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References:
1. Akbarov Z., Rakhimova G., Ismailov S. et all. Register-card of a patient with diabetes and its filling//Learner's guide. - Tashkent, 2006. - 29 p.
2. Akbarov Z., Ismailov S., Kayumova D., Alikhanova N. Frequency of vascular lesions in individuals with intermediate hyperglycemia and newly diagnosed diabetic patients//Biology and Medicine. - Issues 32-1. - P. 74-78.
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4. Balabolkin M.//Arhives of Therapy. - 1993. - No. 10. - P. 4-9.
5. Zhuk E. The experience of usage of all-European program Diabcare in patients with diabetes mellitus in the city of Novosibirsk//The problem of Endocrinology. - 1996. - No. 2. - P. 11-13.
6. Ikramova F., Rakhimova G., Sherov U. The prevalence of cardiovascular disease and diabetic microvascular complications in patients with type 2 diabetes according to the screening in Bukhara region//Biology and Medicine Issues. - 2008. - No. 2/1. - P. 86-88.
7. Ismailov S., Sultanov B., Khaydarova F. Risk factors for type 2 diabetes and IGT among urban residents of Uzbekistan//Biology and Medicine Issues. - 2007. - No. 1. - P. 88-92.
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9. Lisitsyn Y.//Physician. - 1994. - No. 5. - P. 2-4.
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11. Rahimdzhanova M., Akbarov Z., Ismailov S. and others. Some of data from register of diabetes in Andijan region//Biology and Medicine Issues. - 2008. - No. 2/1. - P. 91-94.
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13. WHO. Book of data. The result of evaluation of risk factors of non-infectious diseases with use of STEPS methodology. - Uzbekistan, Tashkent, 2015. - 71 p.
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Alikhanova Nadira Mirshavkatovna, PhD in Medicine, Academic Secretary of RSSPMC of Endocrinology MH of Uzbekistan E-mail: nodi200468@mail.ru
Ismailov Said Ibragimovich, MD (DMSc.), Professor, Director of RSSPMC of Endocrinology MH of Uzbekistan E-mail: endocrin@uzsci.net
Akbarov Z. S.,
MD (DMSc.), Professor, Head of Diabetology Laboratory
E-mail: zair.akbarov@mai.ru
Prevalence of coronary artery disease and miocardial infarction in patients with type 2 diabetes according to the register in Uzbekistan
Abstract: Clinical course of type 2 DM was analyzed based on 61 568 register-cards, taken from National Register of DM, Uzbekistan. 10 130, from the total number of patients, were found to have CAD and 949 MI. From the analysis of management of DM, macrovascular complication and causes of mortality it becomes clear that earlier mortality and disabilities resulted from poor compensation of diabetes. It was found that in the many cases the carried out management did not comply with commonly accepted standards of treatment.
Keywords: diabetes, CAD, MI, register, cards, decompensation, macroangiopathy, management.
Urgency. Angina belongs to a group of common diseases with high prevalence — about 20 thousand cases per million of population. The number of people with angina pectoris in Russia amounts to 2.8-5.6 million and the number of affected with it individuals keeps increasing worldwide due to the aging of population and the improvement of activities aimed at prevention of atherosclerosis. The burden of cost from the treatment of patients with stable CAD
worldwide is high (in EU spending amounts to about 45 billion Euros, which comprises 2.6 % of the total health budget). According to the Division of Epidemiology and Prevention of Republican Specialized Center of Cardiology, in Uzbekistan, the prevalence of CAD in Uzbekistan comprises 8-10.5 %.
It is known that in 40-60 % the cause of death in diabetes is MI, atherosclerosis of main vessels in diabetes develops 4-6 times
Prevalence of coronary artery disease and miocardial infarction in patients with type 2 diabetes according to the register in Uzbekistan
more often than in those without diabetes, DM increases the risk of MI and mortality among patients 2-4 times more often than in its absence [8; 9]. DM is an independent risk factor for CAD.
Epidemiological studies on the prevalence of CAD in patients with type 2 diabetes in Tashkent demonstrated an obvious correlation of CAD occurrence with the presence of macroangiopathy, age, type of diabetes, risk factors for cardiovascular disease, and duration of DM (Akbarov Z. S., Khaydarova F. A., Kayumova D., 1995, 2005). It was shown that CAD had a higher degree of occurrence in patients with diabetes, ranging from 42.1 to 82.5 %, and occurrence of MI, in the studied population, was found to be 16 times higher among individuals with type 2 diabetes than in those without diabetes and, in contrast to other forms of ischemic heart disease, there was clear relationship with the degree of compensation of carbohydrate metabolism.
Establishing a national register of type 2 diabetes in Uzbekistan, in view of the above, was obviously reasonable and essential effort in shedding light on the true state of issues, associated with diagnosing of type 2 diabetes and its macrovascular and microvascular complications and for estimating the quality of medical and preventive care in the regions.
Objective: to study the clinical and epidemiological aspects of diabetes and concomitant CAD according to the DM register in
Uzbekistan.
Materials and methods of study. Clinical course of DM was studied with aid of register-cards, elaborated by employees of the center with account taken of EASD recommendations and experience of other countries [1; 3; 4; 7]. Such analysis was carried out in all regions of Uzbekistan, except for the city of Tashkent.
Overall 61 568 register-cards of patients with type 2 diabetes were analyzed across all regions. 11 079 people among them were recorded to have macrovascular lesions in the form of CAD, MI, including 5 325 (8.6 %) men and 4 805 (7.8 %) women. MI was registered in 314 (0.5 %) men and 635 (1.0 %) women.
Results and discussion. Analysis of the prevalence of CAD in patients with type 2 diabetes by regions demonstrated that its highest rates were in Samarkand, Andijan, Tashkent and Kashkadarya regions and the lowest ones were in Jizzakh, Surkhandarya, Syrdarya, Khorezm and the Republic of Karakalpakstan. This causes a lot of reasonable questions and apparently is evidence of a low quality of diagnosing of this disease or lack of due awareness on the part of physicians to the problem of macroangiopathy. The situation was even worse regarding registration of MI across all the regions and according to the register, only some regions, including Tashkent, Namangan and Fergana had more adequate record keeping, and the Republic of Karakalpakstan, Kashkadarya, Khorezm regions had the lowest percentage of MI indicators, which intrinsically demonstrates a level of quality of the management of these patients. Cases of recurrent MI were only registered in 8 regions and such records were not maintained in Kashkadarya, Samarkand, Surkhandarya, Syrdarya and the Republic of Karakalpakstan.
Analysis of the prevalence of MI and CAD in patients with type 2 diabetes, in respect to age and gender showed that the gained data did not correspond to the data on MI and CAD prevalence provided in epidemiological studies of several authors [5; 6; 8], where the values were significantly higher. It is known from epidemiological studies that the prevalence of type 2 diabetes increases with age [6; 7; 9]. Similar, to some extent, pattern was confirmed by the results of the register. Thus, the prevalence of type 2 diabetes, according to the obtained results, reaches its maximum in individuals at age of 50-59, where the number of men in this group comprised 1 816 and women — 1982. Starting from 60 and further to 80 years
of age the ratio men to women shifts and prevalence becomes higher among men.
The highest prevalence rate of CAD in both men and women was in the age group of 50-59 years (6.2 % and in women higher than in men) and 60-69 years (5.1 %); concerning MI — the highest rates at 40-49 years of age and then the highest rates among women are twice as likely than men (66.9 % vs. 33.1 %).
Analysis of carbohydrate metabolism compensation in patients with type 2 diabetes according to the register shows the discrepancy between the figures of fasting plasma glucose and postprandial glycemia with glycated hemoglobin, which raises questions about the reliability of the results. The average values of fasting plasma glucose and postprandial blood glucose in patients with both MI and CHD indicate significant decompensation in patients that is associated with inadequate glycemic control, both by doctors and by patients, as well as, probably, due to inadequate provision of antidiabetic agents.
In compliance with current recommendations, compensation criteria for diabetes include blood lipid values, the level of which play essential role in the development of diabetic complications and especially of diabetic macroangiopathy [6; 8; 9]. According to the register, the rates of cholesterol and triglycerides of patients with type 2 diabetes with concomitant CAD were high, but at the same time, these values were not specified in all provinces, such in Kashkadarya region cholesterol and triglycerides in patients with CAD and MI were not determined at all. Unsystematic approach was seen also from other facts, such as detection of only blood cholesterol in some regions (Navoi, Namangan), absence of records on the lipids of patients with MI and CAD (Jizzakh, Surkhandarya and Khorezm).
Evaluation of the medical care provided to patients with CAD and MI, depending on the regions showed that in total across the Republic antihypertensive therapy is administered to 23 081 (37.5 %) patients, with a very low percentage in Kashkadarya, Khorezm and the Republic of Karakalpakstan, and absolutely absent records on antihypertensive therapy in Surkhandarya. Of no less importance is also the completeness of the records, which should specify the specific points of antihypertensive therapy, such as types of agents used for compensation of hypertension and how they affect hypertension. Hereby, although the region ofJizzakh contained records of antihypertensive therapy of567 patients, there was no information on the groups of drugs used for the management of hypertension. From generalized data available it could be concluded that ACE inhibitors were used in 19 800 cases (32.2 %), beta-blockers — in 6 324 (10.3 %), angiotensin receptor blockers — 2 484 (4.03 %), calcium channel blockers — 161 (0.3 %), diuretics — 5 634 people (9.2 %). Interestingly though, there were no records of combined treatment with different groups of antihypertensive drugs.
Lipid-lowering therapy was administered to 21 685 (35.2 %) patients with the predominant majority ofpatients — 18 466 (30 %) receiving niacin; fibrates were used in 2 380 (3.9 %) patients, and comparatively very few cases of use of statins — in 2 125 (3.5 %) patients. Of all patients with MI and CAD, antianginal drugs were receiving 4 057 individuals (6.6 %).
Thus, the analysis of register-cards showed that today, in the regions across the country the maintained records both on the registration of patients with type 2 diabetes and its macrovascular complications are inadequate.
Glycemic control in terms of fasting plasma glucose and postprandial glucose does not allow making an objective judgment about the level of compensation of carbohydrate metabolism due to the
fact, that the concept, in general, includes also normal blood lipids and optimal blood pressure levels. An assessment of quality of medical and preventive care for patients with diabetes who have concomitant CAD and MI, demonstrates that it does not meet commonly accepted standards [11; 12]: inadequately low percentage of prescribing first-line drugs for the management of these patients — ACE inhibitors, beta-blockers, statins, antiplatelet agents, not to mention about combination therapy.
Conclusions
61 568 register-cards of patients with type 2 diabetes were analyzed for assessment of prevalence of CAD in the given population and for assessment of medical and preventive measures provided to patients with CAD. 10 130 (16.5 %) of all patients were found to have CAD and 949 (1.5 %) ofthem had MI. In general, the number of men with CAD was 5 325 (52.6 %), which was higher than among women — 4 805 (47.4 %). However, concerning particularly MI, the number of women with MI was twice higher than that of men (66.9 % vs. 33.1 %).
Indicators of fasting plasma glucose and postprandial blood glucose in patients with CAD and MI did not range significantly between each other, remaining within high values: 8.5 ± 0.1 and 10.4 ± 0.2 mmol/l, respectively. HbAlc was a common value, registered in all regions, but they were inadmissibly high: 8.5 ± 0.2 %.
Concerning registration ofblood lipids, it can be said that this aspect was also defective, with some regions determining only one part of lipid spectrum and one region completely omitting registrations of lipids. Despite high levels of cholesterol and triglycerides, lipid-lowering therapy in 30 % of cases consisted only of nicotinic acid and statins were administered with unreasonably low frequency — 3.5 %.
Analysis of prescriptions for patients with type 2 diabetes in the presence of CAD and MI showed that drugs of first choice were not used frequently enough: ACE inhibitors — 32.2 %, beta-blockers — 10.3 %, diuretics — 9.2 %. There were no records on usage of antiplatelet agents. Unsatisfactory situation was also with administration of combination therapy with different groups of drugs, which can be concluded from absence of any records about such.
References:
1. Akbarov Z., Rakhimova G., Ismailov S. et al. Register-card of a patient with diabetes and its filling//Learner's guide. - Tashkent, 2006. - 29 p.
2. State Register of patients with diabetes, software "Diabetes Register 2008". - Moscow, 2008.
3. Zhuk E. The experience of usage of all-European program Diabcare in patients with diabetes mellitus in the city of Novosibirsk//The problem of Endocrinology. - 1996. - No. 2. - P. 11-13.
4. Ikramova F., Rakhimova G., Sherov U. The prevalence of cardiovascular disease and diabetic microvascular complications in patients with type 2 diabetes according to the screening in Bukhara region//Biology and Medicine Issues. - 2008. - No. 2/1. - P. 86-88.
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Asatova Munira Miryusupovna, MD, Professor, Head of the Department of Obstetrics, Gynecology and Perinatal Medicine of the Tashkent Institute of Postgraduate Medical Education Khegay Olga Aleksandrovna, a senior fellow of the department E-mail: ohegay899@gmail.com Jalalov Uktam Jalilovich, candidate of the department
Estimation of efficiency two protocols of correction of autoimmune thyroiditis in patients with reproductive dysfunction
Abstract: There were held a prospective, parallel-group study of 80 patients at different stages of autoimmune thyroiditis (AIT), before and after the correction of levothyroxine, and the combination levothyroxine with thiamazolum. It is shown that at AIT along with thyroid disbalance, elevated antithyroid antibodies observed elevated levels of proinflammatory cytokines. Correction of AIT combination with levothyroxine thiamazolum led to a significant reduction in levels of pro-inflammatory cytokines, titers of antithyroid antibodies, thyroid imbalance and restoration.
Keywords: autoimmune thyroiditis, antithyroid antibodies, cytokines, infertility, miscarriage.
