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55Khasanjanova F.O., Tashkenbaeva E.N., Muinova K.K., Samadova N.A.
Department of Internal Medicine No. 2, Samarkand State Medical Institute, Republic of Uzbekistan
DOI: 10.24411/2520-6990-2020-12043 TRADITIONAL RISK FACTORS ASSOCIATED WITH THE DEVELOPMENT OF UNSTABLE
ANGINA PECTORIS IN YOUNG ADULTS
Abstract.
Coronary heart disease (CHD) is a chronic disease with a multifactorial etiology. With the development of unstable variants of angina pectoris (NVS), which is one of the variants of IHD at a young age (MV), there are factors that contribute to the early development and progression of coronary artery atherosclerosis. Currently, the influence of risk factors (RF) on the development of NSAIDs in CF has not been adequately studied. Among the FRs of the early development of NVS, traditional and additional ones are distinguished. The traditional RFs for the development of NVS include: gender, age, smoking and second-hand smoke, a genetic predisposition, arterial hypertension (AH), diabetes mellitus (DM), burdened heredity, dyslipidemia, obesity, lack of exercise, depression.
Key words: unstable variants of angina pectoris, risk factors, young adults, gender, age, hypertension, diabetes, smoking, obesity etc.
Coronary heart disease (CHD) is one of the most important medical problems of the century. This heart disease is caused by a lack of oxygen supply to the heart due to a violation of blood supply due to damage to the coronary arteries. The widespread and great social significance of coronary heart disease necessitates the timely and most reliable diagnosis of this disease. Despite significant success in solving the prognosis, therapy and prevention of cardiovascular diseases, mortality and disability of people of working age from this pathology is growing. The solution to this problem largely depends on the effective and timely diagnosis of pathological changes in the heart muscle. The early detection of IHD, as well as its detection in patients with an asymptomatic course, is of great clinical importance, and the development of simple and affordable methods for the early diagnosis of coronary heart disease in the early stages is an urgent task [1].
CHD is a chronic disease with a multifactorial etiology. With the development of unstable variants of angina pectoris (NVS), which is one of the variants of coronary heart disease in young patients (MV), the lifestyle changes of young people in many countries, including unhealthy diet, physical inactivity, increased consumption of easily digestible carbohydrates, trans-genic fats, chronic stresses, make a big contribution. overfatigue, which is accompanied by the development of dyslipidemia, obesity, diabetes mellitus [7, 17, 27]. Young people often take extra and overtime work, they have a high general pace of life, they are prone to chronic stresses, which in some cases leads to smoking, drinking alcohol, energy drinks and overeating [29,58]. However, the screening of these factors does not reveal approximately half of the people in the population who subsequently develop the disease, which stimulates the search for other risk factors (RF) and their combinations [6.33].
At present, a large number of studies have been conducted to study external risk factors, while the epi-demiological characteristics of CVD are not well understood.
It has been established that patients with NVS in CF have factors contributing to the early development and progression of coronary artery atherosclerosis [7]. Patients in whom an NSA has manifested in MV differs from the elderly in the structure of RF, clinical manifestations and prognosis of the disease. Among the FRs of the early development of NVS, traditional and additional FRs are distinguished.
Conventional RF for the development of NVS: gender, age, genetic risk factors, active and passive smoking, arterial hypertension (AH), diabetes mellitus (DM), dyslipidemia, obesity, aggravated heredity (OH), depression.
Additional RFs for the development of NVS include oral contraceptives, hormonal therapy, childbirth, abortion, alcohol abuse, energy drinks, cocaine, psychological factors, social factors [14], occupation, organizational conditions and working hours [10], stress, low fruit and vegetable consumption [70], excessive physical activity, meteorological and seasonal factors, air pollution, urbanization, elevated lipoprotein (a), fibrinogen, blood D-dimer, factor V Leiden, hyperhomo-cysteinemia, rheumatoid arthritis, polymorbidity, Kawasaki disease in childhood, hyperteriosis, HIV infection with highly active antiretroviral therapy, periodontal disease, etc.
The study of traditional RF associated with the development of NVS in patients with CF is relevant for improving early diagnosis, development and implementation of preventive programs in this category of patients [10].
Age and gender.
In recent years, features of the development and course of coronary heart disease, in particular its acute forms, in various groups of patients, depending on gender, age and other signs, have been actively studied [34]. When conducting numerous studies, it was proved that the male sex acts as an independent RF for the development of NVS, especially in the age group up to 45 years [30, 32, 40.54, 58]. Analysis of mortality from AMI from 2012 to 2016 showed that mortality from
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acute myocardial infarction (AMI) in men exceeded the mortality rate in women in the general group by 1.4-1.5 times, in working age - 5.5-6. 2 times [12]. Among men, the risk of NSAID increases with each passing year. In women in the premenopausal period, the risk corresponds to the risk of men who are 10 years younger. The low incidence of women of this age is explained by the protective effect of estrogen circulating in the blood on the vascular endothelium [24]. Estrogens serve as important modulators of lipid metabolism, the state of the endothelium of the vascular wall and regulators of homeostasis [20]. Moreover, on the angiography of women of this age, most often, intact coronary vessels are detected.
Smoking.
The most common proven RF associated with the early development of NSA is smoking. It is smoking that is one of the most important modifiable RF among young patients with NSAIDs [13,14, 40,41]. It was reported that the prevalence of smoking in young people under the age of 45 years with IHD ranged from 60% to 90% compared with 24% to 56% in patients older than 45 years [10]. According to WHO, more than seven million people a year die as a result of its influence. It is also worth noting that smoking was common among young patients with NVS five times more than in patients of the same age hospitalized in the hospital with heartless complaints [40]. This RF is more common in CF patients and leads to the manifestation of the disease 10 years earlier than among non-smoking patients [28]. It becomes a peculiar way of life and is regarded as a painful addiction and illness. Most of the population of the Russian Federation is exposed to daily passive smoking [2], which, just as active, can lead to the development of atherosclerosis [51,53]. In the case of CVD, smoking has a negative effect on endothelial function, oxidative processes, platelet function, fibrinolysis, inflammation and vasomotor function, causing the development of atherosclerosis and increasing the risk of subsequent thrombotic complications. When smoking, LDL oxidation increases, HDL levels decrease, spontaneous platelet aggregation increases, and neutrophil function is impaired [46]. It is smoking that provokes RF of coronary plaque erosion, which is a particularly common mechanism of ACS [57]. The risk of developing NVS decreases after the patient quits smoking, and the beneficial effect of smoking cessation on the prognosis is correlated with the duration of smoking. The positive effects of smoking cessation in men and women do not differ, but mortality from CVD in nicotine-dependent women is higher than in men [48].
Arterial hypertension.
Arterial hypertension (AH) is one of the leading risk factors for NSAIDs. It is worth noting that in young patients it is difficult to assess the exact prevalence of hypertension, since the available data vary significantly by age classes, ethnicity, etc. It is shown that one young adult out of five suffers from hypertension [38]. According to a study conducted by N.T. Vatutin and E.V. Sklyannaya (2017), the prevalence of hypertension among people with CF is 14.2%, separately among men
there is a significantly higher prevalence of hypertension (22.2%) than among women (4.5%) [4]. In the USA, in the Natioanal Longitudinal Study of Adolescent Health to Adult Health, about 19% of the 14 thousand participants were hypertensive patients aged 2432 years [25]. The BPLTCT (Blood Pressure Lowering Treatment Trialists Collabration) study examined the effect of lowering blood pressure on CVD mortality. The study showed that a decrease in blood pressure (regardless of treatment regimen) is directly related to a decrease in mortality from CVD. You need to lower blood pressure at least 140/90 mm Hg. Art., and patients with type 2 diabetes - at least 130/80 mm. Hg. Art. [22].
Diabetes mellitus
Diabetes mellitus (DM) appears to be less common in young patients with NVS than in older patients. Patients suffering from type 2 diabetes have a risk of mortality from CVD 2-6 times higher than that of people who do not suffer from this pathology. Each percent increase in glycated hemoglobin increases the relative risk of CVD by 18%. It is diabetes that causes an increase in the incidence and mortality from CVD, and this occurs at an earlier age and at a higher rate than in the group of non-diabetic patients [23]. The increased risk of developing cardiovascular lesions in type 2 diabetes in 50% of cases is explained by the greater frequency and severity of traditional RF in patients with diabetes [5]. The progression of the atherosclerotic process occurs especially quickly in patients with type 2 diabetes, and myocardial damage as a result of AMI is more extensive than in patients without diabetes, and therefore a high incidence of AMI complications is associated [3,8].
Dyslipidemia. Multiple studies have shown that an increase in plasma of free cholesterol (cholesterol), low density lipoproteins (LDL) and very low density lipo-proteins (VLDL) is clearly associated with the development of atherosclerosis. A decrease in plasma concentrations of total cholesterol by 10% reduces the increase in the incidence of NSAIDs by 25% after 5 years. In the same way, a decrease in LDL by 1 mmol / L is accompanied by a decrease in CVD by 20%. A sufficient number of studies recorded a high prevalence of lipid abnormalities in young people with coronary artery disease compared with the older age group. According to a study by Khan and colleagues in Bangladesh, the incidence of hypercholesterolemia in young patients with NVS is similar to that in older patients, but lower average levels of high density lipoprotein (HDL) and higher triglycerides (TG) were observed among young patients with NVS) [7].
Overweight and / or obesity
Obesity is more common in patients with early development of NVS and is an independent predictor of the early development of coronary atherosclerosis in CF, which is shown in a number of studies. In the Fram-ingham study, it was shown that the contribution of obesity to the occurrence of NVS in people with CF can be up to 23% of cases in men and 15% in women. The association of obesity with the presence of atherosclerosis in CF was demonstrated in a study of autopsies of
3,000 people aged 15-34 years who died from non-car-diological causes. The presence of fat strips and atherosclerotic plaques in the right and anterior descending coronary arteries was assessed. The number of fat strips increased with increasing body mass index (BMI), but did not depend on the thickness of the subcutaneous fat. The number and extent of atherosclerotic plaques were also associated with overweight and obesity. [1].
Genetic predisposition.
The most important FR for the development and progression of atherosclerosis along with smoking, hypertension, dyslipidemia, and obesity is a genetic predisposition. Genealogical studies demonstrate not only the influence of hereditary mechanisms on the early development of atherosclerosis as such, but also on its primary localization [14]. Among a large number of studied genes (more than 2.5 thousand), 21 genes associated with the development of CVD were diagnosed [33]. If the relationship between environmental factors and NSA is well known, the significance of genetic markers is not fully understood [14].
Not so long ago, a group of so-called "new" RFs was identified, which primarily includes polymorphisms in genes. The determination of the structural polymorphisms of the genes underlying these disorders is one of the approaches to solving the problem of early diagnosis and prevention of coronary heart disease, as it allows the assessment of the individual genetic risk of developing the disease [48].
In order to search for specific mechanisms for the realization of an individual's genetic predisposition or resistance to the development of the atherosclerotic process in coronary vessels and the occurrence of acute coronary conditions in patients with coronary artery disease, the level of inflammatory and anti-inflammatory cytokines in association with phenotypic markers of predisposition to initiation of coronary artery disease has been analyzed [55].
The cytokine genes have an extremely high degree of polymorphism, and the number of sites of this polymorphism in one gene can reach several tens. In other words, the presence of allelic polymorphism in the promoter regions of the genes provides a diversity of individuals according to the degree of cytokine production during the formation of cellular reactions. Polymorphism of cytokine genes is an essential factor in predisposition to the development of the disease and its long, complicated course.
Gene interleukin 1 C (+3953) T. The interleukin (IL) 1B gene encodes the cytokine IL-1-beta of the IL-1 family, which is involved in the regulation of immune responses and inflammatory processes. IL-1 is one of the first open cytokines, a regulator of inflammation and immunity. It is synthesized by many body cells, primarily activated macrophages, keratinocytes, stimulated by B-lymphocytes and fibroblasts. IL-1 perform a number of functions in the immune system: initiate and regulate immune processes, participate in the development of acute and chronic inflammation. IL-1 is an inducible protein, the synthesis of which begins on tissue damage, and is necessary for the development of inflammation and the implementation of the whole com-
plex of protective reactions called acute phase response. The balance between production, expression and inhibition of the synthesis of cytokines of the IL-1 family plays an important role in the outcome of the inflammatory reaction [6].
The portion of the IL1B gene DNA sequence in which cytosine (C) is replaced by thymine (T) at position 3953 is designated as the genetic marker C (+3953) T.
From literature data it is known that individuals homo- or heterozygous for the highly producing allele IL-1 beta (C3953T) produce 4 and 2 times more cytokines, respectively, than individuals with the normal variant of the gene being studied. In patients with substitutions in the IL1B C (+3953) T gene, inflammation can occur more acutely, lead to serious complications and cause a chronic process. Thus, in carriers of such a change, the risk of severe forms of NSAIDs is higher compared to individuals with an unchanged genotype [31].
Interleukin 10 G1082A. It is known that IL-10 is an anti-inflammatory cytokine that has an inhibitory effect on T-helpers of the 1st clone, thus reducing the synthesis of pro-inflammatory cytokines [3]. In the case of a low level of IL-10, a high concentration of pro-inflammatory cytokines is maintained, which also leads to an unfavorable course and outcome of the disease. Thus, a decrease in IL-10 production in carriers of the allele A of the IL-10 gene polymorphism (G1082A) is an important link in the pathogenesis.
From the literature it is known that the main function of interleukin-10, realized by changing the immune response from Th1 to Th2, is manifested in the suppression of excessive synthesis and hyperactivation of pro-inflammatory cytokines and enzymes. It is likely that the immunosuppressive function of interleukin-10 on immunocompetent cells in patients with NSA leads to reduced production of pro-inflammatory cytokines (IL-1 and IL-6), providing a "benign" course of the disease. [31].
Burdened heredity (OH). Among young patients with NSA, people with OH are more likely to have it, which is 41-64% in patients with CF and 12-43% in older patients [1]. It is considered if there is a kinship between CVD in first-line relatives (myocardial infarction, stroke up to 55 years in men and up to 65 years in women, or sudden death of the mother up to 55 years or up to 45 years). OH is the most important RF for the development of CVD: a family history of early cardiovascular death is associated with an increased risk of CVD in people with CF [47]. OH as a proven RF of CVD development was demonstrated in large cohort studies of patients [18]. The data of many large prospective epidemiological studies indicate a statistically significant association of heredity, burdened by the early development of NSA in parents or siblings. So, in the Framingham study, confirmed CVD associated with atherosclerosis in one of the parents, sibling, was associated with a 2-fold increase in the risk of CVD, regardless of the presence of other traditional RFs. Premature death from coronary heart disease in the family is associated with an increased risk of death from ACS, including premature, in other
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family members [19]. However, the interpretation of the mechanisms determining the inheritance of CVD is far from complete.
Depression is widespread among CVD patients [42]. R.G. Oganov et al. [39], G.V. Pogosova [36] revealed the widespread prevalence of depression and anxiety in Russia and their negative impact on the development and outcome of coronary heart disease associated with an increase in the tone of the sympathetic nervous system, hemostatic disorders with a tendency to hypercoagulation of blood. G. Parker et al. we identified a group of patients in whom depression formed immediately after the development of ACS, and compared it with a group of people suffering from depression long before its development, as well as with patients in whom depression was noted immediately before hospitalization, and found that it was the depression that arose after this syndrome , was a predictor of the outcome of a cardiological disease. In the general population, in women, depression develops about 2 times more often than in men and is an important FR of NVS or cardiac death by about 50%. In addition, depression in women is a powerful predictor of early AMI, and the relationship of depression with the development of AMI and cardiac death is more pronounced for women of young and middle age than for their male peers. When studying the role of psychological disorders in CVD diseases on twins, common genetic factors were found that made a significant contribution to the development of depression and coronary heart disease [28]. However, it has not been proven that effective treatment for depression can improve patient survival rates [48].
Thus, the study of the main clinical characteristics with an assessment of the role of the most significant traditional risk factors will expand the understanding of the causes of development and the peculiarities of the course of NSAIDs in CF patients, which will contribute to improving early diagnosis, developing and implementing a set of preventive programs.
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