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UDC 616.72-002.77:616.15-073
ASSESSMENT OF VEGETATIVE STATUS IN PATIENTS WITH RHEUMATOID ARTHRITIS BY LASER DOPPLER FLOWMETRY (NEW OPPORTUNITIES OF THE KNOWN METHOD)
Altai State Medical University, Barnaul Andrienko A.V., Lychev V.G., Bublikov D.S.
A new method for evaluating the vegetative regulation of the circulatory system with the help of laser Doppler flowmetry is proposed, with the subsequent calculation of the coefficient of vegetative regulation. The method is simple, convenient to use, acceptable for use in a wide range of patients (including diseases of the musculoskeletal system). With the help of the new method, autonomic dysfunction was revealed in patients with rheumatoid arthritis, consisting of a statistically significant increase in the arithmetic mean of the coefficient of vegetative regulation in comparison with the control group. This fact indicates a more widespread prevalence of sympathicotonia in the regulation of the circulatory system in this pathology.
Key words: rheumatoid arthritis, vegetative regulation, laser Doppler flowmetry, vagotonia, sympathicotonia, eutonia.
Rheumatoid arthritis is a chronic inflammatory autoimmune disease of the rheumatological profile with an unspecified etiology, characterized by the development of erosive arthritis as well as systemic (extraarticular) manifestations in the form of polyvisceropathies, vasculitis, amyloidosis, etc., which leads to disability of patients and a decrease in the duration of their life. Rheumatoid arthritis is one of the most common immunopathological diseases: its prevalence among the adult population is from 0.5 to 2%. The most vulnerable group is the young, able-bodied age group - 35-45 years old. Thus, the disease has tremendous medical and socio-economic importance.
A huge role in the formation of an unfavorable prognosis for patients is given to the development of cardiovascular complications of rheumatoid arthritis, which are a consequence of immuno-complex vasculitis, early and rapidly progressive atherosclerosis, as well as disorders of hemorhe-ology and microcirculation. A considerable number of studies have been devoted to the study of the above-mentioned violations [1, 2].
At the same time, an undeservedly small role in the risk of development and progression of vascular disorders in rheumatoid arthritis is given to autonomic dysfunction, which can be observed in this disease for a number of reasons: concomitant thyroid disorder, polyneuropathy, relative or absolute hypercatecholaminemia, etc. Meanwhile, there is a generally known fact of aggravation of the risk of cardiovascular accidents with the prevailing influence of the sympathetic department of the au-tonomic nervous system (sympathicotonia). Data on the functioning of the autonomic nervous system by rheumatoid arthritis are extremely scarce and, at times, contradictory: there are reports indicating an increase in the tone of both sympathetic and parasympathetic divisions; a number of au-
thors insist on the predominance of eutonia [3, 4]. In addition, one can not ignore the fact that patients are poorly tolerated by a number of methods of investigating the function of the autonomic nervous system: in the case of musculoskeletal injuries (for example, in patients with rheumatoid arthritis), carrying out functional tests with physical exertion can be difficult due to impaired joint function.
Research objective: to develop a simple, easy-to-use, non-invasive method for evaluating the vegetative regulation of the circulatory system, acceptable for use in a wide range of patients (including with the pathology of the musculoskeletal system); to reveal with its help vegetative dysfunction in patients with rheumatoid arthritis.
Materials and methods
The study included female patients diagnosed with rheumatoid arthritis (n = 75), in the advanced stage of the disease, seropositive for rheumatoid factor and antibodies to cyclic citrulline peptide, I-II degree of activity according to DAS-28-CRP, I-II radiographic stage. The mean age of the patients was 33.03 ± 1.23 years. The control group (n = 85) consisted of female patients with no history of anamnesis and objective examination of signs of musculoskeletal system diseases (mean age 33,14 ± 1,30 years). Exclusion criteria were: tumor diseases, pathology of cardiovascular, respiratory and endocrine systems, anemia, pregnancy).
The vegetative status was assessed using laser Doppler flowmetry on the LAKK-2 apparatus (Laz-ma, Russia) with the calculation of the coefficient of vegetative regulation [5]. In this case, the sensor was attached to the index finger (palm surface) and recorded fluctuations of microcirculation parameters with simultaneous counting of the number of cardiac contractions and subsequent calcu-
lation of the coefficient of vegetative regulation (CVR) according to the formula:
CVR = HR / (MT x 0.25) + PN, where: HR -the number of heartbeats; MT - myogenic tone of precapillary link; SI - the index of arterio-venous shunting.
For convenience in calculating the coefficient of vegetative regulation, the authors proposed a nomogram, shown in Figure 1.
The determination of the CVR is carried out in the following sequence:
- on the "Heart rate" axis, a point corresponding to the heart rate is determined;
- on the axis "(MT * 0.25) + SI" the point corresponding to the given value obtained on the apparatus of Doppler flowmetry is determined;
- calculated the magnitude of CVR, which is determined by the intersection of perpendiculars, derived from the two above-mentioned points.
Statistical processing was carried out using the MS Excel 2003 software package and the Statisti-ca 6.0 program. To check the normality of the distribution of quantitative indicators, the Shapiro-Wilk criterion was used. Due to the fact that the sample did not correspond to the normal distribution, the Mann-Whitney method was used (the critical significance level was assumed to be p <0.05).
Discussion
Evaluation of autonomic regulation is relevant in patients with rheumatoid arthritis, which is caused by an imbalance in the functioning of the sympathetic and parasympathetic parts of the nervous system and neurohumoral disorders. A rational approach to the onset of vasotropic therapy in each patient with this pathology should include a preliminary identification of the vegetative tone of the circulatory system, since most
The type of vegetative regulation was evaluated based on the numerical value of CVR: from pronounced vagotonia to pronounced sympathicoto-nia (Table 1).
Table 1
Results
In patients of the control group, there was registered a statistically significant (p = 0.004) decrease in the arithmetic mean of the vegetative regulation factor (19.28 ± 6.22) compared with the group of patients suffering from rheumatoid arthritis (22.44 ± 4.18). This fact indicates a more spread prevalence of sympathicotonia in the regulation of the circulatory system in this pathology. When conducting in-tra-group analysis, it was found that this difference is due to the quantitative predominance among patients with rheumatoid arthritis of the category of persons with pronounced and moderately expressed sympathicotonia (7% and 21%, respectively). However, the fact that the frequency of occurrence of the eutonic type of vegetative regulation does not have a statistically significant difference with the control group (p = 0.064) deserves attention. The distribution of vegetative tonus variants in both groups is presented in Table 2.
Table 2
of the so-called "vascular" drugs have a vegetotropic effect (for example, pentoxifylline causes a sympathicotonic effect, especially when administered intravenously in high doses). This is especially true for cases of the disease that occur with a variety of vascular complications (Raynaud's syndrome, vasculitis, etc.).
Moreover, assessment of the state of vegetative regulation is important in the management of patients with a comorbid background, in particular
CVR Type of autonomic regulation
24,50-35,77 Pronounced sympathicotonia
19,50-24,49 Slightly pronounced sympathicotonia
16,20-19,49 Eutonia
12,50-16,19 Light vagotonia
8,55-12,49 Pronounced vagotonia
Vegetative tonus Group 1 (n = 75), % Group 2 (n = 85), % P
Pronounced sympathicotonia 7 4 0,0052
Slightly pronounced sympathicotonia 21 12 0,0022
Eutonia 41 43 0,064
Light vagotonia 18 30 0,0045
Pronounced vagotonia 13 11 0,041
in the combination of rheumatoid arthritis with diseases of the circulatory system (arterial hypertension, ischemic heart disease, chronic heart failure). This is due to the fact that beta-adrenoblock-ers, dihydropyridines and other groups of cardiac drugs affect the sensitivity of adrenal receptors in the heart and vessels or cause the activation of the sympathetic part of the autonomic nervous system reflexively as a result of lowering blood pressure.
The existing methods for assessing the state of autonomic regulation of the circulatory system, used in research and clinical practice, have the main common drawback: the interpretation of the frequency and variability of sinus rhythm in patients is performed without taking into account the parameters of peripheral circulation. The drawbacks of these methods are also their labor intensity, the need to monitor the electrocardiogram.
The proposed method of determining the vegetative tone with the help of Laser Doppler flow-metry makes it possible to provide an estimation of vegetative regulation as an integrative value uniting different levels of vegetative regulation: central hemodynamics (HR) and the work of the so-called "peripheral heart", expressed by the parameters of flowmetry (myogenic tone of precapillary link, arterio-venous link shunting index).
Thus, the method will significantly expand the prospects of Doppler flowmetry, previously used in scientific and clinical studies solely for the purpose of studying microcirculation disorders [6].
Conclusion
The Laser Doppler flowmetry method can be used to study the autonomic regulation of the circulatory system in various diseases.
In patients with rheumatoid arthritis, there is a disturbance in the regulation of vegetative tonus, which is manifested by sympathicotonia.
References
1. Popkova T.V., Novikova D.S., Pisarev V.V. Risk factors for cardiovascular disease in rheumatoid arthritis. Scientific and practical rheumatology. 2009; 3: 4-11.
2. Nasonov E.L. The problem of atherothrom-bosis in rheumatology. Bulletin of the Russian Academy of Medical Sciences. 2003; 7: 6-10.
3. Яковлева Е.В., Зюзенков М.В. Психовегетативные соотношения при ревматоидном артрите. Медицинские новости. Yakovleva E.V., Zyuzenkov M.V. Psycho-vegetative relationships in rheumatoid arthritis. Medical News. 2001; 2: 4749.
4. Petrova E.V., Dmitrieva N.S., Myasoedova E.E. The changes of vascular elastisity and the particular features of neurovegetative regulation at re-umatoid artritis. Journal of New Medical Technologies. 2009; 16(2): 78-80.
5. Andriyenko A.V., Lychev V.G., Bublikov D.S. A method for evaluating the vegetative regulation of the circulatory system. The patent of Russia № 2526257, 2014; Bull. №23.
6. Krupatkina A.I., Sidorova V.V. edited Laser Doppler flowmetry of the microcirculation of blood: A guide for doctors. Moscow: Meditsina. 2005.
Contacts
Corresponding author: Andrienko Alexey Vladi-mirovich, Candidate of Medical Sciences, Associate Professor, Head of the Department of Hospital Therapy and Endocrinology of ASMU, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel.: (3852) 405657. E-mail: andrienkoa.a@yandex.ru
Lychev Valery Germanovich, Doctor of Medical Sciences, Professor of the Department of Hospital Therapy and Endocrinology of ASMU, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel.: (3852) 405657. E-mail: andrienkoa.a@yandex.ru
Bublikov Dmitry Sergeyevich, Candidate of Medical Sciences, Associate Professor of the Department of Polyclinic Therapy and Medical Rehabilitation with a course of further vocational education of ASMU, Barnaul. 656038, Barnaul, Lenina Prospekt, 40. Tel.: (3852) 405657. E-mail: bublikov.dim@yandex.ru
