Method for diagnosis of hypertrophy of the right ventricle in patients with chronic obstructive bronchitis

 

The invention relates to medicine, cardiology. In patients with chronic obstructive bronchitis record the ECG by a standard method. Analyze the following parameters: the amplitude of S-wave in the first standard abstraction, the sum of the amplitude of R in the first thoracic and S in the fifth thoracic leads, the amplitude of R-wave in the strong abstraction from the right hand, the amplitude of the T wave in the first and second thoracic leads, take into account the patient's age and disease duration. The abovementioned parameters are substituted in the original mathematical formula. The presence of hypertrophy of the right ventricle diagnosed by the value of the calculated index Z. the Method can improve the accuracy of diagnosis. 1 Il., 3 table.

The invention relates to medicine, namely to cardiology dedicated to the diagnosis of hypertrophy of the right ventricle of the heart.

The urgency of the problems associated with a high incidence of hypertrophy of the right ventricle in patients with chronic obstructive bronchitis, including among young people, working age. The high incidence of life-threatening disorders of heart rhythm, progression of right ventricular failure in question the NGOs in the early stages of its development potential is large, the effectiveness of therapeutic and preventive measures. At the same time, research conducted in the Paris center. The laennec showed that out of 85 patients with clinical manifestations of chronic pulmonary heart only 25 were detected ECG signs of hypertrophy of the right ventricle. More than half of the patients died within three years, which allowed to conclude that the ECG diagnosis is late and may not be used for verification of pulmonary heart (see, for example, Weitzenblum E., Jezek V. Evolution of pulmonary hypertension in chronic respiratory diseases. - Bull. Europ. Physopath. resp. - 1984. - Vol.20, N1. - P. 73-81).

Currently there are a large number of non-invasive methods for diagnosing pulmonary heart (LS), which is revealed hypertrophy his right departments. Among the various electrophysiological techniques used for the diagnosis of hypertrophy of the right ventricle of the heart, electrocardiography (ECG) remains the most common method of research (see, for example, V. A. Yakovlev, I., Kurenkova. Pulmonary heart. - St. Petersburg, Russia; Medical information Agency, 1996. - S. 351).

A known method for the diagnosis of hypertrophy of the right ventricle of the heart based on the comparison of ECG data and postmortem studies have 96 deceased Bo who is the increase in time of ventricular activation 0,03 with in the first chest leads. This sign was found in 80,4% of all cases. The authors believe that the most informative characteristic that can be used for the diagnosis of HP is reduced RV index5/SV5)/(RV1/SV1below 10 (see, for example, B. I., dubchak, M. S. Hnatiuk, I. E. Blicher, L. A. Gnatyuk. Chronic pulmonary heart with fibrous-cavernous pulmonary tuberculosis (electrocardiographic ergonometrically study) - Problems of tuberculosis, 1984. - N 3. - S. 51-55).

The disadvantage of this method is the possibility of diagnosis only pronounced hypertrophy of the right ventricle.

A known method for the diagnosis of hypertrophy of the right ventricle of the heart based on the analysis of the amplitude of krupnomolotoy ECG. B. C. Device using krupnomolotoy ECG considers the most informative signs following drugs: PII>2 mm; PIII>2 mm; PII/TII>1 mm; PIII/PI>2.5 mm; SV6>5 mm; PaVF>1.5 mm the Author presents a table in which all signs of drugs assigned to a specific ball weight, obtained in the result of the regression analysis (see , for example, B. S. Device. Early electrocardiographic signs of chronic pulmonary heart. - Cardiology, 1975. - the key to hypertrophy of the right ventricle of the heart.

A known method for the diagnosis of hypertrophy of the right ventricle, based on quantitative characteristics obtained by measuring the amplitude of the ECG (see , for example, C. N. Orlov. Guide to electrocardiography. - Moscow, Medicine, 1983. - S. 140). According to C. N. Orlov, in practice it is advisable to follow the following basic characteristics of the drug: the deviation of the electric axis of the heart to the right; the deviation of the heart apex posterior (type SI-SIII); rotation around the longitudinal axis of the right ventricle anteriorly (type SI-QIII); "P pulmonale"; negative RaVL; blockade of the right bundle branch; expressed prong SV5-6; reduction in the amplitude of the RV5-6; the presence of S-wave in all chest leads; reduction of ST segment, the appearance of negative T in II, III, aVF, V1-2leads.

The disadvantage of this method is its low sensitivity and specificity, as well as for diagnostics only pronounced hypertrophy of the right ventricle, when there are already ECG changes. Diagnosis of severe hypertrophy of the right ventricle on the EKG does not cause special difficulties, at the same time, it is difficult or almost impossible to put electrocardiographic diagnosis slight hypertrophy ITEC experts who thinks, what ECG in chronic HP may not be changed even when installed on sections of hypertrophy of the right ventricle (see, for example, Chronic pulmonary heart. - Reports of the who expert Committee, Moscow, 1961). Specificity and especially the sensitivity of the ECG in the diagnosis of mild or moderate hypertrophy of the right ventricle is lower than that of hypertrophy of the left ventricle (see, for example, A. B. de Luna. Guide to clinical ECG. - Moscow; Medicine, 1993.- S. 221).

The closest technical solution of the proposed method for the diagnosis of hypertrophy of the right ventricle is a method of diagnosis of hypertrophy of the right ventricle of the heart based on the analysis of the standard ECG emitting complex ECG signs of drugs (see, for example, J. Widimsky, A. Valach, R. Dejdar. The electrocardiograpfic pattern of right ventricular hypertrophy in cor pulmonale. - Cardiologia, 1960. - Vol. 36. - N 1. - P. 287-293). This way to the present time used in clinical practice and research. J. Widimsky divided all ECG signs of hypertrophy of the right ventricle when drug on direct and indirect. Direct ECG characteristics he attributed: RV1>7 mm; RV1/SV1>1 mm; RV1+RV5>10.5 mm; the activation of the right ventricle in the V10,03-0,05 C; QR and V1with the exception of hell right bundle branch and later RV1>15 mm; the signs of overload of the right ventricle in the V1-2. Indirect signs: RV5<5 mm; SV5>5 mm; SV5/SV5<1; incomplete blockade of the right bundle branch and later RV1<10 mm; full blockade of the right bundle branch and later RV1<15 mm; index (RV5/SV5):(RV1/SV1)<10; negative prongs TV1-5; SV1<2 mm; pulmonary PII-III; the deviation of the electric axis of the heart to the right more than +110o; type ECG P/Q in AVR>1. According to the author, direct characteristics due to the increased weight of the hypertrophied right ventricle. Indirect signs appear, usually in the early stage of the disease, although they may be the result of changing the position of the heart. The presence of two or more direct ECG signs provides an accurate diagnosis of drug discovery, one direct and one or more indirect signs is likely; if there is one forward or one indirect indication is questionable (see , for example, J. Widimsky, A. Valach, R. Dejdar. The electrocardiograpfic pattern of right ventricular hypertrophy in cor pulmonale. - Cardiologia, 1960. - Vol. 36. - N 1. - P. 287-293).

The disadvantage of this method is its low information, especially when a small degree of hypertrophy of the right ventricle, when there is no znacenija. - Cardiology, 1982. - #4. - S. 26-30). The information content of this method is reduced and in severe hypertrophy, accompanied by morphological changes of the right ventricle and a decrease of bioelectric activity of the myocardium (see, for example, M. S. Hnatiuk. Electrocardiographic and morphometric changes of the heart in chronic pneumonia. Clinical medicine, 1984. - #4. - S. 67-71).

The goal of our proposed method is to increase the accuracy of diagnosis of hypertrophy of the right ventricle (PJ) heart small and moderate severity, i.e., in the early stages, on the basis of ECG data and patient history.

The task is accomplished as follows. ECG is performed by a standard method. Analyze the amplitude of the following teeth ECG in mm: S1RV1+SV5, RAVR, TV1and TV2, i.e. the amplitude of teeth T in leads V1V2. Study history: the patient's age and duration of illness. These indicators are substituted into the formula and calculate z

Z=-3,78+0,063B+0,283D3-0,150S1+0,23(RV1+SV5)-0,149RAVR+0,298

When Z1.5 to diagnose the presence of hypertrophy of the right ventricle of the heart.

The novelty of the method: 1. For the first time for the diagnosis of hypertrophy of the right ventricle in patients with chronic obstructive bronchitis proposed canonical equation (with the definition of the indicator Z) based on discriminant analysis, which included 5 of the ECG S1RV1+SV5, RAVR, TV1and TV2.

2. For the first time for the diagnosis of hypertrophy of the right ventricle of the heart is not only a set of electrocardiographic data, but some data history (duration of disease, age of patient).

3. The method allows to diagnose the hypertrophy of the right ventricle in patients with chronic obstructive bronchitis with validity not less than 95%, with increasing Z more than 1.5, even when otstott hypertrophy of the right ventricle of the heart, we have studied the amplitude characteristic (in mm) of teeth standard ECG in 400 patients with chronic obstructive bronchitis. Diagnosis of hypertrophy of the right ventricle of the heart was performed echocardiographically on the computer system of sonography "ACUSON 128 XP/10C (USA). Detection during echocardiographic studies of comorbidity of the left ventricle (hypertrophy or dilatation) was a criterion for exclusion of patients from the studied group. ECG was performed according to standard methods (speed of 50 mm/s with amplitude of 10 mm/mV) in 12 leads in position of the patient on his back on a computer electrocardiograph "biotic" (Tomsk). The presence of ECG signs of blockages bundle and/or myocardial infarction at any site was an exclusion criteria from the study. Then it calculated the amplitude of teeth standard ECG in mm Calculated 25 ECG criteria characterizing the electrical activity of the right departments of heart and has the fixed value in the diagnosis of hypertrophy mud, offered in various monographs: RV1; SV1R/S in the V1; Input voltage in V1; RV5; RV6; SV5; SV6R/S in the V5and V6respectively; QRV1; S1; SII; SIII; QIII+SI; QIII; PII; RV1+SV5; RV1+SV6; RAVRR/S in the V2R/S in the V3iladelphia: Saunders Co. - 1980. - P. 198; J. Widimsky, A. Valach, R. Dejdar. The electrocardiograpfic pattern of right ventricular hypertrophy in cor pulmonale. - Cardiologia, 1960. - Vol. 36. - N 1. - P. 287-293; C. I. Orlov. Guide to electrocardiography. - Moscow, Medicine, 1983. - S. 140; A. B. de Luna. Guide to clinical ECG. - Moscow, Medicine, 1993. - S. 221). In addition, the analysis included independent variables: patient age and duration of disease, because according to the literature pulmonary heart (in the form of hypertrophy of the right ventricle) occur in patients with extensive "experience" of the disease, usually at the age of 55-60 years (Danilov, I. P., Makarevich A. E. Chronic bronchitis: epidemiology, pathogenesis, clinic and treatment. - Minsk: Belarus, 1989. - 207 S. ).

To obtain predictive models applied discriminant analysis, applied using the software package "STATISTIKA OF 5.5". Discriminant indicators were age, disease duration and 5 ECG criteria. It S1RV1+SV5, RAVR- criteria enlarged right ventricle resulting from anatomical correlation studies, as well as TV1and TV2. The figures obtained with coefficients in them (PL.1) was used for the solution of the canonical equations, which were calculated pokazatel her.

The resulting equation takes the form Z=-3,78+0,063B+0,283D3-0,150S1+0,23(RV1+SV5)-0,149RAVR+0,298TV1-0,175TV2
where In - patient age (years);
D3 - disease duration (years);
S1- amplitude of S-wave in the first standard lead (mm);
RV1+SV5- the sum of the amplitude of R in the first thoracic and S in the fifth chest leads (mm);
RAVRthe amplitude of the R-wave in the strong abstraction from the right hand (mm);
TV1the amplitude of the T wave in the first chest leads (mm);
TV2the amplitude of the T wave in the second chest leads (mm).

The amplitudes of the ECG teeth, designed for the specific examined the patient, are substituted in the equation. It also takes into account the patient's age and disease duration. If the solutions of the equation Z takes a value less than 0, then the conclusion about the absence of hypertrophy mud. If Z takes a value greater than 0, then the States have examined hypertrophy mud, even in the absence of ECG changes. This linear model formed the basis of the recip is trofie mud hearts on Z-values were determined using a logistic regression model, created on the basis that we have studied a sample of patients (Fig.1).

If the indicator Z took the values less than 0, then the probability of the presence of hypertrophy mud was less than 10%. When the value of Z from 0 to 1 probability hypertrophy mud ranged from 20% to 76%, with increasing Z-values more than 1.5 degree of probability of presence of hypertrophy PJ respectively increased to 95% (see drawing).

The method is as follows. The patient with chronic obstructive bronchitis record the electrocardiogram by a standard method (speed of 50 mm/s with amplitude of 10 mm/mV) in 12 leads in position on the back, on computer electrocardiograph "biotic" (Tomsk). The presence of ECG signs of blockages bundle and/or myocardial infarction at any site are the exclusion criteria from the study, and then calculate the amplitude of teeth S1RV1+SV5, RAVR, TV1and TV2ECG mm Refine the data of anamnesis: the patient's age and duration of illness. These figures put the proposed formula and calculate the index of z When Z1.5 to diagnose the presence of hypertrophy of the right ventricle of the heart.

Examples of specific implementation of the method
Premna allergic asthma, intermittently throughout. Sensitization to household allergens. Vasomotor rhinitis.

Complaints when applying for a cough with yellow sputum, shortness of breath. History: asthma 1 year.

Objectively: General condition of moderate severity. Skin pale, dry, warm. Subcutaneous fat is poorly expressed. No edema. The joints are not changed. Breath free. BH 16 minutes Percutere the lung sound throughout. Tour lungs normal. Auscultation of breath vesicular, single dry rales. Heart sounds rhythmic, clear. No noise.

The survey was conducted. OAK: erythrocyte sedimentation rate 5 mm/h er 4, heme. 130, lake. 7,5, 55%, lim-35%, mon.-6% e-4%. Urinalysis and biochemical analysis of blood without features. The study of blood gas composition revealed mild arterial hypoxemia. Indicators spirometry indicate a slight violation of bronchial obstruction in normal lung capacity.

ECG revealed mild diffuse changes in the myocardium. The survey was conducted as previously described. The survey results are presented in table 2.

After exposing the obtained values into the formula, we have calculated the index Z
Z= -3,78+0,6326+0,2831-0,1754= -1,9. Conclusion.

When the value Z= -1,9 the probability of hypertrophy of the right ventricle of the heart is 0.5% (see Fig.1) that allows a high degree of probability to exclude the presence of hypertrophy of the right ventricle of the heart in this patient. Conducting two-dimensional echocardiographic examination of the heart confirmed our assumption. The thickness of the anterior wall of the right ventricle was 0.38 mm, which indicates the absence of hypertrophy of the right ventricle of the heart.

Example 2. Patient N., 48 years old, was treated in the pulmonary Department GNCC ASS with a diagnosis of Chronic suppurative obstructive bronchitis, exacerbation. Emphysema. DN-2. Chronic pulmonary heart decompensation. NK-1.

Complaints received at a cough with purulent sputum, shortness of breath with little exertion, low-grade fever in the evenings.

History: Chronic bronchitis 10 years. Acute annually. The deterioration came two weeks ago when after cooling, the temperature rose to 38, he had cough with purulent sputum. Were outpatients. Improvements in treatment has not been achieved.

Objectively: General condition of moderate severity. Skin bled all fields sound box. The vesicular breath throughout. The mass of the scattered dry rales. Respiratory rate 22 / minute. Pulse 80 per minute. Blood pressure 140/100. Heart sounds normal sonority and rhythmic. The noise is not heard. The abdomen is soft, painless. The liver is not enlarged. The survey was conducted. OAK: erythrocyte sedimentation rate 5 mm/h, er 6,24, heme. 16.5, and lake. 7,5, 55%, lim-35%, mon.-6% e-4%. Urinalysis and biochemical analysis of blood without features. The study of blood gas composition showed moderate arterial hypoxemia. Indicators spirometry indicate a significant reduction in lung capacity with a moderate violation of bronchial obstruction. ECG revealed overload of the right ventricle. Reliable signs of hypertrophy of the right ventricle is not revealed. The survey was conducted as previously described. The survey results are presented in table 3.

After exposing the obtained values into the formula we have calculated the index Z
Z= -3,78+0,06348+0,28310-0,1501+0,232-0,1491+0,2981-0,1756= 1,5.

Conclusion.

A positive value of Z= 1,5 allows a high degree). Conducting two-dimensional echocardiographic examination of the heart confirmed our assumption. The thickness of the anterior wall of the right ventricle was 0.65 mm, which indicates that the hypertrophy of the right ventricle of the heart.

Testing of the proposed method was conducted on 60 patients with chronic obstructive bronchitis with varying degrees of hypertrophy of the right ventricle of the heart, confirmed by echocardiography, and 30 patients without hypertrophy of the right ventricle. The results obtained when examining these patients, completely similar to the results described in the examples.

Thus, the application of this method for the diagnosis of hypertrophy of the right ventricle of the heart avoids the drawbacks and prototype and to achieve the project objectives. This method allows for early diagnosis of hypertrophy of the right ventricle, when there are no ECG changes. The study of the patient's history (duration of disease, age), the amplitude characteristic of the particular teeth, his ECG allows you to take an individual approach to the diagnosis of hypertrophy of the right ventricle of the heart. Way to be accessible, easily reproducible, which will allow us to recommend it as a screening during the mass profileentry of the right ventricle in patients with chronic obstructive bronchitis, including determination of the amplitude of the indicators of teeth, electrocardiogram RV1, SV5, TV1, TV2, characterized in that it further identify indicators electrocardiogram S1, RAVRRV1+SV5patients ' age and disease duration, calculate the index of Z by the formula
Z= 3,78+0,063In+0,283DZ-0,150S1+0,23(RV1+SV5)-0,149RAVR+0,298TV1-0,175TV2,
where In - patient age, years;
DZ - disease duration, years;
S1- amplitude of S-wave in the first standard lead, mm;
RV1+SV5- the sum of the amplitude of R in the first thoracic and S in the fifth thoracic leads, mm;
RAVRthe amplitude of the R-wave in the strong abstraction from the right hand, mm;
TV1the amplitude of the T wave in the first chest leads, mm;
TV2the amplitude of the T wave in the second chest leads, mm, and when Z1.5 to diagnose the presence of hypertrophy of the right ventricle of the heart.

 

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