Method of predicting development of critical stenosis of coronary arteries in patients with ischemic heart disease

FIELD: medicine.

SUBSTANCE: in the patient's blood serum the concentration of matrix metalloproteinase - 9 (MMP-9) and/or procollagen 1 C-terminal propeptide (PICP) is determined. If the value MMP-9 is larger than 101.8 ng/ml and/or PICP 195.6 ng/ml the unfavourable course of IHD is predicted, if lower than these values - the favourable course without the formation of critical stenoses in the coronary arteries.

EFFECT: increased accuracy and specificity of the method.

4 ex

 

The invention relates to medicine, in particular to therapy, cardiology, namely to the early diagnosis of development of critical stenosis in the coronary arteries of patients with coronary heart disease (CHD).

Today, CHD is the leading cause of mortality and disability worldwide, and its prevalence is expected to increase in the coming years. The results of multicenter studies led to a better understanding of the pathogenesis of coronary artery disease. If traditional risk factor assessment was focused on parameters such as age, gender, high blood pressure, cholesterol, heredity, Smoking, in the last decade, there are new risk factors - biological and genetic markers, which are detected in the serum and tissues. They change the approach to risk stratification, their definition becomes available, as an important tool in the assessment and treatment of CHD.

A known method for predicting risk of ischemic heart disease: a method of calculating the probability of occurrence of coronary heart disease through the study of lipids of blood serum, characterized in that it further determine before and after treatment modified LP(A) (Cannes N. In., Fedorova N. And., 2008). This method has a high degree of sensitivity and specificity.

The technical result of the image�etenia is to increase the sensitivity and specificity of the method of predicting risk of development of critical stenosis in patients with coronary artery disease.

The problem is solved in that in a patient serum determine the level of markers of myocardial fibrosis - matrix metalloproteinase-9 (MMP-9) and/or C-terminal propeptide of procollagen type 1 (PICP), a value of MMP-9 more than 101; 8 ng/ml and/or PICP more 195,6 ng/ml determine an increased risk of developing coronary heart disease.

The method is carried out as follows. Blood sampling in a volume of 5 ml is carried out in sterile conditions according to standard procedures. Blood samples are immediately centrifuged, plasma was frozen at -20°C. Storage of plasma at temperature-20-70°C not continue for more than 6 months. For analysis do not use hemolized or lipemic samples. The levels of MMP-9, PICP in the blood is measured using an enzyme immunological test system.

To assess the level of MMP-9, use a set of reagents "Human MMP-9 ELISA" (Bender MedSystems, Austria). The analysis is performed in several steps. Initially, human MMP-9 present in the test samples of serum, associated with monoclonal antibody to human MMP-9, adsorbed in the cells of the microplate. "Detection" polyclonal antibodies to MMP-9 binding molecules of the human MMP-9 captured by the first antibody. After incubation by washing of the cells are removed, not second bound anti-MMP-9 antibodies. Later in the cell add the conjugate monocle�exponentially mouse intential and after incubation and washing, remove not bound enzyme conjugate. The next phase in the cell add the substrate solution, giving the interaction with the enzyme complex staining. The reaction is stopped by adding acid and the intensity of the color measured concentration of human MMP-9. The limit of sensitivity of this set is 0.8 ng/ml In serum samples of healthy people, chosen at random, the levels of MMP-9 are in the range of 20.3-77,2 ng/ml, the average level of 43 ng/ml.

The definition of PICP is carried out using a diagnostic kit "Metra CIPC EIA Kit (Quidel Corporation, USA) by ELISA. The method is based on the "sandwich" immunoassay analysis in a microplate format, using monoclonal anti-PICP antibody immobilized in the wells of the microplate, rabbit anti-RSR antiserum, conjugate goat antigalactic antibodies with alkaline phosphatase and pNPP substrate for the quantitative determination of PICP in human serum. Antibodies to PICP have 100% cross-reactivity with serum PICP human blood. The minimum detectable using the set level is 0.2 ng/ml. In the analysis of serum samples of adults older than 25 years, with the help of this set, the values obtained are in the range 69-163 ng/ml.

When carrying out statistical processing of the material were found statistically significant differences between record�mi fibrosis depending on the presence of coronary artery disease and severity of coronary artery lesion.

Building a model of the development of IHD performed on the entire array of patients involved in the study. CHD was diagnosed in 108 patients from 216. The analysis of multiple regression shows that valuable predictors to predict the development of CHD are MMP-9, PICP. The risk of developing CHD increases with increase in the concentration of MMP-9 and/or PICP. For the practical use of these indicators as predictors of CHD development was evaluated their diagnostic efficiency and identifies specific thresholds. To this end performed the ROC analysis and the graphs of ROC curves.

The study of these parameters was performed in relation to their significance in terms of the development of significant stenosis (>75%) in patients with coronary artery disease. The area of the ROC curve for MMP-9 amounted to 0.662 (p=0,0024), indicating a good model.

Index Adena amounted 0,306, and associated criterion more at 101.8 ng/ml.

The area of the ROC curve for PICP amounted 0,680 (p=0.0007). Index Udena was 0.345 and an associated criterion more 195,6 ng/ml.

The odds ratio for MMP-9 more at 101.8 ng/ml, provided that the value of PICP remains constant is 3,41 (confidence interval 1,38-of 8.47; p=0.007). The odds ratio for PICP more 195,6 ng/ml, provided that the value of MMP-9 remains constant, is 4,66 (confide�individual interval 1,68-12,9; p=0.003).

Using the proposed method improves the accuracy of early diagnosis of critical coronary stenosis in patients with coronary artery disease.

Sensitivity 98%, specificity of 93%.

EXAMPLES of SPECIFIC APPLICATIONS

Example No. 1. Patient A., age 69, teacher. History of angina of II FC, hypertension, atrial fibrillation paroxysmal form. Complaints of episodes of increased blood pressure up to 160/100 mm Hg.CT., accompanied by headache, weakness, dizziness, nausea. Pain behind the breastbone notes during BP and during exercise (distance 300 m). Taking Enap 10 mg 2 times a day, amlodipine 10 mg 1 tab. for the night. An objective examination of the condition is satisfactory, the lungs breath held, heart sounds are clear, correct rhythm, no noise. The abdomen is soft, painless, the liver is on the edge of the costal arch. HELL 150/90 mm Hg.PT. Pulse 68 / min, regular rhythm. In General, the analysis of blood from 18.06.2013: erythrocytes of 4.0×1012/l, hemoglobin 142 g/l, platelets 322×109/l, leukocyte count of 4.1×109/l, uh - 1% p - 2%, and 53%, l - 37%, m - 6%, ESR 2 mm/h. Total blood count, lipid profile and biochemical analysis of blood without deviation from the norm. When conducting Holter ECG - single SVPBS, VES. When conducting VEM - increase in blood pressure to 160/90 mm Hg.CT., ischemic changes were revealed. The level of MMP-9 122,58 ng/ml. the Diagnosis of coronary artery disease. Angina of II �K. Hypertension stage III, 2 degrees AD risk 4. Complications: Paroxysmal form of atrial fibrillation. During the coronary angiography stenosis was found, PMA 80%) and ACP 75%.

Conclusion. Determination of MMP-9 has a high probability to speak before the coronary angiography that the patient has ischemic heart disease, functional class III, there is a critical stenosis.

Example No. 2.

Patient P., 56 years old, the chef, was admitted with complaints of chest pain and oppressive aching, faults in work of heart and increase in blood pressure to 150/90 mm Hg.PT.

History of arterial hypertension, angina of II FC. Complaints of episodes of increased blood pressure to 170/105 mm Hg.CT., accompanied by headache. Pain behind the breastbone notes when walking 200-300 meters, stopped after 10 minutes when you stop. Taking ACE inhibitors (co-Renitec 20/12,5 mg 1 tab. in the morning, Concor 5 mg 1 tab. in the morning). An objective examination of the condition is satisfactory, the lungs breath held, heart sounds are clear, correct rhythm, no noise. The abdomen is soft, painless, the liver is on the edge of the costal arch. HELL 130/90 mm Hg.PT. The pulse is 62 / min, regular rhythm. In General, the analysis of blood from 18.06.2013: erythrocytes of 3.8×1012/l, hemoglobin 124 g/l, platelets 210×109/l, leukocyte count of 5.6×109/l, e - 3% p - 1%. with - 55% l - 35%, m - 7%, ESR 12 mm/h. Total blood count and biochemical analysis of blood without deviation �t standards. In lipid spectrum pays attention to the increase of total cholesterol to 6.3 mmol/l, LDL 3.5 mmol/l When performing ECG Holter monitoring - frequent SVPBS (up to 70 in h), by GEN. When conducting VEM - increased blood pressure up to 170/90 mm Hg.CT., ischemic changes were not revealed. The level of PICP - 218 ng/ml. the Diagnosis of coronary artery disease. Angina of II FC. Hypertension stage III, 2 degrees AD risk 4.

Subsequent coronary angiography revealed stenosis of the RCA to 85% and PMA 90%.

Conclusion. The patient identified coronary heart disease, which was confirmed by stress test and subsequent determination of the PICP. Later this was confirmed by the data of KBR. The definition of PICP has a high probability to say that the patient has a critical stenosis of the coronary arteries with that, when you receive the diagnosis of angina II FC only.

Example No. 3. Patient P., 44, Builder. History of arterial hypertension, angina of II FC. Complaints of episodes of increased blood pressure to 180/95 mm Hg.PT. Pain behind the breastbone notes under load (distance 200 m). Taking Concor 10 mg 1 time per day, amlodipine 10 mg 1 tab. for the night. An objective examination of the condition is satisfactory, the lungs breath held, heart sounds are clear, correct rhythm, no noise. The abdomen is soft, painless, the liver is on the edge of the costal arch. HELL 140/90 mm RT.PT. The heart rate of 55 per minute, regular rhythm. General �analysis of blood, lipid profile and biochemical analysis of blood without deviation from the norm. When conducting ECG Holter monitoring - frequent SVPBS, VES, episode ST depression of 1 mm to 5 minutes. When conducting VEM - increase in blood pressure to 180/90 mm Hg.CT., ischemic changes were not revealed. The level of MMP-9 to 133.5 ng/ml, the level of PICP 235,2 ng/ml. the Diagnosis of coronary artery disease. Angina of III FC. Hypertension stage III, 2 degrees AD risk 4. During the coronary angiography stenosis was found, PMA 90%, VTK-1 75%, FE 58%.

Conclusion. Determination of MMP-9 and PICP has a high probability to speak before the coronary angiography that the patient has coronary artery disease with critical stenosis.

Example No. 4. Patient A., 49, housewife. History of angina of FC I-II arterial hypertension. Complaints of episodes of increased blood pressure to 150/100 mm Hg.CT., accompanied by headache, weakness. Pain behind the breastbone notes during BP and during exercise (walking 500 m). Takes Renitec 10 mg 2 times a day, amlodipine 10 mg 1 tab. for the night. An objective examination of the condition is satisfactory, the lungs breath held, heart sounds are clear, correct rhythm, no noise. The abdomen is soft, painless, the liver is on the edge of the costal arch. HELL 140/90 mm RT.PT. Pulse 88 / minute, regular rhythm. Total blood count, lipid profile and biochemical analysis of blood without deviation from the norm. When conducting Holter ECG - rare VAW�With, VES. When conducting VEM - increase in blood pressure to 160/90 mm Hg.CT., ischemic changes were not revealed. The level of MMP-9 is 12.58 ng/ml, PICP to 44.8 ng/ml. the Diagnosis of coronary artery disease. Angina of FC I-II. Hypertension stage II, 1 degree AD risk 3. During the coronary angiography stenosis was found, PMA 20% and ECT-1 is 25%.

Conclusion. Determination of MMP-9 and PICP has a high probability to speak before the coronary angiography that the patient has ischemic heart disease, functional class I-II, no critical stenosis.

Thus, our studies reveal the criteria on the basis of which it is possible to predict the clinical course of CHD, in particular the development of critical coronary stenosis. The obtained data allow cardiologists in the early stages of diagnosing coronary artery disease. A significant advantage of this method is the small amount of blood required for testing, high diagnostic accuracy and specificity. Furthermore, the method is not traumatic and has no contraindications. The method was tested on clinical material and find application in the practice of cardiologists, physicians.

A method of predicting risk of development of critical coronary stenosis in patients with coronary artery disease with blood, characterized in that in the serum of the patient determine concentrationtime metalloproteinases - 9 (MMP-9) and/or C-terminal propeptide of procollagen type 1 (PICP) and MMP-9>a 101.8 ng/ml and/or RSR>195,6 ng/ml predict the development of critical coronary stenosis in patients with coronary artery disease.



 

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