Method for the diagnosis of arrhythmogenic cardiac glycosides

 

The invention relates to medicine, particularly cardiology. Patients spend Holter ECG monitoring, echocardiography, register signalsinto ECG before, during acute drug test with strophanthin and on the background of a course of treatment with digoxin. When the negative dynamics of quantitative indicators signalsstrignanos ECG, new late potentials, arrythmia predict the risk of developing fatal arrhythmias. The method allows for timely adjustment of treatment. 1 table, 1 Il.

The invention relates to medicine and can be used in cardiology and functional diagnostics of cardiovascular diseases.

Currently, heart failure is one of the major health problems in developed countries: at least 15 million people suffer from chronic heart failure (CHF)and more than 1 million cases are diagnosed annually. Mortality remains high, three-year survival rate is less than 50%, the risk of sudden death 5 times higher than in the General population. Huge economic losses associated with increased 3 times over the last 15 years the number of them its outcome, is the degree of dysfunction of the heart muscle, which lies at the basis of the syndrome of heart failure. Because heart failure is a clinical syndrome with characteristic clinical signs and symptoms, it may be due to various heart diseases, including arrhythmia and conduction disorders, lesions of the endocardium, myocardium, heart valves. In everyday practice, in addition to clinical examination, securities of the existing non-invasive methods of diagnosis of heart failure and quality control of treatment is echocardiography.

Successes and failures in the development of basic approaches to drug therapy of chronic heart failure has led to increase in the last decade, interest in the problem of objectification of monitoring the adequacy and safety of the treatment.

Despite the fact that at the present time practical medicine has a huge Arsenal of cardiotropic funds, glycosides remain the primary drugs therapy with various cardiovascular diseases. Digitalis preparations are already more than 200 years are used in the treatment of chronic heart failure. In most clinicalguidelines time that allowed to record only relatively stable rhythm. However, there are descriptions of cases, loss of consciousness, as manifestations of ventricular tachycardia and fibrillation on the background of the use of cardiac glycosides in therapeutic doses (Mazur N. A., Kurbanov R. D.. 1984; Denisyuk C. I. et al., 1997). This is an indication of the risk of deterioration of the flow ventricular arrhythmia until sudden death during treatment with cardiac glycosides. From the perspective of practical cardiologist facing the problem of long-term observation and treatment of the patient with chronic heart failure, the greatest importance is information on how reliably the risk - benefit ratio glycoside therapy.

Late ventricular potentials (PPS) are electrocardiographic phenomenon, reflecting the processes of slow conduction of excitation in the myocardium, their presence is associated with an increased risk of developing ventricular tachycardia and sudden death.

The invention of the method for the diagnosis of arrhythmogenic action of cardiac glycosides is early identification of predictors of adverse side effects of drugs without their life-threatening arrhythmias to determine and clarify further tactics of treatment and follow-up of patients with chronic heart failure, correction therapy cardiac glycosides.

The invention consists in implementing a comprehensive analysis signalsstrignanos ECG emitting PPG, Holter ECG monitoring, echocardiography to obtain the final conclusions forecasting electrical instability, unfavorable course of the disease on the background of a course of treatment with cardiac glycosides, identifying risk factors for life-threatening conditions, sudden cardiac death.

The method is as follows. The patient conduct a survey tool, including Holter ECG monitoring (analysis of ventricular arrythmia), echocardiography (definition of end-diastolic and systolic volumes, ejection fraction) log signalsinto ECG emitting quantitative parameters prior to the appointment of cardiac glycosides. In the dynamics on the background of a course of treatment in acute drug test using cardiac glycosides repeat registration signalsstrignanos ECG with specification of quantitative indicators.

When evaluating the prognostic significance of a comprehensive analysis of signal-averaged ECG indicators of echocardiography, data halter is tological values SU-ECG during the course of treatment with the use of cardiac glycosides correlate with poor contractility of the left ventricle (elevated values of end-diastolic volume (BWW) end-systolic volume (CSR), lower ejection fraction (EF), with diffuse or regional hypokinesia, with aneurysms of the heart), the appearance of ventricular arrythmia higher grades, which determines the arrhythmogenic action of cardiac glycosides in patients without clinical signs digitalises intoxication, from this, ultimately, will depend on the tactics of conducting the patient with chronic heart failure.

Examined 32 patients with cardiovascular diseases in the age from 38 to 72 years (average 52,36,4). 12 patients were observed with a diagnosis of coronary artery disease, angina II-III FC; 11 patients had history of myocardial infarction older 4 - 7 years. 2 patients diagnosed with dilated cardiomyopathy, in 7 patients, concomitant aortic-mitral heart disease.

6 (18,8%)patients had a permanent form of atrial fibrillation, older than 1.5 years. 9 patients (28%) diagnosed with ventricular premature beats: 6 patients - a single, not more than 20 per hour, 3 - polytopia, but isolated to within 5-7 hours.

Chronic heart failure I FC was observed in 2 patients, chronic heart failure II FC - 14 patients, CHF FC III - 12, IV CHF FC - 4 vigils, daily monitoring of ECG, settings signalsstrignanos ECG indicators of echocardiography.

During the control study prior to the appointment of cardiac glycosides pathological parameters that meet the criteria PGGG, were isolated from 11 patients (34.4 percent), p<0,05; of these, 7 patients with postinfarction cardiosclerosis, 1 - with angina FC III, 2 diagnosed with concomitant aortic-mitral heart disease, 1 patient - dilated cardiomyopathy. Of the 11 patients, one marked HSN PFC, 6 - FC III, 4 - IV CHF FC.

Arrhythmogenic effect of digoxin - significant increase in the mean number of ventricular arrhythmia was noted in 15 (46.9 per cent)patients. When repeated Holter monitoring after digitalization in the specified group the increase in ventricular arrythmia was 4,5233,287 marked not only increased the number of arrythmia, but also the emergence of rhythm more complex gradations - IV-B and V. All patients who have had arrhythmogenic effect, had no signs digitalises intoxication.

Acute drug test (OLT) was performed in patients with Stratan-Tina at a dose of 0.5 mg on the background of the glycosidic saturation, while the quantitative parameters of the SU-ECG actualsales SU-ECG (see table), use of the drug in the OLT led to marked changes in the studied parameters: HF QRS-Dauer increased on average by 16% (p<0.05), and increased duration of low-amplitude signals at the end of the QRs complex'lah Fd (40 uV) to 47% (p<0.01), and RMS (40 ms) was reduced by 56% (p<0,01).

Patient P., 64 years old, was admitted to hospital 3.03.2000, with a diagnosis of coronary artery disease, angina FC III, HSN III FC, sinus tachycardia, ventricular extrasystole I gradations. Concomitant diagnosis: obliterating atherosclerosis of the lower extremities.

The strokes were followed for 16 years. Us is avago syndrome in the chest, emerging at the slightest exertion, rest for edema which was used up to 3-4 tablets of nitroglycerin. At night noted the occurrence of episodes of palpitations, shortness of breath, forced to take a forced position: sitting in bed, with lowered legs.

Admission: the borders of relative dullness of the heart is displaced to the left, the colours weakened. Pulse 110 per minute. HELL 140/90 mm RT. Art.

Electrocardiographic conclusion: sinus tachycardia, ventricular extrasystole I gradations, signs of left ventricular hypertrophy with systolic overload. Holter monitoring: 253 episodes of ventricular arrythmia.

Echocardiography: marked dilatation of the left ventricle (KDR - 7,3 cm, DAC - 5.4 cm), and ejection fraction of 34%, dilatation of the left atrium.

SU-ECG on the day of receipt 3.03.2000,: HF QRS-Dauer - 117 MS, RMS (40 MS) - 29 Áv, 'lah Fd - 26 MS.

Treatment was conducted: polarizing mixture with strophanthin 0.25 mg, nitrates prolongirovannogo actions, in the evening intravenous bolus injection strofantina 0.25 mg, furosemide 40 mg orally in the morning.

OLT was performed with strophanthin dose of 0.25 mg intravenous bolus on the 3rd day from the date of receipt and the start of treatment, pre-recorded is in 20 min: HF QRS-Dauer - 141 MS, RMS (40 MS) - 12 Áv, 'lah Fd - 48 MS (Fig.1B). ECG was recorded frequent ventricular premature beats to 11-13 min, complete.

After discontinuation of intravenous strofantina assigned to digoxin in a daily dose of 50 mg On the 7th day course of treatment with digoxin indicators SU-ECG: HF QRS-Dauer - 129 MS, RMS (40 MS) - 18 Áv, 'lah Fd - 39 MS (Fig.1B). When Holter monitoring: 18346 episodes of ventricular extrasystoles, 328 of completo, 36 triplets.

This clinical observation confirms the negative influence of cardiac glycosides on the performance of the SU-ECG in a patient with extended cavity of the left ventricle, reduced ejection fraction, which was accompanied by increased ventricular arrythmia and the emergence of arrythmia high gradations.

We do not exclude that the effect of digoxin in hypoxia and metabolic acidosis causes specific changes in the ion channels of the cell membrane and leads to the violation of the relation of intra - and extracellular potassium and calcium, to the development of hypokaliemia, hypomagnesaemia. The positive inotropic action of glycosides promotes increased oxygen consumption, in this part of cardiomyocytes that were dormant (sleeping myocardium"), die in apoptosis cardiomyocytes, which are dormant, increasing the heterogeneity of the myocardium. Transient dispersion of refractory periods and heterogeneous repolarization fibers of the myocardium contributes to the slow initiation, formation of fragmented activity, performance quantitative indicators identified during the registration SU-ECG.

According to our research of arrhythmogenic action of cardiac glycosides is marked to a greater extent in patients with negative dynamics of quantitative indicators SU-ECG on the background of a course of treatment digoxin: in 14 (93.3%) of the 15 patients with arrhythmogenic effect deteriorated parameters SU-ECG, 6 (43%) late potentials registered on the background of chronic intake of cardiac glycosides.

10 (58,8%) of 17 patients with delayed fragmented activity, registered in the appointment of digoxin, the ejection fraction did not exceed 352.4% of CRA - 6,93,7 cm, these same patients are most pronounced arrhythmogenic action: the emergence of ventricular arrythmia high gradation curves with repeated testing remained above normal (92-94 min), which, apparently, is associated with high activity of the sympathetic-adrenal system.

So olili the relationship between the frequency of detection PPG and contractile function of the left ventricle: in patients with elevated values BWW, CSR, reduction of PV, with diffuse or regional hypokinesia, with aneurysm of the heart often recorded late activity at the end of the QRs complex. In patients with advanced cavity of the left ventricle, reduced ejection fraction exchange treatment digoxin with previous digitisation leads to deterioration of the quantitative indicators of the SU-ECG and is accompanied by the occurrence of late potentials in 19% of cases. The negative dynamics of the SU-ECG may be accompanied by the manifestation of arrhythmogenic effect in 93.3% of the observations.

The results of our research show a clear relevance registration SU-ECG with the release of late ventricular potentials in combination with echocardiography and Holter-ECG monitoring in patients with chronic heart failure to timely forecasting of electrical instability of the myocardium.

The method can be used in intensive care units, cardioblate, cardiology and internal medicine departments, outpatient technique to identify and clarify further tactics of treatment and follow-up of patients with chronic heart failure, correction of therapy heart is iagnostic arrhythmogenic action of digoxin, includes standard electrocardiographic examination, Holter ECG monitoring, characterized in that conduct echocardiography register signalsinto ECG prior to the appointment of digoxin in acute drug test with strophanthin and on the background of a course of treatment with digoxin negative dynamics identified in the acute drug test with strophanthin quantitative indicators signalsstrignanos ECG: increase the duration of the filtered QRS complex, the reduction of the RMS amplitude of the last 40 MS of the QRS, the increase in the duration of low-amplitude signals of the terminal part of the QRS, the new late potentials, arrythmia predict the risk of developing fatal arrhythmias.

 

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