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ACUTE AND CHRONIC ISCHEMIC HEART DISEASE: ASSESMENT OF RENAL FUNCTION AND CLINICOANAMNESTIC DATA (PART OF RACSMI-UZ REGISTER
STUDY)
Nagaeva Gulnora Anvarovna
PhD, Researcher at the "Prevention of CVD" department JSC «Republican Specialized Center of Cardiology» Mamutov Refat Shukrievich Doctor of Medical Science, Professor Scientific Head of «Prevention of CVD» department JSC «Republican Specialized Center of Cardiology»
Moon Olga Ruslanovna Researcher at the "Prevention of CVD" department JSC «Republican Specialized Center of Cardiology» Aliyeva Zukhra Hamidovna Researcher at the "Prevention of CVD" department JSC «Republican Specialized Center of Cardiology»
ABSTRACT
Patients with acute ischemic heart disease characterized by a severe comorbid states, sometimes not cardiac; low compliance to drug therapy and low values of the lipid profile, which have an inverse correlation with glomerular filtration rate of the kidneys.
Keywords: acute and chronic ischemic heart disease, renal function, glomerular filtration rate, lipid profile of the blood, de Rytis coefficient.
Formulation of the problem. Acute coronary syndrome (ACS) and myocardial infarction (MI) constitute a significant part in the structure of causes of emergency hospital admissions of patients with cardiovascular diseases (CVD). [1] Despite advances in the treatment of these patients, the problem of reducing their hospital and distant mortality remains sufficiently serious [2]. Some authors indicate that in the acute period of myocardial infarction blood lipid levels significantly reduced. Therefore, in CHD observed significant changes in lipid metabolism of blood. From these positions, in the last decade, an important indicator in the diagnosis and prognosis of CVD is the total cholesterol and triglycerides level (TCS+ TG) [3,4].
Some studies have shown an association of dyslipidemia and mixed dyslipidemia with proteinuria, and decreased glomerular filtration rate (GFR) has been associated with increased levels of triglycerides and low-density lipoprotein and decreased high-density lipoprotein content [5]. Piecha G. et al. (2009) found that the hypertriglyceridemia observed in the early stages of chronic kidney disease [6].
Analysis of recent research and publications. Epidemiological studies reveal a high incidence of renal dysfunction in patients hospitalized with MI [7,8]. Coronary heart disease (CHD) [9,10] and increased risk of cardiovascular and total mortality more common among patients with chronic kidney disease (CKD) than in the general population [11-13]. It should be emphasized that the reduction of renal function
among patients with MI occurs more frequently than it is diagnosed. According to the results of large cohort studies, the presence of renal dysfunction affects the choice of physician treatment strategies: for these patients more rarely prescribed angiotensin converting enzyme inhibitors (ACEI), ^-blockers (BB), antiplatelet agents, statins and conducted thrombolysis [7.14]. Renal dysfunction, according to some authors, is associated with higher recurrence rate of myocardial ischemia, reinfarction, stroke, serious bleeding complications, acute heart failure, and others. Even low and moderate renal dysfunction is a significant independent predictor of mortality risk in patients with ACS, but the more pronounced renal dysfunction, the higher the risk of complications [15, 16].
Performing surgical or endovascular revascularization does not lead to a complete cure of patients, as it does not correct the underlying cause of IHD - coronary atherosclerosis, an indirect indicator of which is lipid profile. According to the European Register, the annual risk of cardiovascular death in patients after revascularization is an average of 3.7%, so in spite of conducted intervention, such patients are at high risk group and require further medical therapy [17,18].
Selection of the unsolved part of the problem. Insufficiently studied problem of the relationship of renal dysfunction and comorbid conditions, severity of MI and its complications; not clearly defined the role of renal dysfunction as a predictor of adverse outcomes in patients with MI. As a consequence - the existing guidelines on the patients with AMI / ACS management
Notes: p - significance of differences between groups; n - number of patients; SBP - systolic blood pressure; DBP - diastolic blood pressure; BMI - body mass index.
does not always taken into account the determination of renal function in prognosis of these patients [1,19].
The purpose of the article. In light of the foregoing the purpose of this study within the registry of acute coronary syndrome and acute myocardial infarction (RACSMI-Uz study) was: evaluation of renal function and clinical and anamnestic data in patients with ACS / AMI included in the register of ACS / AMI in the experimental district of Tashkent city.
Basic materials and methods. The study included 67 patients hospitalized in the appropriate health care facilities of pilot district of Tashkent city diagnosed with ACS / AMI, including men - 35 (52.2%) and women - 32 (47.8%). The average age of hospitalized respondents was 68,1±7,8 years.
Inclusion criteria - patients aged 18 to 70 years living in a pilot district of Tashkent city, hospitalized in the appropriate health care facilities with the diagnosis of ACS / AMI in the period from 01.01.15 to 01.10.15 y.
Exclusion criteria - patients younger than 18 and over 70 years old, with malignant neoplasms, acute cerebrovascular accident in the previous 3 months.
The structure of the diagnoses on admission to hospital was the following: AMI with Q -5 (7,5%); AMI without Q - 14 (20.9%); ACS with ST elevation - 6 (8.9%); ACS without ST-elevation - 12 (17.9%) and unstable angina(UA) - 30 (44.8%) cases.
All patients were conducted with the following investigations: anamnestic data collection, according to
the Register of ACS / AMI protocol; physical examination with calculation of body mass index (BMI). General clinical laboratory tests included determining of lipid profile (total cholesterol (TCS) and triglycerides (TG)); assessment of creatinine level with subsequent calculation of glomerular filtration rate (GFR) using the MDRD formula and staging of CKD; biochemical blood tests with a certain level of hepatic transaminases - alanine aminotransferase (ALT) and aspartate aminotransferase (AST) and coefficient de Rytis (the ratio of AST / ALT) calculating.
As the ongoing hospital treatment and condition stabilization the configuration of the diagnosis changed. Depending on this, the patients were divided into two groups: 1st g. - 32 patients who had at the discharge diagnosis of AMI with / without Q and 2nd g. - 35 patients who was recorded with II-III FC (functional class) of stable angina.
Statistical data processing was performed using the application package Statistica 6.0. The significance of differences was determined according to the Student t-test. To analyze the significance of differences between the quality indicators used criterion ^2. Assessment of the relationship of indicators determined by calculating the linear regression and correlation. Changes were considered reliable at p <0.05.
Both groups were comparable by age and height-weight parameters. BMI - as in the 1st and the 2nd groups was on average 29.2 and 29.1 kg / m2, but in the 2nd gr. the number of males appeared comparatively greater (Table 1).
Table 1.
General comparative characteristic of the patients
Feature 1st group Q-AMI; Non Q-AMI (n=32) 2nd group Stable angina II-III FC (n=35) P
Number of men, n (%) 14 (43,7%) 21 (60,0%) 0,278
Age, years 59,6±8,1 61,4±6,7 0,224
Average SBP, mm Hg 135,3±14,6 138,2±25,8 0,578
Average DBP, mm Hg 84,0±11,8 85,0±12,6 0,739
Average heart rate, beats / min 75,3±17,5 80,7±19,2 0,235
Weight, kg 83,0±14,1 82,1±14,1 0,795
Height, m 1,7±0,1 1,7±0,1 1,000
BMI, kg / m2 29,2±5,0 29,1±4,3 0,930
From anamnesis, it was found that in the 1st g. prevailed stroke, chronic renal failure, performed percutaneous coronary intervention (PCI) on coronary vessels of the heart and the presence of diabetes, while in 2nd g. prevailed data on the performed coronary artery bypass grafting (CABG) and presence of coronary stenosis > 50% (Table 2).
Our results have demonstrated that all patients were observed changes in renal function of varying severity, but in patients with AMI were not only a high incidence of kidney dysfunction, but also the presence of its more severe forms, that is consonant with the data of some researchers [20]. We have
identified renal dysfunction in patients with acute myocardial infarction associated with the prevalence in anamnesis of concomitant chronic renal failure, diabetes and performed PCI on coronary vessels of the heart, which is also consonant with literature data [21, 22].
According to anamnestic data, it has also been found that the most frequently used drugs were acetylsalicylic acid (50% and 68.6%, respectively, in the 1st and 2nd groups), and ^-blockers (62.5% and 60%, respectively). At the same time ACE inhibitors took about 1/3 of the patients both in the 1st and 2nd groups. Nitrates are used much less frequently, and
statins were taken only in the 2nd gr. The calculation of the average number of drugs per 1 patient showed significant benefit in patients of the 2nd gr. (Table 2). The comparison with the literature data, our results were several different. In particular, pharmacoepidemiological study in the Stavropol region indicated that antiplatelet group, including ASA was
used about 62.5% of patients, while BB and ACE inhibitors - 47.5%, and statins - 19% [23]. The comparative analysis of EUROPA & HOPE studies has been shown that antiplatelet agents are used in 76% and 92%, respectively; BAB - 39% and 62%, and statins - 29% and 58% of the cases [24].
Table 2.
Anamnestic data of examined groups of patients.
Feature 1st gr. Q-AMI; Non Q-AMI 2nd gr. Stable angina II-III FC P x2
n=32 100% n=35 100%
Postponed and associated pathological conditions
PICS 8 25,0 8 22,8 0,935 0,007
ACVA 2 6,2 1 2,8 0,937 0,006
CRF 10 31,2 6 17,1 0,286 1,136
PCI 9 28,1 5 14,3 0,275 1,190
CABG - - 4 11,4 0,145 2,120
Stenosis> 50% 6 18,7 10 28,6 0,512 0,429
DM 18 56,2 14 40,0 0,278 1,178
Groups of drugs used at the prehospital stage
ASA 16 50,0 24 68,6 0,194 1,687
BB 20 62,5 21 60,0 0,967 0,002
ACEI 12 37,5 8 22,9 0,298 1,084
ARA II - - 9 25,7 0,006 7,423
Statins - - 14 40,0 0,000 13,852
Nitrates 2 6,2 4 11,4 0,754 0,098
Ca2+ antagonists 2 6,2 11 31,4 0,022 5,262
Average number of drugs per 1 patient 1,6±1,3 2,7±1,9 0,008
Notes: PICS - postinfarction cardiosclerosis; ACVA - acute cerebrovascular accident; CRF- chronic renal failure; PCI -percutaneous intervention; CABG - coronary artery bypass grafting; DM - diabetes mellitus; ASA - acetylsalicylic acid; BB -beta-blockers; ACEI- angiotensin converting enzyme inhibitors; ARA II - angiotensin II receptor antagonists.
The evaluation of laboratory data showed that the patients of the 1st group, despite the acuteness of the disease (AMI with / without Q), have relatively low levels of total cholesterol and triglycerides, which confirms their total index (total cholesterol + TG), which was lower in 1,5 times than in the second group (Table 3).
The indicators of hepatic transaminases and their ratio characterized by the reverse trend. In particular, the level of ALT in the 1st group was 65,6 ± 21,3 U/L, which is by 1.7 times higher than in the 2nd group. De Rytis coefficient was also higher in patients with AMI than in patients with stable
angina. Aminotransferases play a central role in the proteins metabolism and relationship with carbohydrates metabolism. Selective tissue specialization makes their marker enzymes: ALT - for a liver, AST - for a myocardium. They refer to indicator enzymes, activity of which increases with tissue damage due to cell destruction and release of the enzyme into the circulating blood. The results obtained by us also showed that the patients with the acute form of IHD has occurred with the relative increase of the ALT and AST levels and a respectively increase in the coefficient de Rytis.
Table 3.
Laboratory and diagnostic criteria of compared groups of patients.
Feature 1st group Q-AMI; Non Q-AMI (n=32) 2nd group Stable angina II-III FC (n=35) P
Hb. g/l 115,3±29,4 126,2±14,1 0,054
Total CS, mg/dl 148,3±101,1 199,9±50,3 0,009
TG, mg/dl 163,4±111,1 283,2±237,5 0,011
CS+TG 291,3±207,4 455,6±267,0 0,007
ALT, U/L 65,6±21,3 39,0±21,1 0,000
AST, U/L 33,2±19,5 29,9±11,6 0,398
AST/ALT 1,55±1,08 0,92±0,45 0,002
Glucose, mmol/l 7,2±2,7 7,9±4,3 0,433
Creatinine, mkmol / l 198,7±39,9 116,2±46,3 0,000
GFR ml / min / 1,73m2 64,1±33,7 67,0±21,4 0,673
Avg. stage of CKD 2,3±1,2 2,3±0,7 1,000
1st stage of CKD, n (%) 8 (25,0%) 3 (8,6%) 0,128
2nd stage of CKD, n (%) 14 (43,7%) 22 (62,8%) 0,186
3rd stage of CKD, n (%) 4 (12,5%) 8 (22,9%) 0,432
4th stage of CKD, n (%) 4 (12,5%) 2 (5,7%) 0,587
5th stage or TKF, n (%) 2 (6,3%) - 0,434
Notes: Hb - haemoglobin; CS - cholesterol; TG - triglycerides; GFR - glomerular filtration rate by the MDRD formula; CKD - chronic kidney disease; TKF - terminal kidney failure.
The laboratory picture of renal function revealed that in the first group prevailed patients with CKD stages 1 and 2 (43.7% and 25%, respectively), while in the second group - with CKD stages 2 and 3 (62.8% and 22, 9%, respectively) despite the fact that GFR comparative analysis revealed no significant differences between the analyzed groups. However, terminal stage of CKD was the prerogative of the patients with AMI (Q /non- Q) (Table 3).
In-depth analysis of laboratory data found an inverse correlation between GFR and blood levels of triglycerides (p <0.05), while the ratio between GFR and de Rytis coefficient had a direct correlation, which has not reached the confidence level (Figure 1a, 1b).
Thus, our results indicate the presence of correlation of renal function with a blood lipid profile, and once again showed that the evaluation of serum creatinine in patients with ACS / AMI have to be supplemented by the calculation of GFR, the value of which can be regarded as an independent prognostic marker .
Conclusions.
1. Postponed in anamnesis myocardial infarction and percutaneous intervention, as well as the presence of
concomitant chronic renal failure and type 2 diabetes were the prerogative of individuals with acute IHD, while the patients with stable form of IHD was characterized by the presence of coronary stenosis > 50% and transferred aorto-coronary bypass grafting surgery.
2. Regardless of the severity of coronary artery disease, the most frequently used groups of outpatient drugs turned ^-blockers and acetylsalicylic acid, however, quantitative daily ration of medicines was higher in patients with stable form of CAD by more than 1.5 times.
3. Patients with AMI with / without Q have relatively low values of lipid profile and increased level of coefficient de Rytis. Despite the fact that the glomerular filtration rate was comparable in both groups of patients, however, terminal stage of kidney disease was the prerogative of the respondents with acute form of disease.
4. The analysis of correlation dependence established the presence of inverse correlation between glomerular filtration rate and blood triglyceride levels (p <0,05) in ischemic heart disease.
correlation coefficient r -0,3748
t -2,742
degrees of freedom 46
p 0,008675 0,008675
Figure 1A. The correlation between the level of blood triglycerides and GFR values (Notes: X-axis - the level of triglycerides,
Y-axis - GFR)
correlation coefficient r 0,07172
t 0,4004
degrees of freedom 31
p 0,6916 0,008675
Figure 1B. The correlation between de Rytis coefficient and GFR (Note: X-axis - de Rytis coefficient, Y-axis - GFR)
Summary
This article presents the first results of the "RACSMI-Uz'study, which is held at the moment in one of the districts of Tashkent city. Issues relating to drug therapy and invasive treatment in all stages of cardiological care (pre-hospital, hospital and post-hospital) and its chronological components, as well as evaluation of hospital and post-hospital mortality are in the process of analyzing, the results of which will optimize activities for the management patients with ACS / AMI at all stages of specialized cardiological care.
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КАЧЕСТВО ЖИЗНИ ЖЕНЩИН РЕПРОДУКТИВНОГО ВОЗРАСТА С СИНДРОМОМ
ХРОНИЧЕСКОЙ ТАЗОВОЙ БОЛИ
Ночвина Елена Анатольевна
Винницкий национальный медицинский университет им. Н.И. Пирогова,
Украина,
кандидат медицинских наук, ассистент кафедры акушерства и гинекологии №2
LIFE QUALITY IN WOMEN OF REPDUCTIVE AGE WITH CHRONIC PELVIC PAIN SYNDROME
Nochvina E.A. - Vinnitsa National Medical University named after N.I. Pirogov, department of Obstetrics and Gynecology № 2.
АННОТАЦИЯ
В статье представлены результаты оценки качества жизни женщин репродуктивного возраста с синдромом хронической тазовой боли как интегрального показателя состояния здоровья пациенток, позволяющего определить степень социально-психологических изменений, проследить их в динамике, а также оценить эффективность лечения.
ABSTRACT
The article presents the results of evaluation of the life quality in women of reproductive age with chronic pelvic pain syndrome as an integral indicator of the health of patients, whoch allows determine social and psychological changes, track their dynamics and to evaluate the effectiveness of treatment in a future.
Ключевые слова: синдром хронической тазовой боли, качество жизни
Key words: chronic pelvic pain syndrome, life quality in women
Постановка проблемы.
По данным ВОЗ, масштаб распространения болевого синдрома в экономически развитых странах мира вполне сопоставим с пандемией. Эпидемиологические исследования последних лет, проводимые в США, Англии, Франции, Норвегии и в других странах, свидетельствуют о том, что от боли страдает от 7 до 64% населения, при этом от хро-
нической боли - от 8 до 45% [4].
Более 60% женщин, ежегодно обращающихся за помощью к акушеру-гинекологу, жалуются на тазовые боли. По данным современной литературы около 39% женщин репродуктивного возраста страдают хроническими тазовыми болями. Тазовая боль служит показанием для 12% от всех гистерэктомий, проводимых в мире [4].
