Method of predicting risk of unfavourable yearly outcome in patients with st- elevation myocardial infarction

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be used for prediction of unfavourable yearly prognosis of ST-elevation myocardium infarction (STEMI). When patient is taken to hospital, class of cardiac failure and content of interleukin IL-12 in blood plasma are taken into account. Probability of myocardial infarction unfavourable yearly prognosis is estimated by mathematical formula applying independent variables and obtained in examination constants.

EFFECT: increase of accuracy of myocardial infarction unfavourable outcome prediction due to taking into account interleukin IL-12 content.

1 tbl, 2 ex

 

The invention relates to medicine, namely to the diagnosis of cardiovascular disease, and can be used to predict adverse annual forecast of myocardial infarction.

Looking for new opportunities in the early diagnosis of late complications of myocardial infarction (mi) at the present time is a priority, as this approach determines the most efficient way of secondary prevention of coronary heart disease. In order to predict the deaths of myocardial infarction at the present time offered a variety of scales. However, none of them takes into account non-fatal complications to THEM, does not give an accurate prediction due to the absence in the structure of their scoring risk the main pathogenetic mechanism of destabilization of atherosclerotic plaques - subclinical inflammation.

Known scale GRACE (GRACE RISK SCORE used to assess the risk of fatal outcome of the disease and repeated non-fatal mi within 6 months (K.A.Fox, O.H.Dabbous, R.J.Goldberg et al. // BMJ. - 2006. - Vol.333. - P.1091). This scale takes into account age, blood pressure and heart rate, creatinine levels in blood plasma (a measure of kidney function), the class of acute heart failure by Killip, as well as the traditional factors of severity of myocardial infarction - episode of cardiac arrest, not what stabilnosti on the electrocardiogram, increase cardiometer (myocardial enzymes released into the blood when necrosis).

The disadvantages of scale is that it does not take into account as risk factors for the activity indicators of subclinical inflammation, evaluates only the 6-month forecast developed for patients of the European population, does not take into account other cardiovascular events (stroke, unstable angina).

Closest to the claimed method is the determination of adverse outcome in patients with myocardial infarction with ST segment elevation on the scale of CADILLAC, which allows to predict the risk of death within 12 months of observation (A.Halkin, M.Singh, E.Nikolsky et al. // J. Am. Coll. Cardiol. - 2005. - Vol.45. - P.1397-1405). The basis of this scale are the following indicators: the ejection fraction of the left ventricle is less than 40% by echocardiography, renal failure, class of acute heart failure in Killip from 2-4, the blood flow after surgery, percutaneous coronary intervention TIMI 0-2, age over 65 years, presence of anemia, trehdozovogo of coronary lesion (stenosis > 50%). The lack of scale is that it does not account for non-fatal complications of myocardial infarction (repeated myocardial infarction, stroke, hospitalization for progression of coronary insufficiency), risk assessment is only possible according to angiographies implementation of primary percutaneous coronary intervention, that requires significant effort and time.

During the development of the proposed method for predicting the risk of negative annual Exodus to THEM with ST-segment elevation investigated the characteristics: age, sex, glomerular filtration rate by Cockroft-Gault, class of acute heart failure by Killip, body mass index, myocardial infarction in anamnesis, angina history, Smoking, diabetes, hypertension, stroke history, chronic congestive heart failure in history, the level of glycemia at admission and discharge, the level of blood haemoglobin at admission and discharge, increasing the MB fraction of creatine kinase, lipid parameters, localization changes on electrocardiogram, systolic and diastolic blood the pressure at admission and discharge, the heart rate at admission and discharge, the ejection fraction of the left ventricle on echocardiography, percutaneous coronary intervention with reperfusion symptom-related artery, effective thrombolytic therapy, time from the onset of angina pain to revascularization, regular during the year, aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, statins. Additionally, in the serum of venous blood enzyme-linked immunosorbent assay investigated the poison of factors of subclinical inflammation: interleukin-1α, -6, -8, -10, 12, tumor necrosis factor alpha-α, C-reactive protein.

For statistical analysis, we use step-by-step algorithm of regression analysis by Cox (SPSS 10.0.5 company SPSS Inc. (USA)), which allows of the proposed data to determine the most diagnostically sensitive and specific combination. Many of the listed indicators as predictors of adverse annual forecast after suffering THEY identified: class acute heart failure Killip classification and concentration of interleukin-12 (PL.):

Table
Characteristic predictors
PredictorsInWaldreliabilityOSH (95% CI)
Class base on Killip1,7365,2050,0235,7 (1,3; 25,2)
IL-122,06520,285<0,00017,9 (3,2; 19,4)
The constant b020,531<0,0001

Thus, the technical result of the invention is to improve the accuracy of predicting adverse myocardial infarction by taking into account the level of interleukin-12 in the serum of venous blood. To date for patients with myocardial infarction interleukin-12 was not considered as a marker of severity and poor prognosis.

A method for forecasting annual risk of adverse outcome in patients with myocardial infarction with ST-segment elevation, including assessment of the class of acute heart failure Killip classification.

The difference is that further define the level of concentration of interleukin-12 in the serum, and the likelihood of an unfavorable outcome of myocardial infarction evaluated by the formula:

Y=exp (0+1·X1+2·X2)/[1+exp (0+1·X1+2·X2)],

where X1and X2as independent variables, while X1=1, 2, 3, or 4 in accordance with the class of acute heart failure Killip classification, a X2depends on the rate of IL-12 and takes on the values: 1 with IL-12 to 89.99 PG/ml, 2 - when the IL-12 from 90 PG/ml to 119,99 PG/ml and 3 with IL-12 120 PG/ml and above;

in0in1 in2constants in0=6,623;1=1,736 and2=2,065.

To compare the forecast accuracy of the proposed method and the known scales were used ROC curve, the area under which (With statistics) reflects the diagnostic power of the model (the ideal model is coming to 1.0). The value of the C-statistics of the proposed method were 0.89 (0,80; 0,99), which is much higher than other scales (0,55-0,62).

The essence of the proposed method is illustrated by examples of its implementation.

Example 1

Came to an emergency Department patient Century, 51 years, female, unemployed, weight 84 kg, height - 172 see When entering complained of, for the first time emerged as a burning pain behind the breastbone for 5 hours, with no effect from the introduction of narcotic analgesics on the stage of the ambulance. Diabetes and hypertension in history was not. Heredity burdened by mother (stroke), does not smoke. When entering HELL - 135/70 mm Hg, heart rate is 69 per minute. ECG patient elevation of the ST segment in the front group leads, according to echocardiography ejection fraction of the left ventricle is 51%. The severity of heart failure is regarded as Killip I for admission (rales in the lungs. Creatinine at admission - 0,086 mmol/l, creatine-kinase isoforms MB - 68 u/l, anemia was not. Immediately Providna coronary angiography revealed the extent the eskers of several coronary arteries not more than 50% and thrombotic occlusion of the anterior descending artery in the middle segment. 38 minutes from receipt of successful angioplasty with stenting circumflex artery. After 12 days from the moment of hospitalization taken a blood on markers of inflammation, resulting in the following values: CRP to 1.87 mg/l, TNF alpha 7,11 PG/ml, IL-8 9,24 PG/ml, IL-6 is 1.73 PG/ml, IL-1A of 0.91 PG/ml, IL-10 3,89 PG/ml, IL-12 125,12 PG/ml during the hospital period of recurrence of coronary pain was not, according to the results of early stress test tolerance to physical load average. At discharge the assigned standard coronarography and antiplatelet therapy, which she took in the entire period after hospitalization. However, after 6 months was admitted again to hospital re-myocardial infarction with ST-segment elevation on the front wall, the results again conducted coronary angiography - stent restenosis anterior descending artery and the increase in the degree of stenosis of other coronary arteries up to 75%. Re-myocardial infarction patient was complicated by cardiogenic shock requiring intra-aortic balloon counterpulsation and stenting of all stenoses, but within 4 days progressed multiple organ failure, which led to the death of a patient.

Thus, the original patient was characterized by favorable prognosis of myocardial infarction: primary admission scores in school the Lam CADILLAC, GRACE, TIMI, PAMI - 0 (out of 18 possible), 96 (372), 2 (out of 14 possible), 2 (out of 15) respectively, which were determined by the low likelihood of patient death in early and long-term. However, according to the proposed method of prognosis for this patient revealed a high probability (3 credits 38,5%) of adverse outcome given the high initial concentration of interleukin-12.

Example 2

Patient M., 72 years; height is 158 cm, weight 104 kg came to an emergency Department with complaints of pain anginal syndrome in the chest for three hours, in the long history of arterial hypertension, diabetes mellitus and angina within FC III. ECG showed signs of posterior myocardial infarction with ST segment elevation (STEMI. On echocardiography ejection fraction was 49%. In the lungs wheeze no (Killip I). AD - 110/60 mm Hg heart rate was 108 per minute. The level of creatine kinase isoforms MB - 32,8 u/l, creatinine - 0.12 mmol/l, anemia was not. Long took beta-blockers and aspirin. Heredity is not burdened. After 20 minutes of receipt of an urgent coronary angiography revealed an isolated stenosis of the right coronary artery, Providna successful angioplasty with stenting. Stress test showed an average tolerance to physical load. Discharged home. After 12 days from the moment of hospitalization taken blood on the stamp is s inflammation, we obtained the following values: SRV 10,83 mg/l, TNF alpha 5,68 PG/ml, IL-8 4,36 PG/ml, IL-6 5,38 PG/ml, IL-1A was 1.04 PG/ml, IL-10 2,32 PG/ml, IL-12 68,13 PG/ml Within one year featured products. After 12 months, the outcome of myocardial infarction favorable, endpoint not found.

At receipt points on TIMI - 5 CADILLAC - 6, PAMI - 7, GRACE - 137 to assess the probability of death and 162 for the combined point (death/re-myocardial infarction), which was identified in a patient with medium and high risk. According to the new method for predicting the patient has no risk factors for adverse outcome in one year (the probability of 3.3%).

A method for predicting annual risk of adverse outcome in patients with myocardial infarction with ST-segment elevation, including assessment of a class of heart failure Killip classification, characterized in that it further determine the concentration of serum interleukin IL-12, and the likelihood of an adverse outcome within one year after myocardial infarction evaluated by the formula
y=exp (0+1·X1+2·X2)/[1+exp (0+1·X1+2·X2)],
where X1and X2as independent variables, while X1=1, 2, 3, or 4 in accordance with the class of acute cardiac insufficiency classification cat is the ratification, and X2depends on the rate of IL-12 and takes on the values: 1 with IL-12 to 89.99 PG/ml, 2 when IL-12 from 90 to 119,99 PG/ml and 3 with IL-12 120 PG/ml and above;
in0in1in2constants in0=6,623;1=1,736 and2=2,065.



 

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