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13medical sciences / «c®yl®qyiym-j®yrmal»#i9î7i),2©2©
Khasanjanova F.O., Tashkentenbaeva E.N., Khaydarova D.D., Muxiddinov A.I.,
Samarkand State Medical Institute Samarkand branch of RSCEMP, Samarkand, Uzbekistan
DOI: 10.24411/2520-6990-2020-12042 ESPECIALLY THE EFFECTS OF RISK FACTORS ON THE TREATMENT OUTCOME OF PATIENTS WITH ACUTE CORONARY SYNDROME WITH ST-SEGMENT ELEVATION IN MEN
AT A YOUNG AGE
Abstract.
The influence of risk factors on the outcome of the disease in patients with ACS with St elevation (STEMI) during thrombolytic streptokinase therapy was evaluated. A retrospective study of the medical histories ofpatients with STEMI for 2017-2019, who were urgently delivered by ambulance teams to the Samarkand branch of the Republican scientific center for emergency medical care (SF rncemp), in the Department of cardiac resuscitation for TLT with streptokinase 1.5 million IU. The examination and treatment included patients in whom the disease arose in the first 2-6 hours from the onset of anginal attacks, which did not stop, despite the ongoing antianginal therapy. Transient changes were recorded on the ECG: elevation of the ST segment, increase in the degree of T wave inversion, various rhythm and conduction disturbances.
Keywords: acute coronary syndrome, thrombolysis, streptokinasa young age
Relevance: The prevalence of cardiovascular diseases (CVD) in the world is increasing, and the total number of projected deaths from this class of diseases by 2020 will reach 20 million [5]. In Uzbekistan, over the past two decades, there has been an increase in morbidity and mortality from CVD, and the structure of mortality does not differ from the world [12]. Coronary heart disease (CHD) is the leading cause of death worldwide. Despite the fact that the prevalence of coronary heart disease continues to increase, in Europe there has been a decrease in the mortality rate associated with coronary heart disease in recent decades [9].
Recently, there has been a tendency in the world to increase the number of young patients with acute coronary syndrome (ACS), which is one of the variants of the course of coronary artery disease and this is an important socio-economic problem due to early disability and early mortality [13] . According to several foreign authors, the incidence of ACS among young people (under the age of 45 years) is 3-10% [9.14]. Stable angina pectoris in young people occurs in 0.4-1.6% of cases. In more than half of cases, the debut of the disease at a young age is acute myocardial infarction (AMI), in the vast majority of cases it develops in men (92-95% of cases).
As a rule, in young people, the occurrence of ACS is preceded by a short ischemic history. Foreign studies have shown that only 24% of young patients before the onset of a real coronary event sought medical help in connection with angina pectoris, and 69% of patients younger than 45 years had no chest pain. The duration of the angina clinic in most young patients was observed for several days, and signs of myocardial damage on the electrocardiogram (ECG) were detected immediately after a pain attack [10,15,16].
ACS is a clinical form of coronary heart disease in its critical phase in cases where stenosis of the coronary arteries becomes hemodynamically significant and is accompanied by a manifestation of anginal pain syndrome [1,2,9]. In most cases, the critical phase of coro-
nary heart disease is a consequence of the morphofunc-tional instability of the atherosclerotic plaque, causing occlusive thrombosis and coronary artery thromboembolism with the formation of necrosis of the corresponding myocardial vascularization pool [3,4,5]. Stratification of the degree of risk of complications in ACS allows you to determine the prognosis for the patient and prescribe the most rational treatment for him. In the management of such patients, the doctor must clearly understand the timeliness of the diagnostic and accurately determine the degree of risk for the application of the correct algorithm of action. The algorithm of action should include thrombolysis, angioplasty, or stenting of the coronary vessels in the presence of ST segment elevation [10,11,13]. Timely solution of this problem allows to reduce the volume of the affected myocardium, and, therefore, leads to improved prognosis and increased survival of patients [6,7,12]. The experience of using thrombolytic therapy (TLT) with ACS has been around for almost half a century. Thrombolytic drugs affect the fibrinolysis system through various mechanisms. So, streptokinase forms a complex with plasminogen, as a result of which its active site opens. This site facilitates the transition of other plas-minogen molecules to plasmin. This leads to the appearance of streptokinase-plasmin complexes, which is resistant to the neutralizing effect of a2-antiplasmin and causes a fibrinolytic effect. At the same time, the strep-tokinase-plasminogen complex activates to approximately the same degree both fibrin-related blood clots and free plasminogen molecules circulating in the blood [3,7,9]. In the absence of thrombolytic therapy, angioplasty and stenting of the coronary arteries, in the presence of an ACS clinic, treatment with aspirin, clopidogrel, heparin, p-blockers, nitrates should be started. The next step is to determine the degree of risk. At high risk, glycoprotein receptor blockers and coro-noventriculography are prescribed, according to the results of which one or another recanalization intervention is performed. Low risk requires re-determination of troponin, one of the main markers of necrosis. With
«C@yL@qyiym-J®yrMaL»#19î71),2©2© / MEDICAL SCIENCES
a positive result, treatment is carried out in the same way as patients with myocardial infarction, with a negative result, monitoring of patients in dynamics is necessary. Another relevant aspect of this pathology is the combination of various diseases in one patient. Poly-morbidity is typical for patients of older age groups, whose age exceeds 60 years [6,8,10].
To date, the most vulnerable group of patients who die before admission to hospitals are people under the age of 45, since this part of the population is the labor and intellectual potential of society. The main reasons for these phenomena are the low effectiveness of primary and secondary prevention of coronary heart disease, as well as the problems of diagnosis and treatment.
Objective: to assess the influence of risk factors on the outcome of the disease in men at a young age ACS with ST elevation (ACSST) during thrombolytic therapy with streptokinase.
Materials and methods: A retrospective study of the case histories of patients with ACSST for 20172019 was carried out, which were urgently delivered by ambulance teams to the Samarkand branch of the Republican Scientific Center for Emergency Medicine (SF RSCEM), to the cardiopulmonary resuscitation unit for streptokinase TLT 1, 5 million IU.
The examination and treatment included patients in whom the disease arose in the first 2-6 hours from the onset of anginal attacks, which did not stop, despite the ongoing antianginal therapy. Transient changes were recorded on the ECG: elevation of the ST segment, increase in the degree of T wave inversion, various rhythm and conduction disturbances.
Thrombolysis was carried out according to standard schemes, and then traditional methods of treatment were carried out for patients: nitroglycerin infusion on the first day of the disease, antiplatelet agents, an-tiplatelet and anticoagulant therapy, p-blockers, ACE inhibitors, statins. Enzymatic diagnostics: troponins I, MB fractions of creatine phosphokinase (MV-CPK).
Patients were divided into 2 groups: the 1st group of 76 patients receiving TLT - streptokinase 1.5 million IU, the 2nd group of 68 patients receiving traditional therapy. The mean age of patients was 37 ± 1 years. Quantitative data are presented in the form of the mean and standard error of the mean (M ± m), processing the results by nonparametric statistics, and Wilcoxon-Mann-Whitney criteria were applied. The differences were considered statistically significant at p<0.05.
Results and discussions: The 1-group included 76 patients, of whom men were. The 2nd group included 68 patients. In the 2nd group, an older age was noted than in the 1st group - 30.8 ± 0.5 and 35.6 ± 0.5, respectively.
All patients had two or more concomitant pathologies. Arterial hypertension was detected in 68% of patients, diabetes mellitus (DM) - in 22%, hypercholes-terolemia - in 75%. 73% of patients had a history of coronary heart disease (from 1 year to 15 years), 23% of patients had acute myocardial infarction (AMI), and 4% of patients underwent coronary artery bypass surgery. On the 1st day, 17.1% (13) patients had signs of
acute heart failure (AHF). The severity of the manifestations of AHF was distributed as follows: Killip I -7.8%, Killip II-3.9%, Killip m-3.9%, Killip IV-1.3%. In patients in group 1-2, chronic heart failure (CHF) according to the New York Heart Association (NYHA) II FC 83.4% and 88%, III FC - 16.6% and 12%, heart defects 12.3% and 16,6%.
Depending on the time of administration of throm-bolytic, patients of the 1st group were divided into 3 subgroups: I subgroup of 9 patients (12%), who received thrombolytic during the first 2 hours from the onset of an anginal attack; Subgroup II of 19 people (25%) - streptokinase was administered within 2 to 4 hours from the onset of the attack; Subgroup III 48 people (63%) thrombolytic administration was performed in the time range of 4-6 hours from the onset of the disease.
Among the deceased patients in both groups, the first place in the frequency of occurrence was made by hypertension (GB) and discirculatory encephalopathy, which was observed in patients.
DM increases the risk of ACS by 2-4 times, and more so in women than in men. With the use of various fibrinolytic drugs, mortality from AMI among patients with diabetes is reduced in the same way as among patients without diabetes [2,11]. The clinically verified diagnosis of diabetes in our study in groups 1 and 2 of 2 (2.6%) and 3 (4.4%) cases, p = 0.5, then hyperglycemia was detected in all deceased patients in groups 1-2.
Multiple epidemiological studies have shown that there is a clear correlation between the increase in plasma levels of total cholesterol (OXC), low-density lipoprotein cholesterol (LDL cholesterol) and the risk of developing atherosclerosis and coronary heart disease, whereas high-density lipoprotein cholesterol (HDL cholesterol) the correlation is negative, i.e. their increased level can be considered an anti-risk factor [1]. The risk of developing CHD associated with an increase in the level of cholesterol is more pronounced in young people (<55 in men, <65 in women) versus old, which is 2.5 times higher in young people than in older people [7]. In our study, hypercholesterolemia of 4.45 ± 0.19 and 4.88 ± 0.39, respectively, was observed in groups 1 and 2, respectively, p = 0.5.
Conclusions:
Thus, risk factors such as hypercholesterolemia, burdened CVD heredity are predictors that worsen the prognosis of the disease, regardless of the thrombolytic drug used.
In patients with ACSST in a combination of diabetes and hypertension of a young age, the condition worsens regardless of the thrombolytic therapy, which again indicates a high risk of developing cardiovascular complications in people of this group.
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