CC BY
17
Kurbanov R. D., Mullabaeva G. U., Irisov J. B.,
Republic Specialized Centre of Cardiology, Tashkent, Uzbekistan E-mail: [email protected]
THE INFLUENCE OF MYOCARDIAL REVASCULARIZATION ON THE VENTRICULAR ARRHYTHMIA IN PATIENTS WITH ISCHEMIC HEART DISEASE
Abstract:
Aim: The study the relations between of character ventricular arrhythmia (VA) with the degree of coronary lesions and the myocardial revascularization impact on the dynamics of VA. Material and methods: Out study included 47 patients (mean age 57.4 ± 8.5years) with CAD and ventricular potentially malignant arrhythmia II-IV class (Lown-Wolf), which according to the results of coronary angiography had recomended revascularization. All patients had a echography, Holter ECG, tredmil-test before revascularization and after 3 month. 30(63.8%) pts. were revascularized by coronary angioplasty, 14(29.8%) pts. by CABG surgery, 3 pts. (6.4%) were angiographically intact spacecraft. Results: in the analysis of the data showed that ventricular arrhythmias high grade significantly more frequently recorded in multivessel coronary lesions. Analysis was revealed a direct correlation between the degree of the weak force left main coronary artery stenosis and LAD frequency and VA IVa and IVb class (r = 0.397 and r = 0.495, respectively). After 3 months of therapy in the whole group there was a significant decrease in the number ofpatients with high grade VA (p < 0.05), and in group of patients after CABG decreased 4 times quantity of patients with VT (p = 0.005).
Conclusion: In patients with CAD incidence of high grade VA is in direct proportion to the degree of coronary artery lesion. Against the background of effective full myocardial revascularization was observed a decrease in detection rate of ventricular potentially malignant arrhythmia, and in some cases complete suppression.
Keywords: coronary heart disease, ventricular arrhythmias, myocardial revascularization.
More than 75% of patients cause ventricular arrhythmia (RA) is ischemic heart disease (IHD) [1]. According to some data [2; 3; 4], single ventricular extrasystoles (VES) are registered in patients with IHD in 90-99% of cases, primarily monomorphic, in 30% there are VES of high grades.
The problem of managing patients with VA, especially high grades, i.e. in patients with IHD, despite the advances in the development of new antiarrhythmic drugs (AAD), in surgical treatment of IHD, improvement of technical support of operations, surgery of arrhythmias and implantable devices, remains relevant [5; 6]. That is why our research was aimed at studying the most poorly studied aspects ofVA in patients with chronic IHD, namely, studying its relationship to the severity of the underlying disease. At present, the role of myocardial revascularization in the modification of the electrophysiologic substrate of arrhythmia of various genesis in patients with chronic forms of IHD has not been fully determined.
Purpose of the study. To study the frequency and character of VA in patients with IHD and the impact on it of revascularization of the myocardium.
Material and methods. The study included 47 patients with IHD and VA of high grades (grade 2 and higher by Lown-Wolf), aged 35 to 70 years (mean age 57.4 ± 8.5 years), of which 72.3% men and 27.7% women.
Criteria for excluding patients from the study: Stable angina IV functional class (FC); unstable angina, acute stage of myocardial infarction (MI) before operative intervention; left ventricle aneurysm (LV); congestive heart failure CHF IV FC (NYHA); LV ejection fraction (EF) < 35%; diabetes mellitus type 1 and 2; persistent and permanent form of atrial fibrillation; syndrome of weakness of the sinus node or dysfunction of the sinus node in the anamnesis; hemodynamically significant congenital and acquired heart defects.
All patients underwent a clinical examination, a 12-lead rest ECG, echocardiogram, coronaroangiography, 24-hour Holter monitoring (HM), cardiac angiography, treadmill test.
In accordance with the protocol of the study, planned visits were made before the revascularization of the myocardium, and then in 3 months.
In the analysis of the daily record, the total duration of daily myocardial ischemia, the maximum depth of the ST
THE INFLUENCE OF MYOCARDIAL REVASCULARIZATION ON THE VENTRICULAR ARRHYTHMIA IN PATIENTS WITH ISCHEMIC HEART DISEASE
segment decrease, the daily number of episodes of pain and painless ischemia, heart rate at the onset of ischemic episodes were calculated. In the analysis of VA, the morphology of the arrhythmia, the connection with the exercise and ischemic episodes were studied [8; 9].
The treadmill test was conducted using the Bruce protocol. The duration of each stage was 3 minutes. The ECG was recorded in 12 leads. During the entire sample, constant monitoring was monitored for the value of the maximum (among all 12 responses) displacement of the ST segment and the detectability and dynamics of VA [9].
When carrying out the loading test, the quantitative and morphological characteristics of the VA were compared at rest, against the background of the exercise and in the recovery period. The increase in VA with the appearance of new gradations during the sample, in the absence of preload, was the criterion for stopping the test even in the absence of ischemic changes in the ST segment.
All patients included in the study underwent coronary angiography (CAG) under the standard Judkins technique with transradial access [12]. Criterion for a hemodynami-cally significant lesion was a narrowing of the coronary vessel more than 75% in diameter, with lesion of the left coronary artery (LCA) - more than 50% in diameter. Stenosis of 20% in diameter and less than CA was regarded as "no signs of atherosclerotic lesion of the CA". The division of the CA into segments was carried out in accordance with the ACC/AHA Coronary Angiography Manual [13].
The statistical analysis of the data was carried out using the "Statistica 6.0" software packages. To compare the qualitative features, the percentage ratio, the exact Fisher test, was used. Differences were considered statistically significant at p < 0.05.
The results and discussion.
All patients registered a sinus rhythm with an average frequency of cardiac contraction (HR) in the daytime hours-72 ± ± 5.6, night hours-62 ± 6.2. According to the classification of B. Lown and M. Wolf(l97l), 27.6% had frequent VES (more than 30 per hour), polytope-23,4%, pair-27,6%, group and unstable VT- in 21.4% of patients.
With regard to the quantitative characteristics of arrhythmias, single VES were 2775.3 ± 485.7, paired VES-19.2 ± 5.9 and episodes VT-1.5 ± 0.2.
During the stress test, VA appeared and progressed in 32(68.1%) patients, the remaining 12(31.9%) increased in comparison with the baseline level. At the same time, 28(59.5%) patients had a clear association ofJA with the onset of depression of the ST segment and anginal syndrome. According to the CAG data, atherosclerotic lesion of the CA was detected in 93.6% of patients, later, revascularization of
the miocardium was performed and only 6.4% of the CA were angi. According to the CAG data, atherosclerotic lesion of the CA was detected in 93.6% of patients, later, revascularization of the miocardium was performed and only 6.4% of the CA were angiographically intact. The single-vessel lesion occurred in 25.5%, the two-vessel lesion was defined in 23.4% and the multivessel lesion occurred in 44.7% of the patients, including lesion of the left main trunk. Attention is drawn to the fact that, with the latter variant of the CA lesion, VA of high grades. With the help of the correlation analysis, a direct relationship between the degree of stenosis of the left coronary arteries and the number of paired and group VES (r = 0.397 and r = 0.495, respectively) was found, but in relation to other types of VA, the relationship with the coronary lesion was not found. The weak correlation was observed between the number of affected CA, the degree of affection of the lesions arteries and the degree of ischemic changes recorded during the stress test (ST depression, mm) - (r = 0.401 and r = 0.376, respectively). Taking into account the data of the anamnesis, the results of the objective methods of examination, the features and the atherosclerotic lesion of the CA 44 (78.7%), the patients were promptly operated. At the same time, from the group of operated patients, 30 patients underwent percutaneous intervention, and 14 - CABG. In the analysis of antiarrhythmic (AA) effectiveness of myocardial revascularization in a three-month period, regardless of the genesis ofVA and the type of surgical intervention, it was 84.2%. In the distribution of all patients from the viewpoint of the type of operation, it turned out that AA efficiency of myocardial revascularization in patients who underwent CABG was 89.1%, and percutaneous intervention -78.9%. Myocardial revascularization was effective (in the treatment of both myocardial ischemia and VA) in 80.8% of patients (with a CABG in 83.3%, percutaneous intervention in 80%). The remaining 19.2% of patients showed only anti-ischemic efficacy of the operation. In 40.8% of patients who did not achieve the effect on VA, myocardial revascularization was incomplete. When analyzing the results of 24-hour ECG after 3 months, a decrease in the number of patients with highgrade VA was revealed, and to a greater extent it was expressed among patients who underwent percutaneous revasculariza-tion. So, after percutaneous revascularization paired VES were found all in 8% (initially in 20% (p = 0.415)), and paroxysms ofVT-in 16% of patients (initially in 48%, p = 0.017). In addition, 15% of patients with VA were completely absent. In the group of patients after CABG there was a 4-fold decrease in the number of patients with VT (p = 0.005).
The conclusion. In patients with IHD, the frequency of occurrence of high-grade VA of high grades is in direct proportion to the degree of CA lesion. Against the background of effective full-scale myocardial revascularization, there was
a decrease in the detectability of life-threatening VA, and in reaches the effect after three months of observation. In this
some cases, its complete suppression.The antiarrhythmic ef- case, it does not depend on the type of surgical intervention,
ficacy of myocardial revascularization in patients with IHD the degree of completeness of myocardial revascularization
with high-grade VA is lower than anti-ischemic efficacy and of the VA types.
References:
1. Zipes D. P., Camm A.J. et al. ACC/AHA/ESC Practice guidelines ACC/AHA/ESC2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death // JACC. 2006.- V. 48.- No. 5.-P. e247-e346.
2. Yalovets A. A., Nikiforov B. S., Filippov V. Yu. The rhythm disturbance due to coronary disease // Arrhythmology annals. 2004.- No. 35.- 105 p.
3. Filippov V Yu., Nikitin A. E., Svistov A. S. Сравнительная характеристика аритмической активности больных ИБС до и после реваскуляризации миокарда // Вестник аритмологии. 2002.- No. 28.- С. 29-32.
4. Бойцов С. А., Кофаль Л. А., Фролов А. А. и др. Динамика нарушений сердечного ритма после хирургического лечения ИБС по данным суточного мониторирования ЭКГ // Вестник аритмологии. - No. 13. 1999.- С. 5-9.
5. Татаринова А. А. Диссертация на соискание ученой степени кандидата медицинских наук: Влияние реваскуляризации миокарда на желудочковые аритмии высоких градаций и показатели электрической нестабильности миокарда у больных ишемической болезнью сердца // 2011.
6. Myerburg R.J. Sudden Cardiac Death: Exploring the Limits of Our Knowledge // J. Cardiovasc. Elec trophysiol. 2001.-V. 12.- P. 369-381.
7. Lown В. Podrid P., Graboys T. B. et al. Consideration of current methods for drug selection in treating malignant ventricular arrhythmias // Amer. J. Cardiol. 1987.- V. 60.- P. 3F-9F.
8. Bigger J. T. Identification of patients at high risk 10. for sudden cardiac death // Am. J. Cardiol. 1984.- V. 54.- P. 3D-8D.
9. Аронов Д. М., Лупанов В. П. Функциональные про- 11. бы в кардиологии / - М.: МЕДпресс информ, 2007.
10. Judkins M. P. Selective coronary arteriography. A percutaneous transfemoral technique // Radiology. 1967.- V. 89.- No. 5. - P. 815-824.
11. Scanlon P.J. FCC/FYF Guidelines for coronary arteriography / P. J. Scanlon, D. P. Faxon, А/М/ Audet [et a\]H Ibid. 1999.- Vol. 33.- P. 1756-1823.
