Method for early diagnosis of autonomic cardiac neuropathy in children with diabetes mellitus type i

 

The invention relates to medicine, particularly cardiology. In children with diabetes mellitus type 1, conduct daily monitoring of heart rate (HRV). Analyze HRV during sleep. Count the number of periods of high variance (TTD) per night. Take into account the absolute number of PPD and its percentage representation in the structure of sleep at night, and the nature of awakening. An early sign of independent cardiac neuropathy in children with diabetes mellitus type 1, consider increasing the number of PPD more than 5 percentage more than 50% in the structure of nighttime sleep and awakening from a period of stable rhythm with a sharp rise in heart rate. table 2.

The invention relates to medicine, namely to pediatric cardiology and endocrinology.

Autonomic cardiac neuropathy (DCA), developing diabetes mellitus type I (DM I), is one of its complications, can lead to cardiomyopathy, cardiac arrhythmias, painless forms of myocardial infarction, circulatory failure and sudden cardiac death in adult patients. The difficulties of early diagnosis of DCA in DM I in children are associated with the absence of her specifies the temporary methods.

The counterpart of this method for the diagnosis of DCA in DM I the authors offer a definition of vegetative ensuring activity of the heart through cardiovascular tests, such as test with deep breathing, Valsalva's test, orthostatic test, sample with isometric tension (Kazakov L. C. et al. Diagnostic value of cardiovascular tests in the assessment of autonomic neuropathy in diabetes diabetes in children // journal of Arrhythmology. - 2000. - 8. - S. 87-88.).

Some drawbacks of the method for the diagnosis of DCA in DM I are - an assessment of the functioning, only the parasympathetic division of the autonomic nervous system; - low sensitivity and complexity of conducting vegetative samples, which leads to a pronounced variability and inaccuracy of measurement results; the prototype of the method of early diagnosis of DCA in children with type I, according to the authors, is to determine the status of the autonomic ensuring activity of the heart using the daily (Holter) monitoring of cardiac rhythm (HMM) to estimate the parameters of its variability (HRV) (heart rate Variability standards of measurement, physiological interpretation and clinical isplsi electrophysiology) // The Bulletin of Arrhythmology. - 1999. - 11. - S. 53-78).

Assessment of HRV is based on the performance analysis over time: rMSSD (MS) is the square root of the sum of differences of successive RR intervals that characterize the function of the concentration of rhythm; pNN50 (%) - percentage representation of episodes differences of successive RR intervals greater than 50 MS, which characterizes the sensitivity of the pacemaker to the parasympathetic influences. Low values of rMSSD and pNN50 in adult patients with DM I with duration of disease more than 5 years indicate a weakening of the vagusnye effect on the heart activity and possible AKN. However, the use of these criteria for the early diagnosis of DCA is not always possible in children because of the high heart rate (HR), leading to diagnostic errors, and the need for dynamic observation of patients, which reduces the effectiveness of early diagnosis AKN.

The authors propose a method for early diagnosis of DCA in children, patients with DM I, which consists in applying an integrated approach to assessing the rigidity of heart rate and reduced sensitivity of the sinus node to the parasympathetic influences with trend analysis heart rate during night sleep, which is possible on the background of the tachycardia. If this is the first representation of the DPP in the structure of nighttime sleep (% TTD) (at a rate of up to 50%) and the nature of awakening (in the norm of TTD with a gradual rise in heart rate). The increase in TTD in the structure of nighttime sleep and awakening from a period of stable rhythm (RPS) with a sharp rise curves characterize the instability of the heart rhythm, which in combination with changes in HRV indicates severe autonomic dysregulation of the activity of the heart and is an early sign of DCA in children with type I.

With the aim of identifying opportunities for early diagnosis DCA 99 children, patients with DM I, aged 8 to 14 years, with disease duration from 2 months to 13 years. Depending on the duration of DM I the children were divided into three groups. The first group consisted of 24 children with disease duration up to 1 year, a second group of 36 children with duration of diabetes of I from 1 to 5 years, in the third group consisted of 39 children with disease duration more than 5 years.

To detect early signs of DCA in children with type I was used daily monitoring of heart rate estimation of the parameters of its variability and trend of the heart rate during sleep at night using a portable heart monitors "Cartotecnica-4000" in terms of the free activity of the subject with subsequent decryption of the records on a personal computer using a special program complex "Incart".

Temporal variability analysis of RIA on the duration of DM I in children (table 1).

So, overall average, the average day and average night pNN50 were lower in children with disease duration more than 5 years compared to those in I (p<0.05 to p<0.05 and p<0,05, respectively) and II groups of children (p<0,001, p<0.001 and p<0,001, respectively). This indicates a decrease in sensitivity of the sinus node to the parasympathetic influences in children with a large duration of diabetes I. General average, average day and average night rMSSD were also less in children with disease duration more than 5 years compared with indices in I (p<0.05 to p<0.05 to p<0,05, respectively) and II groups (p<0,01 p<0.01 and p<0,05, respectively). These changes indicate the emergence of rigidity of the cardiac rhythm in children with duration of diabetes more than 5 years I.

Installed the dependence of changes of indicators of time HRV analysis on duration of diabetes I have children that demonstrates developing disorders of regulation of the cardiac rhythm as the disease progresses and indirectly indicates the possible development of DCA.

To clarify the nature of the impaired autonomic regulation of heart rate was applied to the analysis of the parameters of the trend curves during a night's sleep, which found that in children with type I early a hundred I (table 2).

The incidence of children with an absolute number of periods of high variance (TTD) per night for more than 5 was significantly longer in the II and III groups compared with group I (p<0.05 and p<0.01 respectively). The percentage representation of periods of high variance in the structure of nighttime sleep was higher in children with duration of diabetes more than 5 years I than in children of I and II groups (p<0.001 and p<0,001, respectively).

The revival of the AKP with a sharp rise in heart rate also more prevalent in children with duration of diabetes more than 5 years I than in children of I and II groups (p<0.001 and p<0.01 respectively).

The data obtained indicate the presence of unstable heart rhythm during night sleep in children with type I, reflecting pronounced vegetative down-regulation of heart activity and confirming the presence of DCA. The instability of the heart rhythm during sleep at night according to the trend of the heart rate is detected not only when the duration of diabetes I more than 5 years, but when disease duration from 1 year to 5 years, allowing you to take it to the criteria for early diagnosis of DCA.

Advantages of the method of early diagnosis of DCA in children with diabetes: 1) the possibility of early detection of unstable heart rhythm, which in combination with reduced susceptibility sinus node to couple realnoi neuropathy in children with type I; 2) an objective approach to the assessment of autonomic supply of the activity of the heart in children with type I in the absence of dependence of the results on the frequency of cardiac contractions.

Clinical example: Yaroslavl Artem, 12 years were examined in MMU children's hospital 2, Tver, diagnosed with diabetes mellitus type I, disease duration 8 years, severe, sensory-motor polyneuropathy (medical card patients 615). The boy had no complaints. The heart was visually not changed, the borders of relative cardiac dullness is not extended, the heart sounds weak, rhythmic; at the top and V point to listen systolic murmur of a functional nature. ECG at rest was recorded: sinus tachycardia with HR=90-100 beats per minute, incomplete blockade of the right leg and the blockade of the anterior branch of the left bundle branch. According to kardiointervalografii installed sympathicotonia and normal autonomic reactivity. When Doppler echocardiographic examination has akineticheskie type of Central hemodynamics and mitral valve prolapse II degree without regurgitation.

When the daily monitoring of cardiac rhythm are set to low values couldny night pNN50 - 25%) and rigidity of the cardiac rhythm (total average rMSSD - 38 ms, average daily rMSSD - 27 ms, average night rMSSD - 52 ms). The analysis of the trend in heart rate during sleep at night installed the instability of the heart rhythm (absolute number GSD per night - 7, the percentage representation of the DPP in the structure of nighttime sleep - 53,8%, awakening from a period of stable rhythm with a sharp rise in heart rate). The totality of the data obtained allowed to establish the presence of autonomic cardiac neuropathy.

Maksimov Grisha, 10 years were examined in MMU children's hospital 2, Tver, diagnosed with diabetes mellitus type I, disease duration 3 years, the average degree of gravity (medical card patients 639). The boy had no complaints. The heart was visually not changed, the borders of relative cardiac dullness is not extended, the heart sounds loud, rhythmic; at the top to listen systolic murmur of a functional nature. ECG at rest was recorded: sinus tachycardia with HR=95-110 BPM, incomplete blockade of the right leg and the blockade of the posterior branch of the left bundle branch. According to kardiointervalografii installed sympathicotonia and asimpatikotonia autonomic reactivity. When Doppler echocardiographically in the cavity of the left ventricle.

When the daily monitoring of the cardiac rhythm is set to normal sensitivity of the sinus node to the parasympathetic influences (total average pNN50 - 40%, average daily pNN50 - 25%, average night pNN50 - 62%) and normal function of the concentration of rhythm (total average rMSSD - 81 ms, average daily rMSSD - 53 ms, average night rMSSD - 120 ms). However, the analysis of the trend in heart rate during sleep at night installed the instability of the heart rhythm (absolute number of TTD per night - 6, the percentage representation of the DPP in the structure of sleep at night is 54.5%, awakening from a period of stable rhythm with a sharp rise in heart rate), which allowed us to detect DCA at an early stage of its development.

Thus, detection of an unstable heart rhythm as a result of trend analysis heart rate during night sleep possible to diagnose DCA at an early stage of its development in a child with short duration of diabetes mellitus type I, despite normal levels of heart rate variability, confirming the advantages of this method of diagnosis.

Claims

Method for early diagnosis of autonomic cardiac neuropathy in children with diabetes mellitus type 1, including the assessment of the vapor is combined with trend analysis of heart rate during sleep at night, determine the absolute number of periods of high variance, their percentage representation in the structure of sleep at night, the nature of awakening, and with increasing periods of increased variance of more than 5, their percentage representation of more than 50% in the structure of nighttime sleep and awakening from a period of stable rhythm with a sharp rise in heart rate in combination with changes in HRV diagnose autonomic cardiac neuropathy.

 

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