Method for treating pain-free myocardial ischemia in patients with chronic obstructive bronchitis

FIELD: medicine, cardiology.

SUBSTANCE: in addition to traditional treatment with broncholytics it is necessary to apply analapryl at increasing dosages starting from 2.5 up to 10 mg/d, therapy course lasts for 24 d. Due to anti-ischemic action of analapryl the development of bronchospasm has been excluded.

EFFECT: higher efficiency of therapy.

3 ex, 1 tbl

 

The invention relates to the field of medicine, and relates to such sections of the internal diseases, such as pulmonology and cardiology.

According to the latest recommendations of the group of antianginal drugs include nitrates, beta-blockers, calcium antagonists (3).

In the classification of the American College of cardiology and American Heart Association (ACC/AHA 2003) in the group of antianginal drugs the first place is occupied by beta-blockers (3).

However, the use of beta-blockers in patients with ischemic heart disease combined with chronic obstructive bronchitis (COB) is impossible, because their use increases bronchoobstructive with increasing hypoxia and overload of the right departments of heart.

Nitrates are widely used in the treatment of ischemic heart disease. They increase exercise tolerance, increase the time until the occurrence of angina and reduce the depression of the ST segment on the electrocardiogram during exercise.

Weakness of nitrates is:

1. A high rate of development of tolerance to nitrates in the early stages of treatment.

2. The increase of the specific number of episodes of painless myocardial ischemia among all ischemic attacks, despite the increased tolerance to physical load.

3. In studies ISIS-4 and GISSI-3 proved that the permanent is Naya therapy with nitrates and their derivatives - molsidomine (ESPRIM) does not improve the prediction of life.

4. Poor tolerance of drugs, especially in younger patients.

The use of nitrates in the treatment of such forms of ischemic heart disease as painless myocardial ischemia in patients with chronic obstructive bronchitis can lead to increased ventilation-perfusion disturbances due to the opening of arteriovenous shunts and increasing hypoxia. In addition, when using nitrates may increase the activity of the sympathoadrenal system and plasma aldosterone, which is one of the pathogenesis of painless myocardial ischemia and makes impossible the use of nitrates in patients with this condition.

Calcium antagonists in the recommendations of both European and American scientific societies are second in the group of antianginal drugs in ischemic heart disease, after beta-blockers.

Weakness of calcium antagonists are:

1. The increase in the number of painless episodes of ischemia with long-term use of drugs group of dihydropyridine.

2. The decrease in heart rate due to qualityimage effect of verapamil.

3. No differences in the use of verapamil in comparison with placebo in patients with stable angina (research CRIS).

4. Worsens the prognosis of life when an application is agonist of calcium from the group of benzodiazepines in patients with angina functional class 3-4 (research MDPIT).

The essence of the development of a new method of treatment is the use of an inhibitor of angiotensin converting enzyme enalapril in the treatment of painless myocardial ischemia in patients with chronic obstructive bronchitis, because for this group of drugs today, there are sufficient pathogenetic substantiation and confirmation of the antiischemic effect conducted a multicenter studies in patients with ischemic heart disease (SOLVD, SAVE, QUOVADIS, TRACE, AIRE), but in modern literature data we have not found work on the use of angiotensin-converting enzyme inhibitors in the treatment of such forms of ischemic heart disease as painless myocardial ischemia, including patients in the combination of this pathology with chronic obstructive bronchitis.

The proposed method for the treatment of painless myocardial ischemia in patients with chronic obstructive bronchitis is implemented as follows.

Patients with a diagnosis of chronic obstructive bronchitis in combination with painless myocardial ischemia were treated with enalapril for 24 days. The initial dose was 2.5 mg per day. If tolerated, the dose is gradually increased until the average therapeutic 10 mg per day, under the control of blood pressure.

After 24 days of conduction and monitoring of electrocardiogram (ECG) and 24-hour ECG Holter monitoring Holter for detecting ischemic changes, to assess the effectiveness of therapy.

Example 1. Patient L., 59 years old.

Diagnosis: chronic obstructive bronchitis, stage III, the acute phase.

Emphysema of the lungs. NAM I.

Hypertension grade I, stage III.

CHD: painless myocardial ischemia. CH I.

When admitted to hospital, the patient complained of shortness of breath during normal walking and climbing on the 2nd floor, cough with mucous sputum, chest pain with deep breathing, increased body temperature up to 39°within three days. Pain in the heart is not disturbed.

From the anamnesis: suffering from chronic obstructive bronchitis in the last 10 years. During the year, raising HELL to 160/80 mm Hg

Objective examination.

In comparative percussion of the lungs boxed percussion.

Auscultation of the lungs breathing hard, exhale elongated, single dry rales. NPV 18 in minutes

Borders of relative heart dullness:

right - 1.5 cm laterally from the right edge of the sternum,

left - the left srednechrochnoy line in the 5 intercostal space,

the top - level of the third rib on the parasternal line.

Auscultation - heart sounds, rhythmic, muted, I tone at the top. weakened, the accent of II tone on the pulmonary artery, no noise. HR=88 min, BP 160/80 mm Hg

Upon admission to the hospital on electrocardiogram overload of the right ventricle (P-ulmonale).

Treatment: So Amoxicillin, So Bromhexine, Ing. Atrovent.

After normalization of temperature and improve the clinical condition of the patient was conducted 24-hour ECG Holter monitoring Holter, which revealed a constant colonista ST segment depression in V5 to 1.5 mm without subjective sensations.

Was exhibited concomitant diagnosis of ischemic heart disease: painless myocardial ischemia.

On echocardiography revealed sclerosis of the aorta and intracardially structures, left ventricular hypertrophy, MLG - 370 g, diastolic dysfunction of the left ventricle.

The patient was assigned to enalapril (company Berlin - Chemie, Germany), 5 mg per day.

After 24 days of repeated 24-hour ECG Holter monitoring Holter, which revealed a constant colonista ST segment depression to 0.5 mm.

Thus, when applying the inhibitor of angiotensin converting enzyme enalapril ST segment depression was not diagnostically significant decreased MLI=348 g, improved diastolic function of the left ventricle.

Example 2. Patient P., 54,

Diagnosis: chronic obstructive bronchitis, stage III, the acute phase.

Emphysema of the lungs. Pneumosclerosis. NAM II Art.

CHD: painless myocardial ischemia. SN II.

When entering the patient complained of cough with the Department of mucous sputum, shortness of breath is ri moderate physical activity. Pain in the heart is not disturbed.

From the anamnesis: suffering from chronic obstructive bronchitis for 10 years.

Objective examination.

In comparative percussion of the lungs boxed percussion.

Auscultation of the lungs breathing hard with extended exhalation, single dry rales in the lower lung. NPV 20 minutes

Borders of relative heart dullness:

right - the right edge of the sternum,

left - 1 cm outwards from the left srednechrochnoy line in the 5 intercostal space,

the top - level of the third rib on the parasternal line.

Auscultation - heart sounds, rhythmic, muffled, the relation of tones saved, no noise. HR=96 min, BP 120/80 mm Hg

Upon entering the electrocardiogram revealed overload of the right departments (P-pulmonale).

Treatment: ing. The on-demand salbutamol, Bromhexine.

After improvement of the clinical condition of the patient held a 24-hour monitor ECG Holter, which revealed persistent ST segment elevation in lead V5 with an amplitude of 1.2 mm, the tooth T to 2.5 mm

On echocardiography - sclerosis of the aorta, left ventricular hypertrophy, MLG - 278,

Was exhibited concomitant diagnosis of ischemic heart disease: painless myocardial ischemia.

The patient was assigned to enalapril (company Berlin-Chemie, Germany), 5 mg per day.

After 24 days repeated 4-hour ECG Holter monitoring Holter - revealed ST segment elevation in lead V5 to 1.0 mm with a duration of 2-4 min; total time 10 minutes

Example 3. The patient is 67 years old.

Diagnosis: chronic obstructive bronchitis, stage I, phase of remission. NAM I.

CHD: PX (IM without Q in 1979). Painless myocardial ischemia. MK IIA.

When entering the patient complained of shortness of breath during physical activity. Pain in the heart is not disturbed.

Objective examination.

In comparative percussion of the lungs clear pulmonary sound.

Auscultation of the lungs vesicular breath, exhale is lengthened in the lower departments of medium-bubble wheezing. NPV 18 in minutes

Borders of relative heart dullness:

right - the right edge of the sternum in the 4th intercostal space,

left - the left srednechrochnoy line in the 5 intercostal space,

the top - level of the third rib on the parasternal line.

Auscultation - heart sounds, rhythmic, muffled, the relation of tones saved, no noise. HR=68 min, BP 160/100 mm Hg

Held on 24-hour ECG Holter monitoring Holter, where identified colonista ST segment depression constant up to 2 mm in lead V5.

On echocardiography - sclerosis of the aorta and intracardially structures, left ventricular hypertrophy, MLI=328 g, diastolic dysfunction of the left ventricle.

Was diagnosed coronary heart disease: painless ischemia miokar the A.

The patient was assigned to enalapril (company Berlin-Chemie, Germany), 5 mg per day.

After 24 days of repeated 24-hour ECG Holter monitoring Holter - ST segment on the contour without dynamic offset.

When the control holding echocardiography - MLI=262,

After 18 months, again the control 24-hour ambulatory ECG Holter revealed ST segment without offset from the contour.

The authors compared the results of treatment of coronary heart disease: painless myocardial ischemia in 25 patients with chronic obstructive bronchitis.

Group:

12 patients received in addition to the basic therapy of chronic obstructive bronchitis enalapril (company Berlin-Chemie, Germany) for 24 days. The initial dose was 2.5 mg per day. If tolerated, the dose is gradually increased under the control of blood pressure, to the average therapeutic (10 mg per day).

To compare the results of treatment of painless myocardial ischemia was taken by a group of 13 people who received in addition to the basic therapy of chronic obstructive bronchitis - calcium antagonist diltiazem, which is one of the basic products of the treatment of painless myocardial ischemia. Dose was 60 mg 3 times per day, or 90 mg 2 times a day. The daily dose was 180 mg

Resultativity groups showed no significant differences to reduce the number of episodes of painful and painless myocardial ischemia in patients with chronic obstructive bronchitis. There was also no significant differences in treatment groups diltiazem and enalapril in reducing the time duration of ischemia, and reduce the maximum ST-segment depression.

Thus, the conclusion that in the absence of contraindications to the use of inhibitors angiotensinase enzyme enalapril can be used for the treatment of painless myocardial ischemia in patients with chronic obstructive bronchitis, along with calcium antagonists.

Table 1.

Effect of 24-day medication diltiazem and enalapril on the dynamics of HMM-ECG chronic bronchitis patients with the presence of myocardial ischemia.
IndexMedication
Diltiazem (group 1) n=8Enalapril (group 2) n=7
Before the treatmentAfter the treatment-Δ%Before the treatmentAfter the treatment-Δ%
1. Pain episodes (the average number of episodes per day).9,00±1,473,00±1,08*-66,6%8,33±0,333,67±0,67*-55,9%nd
2. BIM (the average number of episodes per day). 9,00±2,802,50±1,04*-72,2%8,25±1,313,00±1,47*-63,6%nd
3. The duration of ischemia (min)12,13±1,486,38±1,57*-47,4%14,29±1,737,71±1,52*-46%nd
4. The maximum depression 8T,mm2,09±0,281,10±0,28*-47,3%2,04±0,291,16±0,23*43,1%nd
*P1<0,05 - significance of differences between groups before and after treatment.

nd is the difference between the groups after treatment is not valid.

Literature

1. Karpov Y.A. Clinical consequences of inhibiting tissue angiotensin-converting enzyme: the expediency with stable ischemic heart disease. // Cardiology - 2002. No. 6. - pp.86-91.

2. Schaffer MJ, Mareev VY Role of angiotensin-converting enzyme inhibitors in the treatment of patients with ischemic heart disease, stable angina, with good left ventricular function. // Cardiology - 1999. No. 1. - p.75-84.

3. ACC/AHA/ACP-ASIM Guidelines for the management of patients with chronic stable anqina. J Am Coil Cardiol 1999; 33(7): 2081-2118.

The method of treatment of painless myocardial ischemia in patients with chronic obstructive b is onicom, includes the use of bronchodilators, characterized in that the treatment with enalapril within 24 days of the initial dose of 2.5 mg per day and increase to 10 mg if tolerated.



 

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