disease and prognosis in patients with coronary heart disease with stable angina pectoris due to stenosing coronary atherosclerosis (data from a 20-year follow-up). Therapeutic archive. - 2002.- No. 9.- S.13-20.), The results of small invasive techniques, mathematical models appeared (Saygitov RT, Glezer MT. Prediction of posthospital mortality in men and women observed for acute coronary syndrome . / Russian Journal of Cardiology. - 2006. - No. 3. - P.41-48).

Most of the proposed algorithms use the data of additional, often expensive invasive methods, which are not always available in practical healthcare, or the obtained data need cumbersome mathematical analysis (A.V. Kupriyanova, Prediction of hospital outcomes and clinical and morphological parallels in acute myocardial infarction: abstract Dis. Candidate of Medical Sciences. - Irkuts, 2006. - 22 p.).

The technical result of the proposed method lies in the fact that the severity of the condition of a patient with MI, developed against the background of diabetes, is calculated by summing the scores on the map predicting the outcome of myocardial infarction, with a total of 58 points or more, a high probability of a fatal outcome is predicted.

Based on the developed system for predicting the outcome of myocardial infarction, the first stage included a quantitative assessment of the 25 most significant anamnestic, clinical and paraclinical signs presented in the patient examination scheme. The first group included a set of 7 anamnestic signs that took into account gender, age of patients, their ability to work, and the length of the prehospital period; seasonality, MI development option; the duration of diabetes. The second group was based on 16 clinical signs reflecting the nature of the pain syndrome, the degree of circulatory failure, the presence of angina pectoris, the level of blood pressure, the stage of hypertension (arterial hypertension), the localization of myocardial infarction, electrocardiographic signs of necrosis and rhythm disturbances, MI complications, pulmonary complications, data echocardiography and coronarography, severity and compensation of diabetes, the presence of visceral complications of diabetes, blood rheology. The third group - 2 signs formed on the results of pathological examination of the heart and is characterized by the severity of atherosclerotic (At) lesions of the coronary arteries. The use of morphological features in predicting the outcome of myocardial infarction is reliable during contrast coronary angiography and Doppler study of patients with myocardial infarction in the acute period of the disease.

At the second stage, attributes were scored, carried out on a 4-point scale, where the absence of a sign was evaluated at 1 point, a light degree of a sign - at 2 points, moderate - at 3 points, severe - 4 points.

The essence of the proposed method lies in the fact that patients are examined according to the presented scheme and scoring on the map.

Using a map for forecasting, based on a logical-probabilistic algorithm, an analysis of MI outcomes was performed against the background of diabetes in 362 patients (of which 85 cases of fatal outcome from MI), in which the total score varied from 40 to 71. The frequency distribution of occurrences revealed a reliable threshold level the amount of points at which the probability of a fatal outcome in case of myocardial infarction against the background of diabetes in the acute period of myocardial infarction was 58 points (p <0.001). The scheme of examination of patients is as follows:

1. Assessment of anemnestic data taking into account gender, age, working ability, seasonality, duration of the prehospital period, duration of the course of diabetes;

2. Examination of the patient with an assessment of: a) the nature of the pain syndrome; b) a variant of angina pectoris;

3. Blood pressure measurement;

4. Electrocardiography with the definition of: a) localization of MI; b) signs of myocardial necrosis; c) signs of rhythm disturbance; d) complications of myocardial infarction;

5. Determination of the functional state of cardiac activity using echocardiography;

6. Coronary angiography with an assessment of the prevalence, severity and complications of the atherosclerotic process in the coronary arteries;

7. Assessment of the respiratory system - chest x-ray, auscultation of the lungs;

8. Determination of glycemic profile (daily monitoring) - blood sugar; sugar, urine acetone;

9. Consultation with an ophthalmologist, assessment of renal symptoms of diabetic glomerulopathy;

10. Assessment of the rheological properties of blood - coagulogram.

Clinical examples.

Example 1. Patient M., 64 years old, a pensioner, September 18, 2008 was admitted to the cardiology department 10 hours after the onset of an attack of anginal pain. History: stable form of angina pectoris, stage III hypertension, diabetes for 5 years. On admission, the patient was in a serious condition - a clinic of cardiogenic shock, on ECG - an extensive anterior-septal "Q" myocardial infarction with rhythm disturbances like paraxysmal tachycardia, echocardiography revealed diastolic dysfunction of the left ventricle with hypertrophy, according to coronary angiography - subcritical stenosis of the anterior interventricular left ileum coronary artery. The radiograph determines the expressed congestion in the lungs. Blood sugar levels range from 9.3 mmol / L to 14.5 mmol / L. Examination of the fundus - pallor of the optic disc, sclerosis and increased tortuosity of the retinal vessels. According to the coagulogram, a significant increase in blood coagulation time, fibrinogen level, heparin tolerance is reduced. Intensive therapy included the use of narcotic analgesics, nitrates, beta-blockers, ACE inhibitors, antiplatelet agents and direct anticoagulants, diuretics.

Objective: to assess the likelihood of death. To calculate the severity of the condition, we use the forecasting map (Table 1), where gender is 3b, age is 3b, seasonality is 3b, work capacity is 2b, duration of diabetes is 3b, MI development option is 2b, the duration of the prehospital period is 2b, the nature of the pain syndrome - 2b, degree of circulatory failure - 2b, angina pectoris - 2b, blood pressure level - 3b, stage of hypertension - 4b, localization of MI - 4b, electrocardiographic signs of necrosis and rhythm disturbance - 3 and 2b, complications of MI - 4b, pulmonary complications - 2b, echocardio data raffia and koronaroantiografii - 2 and 3b, the degree of severity of diabetes - 3b compensation state DM - 4b, visceral diabetes complications - 2b, blood rheology - 3b, the state of the lumen of coronary arteries - 2b, complicated forms of atherosclerosis - 1b. When summing up, we get 66 points. High probability of death. Patient M., 64 years old, died on the 3rd day, in conditions of progressive heart failure.

Example 2. Patient G., 75 years old, a pensioner, September 12, 2008 was admitted to the cardiology department 5 hours after the onset of an attack of anginal pain. In the anamnesis: in 2006 she underwent a small focal anterior myocardial infarction, in the post-infarction period, angina II FC persisted. Has stage III hypertension. Upon admission, the condition is serious, according to the ECG, the dynamics of repeated large-focal anterior widespread myocardial infarction. Echocardiography revealed diastolic dysfunction of the left ventricle without signs of hypertrophy, the development of acute aneurysm of the anterior apical region of the left ventricle, according to coronarography - subcritical stenosis of the anterior interventricular artery. On the radiograph, a slight increase in the pulmonary pattern was determined. During hospitalization, type II diabetes mellitus was first detected. Blood sugar levels are from 7.14 to 14.8 mmol / L. Mild proteinuria, creatinine 167 mmol / l. The coagulogram revealed manifestations of mild hypercoagulation. The therapy included the use of narcotic analgesics, nitrates, beta-blockers, ACE inhibitors, antiplatelet agents and direct anticoagulants, and diuretics.

Objective: to assess the likelihood of death. To calculate the severity of the condition, we use the forecasting map (Table 1), where gender is 3b, age is 4b, working capacity is 2b, duration of diabetes is 1b, seasonality is 3b, duration of the prehospital period is 1b, and myocardial infarction is 2b, the nature of the pain syndrome - 1b, the degree of circulatory failure - 2b, the variant of angina pectoris - 2b, the level of blood pressure - 2b, the stage of hypertension - 4b, the localization of myocardial infarction - 3b, the electrocardiographic signs of necrosis - 3b, electrocardiographic recognition Ki of rhythm disturbances - 0b, complications of myocardial infarction - 2b, pulmonary complications - 1b, data of echocardiography and coronarography - 1b and 2b, severity of diabetes - 3b, compensation status for diabetes - 4b, visceral complications of diabetes - 3b, blood rheology - 2b, condition lumen of the coronary arteries - 2b, complicated forms of atherosclerosis - 1b. When summing, we get 54 points. The probability of a fatal outcome is low. Patient G., 75 years old, was discharged on the 15th day of myocardial infarction in satisfactory condition.

Table 1 Map for predicting MI outcome in patients with diabetes No. p / p Feature Group Prognostic sign Score score in points Points one. I. Floor 1 - male; 3 - female 2. Age 1 - 41-50; 2 - 51-60; 3 - 61-70; 4 - 71-80 3. Disability 1 - unemployed; 2 - senior citizen; 3 - working; 4 - disabled four. Duration of diabetes 1 - first identified; 2 - up to 2 years, 3 - up to 5 years, 4 - over 10 years 5. Seasonality 1 - winter; 2 - summer; 3 - autumn; 4 - spring 6. Duration will be hired. period 1 - up to 6 hours; 2 - up to 12 hours; 3 - up to 1 day., 4 - over 1 day. 7. MI development option 2 - acute; 3-repeat; 4 - recurrent 8. II. Nature of pain 1 - a typical pain syndrome; 2 - atypical pain syndrome; 3 - painless form; 4 - non-stopping pain syndrome 9. Chr. heart failure 1 - HI; 2 - HIIA; 3 - NIIB; 4 - HIII 10. Angina pectoris 1 - first appeared; 2 - stable .; 3 - progressive; 4 - post-infarction eleven. Blood pressure level 1 - above the norm; 2 - 1 stage of hypertension; 3 - 2 stage of hypertension; 4 - 3 stage of hypertension 12. Hypertonic disease 2 - stage I; 3 - stage II; 4 - III stage 13. IM localization 1 - side wall; 2 - back wall; 3 - anterolateral ;. 4 - anterior septal fourteen. ECG signs of necrosis 1 - ↑ ST / "-" T; 2 - not Q IM; 3 - QIM; 4 - QS IM fifteen. ECG signs of rhythm disturbance 1 - extrasystole; 2 - paroxysmal tachycardia 3 - A / V block; 4 - ventricular fibrillation 16. Complications of MI 1 - parietal thrombus; 2 - acute aneurysm; 3 - heart rupture; 4 - cardiogenic shock 17. Pulmonary complications 1 - small bubbling rales; 2 - er. congestion on Rg of the lungs; 3 - cardiac asthma; 4 - pulmonary edema eighteen. ECHOCG data 1 - diast. LV dysfunction without hypertrophy; 2 - diast. LV dysfunction with hypertrophy; 3 - systole. LV myocardial dysfunction (ejection fraction <45%) 19. Coronaroangiography 1 - minor damage to one coronary artery; 2 - single vascular damage; 3 - bivascular damage; 4 - three-vascular damage twenty. The severity of diabetes 2 - easy; 3 - medium; 4 - heavy 21. LED Compensation 2 - compensation; 3 - subcompensation; 4 - decompensation 22. Visceral complications of diabetes 2 - retinopathy; 3 - glomerulopathy 4 - cardiomyopathy 23. Blood rheology 1 - coagulation without features; 2 - mild hypercoagulation; 3 - severe hypercoagulation; 4 - DIC 24. III. The degree of stenosis of the coronary arteries 1 - moderate stenosis (up to 50%); 2 - subcritical (up to 75%); 3 - critical (more than 75%); 4 - occlusion 25. Complications of Atherosclerosis 1 - ulcerated At plaques; 2 - stratification of the wall of the coronary artery; 3 - calcification; 4 - thrombosis of the lumen of the coronary artery Total points

Claims (1)

A method for predicting the outcome of myocardial infarction (MI) in patients with diabetes mellitus (DM), including the selection of clinical and morphological signs and their four-point assessment, characterized in that the patient distinguishes the following prognostic signs: gender, age, working capacity, seasonality, duration of the prehospital period, the duration of diabetes, the nature of the pain syndrome, the degree of circulatory failure, the variant of angina pectoris, the level of blood pressure, the stage of hypertension, the localization of myocardial infarction, electrocardiographic signs of necrosis and rhythm disturbances, MI complications, pulmonary complications, data of echocardiography and coronary angiography, severity of diabetes, diabetes compensation status, visceral diabetes complications, blood rheology, coronary artery lumen condition, complicated forms of atherosclerosis, prognostic signs are evaluated according to the “Map” for predicting the outcome of myocardial infarction in patients with diabetes mellitus "contained in the description, the scores are summarized and with a total of 58 points and higher predict a high probability of a fatal outcome and IM.