CC BY
23
Karimov Ulugbek Begalievich, Mamasaliev Nematzhon Solievich, Erlich Aleksey Dmitrievich, Andijan State Medical Institute and Republic Scientific Center of Emergency Medicine of the Ministry of Healthcare of the Republic of Uzbekistan E-mail: ulugbek-karimov1973@mail.ru
Clinical population evaluation of the modern course of acute coronary syndrome in the indigenous inhabitants of the Fergana valley in Uzbekistan
Abstract: A two year register of ACS in 658 patients was drawn in the conditions of the Fergana valley in Uzbekistan. It was proved that the register helps objectively view the problems of the approach to treatment and «saving» prevention of the patients with acute coronary syndrome (ACS) and find solutions for them. In the conditions of the research region, they are acceptable, cost-effective and efficient in optimization of methods of early detection and treatment of ACS.
Keywords: acute coronary syndrome, register, the Fergana valley.
As it is known, the differences between the national and foreign researches also cover etiology of acute coronary syndromes (ACS) and occurrence of different variants of their course [1; 2; 3]. In this respect, the study of a clinical course of ACS with a verification of the diagnosis based on standardized evaluation of clinical symptoms, ECG and EchoCG in the conditions of the Fergana valley in Uzbekistan is relevant.
Materials and methods
A two year register of ACS in 658 patients, males (414) and females (198), aged 26 to 88, was drawn. Information about the cases of factual and suspicious for acute myocardial infarction (AMI) was collected for analysis from medical documents of emergency medicine, polyclinics, cardio-health center and in-patient facilities of Andijan in the Fergana valley. Each patient with a suspicion for ACS was drawn a special record of primary registration that included all available information about the patient (questionnaire, physical examination, out-patient card information, history of disease).
In the event of a patient's death, the questioning was conducted; protocols of anatomic-pathological researches and acts of medical
legal autopsy were analyzed. All registered cases, except for lethal ones, were controlled in 6 and 12 months from the onset of the disease. ACS diagnosis was established as «definite» and «possible» with the use of standard criteria ofACC/AHA (2002) and VNOK, all-Russia scientific society of cardiologists (2007) (clinical picture of the disease, changed in ECG, increase of the levels of myocardial necrosis markers and information obtained with the help of visualization methods), and, in the event of death, the data of morphological changes in myocardium and coronary vessels was used.
Statistical processing ofthe data was conducted with the use of STATISTICA 6.0 program and Microsoft Excel 2003. Comparison of discreet values was conducted with the use of criterion x2 with Yates' correction for continuity. If the number of cases in one of the compared groups was 5, Fisher two-tailed criterion (F-criterion) was applied.
Results and their discussion
Results dedicated to the analysis of frequency of associated clinical conditions according to the anamnestic data in patients with ACS are generalized in Table 1.
Table 1. - Frequency of associated clinical conditions in patients with ACS
Associated clinical conditions according to the anamnesis data Total number ofACS patients (n = 612)
Number of co-occurring clinical conditions (abstract number) %
Angina (1) 444 72.5
Myocardial infarction (2) 168 27.4
Chronic cardiac failure (3) 106 17.3
Chronic kidney disease (4) 118 19.3
Atrial fibrillation (5) 23 3.8
Statistics of differentiation according to t-criterion (P) < 0.05 2-3, 2-4
< 0.01 1-2
< 0.001 1-3, 1-4, 1-5, 2-5, 4-5
It was noted (Tab. 1) that ACS is comparatively frequently developed and clinically manifested, according to anamnesis data, against the background of angina (in 72.5 % of cases, P < 0.001), MI — in 27.4 % of cases (P < 0.05), chronic cardiac failure — in 17.3 % of cases (P < 0.05) and atrial fibrillation — in 3.8 % of cases (P < 0.05).
There are relatively more patients with angina in the anamnesis (P < 0.001) and chronic kidney disease (P < 0.05) in the studied group of patients in Andijan compared to the patients from European registers [4; 5]. Tachycardia was rarely noted. Also, it should be
specified that among the patients included in our register, the average age was 58.2 ± 11.3, and minimal and maximal age was 26 and 88 years old respectively.
If we compare the data of ACS patients with the same from other countries and Russia, the age in the studied group will be by 4-8 years less at average [6].
The main clinical data obtained in ACS patients at the moment of admission to the hospital, according to the register, is presented in Table 2.
Clinical population evaluation of the modern course of acute coronary syndrome in the indigenous inhabitants.
Table 2. - The main clinical data obtained in ACS patients at the moment of admission to the hospital
Complaints n ( %) Clinical data n ( %)
Chest pain 570 (93.1) Median time from the onset of symptoms to admission — 2.25 hours 612 (100)
Shortness of breath 42 (6.9) Hospitalization by emergency medicine service 385 (62.9)
Asphyxia 47 (7.7) Hospitalization without medical order 220 (35.9)
Heart beating 461 (75.3) Admission by way of transfer 7 (1.1)
Intermission 23 (3.8) Admission to cardio ICU 180 (29.4)
Weakness, general anxiety, cough 118 (19.3) Hospitalization to a regular department 432 (70.6)
As it can be seen from Table 2, the main symptom that allowed the suspicion for ACS in the research group ofpatients was chest pain (in 93.1 %) and heart beating (in 75.3 %). Other main complaints included shortness of breath (6.9 %), asphyxia (7.7 %), intermissions (3.8 %), general anxiety with cough and sudden weakness (19.3 %).
The data about the time of the onset ofACS symptoms is presented for 96.4 % of patients. Median time from the onset of symptoms to admission (hospitalization) was 2.25 hours (1st and 3rd quartile of distribution — 1.50-4.00 hours). There were no signs of cardiac failure (grade according to Killip = 1) in 565 patients (86.6 %) and there were signs of cardiac failure in 47 patients (7.7 %).
A relatively big number of patients are admitted with ACS diagnosis avoiding «Emergency aid» (35.9 %). This is apparently a
Table 3. - Comparative characteristics of ECG
peculiarity of healthcare and mentality of the population that has to be explained, because, traditionally, the ambulance brings not less than 90 % of ACS patients. Same is for the hospitalization of patients, not to the ICU or cardio ICU (70.6 %), but to a common ward.
ACS patients also had peculiarities in hemodynamic parameters at the time of admission. Thus, mean systolic BP was 140.9 ± 28.2 mm. Mercury (minimal SBP was 60 mm. Mercury and maximal DBP was 110 mm. Mercury). Mean diastolic BP at admission was 81.9 ± 14.7 mm. Mercury (minimum-maximum — 20-110 mm. Mercury) and mean heart rate was 92.5 beats/min (minimum-maximum — 58-170 beats/min).
Table 3 present ECG data of ACS patients at the time of admission.
data in ACS patients at the time of admission
№ Change of ECG at admission of the patients N Indicators of occurrence of ECG changes
Abs. %
1 Elevation of segment ST (1) 612 90 14.7
2 Depression of segment ST (2) 612 299 48.9
3 New pathologic wave Q(3) 612 82 13.4
4 New negative wave T (4) 612 600 98.0
5 «Front» localization of changes in ECG (in diversions V1- V3) (5) 612 228 37.3
6 Change of ECG in other diversions (6) 612 382 62.4
7 New complete left bundle branch block (7) 612 5 0.8
8 Signs of left ventricle hypertrophy (8) 612 234 38.2
Statistics of differences according to t-criterion (P) < 0.05 2-1, 5-3, 5-7
< 0.01 2-5, 4-6, 6-8
< 0.001 1-7, 2-3, 5-7, 4-1, 3-4
№ Indicators Value median 1st and 3rd quartiles of distribution Minimal value Maximal value
1 Creatinine 89.4 |xmol 88.4-113.9 |xmol 40 |xmol 230 |xmol
2 Glucose 5.2 mmol/l 4.7-6.0 mmol/l 3.3 mmol/l 9.6 mmol/l
3 Glucose, fasting 4.9 mmol/l 4.0-5.7 mmol/l 3.0 mmol/l 8.8 mmol/l
4 Total cholesterol 6.1 mmol/l 5.8-6.6 mmol/l 5.8 mmol/l 6.6 mmol/l
5 Leucocytes 6.1 thousand/ml 5.4-6.9 thousand/ml 3.3 thousand/ml 5.8 thousand/ml 120 g/l
6 Hemoglobin 98 g/l 93-108 g/l 76 g/l 32.7 %
7 Hematocrit 29.6 % 27.8-32.7 % 27.2 % 320.0 thousand/ml
8 Thrombocytes 260.0 thousand/ml 225.0-287.5 thousand/ml 180.0 thousand/ml 62 %
9 EchoCG data: • Leftventricular ejection fraction (EF); • EF < 40 % in 372 patients (60.8 %). 42.0 % 38.0-48.0 % 28 %
10 GRACE scale: • > 1 for ACS w/o elevation of ST and > 2 for ACS with elevation of ST — 53.9 %; • > 150 grades (patients with a high risk of death) — 9.8 %.
11 RECORD scale: • > 2 grades — 50.6 %; • > 3 grades — 13.4 %.
Table 4. - Comparative characteristics of data of clinical and biochemical blood tests and other methods of examination in ACS patients at the time of admission
As it can be seen in Table 3, new negative wave T (98.0 %), change of ECG in other (except for Vj-V3) diversions (62.4 %), depression of segment ST (48.9 %), signs of LVH (38.2 %) and «Front» localization of changes in ECG (in diversions Vj-V3) (37.3 %) were revealed most often in ECG ofACS patients at admission. Elevation of segment ST in ECG was established in 14.7 % of patients; new pathological waves Q— in 13.4 % and new complete left bundle branch block — in 0.5 %.
It should be noted that the share of ACS patients with elevations of ST is traditionally higher and forms around 1/3 of ACS patients. Our group had quite a lot of «young» and «light» patients with ACS without elevations of ST, perhaps, this is why they were treated in a common ward and not in an ICU.
Thereupon, data of clinical and biochemical blood tests and other methods of examination in ACS patients at the time of admission were analyzed (Table 4).
Table 4 shows that a mean value of different indicators (biochemical, clinical, echo-cardio graphic etc.) in ACS patients at the time of admission was: creatinine — 89.4 ^mol (min.-max. — 140230 ^mol), glucose — 5.2 mmol/l (min.-max. — 3.3-9.6 mmol/l), glucose in fasting — 4.9 mmol/l (min.-max. — 3.0-8.8 mmol/l), total cholesterol — 6.1 mmol/l (min.-max. — 5.8-6.6 mmol/l), leucocytes — 6.1 thousand/ml (min.-max. — 3.3-5.8 thousand/ml), hemoglobin — 9.8 g/l (min.-max. — 76-120 g/l), hematocrit — 29.6 % (mini.-max. — 27.2-32.7 %), thrombocytes — 42.0 % (min.-max. — 180.0-320.0 thousand/ml) and EF — 42.0 % (min.-max. — 28.0 and 62.0 %).
It should be noted that at the time of admission, 240 ACS patients (39.2 %) had left ventricular ejection fraction < 40 %. Ejection fraction > 40 % was revealed in 372 patients (60.8 %); P < 0.05.
During the analysis according to the values of prognostic scales, it was established that the share of patients with intermediate and high risk of death at hospital according to GRACE scale (> 1 for ACS w/o elevation of ST and > 2 for ACS with elevation of ST) is determined with frequency 53.9 %, and the share with a very high risk of death at hospital according to GRACE scale (> 150 grades) — 9.8 %.
According to RECORD scale, intermediate and high risk of death at hospital (> 2 grades) was noted in 50.6 % of patients, and a very high risk of death at hospital (> 3 grades) — in 13.4 % of patients (P < 0.001).
Conclusions
1. Most common clinical symptoms of ACS are chest pain (93.1 %), heart beating (75.3 %) and fatigue (19.3 %). Most ACS patients have decreased left ventricle ej ection fraction and decreased hemoglobin level and a high risk of death at hospital (50.6 %).
2. Among the deceased from ACS, there were significantly more patients aged > 65. Deceased patients often had MI in their anamnesis (100.0 %) and kidney failure (100.0 %); but they smoked less often, had angina and arterial hypertension. There were significantly more patients of high and very high risk (81.8 %) according to RECORD scale. Those deceased at hospital were given aspirin more often (100.0 %), ACE inhibitors (100,0 %) and AC (100.0 %); thrombolytic therapy and beta blockers were not used (0.0 %).
3. Registers and conduct of registration programs similar to RECORD register helps objectively view the problems ofthe approach to treatment and « saving» prevention of the patients with acute coronary syndrome (ACS) and find solutions for them. In the conditions of the research region, they are acceptable, cost-effective and efficient in optimization of methods of early detection and treatment ofACS.
References:
1. Evstifeeva S. E., Lupanov V. P., Samko A. N. Evaluation of clinical treatment, forecast and efficiency of drug treatment, heart bypass and percutaneous transluminal coronary angiography in patients with ischemic heart disease with constrictive coronary atherosclerosis (data from a 5 year prospective observation)//Cardiology. - 2006. - 6: 4-9.
2. Trostyanetskaya N. A., Bykova E. G., Tretyakova N. S., Boldueva S. A. Risk factors and peculiarities of the course of acute myocardial infarction in women depending on age//Cardio-vascular therapy and prevention. - 2008. - 7(6), Annex 1. - P. 371.
3. Canto J. G., Goldberg R. J., Hand M. M. Symptom presentation of women with acute coronary syndromes: myth vs reality//Arch Intern Med. - 2007, Dec 10. - 167(22): 2405-2413.
4. Asian Pacific Journal of Cancer Prevention. - 2009. - Vol. 10.
5. Boersma E., Pieper K. S., Steyerberg E. W. Predictors of outcome in patients with acute coronary syndromes without persistent ST-segment elevation. Results from an international trial of9461 patients. The PURSUIT Investigators//Circulation. - 2000. - 101: 2557-2567.
6. Erlich A. D., Graytsiansy N. A. et al. Characteristics of patients and treatment before the discharge from hospital//Atherothrombo-sis. - 2009. - № 1(2): 105-119.
Kasymova Gulmira Gafurovna, Scientific Research Institute of Hematology and Blood Transfusion
E-mail: evovision@bk.ru
Effect of combined pharmacotherapy lipid peroxidation and activity of enzymes antioxidant protection in rat livergepatoсancerogeneze
Аbstract: When hepatitis carcinogenesis marked imbalance in the system of lipid peroxidation and antioxidant enzyme system. Pharmacotherapy cytostatic leads to even greater intensification of lipid peroxidation. Thus activity of antioxidant defense enzymes even more oppressed. Roncoleukin results to some rebalancing of the system of lipid peroxidation and antioxidant enzyme systems. Which has a temporary nature. The combined use of doxorubicin and ronkolejkin some what reduces the marked of doxorubicin hyperlipidperoxidation and increases the activity of antioxidant enzymes.
Keywords: hepatocarcinogenez, system of lipid peroxidation and antioxidant enzyme systems.
