Method for clinical detection of the risk of pulmonary artery thromboembolism in patients with electrocardiostimulant-corrected atrioventricular blockade

FIELD: medicine, cardiology.

SUBSTANCE: in patients it is necessary to determine the availability of the following clinical signs: the risk for alternative diagnosis and availability of hemoptysis followed by evaluation of each sign in points, correspondingly, 3 and 1 with subsequent establishing the diagnosis by their total. Moreover, additionally, it is necessary to detect the availability of other clinical signs: 2 and more respiratory and/or cardiac symptoms being typical for pulmonary artery thromboembolism to evaluated as 3 points. The appearance of atrial fibrillation signs at ECG should be evaluated as 1.5 points; The fact of electrocardiostimulant (ECS) implantation in previous 6 mo should be estimated as 1 point; the availability of venous thrombosis in the upper limbs after ECS-implantation should be estimated as 1 point. The absence of any out of the above-mentioned clinical signs should be evaluated as 0 points. Then it is necessary to calculate the sum of points obtained and at the sum being above 6 one should conclude upon, correspondingly, high, at the sum ranged 2-6 points - moderate and at the sum being below 2 - low clinical risk of pulmonary artery thromboembolism. The innovation provides increased information value of detection in such patients.

EFFECT: higher accuracy of detection.

3 ex, 1 tbl

 

The invention relates to medicine, namely cardiology, specifically to methods for determining the clinical probability of pulmonary embolism in patients with atrioveitrikulyarnoy blockade corrected pacemaker.

Closest to the present invention is a method for determining the clinical probability of pulmonary embolism (PE), in which the clinical symptoms are scored, and then the points are added up. Clinical signs and symptoms of deep vein thrombosis, namely swelling of the legs, tenderness to palpation of the deep veins evaluated at 3 points, the smaller the likelihood of an alternative diagnosis is estimated at 3 points, heart rate (HR) over 100 per minute is estimated at 1.5 points, immobilization or surgery in previous 4 weeks is estimated at 1.5 points, deep vein thrombosis history is estimated at 1.5 points, hemoptysis is estimated at 1 point, tumors assessed at 1 point. A score of more than 6 state high, 2 to 6 - moderate and less than 2 - a low clinical probability of pulmonary embolism [1, 2]. According to research tools, verifying the diagnosis of pulmonary embolism, with a high clinical probability of this pathology has between 80 and 96%, with an average - at 32-40%, with a low - 3-8% of patients[1, 2, 3].

However, this method ameeshaaeysha disadvantages: its scope is limited, as there are no specific criteria for determining the clinical probability of pulmonary embolism in patients with atrioventricular (AV) block, corrected pacemaker (EX). Criteria of this method is not fully manifested in patients with AV block and the FORMER as the source of pulmonary embolism in these patients, usually located in the subclavian Vienna or cardiac origin, with no deep vein thrombosis. In addition, heart rate AV blockade corrected EX, does not exceed the frequency at which the programmed stimulator (60-70 per minute).

Thus, identifying a known manner the clinical probability of pulmonary embolism in patients with AV block, corrected the FORMER, in some cases does not allow to reliably verify the diagnosis upon further examination, as the first stage of diagnosis - assessment of the clinical probability of pulmonary embolism is hampered by the lack of specific criteria and their values, thereby reducing the information content and accuracy of diagnosis using a known method.

New technical problem - increasing accurate and informative method for determining the clinical probability of pulmonary embolism in patients with atrioventricular block, corrected EX.

The task to solve a new method for determining the clinical probability of pulmonary embolism in patie the tov with AV block, corrected the FORMER, which consists in determining clinical signs such as having a lower probability of an alternative diagnosis, the presence of hemoptysis, evaluating each of them in the points 3 and 1 points and the definition of the diagnosis on their amount, and additionally determine the presence of the following characteristics: 2 or more typical of pulmonary embolism respiratory or cardiac symptoms assessed at 3 points, the appearance of the ECG signs of atrial fibrillation is estimated at 1.5 points, the fact pacemaker implantation in the previous 6 months is estimated at 1 point, the presence of venous thrombosis of the upper extremity after pacemaker implantation is estimated at 1.5 points, the presence of one or several risk factors assessed at 1 point, followed by a total score and a score of 6 is determined correspondingly high, with a score of 2 to 6 - moderate and a score of less than 2 define a low clinical probability of pulmonary embolism.

The method is as follows: in patients with implanted pacemakers find out the history and complaints, investigate ECG, comparing it with the previous studies, ECG, conduct a thorough inspection, including inspection and palpation of the veins of the upper limb, measure its circumference, conduct routine clinical examination (General and biochemical blood tests). The detection is by signs entered in the table, where is the scoring. In the absence of reliable clinical and instrumental signs of disease that are not of pulmonary embolism (alternative) in the column "points" write value "3"if diagnosed with other disorders, in which there are also respiratory or cardiac complaints - write "0". In the presence of hemoptysis in the column "points" write value "1"if the condition is missing, write the value "0". If there are 2 or more typical of pulmonary embolism respiratory or cardiac symptoms (the emergence or strengthening of previously existing dyspnea, pleural chest pain, cough, pain in the chest, hypotension, appearance or worsening right ventricular failure) in the column "points" write value "3"if the condition is missing, write the value "0". When the ECG signs of atrial fibrillation (waves f on the background stimulated or spontaneous ventricular complexes) in the column "points" write value "to 1.5", if this condition does not exist, write "0". If after pacemaker implantation was less than 6 months, then in the column "points" write value "1"if over - write the value "0". If there are signs of venous thrombosis of the upper extremity swelling, increase the circumference of the upper limb from the implanted EX) count in the "points" write value "1,5", if this condition is not present - write the value "0". When the patient has at least one of the risk factors (heart failure, obesity, cerebral vascular accident in history, old age, nephrotic syndrome) in the column "points" write value "1"if the condition is missing, write the value "0". Then calculate the total score. A score of more than 6 define high, 2 to 6 - moderate and less than 2 - low probability of pulmonary embolism.

Determining the clinical probability of pulmonary embolism is the basis for further instrumental diagnosis of pulmonary embolism in order to confirm or exclude. At moderate and high probability of pulmonary embolism diagnosis tool may include the study of perfusion and ventilation method of perfusion and ventilation scintigraphy, angiography, spiral CT angiography, rengenografii, transesophageal and transthoracic echocardiography, ultrasound of the veins. The choice of further diagnostic tests depends on the specific clinical conditions, and diagnostic capabilities of the clinic [3]. With a low clinical probability of pulmonary embolism refusal of further diagnostic tests and antithrombotic therapy is safe for the patient.

Example 1:

Patient M., born in 1941, from 1999 began to notice there is dust dizziness, he lost consciousness. ECG revealed complete AV block, and therefore sent to the Department of surgical treatment of disorders of the heart rhythm. During the examination, the Department in General, the biochemical analysis of blood and coagulation tests, radiographs of the chest and echocardiography revealed no pathology. An operation of the primary pacemaker implantation-530 and electrode Elodie. The VVI mode, the threshold of stimulation 0.9 V, the frequency of stimulation 65 minutes post-operative period was uneventful. The wound healed by first intention. Sutures were removed on the 7th day.

2 months after implantation, the patient was admitted to our Department with complaints of swelling of the left hand, the soreness of her muscles. On examination, an increase in the circumference of the left shoulder and forearm up to 3 cm in diameter. The diagnosis of thrombosis of the left subclavian vein. The treatment, including aspirin, 0.5 g 3 times a day, reopoliglukin 400 ml №10, subcutaneous heparin, starting with 5000 UNITS 4 times daily penicillin, 1,000,000 UNITS intramuscularly 6 times a day. On the background of therapy within 5 days the swelling and soreness of the hands disappeared.

Subsequently, the above effects are almost not occurred, the patient is only occasionally mentioned "swelling" of the left forearm and shoulder pain after exercise. At the same time, since 2001, began to complain of shortness of breath, there is left alone, for no apparent reason, without regard to physical activity, as well as a dry cough. Given the history of Smoking (1 pack of cigarettes per day), these complaints in the outpatient setting were seen as manifestations of chronic obstructive pulmonary disease (COPD), and therefore were treated with ipratropium bromide, Bromhexine, Ambroxol, bronholitin, mukaltin. The efficacy of this therapy was low until 2003, shortness of breath and coughing intermittently.

In 2003, the patient again we observed in clinical conditions. Upon receipt complained of pressing pain in the chest, accompanied by shortness of breath mixed (alone, with little exercise), periodic interruptions in heart work. On examination, pay attention to the presence on the front surface of the chest to the left tortuous and dilated subcutaneous veins, auscultation of the lungs breathing hard, auscultation of heart accent of II tone on the pulmonary artery. ECG - rhythm pacing mode VVI against atrial fibrillation.

Study according to the proposed method. This was a high clinical probability of pulmonary embolism despite the high probability of an alternative diagnosis of COPD (table 1), and therefore held pulmonary scintigraphy with labeled99mTC macroaggregated albumin. Nascentium, made in 4 projections, visualized both lungs. Marked hypoperfusion 1, 2, 3 and perfuse 4, 5 bongaigaon segments of the left lung and Hypo - elements aperfuzii upper right lung. Ultrasonic examination of the heart revealed enlargement of the right ventricular systolic pressure in the right ventricle to 38 mm Hg.

Also spiral computed tomography (CT), helical CT-venography upper left extremity and SKT-pulmonary. On CT-venography diagnosis of thrombophlebitis of the left upper limb was fully confirmed. SKT-angiography at the trunk and branches of the segmental pulmonary arteries were not expanded, filling defects were not found. In reed segments of the left lung to track sub-segmental branches failed, but zones "heart attack", hypoventilation not revealed that in the absence of zones pneumovirus and in comparison with data scintigraphy showed a thrombosis of small branches of the pulmonary artery.

The treatment, including aspirin, 0.5 g 3 times a day, Fraxiparine to 0.6 ml 2 times a day, warfarin (to MHO 2,6), which showed a clinical improvement: the patient's dyspnea disappeared and pressing pain in the chest. Further, at present, the patient has an outpatient takes an indirect is coagulant (MPE level of 2.5-3), complaints of shortness of breath, chest pain does not show.

Example 2.

Two patients, With born in 1947 and L, 1951, with a diagnosis of ischemic heart disease, atherosclerotic cardiosclerosis, complete AV block, corrected EX", were hospitalized (2002 and 2003) to routinely change the FORMER in connection with the discharge of the battery. Study according to the proposed method. Both patients had 2 or more typical of pulmonary embolism, respiratory or cardiac symptoms (3 points), and heart failure, II And extent (1 point), the amount totaled 4 points, indicating a high clinical probability of pulmonary embolism. However, during perfusion scintigraphy of the lungs in patients With perfusion defects are not detected, which allowed us to exclude the diagnosis of pulmonary embolism and the patient's L series scintigrams showed perfusia 4, 5, 9 bongaigaon segments of the left lung, in the absence of changes on the radiograph of the chest in the projection of these segments, as well as the absence of violations of ventilation, identify ventilation lung scintigraphy, which helped to establish the diagnosis of pulmonary embolism and assign adequate antithrombotic therapy.

Example 3.

Patient R., born in 1955, in 2005, a year after pacemaker implantation is about complete AV block, appealed for the scheduled scan settings Extravagana what the surveys according to the proposed method. There were complaints of shortness of breath not related to exercise, but other symptoms of pulmonary embolism was not (0 points), obesity, circulatory insufficiency stage I (1 point). The score was 1. Set at a low clinical probability of pulmonary embolism. Further research and antithrombotic therapy is not required. After adjustment of the stimulation parameters (increase in the frequency and amplitude of pulses) decreased dyspnea.

The proposed criteria for the clinical probability of pulmonary embolism in patients with atrioventricular block, corrected pacemakers, were chosen on the basis of the interpretation of the data, retrospective analysis of case histories of patients with AV block with repeated hospitalizations field pacemaker implantation (1992), and clinical monitoring of patients with moderate and high clinical probability of pulmonary embolism by the proposed method.

Reviewed the records of 274 patients, including 147 women, 127 men, mean age 56,1±1,4 years, the average time after implantation was 3,17±1,4 years. However, we noted the elapsed time after implantation, the complaint arose during this period, the diagnosis and the extent of their validity, possible risk factors of pulmonary embolism. All figures are entered into the database. Then explored with techno-vascular mortality of these patients. To assess the contribution of each factor and their interactions in the study of survival used the regression model is proportional to the risk of Cox [4], which allowed us to identify several working algorithms for determining the clinical probability of pulmonary embolism with different combinations of indicators and their point estimate. (Beta coefficients obtained by regression analysis, were rounded and adapted so that the calculations when determining the clinical probability of pulmonary embolism were similar to the prototype [1, 2]). For each algorithm, we conducted a study of differences in survival of the 2 groups of patients with a low clinical probability of pulmonary embolism and b) with a medium or high probability of pulmonary embolism on the subject algorithm. Groups were made by the method of "matching pairs" [4], i.e. for each test were compared using the same number of patients with similar demographic characteristics and differ only in the clinical probability of pulmonary embolism. Among selected so groups the maximum difference in 5-year survival were available for the test of the proposed method of determining the clinical probability of pulmonary embolism: in the group with a low clinical probability of pulmonary embolism cumulative proportion by Kaplan-Meier represented 0.81, and in the group with medium and high probability of 0.67, which was significantly (p<0,01).

Clinical observation Provo is ilos for 54 patients (34 men, 20 women, mean age of 59.3±2.1 years), 40 of them are moderate, and 14 with a high clinical probability of pulmonary embolism with parameter estimation according to the proposed method. All patients performed perfusion lung scintigraphy, x-rays and, when necessary, SKT, ventilation scintigraphy. In evaluating the results of radiological investigations used PIOPED criteria [5]. The data radionuclide lung examinations were compared with x-ray picture or SKT. The results of this research showed that with high probability (clinical symptoms) diagnosis of pulmonary embolism was confirmed in 13 persons, at moderate - 31.

Thus, the proposed method allows to accurately diagnose clinical probability of pulmonary embolism in patients with atrioventricular block, corrected pacemaker, which is important for improving the quality and duration of life and the most adequate and timely diagnostic and therapeutic interventions in these patients.

LITERATURE

1. Wells PS, Anderson DR, Rodger M, Ginsberg JS, Kearon C, Gent M, et al. Derivation of a simple clinical model to categorize patients probability of pulmonary embolism: increasing the models utility with the SimpliRED Ddimer. // Thromb Haemost 2000; 83: 416-20.

2. Kearon .Diagnosis of pulmonary embolism. // CMAJ·JAN. 21, 2003; 168 (2) R-195

3. Guidelines on diagnosis and management of acute pulmonary embolism. / Task Force on Pulmonary Embolism, European Society of Cardiology. // Eur. Heart J. - 2000. - Vol.21. - P.1301-1336

4. Fletcher, P. Clinical epidemiology. / Rfletcher, Sfletcher, Awagner; Per. s angl. Saibansho, Shuvalovskogo. - M.: Media Sphere, 1998. - 352 S.

5. Value of the ventilation/perfusion scan in acute pulmonary embolism. Results of the prospective investigation of pulmonary embolism diagnosis (PIOPED). The PIOPED Investigators. // JAMA - 1990. - Vol.263. - P.2753-2759.

Application

Table 1
Clinical probability of pulmonary embolism in a patient M
IndexPoints
less likelihood of an alternative diagnosis0
hemoptysis0
2 or more typical of pulmonary embolism respiratory or cardiac symptoms3
the appearance of the ECG signs of atrial fibrillation1,5
implantation of the EX in the previous 6 months0
vein thrombosis of the upper extremity after pacemaker implantation1,5
one or more risk factors0
TOTAL:
Diagnosis: high clinical probability of pulmonary embolism 6

The method for determining the clinical probability of pulmonary embolism in patients with atrioventricular block, corrected pacemaker, which consists in determining clinical signs, such as the likelihood of an alternative diagnosis, the presence of hemoptysis, evaluating each of them in points 3 and 1 points, followed by determination of the diagnosis on their sum, characterized in that it further determine the presence of the following clinical signs: 2 and more typical of pulmonary embolism, respiratory and/or cardiac symptoms and evaluated at 3 points, the appearance of the ECG signs of atrial fibrillation is estimated at 1.5 points, the fact pacemaker implantation in the previous 6 months is estimated at 1 point, the presence of venous thrombosis of the upper extremity after pacemaker implantation is estimated at 1.5 points, the presence of one or more risk factors assessed at 1 point, the absence of any of these clinical signs is estimated at 0 points, followed by counting the total score and a score of more than 6, define, respectively, a high, a score of 2 to 6 - moderate and a score of less than 2 - a low clinical probability of pulmonary embolism.



 

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